Radioresistant Pulmonary Oligometastatic and Oligoprogressive Lesions From Nonlung Primaries: Impact of Histology and Dose-Fractionation on Local Control After Radiation Therapy.

Purpose: We investigated whether pulmonary metastases from historically considered radioresistant primaries would have inferior local control after radiation therapy than those from nonradioresistant nonlung primaries, and whether higher biologically effective dose assuming alpha/beta=10 (BED10) would be associated with superior local control. Methods and Materials: We identified patients treated with radiation therapy for oligometastatic or oligoprogressive pulmonary disease to 1 to 5 lung metastases from nonlung primaries in 2013 to 2020 at a single health care system. Radioresistant primary cancers included colorectal carcinoma, endometrial carcinoma, renal cell carcinoma, melanoma, and sarcoma. Nonradioresistant primary cancers included breast, bladder, esophageal, pancreas, and head and neck carcinomas. The Kaplan-Meier estimator, log-rank test, and multivariable Cox proportional hazards regression were used to compare local recurrence-free survival (LRFS), new metastasis-free survival, progression-free survival, and overall survival. Results: Among 114 patients, 73 had radioresistant primary cancers. The median total dose was 50 Gy (IQR, 50-54 Gy) and the median number of fractions was 5 (IQR, 3-5). Median follow-up time was 59.6 months. One of 41 (2.4%) patients with a nonradioresistant metastasis experienced local failure compared with 18 of 73 (24.7%) patients with radioresistant metastasis (log-rank P = .004). Among radioresistant metastases, 12 of 41 (29.2%) patients with colorectal carcinoma experienced local failure compared with 6 of 32 (18.8%) with other primaries (log-rank P = .018). BED10 ≥100 Gy was associated with decreased risk of local recurrence. On univariable analysis, BED10 ≥100 Gy (hazard ratio [HR], 0.263; 95% CI, 0.105-0.656; P = .004) was associated with higher LRFS, and colorectal primary (HR, 3.060; 95% CI, 1.204-7.777; P = .019) was associated with lower LRFS, though these were not statistically significant on multivariable analysis. Among colorectal primary patients, BED10 ≥100 Gy was associated with higher LRFS (HR, 0.266; 95% CI, 0.072-0.985; P = .047) on multivariable analysis. Conclusions: Local control after radiation therapy was encouraging for pulmonary metastases from most nonlung primaries, even for many of those classically considered to be radioresistant. Those from colorectal primaries may benefit from testing additional strategies, such as resection or systemic treatment concurrent with radiation.

Trends in new and persistent opioid use in older adults with and without cancer.

BACKGROUND: The impact of ongoing efforts to decrease opioid use on patients with cancer remains undefined. Our objective was to determine trends in new and additional opioid use in patients with and without cancer. METHODS: This retrospective cohort study used data from Surveillance, Epidemiology, and End Results program-Medicare for opioid-naive patients with solid tumor malignancies diagnosed from 2012 through 2017 and a random sample of patients without cancer. We identified 238 470 eligible patients with cancer and further focused on 4 clinical strata: patients without cancer, patients with metastatic cancer, patients with nonmetastatic cancer treated with surgery alone ("surgery alone"), and patients with nonmetastatic cancer treated with surgery plus chemotherapy or radiation therapy ("surgery+"). We identified new, early additional, and long-term additional opioid use and calculated the change in predicted probability of these outcomes from 2012 to 2017. RESULTS: New opioid use was higher in patients with cancer (46.4%) than in those without (6.9%) (P < .001). From 2012 to 2017, the predicted probability of new opioid use was more stable in the cancer strata (relative declines: 0.1% surgery alone; 2.4% surgery+; 8.8% metastatic cancer), than in the noncancer stratum (20.0%) (P < .001 for each cancer to noncancer comparison). Early additional use declined among surgery patients (‒14.9% and ‒17.5% for surgery alone and surgery+, respectively) but was stable among patients with metastatic disease (‒2.8%, P = .50). CONCLUSIONS: Opioid prescribing declined over time at a slower rate in patients with cancer than in patients without cancer. Our study suggests important but tempered effects of the changing opioid climate on patients with cancer.

Factors Associated With In-Hospital Mortality in Mycosis Fungoides Patients: A Multivariable Analysis.

Background Mycosis fungoides (MF) is the most common form of cutaneous T-cell lymphoma (CTCL). Although it often has an indolent course, it can progress to more aggressive CTCL forms. There is sparse data in current literature describing specific clinical factors associated with in-hospital mortality in mycosis fungoides patients. An understanding of patients at greatest risk for in-hospital mortality can aid in developing recommendations for prophylaxis and empirical management. Aim We aim to characterize factors associated with in-hospital mortality in MF patients. Materials and methods The Nationwide Emergency Department Sample (NEDS) was queried for MF cases from 2006 to 2015. Baseline demographic and hospital characteristics were stratified based on survival outcomes. Multivariable logistic regression was used to identify factors associated with in-hospital mortality. Results A total of 57,665 patients with MF presenting to the ED between 2006 and 2015 were identified. Sézary syndrome, sepsis, and advanced age were associated with MF in-hospital mortality, while female sex was inversely associated. There was a downtrend in in-hospital mortality among MF patients presenting to the ED from 2006 to 2015. Conclusions Our study highlights factors crucial for risk-stratification for hospitalized MF patients.

Practice Patterns Related to Mitigation of Neurocognitive Decline in Patients Receiving Whole Brain Radiation Therapy.

Purpose: Whole brain radiation therapy (WBRT) is often used as an effective treatment for patients with brain metastasis, although it is also known to have deleterious cognitive effects. Multiple trials have identified strategies to help mitigate neurocognitive decline after WBRT, although there may be barriers to integrating these techniques into routine clinical practice. The aim of this study was to characterize national practice patterns related to neurocognitive preservation strategies used during WBRT. Methods and Materials: We conducted an online survey of all American Society for Radiation Oncology-registered radiation oncologists (ROs), excluding trainees, regarding their practice patterns and attitudes toward employing memantine and hippocampal avoidance whole brain radiation therapy (HA-WBRT). Pearson χ2 tests for categorical variables or Student t tests for continuous variables were used to assess associations between provider characteristics and prescribing of either memantine or HA. All statistical tests were 2-sided and a P value <.05 was considered statistically significant. Results: Among 4408 ROs invited to participate, 417 (9.5%) completed the survey. Among respondents, 79.6% reported having offered memantine, 72.7% HA-WBRT, and 63.1% both for any of their patients undergoing WBRT. Common reasons for not offering memantine included limitations of current evidence (35.3%) and concerns about adverse effects (22.4%). Common reasons for not offering HA-WBRT included resource-intensive treatment planning and treatment delay (43.9%) and concern about obtaining prior authorization (38.6%). ROs with fewer years in practice (mean 15.7 vs 23.4 years) were more likely to prescribe memantine (P < .001), whereas HA was more likely prescribed by central nervous system specialists (P < .001) and ROs in academic settings (P = .04). Conclusions: Our survey suggests that the majority of respondents offer approaches for neurocognitive preservation during WBRT for their patients. Further efforts are needed to broaden education and reduce barriers among ROs to improve implementation of neurocognitive-sparing techniques in patients undergoing WBRT.

Emergency department visits for radiation cystitis among patients with a prostate cancer history.

OBJECTIVES: To elucidate the national burden of emergency department (ED) visits for radiation cystitis (RC), a known complication of radiation therapy (RT) to the pelvic area, among patients with a prostate cancer history, and identify those who are at increased risk of requiring invasive measures. PATIENTS AND METHODS: This study queried the Nationwide Emergency Department Sample for all ED visits from January 2006 to December 2015 with a primary diagnosis of RC and secondary diagnosis of prostate cancer. ED visits were characterised by demographic factors, socioeconomic factors, and hospital characteristics. Weighted frequencies were used to create national estimates for all data analysis. RESULTS: A weighted total of 17 382 ED visits occurred for RC among patients with a prostate cancer history, of which 9655 (55.5%) were treated with an invasive procedure. Notable factors associated with undergoing an invasive procedure included having a prior prostatectomy (odds ratio [OR] 5.48, 95% confidence interval [CI] 2.62-11.46), urinary retention (OR 1.35, 95% CI 1.12-1.64), haematuria (OR 1.20, 95% CI 1.01-1.42), and undergoing a blood transfusion (OR 2.12, 95% CI 1.72-2.62). ED visits that were associated with invasive procedures had a higher median total charge ($34 707.53 vs $15 632.53) and an increased median length of stay (5 vs 3 days) compared to visits without an invasive procedure. CONCLUSIONS: Among ED visits for RC in prostate cancer, approximately one half required an invasive procedure for treatment. While RT remains an effective modality for patients with prostate cancer, providers should be mindful of RC as a potential complication.

Post-operative radiation therapy for non-small cell lung cancer: A comparison of radiation therapy techniques.

OBJECTIVES: Post-operative radiation therapy (PORT) in locally advanced non-small cell lung cancer (LA-NSCLC) has historically been associated with toxicity. Conformal techniques like intensity modulated radiation therapy (IMRT) have the potential to reduce acute and long-term toxicity from radiation therapy. Among patients receiving PORT for LA-NSCLC, we identified factors associated with receipt of IMRT and evaluated the association between IMRT and toxicity. METHODS: We queried the Surveillance, Epidemiology, and End Results (SEER)-Medicare database between January 1, 2006 to December 31, 2014 to identify patients diagnosed with Stage II or III NSCLC and who received upfront surgery and subsequent PORT. Baseline differences between patients receiving 3-dimentional conformal radiation therapy (3D-CRT) and IMRT were assessed using the chi-squared test for proportions and the t-test for means. Multivariable logistic regression was used to identify predictors of receipt of IMRT and pulmonary, esophageal, and cardiac toxicity. Propensity-score matching was employed to reduce the effect of known confounders. RESULTS: A total of 620 patients met the inclusion criteria, among whom 441 (71.2%) received 3D-CRT and 179 (28.8%) received IMRT. The mean age of the cohort was 73.9 years and 54.7% were male. The proportion of patients receiving IMRT increased from 6.2% in 2006 to 41.4% in 2014 (P < 0.001). IMRT was not associated with decreased pulmonary (OR 0.89; 95% CI, 0.62-1.29), esophageal (OR 1.09; 95% CI, 0.0.75-1.58), or cardiac toxicity (OR 1.02; 95% CI, 0.69-1.51). These findings held on propensity-score matching. Clinical risk factors including comorbidity and prior treatment history were associated with treatment toxicity. CONCLUSION: In a cohort of elderly patients, the use of IMRT in the setting of PORT for LA-NSCLC was not associated with a difference in toxicity compared to 3D-CRT. This finding suggests that outcomes from PORT may be independent of radiotherapy treatment technique.

Financial relationships between industry and principal investigators of US cooperative group randomized cancer clinical trials.

Financial conflicts of interest (FCOIs) could bias the potentially practice-changing oncologic randomized clinical trials (RCTs) of tomorrow. This investigation characterized the FCOIs of the principal investigators (PIs) of all currently accruing trials of the four (adult) cooperative groups of the National Clinical Trials Network. For our study, the PI list was first compiled, and each name was then searched in the CMS Open Payments database. For each transaction (general payments (GPs) or research funding (RF)), the amount/number/source of payments was recorded. Results showed that from 2014 to 2019, the 91 PIs collectively accepted nearly one-third of a billion dollars ($10 477 023 GPs and $320 096 233 RF). The mean and median GP was $6505 and $945, respectively, and $301 693 and $49 824 RF, respectively. Multivariable Gamma regression analysis revealed that higher GP sums were associated with RCTs involving any type of systemic therapy, and higher RF sums with medical oncologist PIs, trials with phase III components, and RCTs involving radiotherapy (P < .05 for all). Both higher-volume GPs and RF were predicted by PIs having accepted payment(s) from the manufacturer of the drug utilized in their RCT (P < .001 GP, P = .008 RF). Taken together, the main message of this investigation is that FCOIs may be particularly high in PIs of phase III systemic therapy trials, especially if the PI accepted payments from the manufacturer of the drug utilized in their trial. Such RCTs should be thoroughly scrutinized by medical journals, the FDA, and insurance companies for potential "industry bias" that could influence the integrity of their conclusions.

Linear accelerator-based single-fraction stereotactic radiosurgery versus hypofractionated stereotactic radiotherapy for intact and resected brain metastases up to 3 cm: A multi-institutional retrospective analysis.

INTRODUCTION: Single-fraction stereotactic radiosurgery (SF-SRS) is typically used to provide local control of brain metastases. Recently, hypofractionated stereotactic radiotherapy (HF-SRT) has been utilized for large brain metastases. Data comparing these two modalities are limited for brain metastases ≤3 cm. METHODS: Patients with brain metastases receiving linear accelerator-based SF-SRS or HF-SRT were identified at three institutions. Local progression-free survival (LPFS), intracranial progression-free survival (ICPFS), overall survival (OS), and radionecrosis-free survival (RNFS) were determined from time of treatment. RESULTS: 108 patients (76 intact, 32 resected) with 184 brain metastases (142 intact, 42 resected) were included. There were no significant differences between SF-SRS and HF-SRT for intact metastases in 1-year LPFS (62.8% vs. 58.5%, p=0.631), ICPFS (56.9% vs. 55.3%, p=0.300), and OS (71.6% vs. 70.6%, p=0.096), or for resected metastases in 1-year LPFS (67.3% vs. 57.8%, p=0.288), ICPFS (64.8% vs. 57%, p=0.291), and OS (64.8% vs. 66.1%, p=0.603). There were also no significant differences in 1-year RNFS between SF-SRS and HF-SRT (92% vs. 92%, p=0.325). CONCLUSIONS: There were no significant differences in LPFS, ICPFS, OS, and RNFS between SF-SRS and HF-SRT for brain metastases ≤3 cm suggesting SF-SRS may be preferred due to similar outcomes and reduced number of fractions.

Prevalence of Missing Data in the National Cancer Database and Association With Overall Survival.

Importance: Cancer registries are important real-world data sources consisting of data abstraction from the medical record; however, patients with unknown or missing data are underrepresented in studies that use such data sources. Objective: To assess the prevalence of missing data and its association with overall survival among patients with cancer. Design, Setting, and Participants: In this retrospective cohort study, all variables within the National Cancer Database were reviewed for missing or unknown values for patients with the 3 most common cancers in the US who received diagnoses from January 1, 2006, to December 31, 2015. The prevalence of patient records with missing data and the association with overall survival were assessed. Data analysis was performed from February to August 2020. Exposures: Any missing data field within a patient record among 63 variables of interest from more than 130 total variables in the National Cancer Database. Main Outcomes and Measures: Prevalence of missing data in the medical records of patients with cancer and associated 2-year overall survival. Results: A total of 1 198 749 patients with non-small cell lung cancer (mean [SD] age, 68.5 [10.9] years; 628 811 men [52.5%]), 2 120 775 patients with breast cancer (mean [SD] age, 61.0 [13.3] years; 2 101 758 women [99.1%]), and 1 158 635 patients with prostate cancer (mean [SD] age, 65.2 [9.0] years; 100% men) were included in the analysis. Among those with non-small cell lung cancer, 851 295 patients (71.0%) were missing data for variables of interest; 2-year overall survival was 33.2% for patients with missing data and 51.6% for patients with complete data (P < .001). Among those with breast cancer, 1 161 096 patients (54.7%) were missing data for variables of interest; 2-year overall survival was 93.2% for patients with missing data and 93.9% for patients with complete data (P < .001). Among those with prostate cancer, 460 167 patients (39.7%) were missing data for variables of interest; 2-year overall survival was 91.0% for patients with missing data and 95.6% for patients with complete data (P < .001). Conclusions and Relevance: This study found that within a large cancer registry-based real-world data source, there was a high prevalence of missing data that were unable to be ascertained from the medical record. The prevalence of missing data among patients with cancer was associated with heterogeneous differences in overall survival. Improvements in documentation and data quality are necessary to make optimal use of real-world data for clinical advancements.

Temporal Trends in Opioid Prescribing Patterns Among Oncologists in the Medicare Population.

BACKGROUND: In the wake of the US opioid epidemic, there have been efforts to curb opioid prescribing. However, it is unknown whether these efforts have affected prescribing among oncologists, whose patients often require opioids for symptom management. We investigated temporal patterns in opioid prescribing for Medicare beneficiaries among oncologists and nononcologists. METHODS: We queried the Centers for Medicare and Medicaid Services Part D prescriber dataset for all physicians between January 1, 2013, and December 31, 2017. We used population-averaged multivariable negative binomial regression to estimate the association between time and per-provider opioid and gabapentinoid prescribing rate, defined as the annual number of drug claims (original prescriptions and refills) per beneficiary, among oncologists and nononcologists on a national and state level. RESULTS: From 2013 to 2017, the national opioid-prescribing rate declined by 20.7% (P < .001) among oncologists and 22.8% (P < .001) among non oncologists. During this time frame, prescribing of gabapentin increased by 5.9% (P < .001) and 23.1% (P < .001) among oncologists and nononcologists, respectively. Among palliative care providers, opioid prescribe increased by 15.3% (P < .001). During the 5-year period, 43 states experienced a decrease (P < .05) in opioid prescribing among oncologists, and in 5 states, opioid prescribing decreased more among oncologists than nononcologists (P < .05). CONCLUSIONS: Between 2013 and 2017, the opioid-prescribing rate statistically significantly decreased nationwide among oncologists and nononcologists, respectively. Given similar declines in opioid prescribing among oncologists and nononcologists, there is concern that opioid-prescribing guidelines intended for the noncancer population are being applied inappropriately to patients with cancer and cancer survivors.

Quantifying treatment selection bias effect on survival in comparative effectiveness research: findings from low-risk prostate cancer patients.

BACKGROUND: Comparative effectiveness research (CER) using national registries influences cancer clinical trial design, treatment guidelines, and patient management. However, the extent to which treatment selection bias (TSB) affects overall survival (OS) in cancer CER remains poorly defined. We sought to quantify the TSB effect on OS in the setting of low-risk prostate cancer, where 10-year prostate cancer-specific survival (PCSS) approaches 100% regardless of treatment modality. METHODS: The Surveillance, Epidemiology, and End Results database was queried for patients with low-risk prostate cancer (cT1-T2a, PSA < 10, and Gleason 6) who received radical prostatectomy (RP), brachytherapy (BT), or external beam radiotherapy (EBRT) from 2005 to 2015. The TSB effect was defined as the unadjusted 10-year OS difference between modalities that was not due to differences in PCSS. Propensity score matching was used to estimate the TSB effect on OS due to measured confounders (variables present in the database and associated with OS) and unmeasured confounders. RESULTS: A total of 50,804 patients were included (8845 RP; 18,252 BT; 23,707 EBRT) with a median follow-up of 7.4 years. The 10-year PCSS for the entire cohort was 99%. The 10-year OS was 92.9% for RP, 83.6% for BT, and 76.9% for EBRT (p < 0.001). OS differences persisted after propensity score matching of RP vs. EBRT (7.4%), RP vs. BT (4.6%), and BT vs. EBRT (3.7%) (all p < 0.001). The TSB effect on 10-year OS was estimated to be 15.0% for RP vs. EBRT (8.6% measured, 6.4% unmeasured), 8.5% for RP vs. BT (4.8% measured, 3.7% unmeasured), and 6.5% for BT vs. EBRT (3.1% measured, 3.4% unmeasured). CONCLUSIONS: Patients with low-risk prostate cancer selected for RP exhibited large OS differences despite similar PCSS compared to radiotherapy, suggesting OS differences are almost entirely driven by TSB. The quantities of these effects are important to consider when interpreting prostate cancer CER using national registries.

National Patterns in Prescription Opioid Use and Misuse Among Cancer Survivors in the United States.

Importance: Prescription opioids are frequently prescribed to treat cancer-related pain. However, limited information exists regarding rates of prescription opioid use and misuse in populations with cancer. Objectives: To estimate the prevalence and likelihood of prescription opioid use and misuse in adult cancer survivors compared with respondents without cancer and to identify characteristics associated with prescription opioid use and misuse in adult cancer survivors. Design, Setting, and Participants: This cross-sectional study is a retrospective, population-based study using data from 169 162 respondents to the National Survey on Drug Use and Health from January 2015 to December 2018. Survey data sets were queried for all respondents aged 18 years or older. Those with a reported history of cancer were termed cancer survivors and further divided into more recent (had cancer within 12 months of survey) and less recent (had cancer more than 12 months prior to survey) cohorts. Respondents with nonmelanoma skin cancer were excluded. Main Outcomes and Measures: Prescription opioid use and misuse within the past 12 months. Results: Among 169 162 respondents, 5139 (5.2%) were cancer survivors, with 1243 (1.2%) and 3896 (4.0%) reporting having more recent and less recent cancer histories, respectively. Higher rates of prescription opioid use were observed among more recent cancer survivors (54.3%; 95% CI, 50.2%-58.4%; odds ratio [OR], 1.86; 95% CI, 1.57-2.20; P < .001) and less recent cancer survivors (39.2%; 95% CI, 37.3%-41.2%; OR, 1.18; 95% CI, 1.08-1.28; P < .001) compared with respondents without cancer (30.5%, reference group). Rates of prescription opioid misuse were similar among more recent (3.5%; 95% CI, 2.4%-5.2%; OR, 1.27; 95% CI, 0.82-1.96; P = .36) and less recent (3.0%; 95% CI, 2.4%-3.6%; OR, 1.03; 95% CI, 0.83-1.28; P = .76) survivors compared with respondents without cancer (4.3%, reference group). Younger age (aged 18-34 years vs ≥65 years: OR, 7.06; 95% CI, 3.03-16.41; P < .001), alcohol use disorder (OR, 3.22; 95% CI, 1.45-7.14; P = .005), and nonopioid drug use disorder (OR, 14.76; 95% CI, 7.40-29.44; P < .001) were associated with prescription opioid misuse among cancer survivors. Conclusions and Relevance: In this study, prescription opioid use was higher among more and less recent cancer survivors compared with the population without a history of cancer. Rates of prescription opioid misuse were low and similar among all 3 cohorts. These findings suggest that higher prescription opioid use among cancer survivors may not correspond to increased short-term or long-term misuse.

Multi-institutional retrospective review of stereotactic radiosurgery for brain metastasis in patients with small cell lung cancer without prior brain-directed radiotherapy.

Introduction: Patients with small cell lung cancer (SCLC) brain metastasis (BM) typically receive whole brain radiotherapy (WBRT) as data regarding upfront radiosurgery (SRS) in this setting are sparse. Methods: Patients receiving SRS for SCLC BM without prior brain radiation were identified at three U.S. institutions. Overall survival (OS), freedom from intracranial progression (FFIP), freedom from WBRT (FFWBRT), and freedom from neurologic death (FFND) were determined from time of SRS. Results: Thirty-three patients were included with a median of 2 BM (IQR 1-6). Median OS and FFIP were 6.7 and 5.8 months, respectively. Median FFIP for patients with ≤2 versus >2 BM was 7.1 versus 3.6 months, p=0.0303. Eight patients received salvage WBRT and the 6-month FFWBRT and FFND were 87.8%. and 90.1%, respectively. Conclusions: Most SCLC patients with BM who received upfront SRS avoided WBRT and neurologic death, suggesting that SRS may be an option in select patients.

Nationwide Patterns of Pathologic Fractures Among Patients Hospitalized With Bone Metastases.

OBJECTIVES: Pathologic fractures from bone metastases can significantly affect quality-of-life, although it is unclear which patients may be at high risk of this outcome. We aim to determine risk factors for pathologic fracture among patients admitted with bone metastases and to evaluate the association of pathologic fracture with clinical and economic outcomes. METHODS: The Healthcare Cost and Utilization Project National Inpatient Sample was queried for all patients hospitalized with bone metastases in 2016. Baseline differences between patients with and without pathologic fractures were assessed by χ and analysis of variance testing. Multivariable logistic regression was used to identify factors associated with fractures. RESULTS: In 2016, 272,275 hospital admissions were associated with a diagnosis of bone metastases, of which 11,960 (4.4%) had a primary diagnosis of pathologic fracture. Patients with pathologic fractures had a longer length-of-hospital-stay (mean 7.5 vs. 6.4 d; P<0.001) and higher cost-of-hospital-stay (mean $23,611 vs. $15,942; P<0.001) compared to patients without pathologic fractures. Primary cancers associated with increased likelihood of pathologic fracture included liver and intrahepatic bile duct (odds ratio [OR] 2.34; 95% confidence interval [CI], 1.65-3.32), multiple myeloma (OR 1.94; 95% CI, 1.31-2.86), and kidney and renal pelvis cancer (OR 1.89; 95% CI, 1.50-2.37). CONCLUSIONS: Nearly 5% of hospitalizations with bone metastases presented with a concomitant pathologic fracture, which was associated with longer inpatient stay and higher cost. Patients with hepatobiliary, renal cell carcinoma, or multiple myeloma, had a higher likelihood of pathologic fracture. These groups may benefit from increased outpatient monitoring, prophylactic stabilization, or early irradiation.

Nationwide patterns of hemorrhagic stroke among patients hospitalized with brain metastases: influence of primary cancer diagnosis and anticoagulation.

Brain metastases can contribute to a decreased quality of life for patients with cancer, often leading to malaise, neurologic dysfunction, or death. Intracerebral hemorrhage (ICH) is an especially feared complication in patients with brain metastases given the potential for significant morbidity and mortality. We aim to characterize patients with cancer and brain metastases admitted to hospitals nationwide and identify factors associated with ICH. The 2016 Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) was queried for all patients with cancer hospitalized with a diagnosis of brain metastases. Admissions with a primary or secondary diagnosis of ICH were further identified. Baseline differences in demographic, clinical, socioeconomic, and hospital-related characteristics between patients with and without ICH were assessed by chi-square, Mann-Whitney U, and ANOVA testing. Multivariable logistic regression was used to identify factors associated with ICH. Weighted frequencies were used to create national estimates for all data analysis. In 2016, a total 145,225 hospitalizations were associated with brain metastases, of which 4,145 (2.85%) had a concurrent diagnosis of ICH. Patients with ICH were more likely to have a longer length of stay (median 5 days vs 4 days, p < 0.001) and a higher cost of stay (median $14,241.14 vs $10,472.54, p  < 0.001). ICH was found to be positively associated with having a diagnosis of melanoma (odds ratio [OR] 5.01; 95% Confidence Interval [CI] 3.50-7.61) and kidney cancer (OR 2.50; 95% CI 1.69-3.72). Patients on long-term anticoagulation had a higher risk of ICH (OR 1.49; CI 1.15-1.91). Approximately 3% of patients hospitalized with brain metastases also had a diagnosis of ICH, which was significantly associated with longer length of stay and cost. Patients with melanoma, kidney cancer, and on long-term anticoagulation had a higher risk of ICH. Physicians should consider the risks of anticoagulation carefully for patients with brain metastases, especially those with melanoma and kidney cancer.

Local Ablative Therapies for Oligometastatic and Oligoprogressive Non-Small Cell Lung Cancer.

More than half of all patients with non-small cell lung cancer (NSCLC) have metastatic disease at the time of diagnosis. A subset of these patients has oligometastatic disease, which exists in an intermediary state between locoregional and disseminated metastatic disease. In addition, some metastatic patients on systemic therapy may have limited disease progression, or oligoprogression. Historically, treatment of metastatic NSCLC was palliative in nature, with little expectation of long-term survival. However, an accumulation of evidence over the past 3 decades now demonstrates that local ablative therapy to sites of limited metastases or progression can improve patient outcomes for this complex disease. This review examines the evidence behind local ablative therapy in oligometastatic and oligoprogressive NSCLC, with a focus on surgery, stereotactic radiotherapy, and radiofrequency ablation.

Error Types and Associations of Clinically Significant Events Within Food and Drug Administration Recalls of Linear Accelerators and Related Products.

PURPOSE: Medical devices in radiation therapy undergo a complex process of Food and Drug Administration (FDA) approval. Little is known about which processes within the radiation therapy medical device industry are most prone to events involving wrong dose, volume, or targeting in radiation therapy treatment. METHODS AND MATERIALS: We carried out a retrospective analysis of the United States FDA Medical Device Recalls database for recalls of products classified as "Accelerator, Linear, Medical" from 2010 to 2016. Each recall event was classified using a modified Delphi method among 3 experts in safety according to product type, error category, and severity score. Error categories included inconvenience; suboptimal plan or treatment; incorrect dose, volume, or targeting; and nonradiation injury risk. Variables investigated were product type, recall year, FDA-determined cause, and quantity of units recalled. Univariate and multivariate logistic regression were used to identify factors prognostic of incorrect dose, volume, or targeting. RESULTS: We identified a total of 250 recall events between 2010 and 2016, with 165 eligible for analysis. Linear accelerators (LINACs) (28%) and LINAC control software (19%) were the most frequently recalled products. The most common FDA-determined causes for recalls were software design (42%) and device design (26%). On univariate analysis (P < .05), LINAC control software (odds ratio [OR] 5.4) and oncology information system or treatment management system (OR 3.9) versus LINACs and software design (OR 3.4) versus device design were associated with wrong dose, volume, or targeting events. On multivariate analysis, only the association with LINAC control software (OR 3.7) persisted for wrong dose, volume, or targeting events. CONCLUSIONS: Review of these data shows that problems with LINAC control software were associated with incorrect dose delivery at a 4-fold higher rate than errors with LINACs. Manufacturers should focus on improvements in software design to minimize dose- and targeting-related errors to patients.

Emergency Department Visits for Opioid Overdoses Among Patients With Cancer.

BACKGROUND: Patients with cancer may be at risk of high opioid use due to physical and psychosocial factors, although little data exist to inform providers and policymakers. Our aim is to examine overdoses from opioids leading to emergency department (ED) visits among patients with cancer in the United States. METHODS: The Healthcare Cost and Utilization Project Nationwide Emergency Department Sample was queried for all adult cancer-related patient visits with a primary diagnosis of opioid overdose between 2006 and 2015. Temporal trends and baseline differences between patients with and without opioid-related ED visits were evaluated. Multivariable logistic regression analysis was used to identify risk factors associated with opioid overdose. All statistical tests were two-sided. RESULTS: Between 2006 and 2015, there were a weighted total of 35 339 opioid-related ED visits among patients with cancer. During this time frame, the incidence of opioid-related ED visits for overdose increased twofold (P < .001). On multivariable regression (P < .001), comorbid diagnoses of chronic pain (odds ratio [OR] 4.51, 95% confidence interval [CI] = 4.13 to 4.93), substance use disorder (OR = 3.54, 95% CI = 3.28 to 3.82), and mood disorder (OR = 3.40, 95% CI = 3.16 to 3.65) were strongly associated with an opioid-related visit. Patients with head and neck cancer (OR = 2.04, 95% CI = 1.82 to 2.28) and multiple myeloma (OR = 1.73, 95% CI = 1.32 to 2.26) were also at risk for overdose. CONCLUSIONS: Over the study period, the incidence of opioid-related ED visits in patients with cancer increased approximately twofold. Comorbid diagnoses and primary disease site may predict risk for opioid overdose.