Hospital factors determining overall survival in cancer patients undergoing curative treatment.

BACKGROUND: In oncology, overall survival (OS) and quality of life (QoL) are key indicators. The factors that affect OS and QoL include tumor-related characteristics (stage and grade), patient-related factors (performance status and comorbidities), and cancer-directed therapy (CDT)-related aspects. In addition, external factors such as governance or policy (e.g., inaccessibility to CDT, increased distance to service, poor socioeconomic status, lack of insurance), and hospital-related factors (e.g., facility volume and surgeon volume) can influence OS and QoL. MATERIALS AND METHODS: The primary objective of this narrative review was to identify hospital-related factors that affect OS and QoL in patients receiving curative CDT. The authors defined extrinsic factors that can be modified at the hospital level as "hospital-related" factors. Only factors supported by randomized controlled trials (RCT), systematic reviews (SR) and/or meta-analyses (MA), and population database (PDB) analyses that address the relationship between OS and hospital factors were considered. RESULTS: The literature review found that high hospital or oncologist volume, adherence to evidence-based medicine (EBM), optimal time-to-treatment initiation (TTI), and decreased overall treatment time (OTT) increase OS in patients undergoing curative CDT. The use of case management strategies was associated with better symptom management and treatment compliance, but had a mixed effect on QoL. The practice of enhanced recovery after surgery (ERAS) in cancer patients did not result in an increase in OS. There was insufficient evidence to support the impact of factors such as teaching or academic centers, hospital infrastructure, and treatment compliance on OS and QoL. CONCLUSION: The authors conclude that hospital policies should focus on increasing hospital and oncologist volume, adhering to EBM, optimizing TTI, and reducing OTT for cancer patients receiving curative treatment.

A comparison of conventional and accelerated hypofractionated radiotherapy in definitive chemoradiation for locally advanced head and neck carcinoma: a retrospective cohort study.

PURPOSE: The study evaluates accelerated hypofractionated radiotherapy (AHRT) compared to conventional fractionation radiotherapy (CFRT) in patients with locally advanced head and neck cancer (LAHNC) receiving definitive chemoradiation therapy. MATERIALS AND METHODS: The study includes a retrospective cohort analysis of 120 patients. CFRT arm (n = 65) received 2 Gy per fraction to a dose of 70 Gy over 7 weeks in a three-volume approach, whereas the AHRT arm (n = 55) received 2.2 Gy per fraction to a dose of 66 Gy in 6 weeks with a two-volume approach. The primary outcome was overall survival (OS). RESULTS: With a median follow-up of 18.9 months, 23 patients died in the AHRT arm, and 45 deaths in the CFRT arm. The median OS was 23.4 and 37.63 months in the CFRT and AHRT arms, respectively (hazard ratio [HR] = 0.709; 95% confidence interval [CI], 0.425-1.18; p = 0.189). The median time to loco-regional control was 33.3 months in the CFRT arm and was not reached in the patient group receiving AHRT (HR = 0.558; 95% CI, 0.30-1.03; p = 0.065). The median progression-free survival was 15.9 months in the CFRT arm and 26.9 months in the AFRT arm (HR = 0.801; 95% CI, 0.49-1.28; p = 0.357). Out of 11 acute toxic deaths, eight were in the CFRT arm. CONCLUSION: The study showed a trend towards benefit in terms of locoregional control in the AHRT arm and similar OS. A longer follow-up of patients receiving AHRT is required to assess the benefit.

Volumetric image guidance for intravaginal brachytherapy: A dosimetric and clinical study.

Background: The present retrospective dosimetric and clinical study aims to explore the subset of patients who will benefit from volumetric image guidance in intravaginal brachytherapy (IVBT). Materials and Methods: Sixty-three consecutive patients who underwent IVBT using single-channel intravaginal cylinder were analyzed. The most common IVBT dose protocol was 1100 cGy in two fractions (with external beam radiotherapy [EBRT]) and 2200 cGy in four fractions (when used alone). The factors affecting the dose to organs at risk (OARs) (such as treated length, orientation of applicator, EBRT) and target volume were analyzed. Local control rate and late toxicities were reported. Results: There was a statistically significant increase in equivalent dose at 2 Gy per fraction (EQD2) doses of all OARs with the addition of EBRT. In 39.4%, EQD2 D2cc dose of rectum was more than 65 Gy. There was a statistically significant positive correlation with increasing treated length in D5cc (Gy) of rectum and D5cc (Gy) of urethra (Pearson's correlation coefficient of 0.375, P = 0.002 and Pearson's correlation coefficient of 0.394, P = 0.001, respectively). There was a statistically significant increase in D2cc and D5cc of rectum with posterior orientation. Air gaps were noted in 81% of applications. Median duration of follow-up was 30 months. One patient had vaginal recurrence in lower third of vagina. One patient was recorded with grade 2 hemorrhagic radiation proctitis. Conclusion: Computed tomography (CT)-based volumetric planning is an effective method to evaluate doses to OARs and confirm the adequacy of dose coverage, and we recommend routine use of the same. Image guidance is most beneficial in patients being treated with a combination of IVBT and EBRT, posterior orientation, and those who are treated for the entire length of vagina.

Late toxicities in locally advanced head and neck squamous cell carcinoma treated with intensity modulated radiation therapy.

PURPOSE: The study aims to report late toxicities in locally advanced head-and-neck squamous cell carcinoma (LAHNSCC) treated with intensity-modulated radiation therapy (IMRT). MATERIALS AND METHODS: A retrospective study was conducted on 103 patients of LAHNSCC treated with IMRT. We analyzed the cumulative incidence of late xerostomia, dysphagia, and aspiration at an interval of 6-month, 1-year, 2-year, and 3-year from the start of IMRT. RESULTS: At a median follow up of 4.2 years (interquartile range, 3.5 to 6 years), the cumulative incidence of grade ≥2 late xerostomia was 5.5%, dysphagia was 6.9%, and aspiration was 11.1%. Logistic regression showed that Dmean of ≥26 Gy to parotids had higher risk of xerostomia (hazard ratio [HR] = 5.19; 95% confidence interval [CI], 1.90-14.22; p = 0.001). Late dysphagia was associated with Dmean of ≥45 Gy to pharyngeal constrictors (PC) (HR = 7; 95% CI, 1.84-26.61; p =0.004), ≥55 Gy to larynx (HR = 3.25; 95% CI, 1.15-9.11; p = 0.025), and adjuvant RT (HR = 5.26; 95% CI, 1.85-14.87; p = 0.002). Aspiration was associated with Dmean of ≥45 Gy to larynx (HR = 6.5; 95% CI, 1.93-21.88; p = 0.003), Dmean of ≥55 Gy to PC (HR = 3.54; 95% CI, 1.25-9.98; p = 0.017), and patients having late dysphagia (HR = 4.37; 95% CI, 1.55-12.31; p = 0.005). CONCLUSION: IMRT is a feasible radiation delivery technique in LAHNSCC with a decreased late toxicity profile.

Optimal time management on linear accelerator: A logical model to reduce patient waiting time.

INTRODCTION: Optimal time management is of utmost importance in the radiotherapy department. Inappropriate allocation of time slots leads to prolonged waiting times and decreased patient satisfaction during external beam radiotherapy. The present study tests a logical model to improve the waiting time for the patients. MATERIALS AND METHODS: The treatment time, waiting time, and causes of delay were studied from November 4, 2014, to July 24, 2015. New rules were framed for treatment slot allocation from December 26, 2014. The treatment slots were classified based on the treatment technology (three-dimensional conformal radiotherapy and intensity-modulated radiotherapy) with inclusion of "buffer slots" and patient education. The results were compared before and after rules. RESULTS: A total of 1032 time slots were analyzed, of which 225 "before rules" and 807 "after rules," respectively. There was a significant reduction in the average waiting time for treatment in on-time patients (median [interquartile range (IQR)] of 25.2 min [31.75] vs. 3 min [3.5]; P< 0.00001) as well as in late-coming patients (median [IQR] of 38.2 min [13.795] vs. 21.11 min [12.75]; P= 0.00006). 59.7% (71 patients) of the treatment was delayed "before rules" as opposed to 32.2% (137 patients) "after rules" in on-time patients. Due to better patient education, there was a significant improvement in the patient punctuality toward the allotted time. CONCLUSION: The treatment slots classified based on the teletherapy technique with buffer slots, and patient education helps in better time management on linear accelerator. This methodology significantly reduces waiting time and thereby the number of patients having delay in the treatment.

Toxicity syndrome and early competing deaths in head-and-neck cancer undergoing radiation therapy: Observation and hypothesis.

Radiotherapy (RT) and/or concurrent chemoradiation (CRT) is the mainstay for the treatment of locally advanced head-and-neck cancer (LAHNC). Sepsis remains a poorly understood and unrecognized event in head-and-neck cancer. The study aims to hypothesize a 'toxicity syndrome' leading to sepsis and subsequent sepsis-related deaths. A retrospective audit of all 125 LAHNC patients treated radically from January 2013 to June 2017 was conducted. A total of fifteen toxic deaths were reported. Thirteen deaths were attributed to sepsis. Individual toxicity for death was ascertained only for three cases. A toxicity syndrome namely 'mucositis-dysphagia-aspiration-sepsis (MDAS) complex' was proposed as the cause of death in the rest ten cases. The authors recommend the surveillance of the 'MDAS complex' for the prevention of early toxicity-related deaths in patients with LAHNC undergoing RT or CRT.

Burden of acute toxicities in head-and-neck radiation therapy: A single-institutional experience.

INTRODUCTION: Combined modality therapy is the standard of care in locally advanced head-and-neck cancer (HNC). The incidence of acute toxicities increases with additional therapy. The present study investigated the incidence and patterns of mucositis, dysphagia, aspiration, feeding tube use, admission for supportive care, and treatment compliance in patients with HNC treated curatively with radiation therapy (RT) with or without chemotherapy. METHODS AND MATERIAL: A retrospective review of 164 consecutive HNC patients treated with RT at St. John's Medical College Hospital, Bengaluru, from January 2013 to June 2017 was done. RESULTS: A total of 148 HNC patients were treated with a curative intent and 122 (82.4%) were locally advanced HNC. Combined Modality treatment was received by 119 (80.4%) patients. Eighty-four (56.7%) patients were treated by concurrent chemo-radiation. IMRT technique was used in 125 (84.5%) patients. The incidence of grade 3-4 mucositis, dysphagia and aspiration was 25%, 46%, and 10%, respectively. Nasogastric tube feeding was necessitated in 18.9% (n=28) and 27% (n = 40) required inpatient admission for supportive care. Twenty-nine (19.6%) patients did not complete planned RT dose and 46 (31%) patients had unscheduled RT break (>2days). Fifty-six (66.7%) patients did not receive planned chemotherapy. CONCLUSIONS: Acute toxicity due to RT in HNC remains a challenge despite using modern techniques. A significant proportion of patients require supportive therapy for more than 12 weeks and did not complete the scheduled treatment.

Early Competing Deaths in Locally Advanced Head-and-Neck Cancer.

INTRODUCTION: The competing (noncancer) deaths have increased with aggressive treatment approach and better disease control in locally advanced head-and-neck cancer. AIM: The aim of this study is to find incidence, cause and predictors of early competing mortality in locally advanced head-and-neck cancer patients undergoing combined modality therapy. SUBJECTS AND METHODS: In this retrospective study, a total of 125 locally advanced head-and-neck patients treated from January 2013 to June 2017 were analyzed. The total number of deaths, cause, and the time of death from the start of therapy was recorded. To study the risk factors of competing deaths, univariate and multivariate logistic regression was applied. Data were analyzed using SPSS v. 24 software. RESULTS: A total of 51 deaths (31 cancer deaths and 20 competing deaths) recorded at a median follow-up of 16 months (1-62 months). The incidence of early competing mortality was 12% (n = 15) with a median time of 2.7 months from treatment initiation. Sepsis was major cause of early competing death (n = 13). On univariate and multivariate logistic regression analysis, competing death was significantly associated with pharyngeal (oropharynx, hypopharynx, and larynx) site primary (odds ratio [OR] = 3.562; 95% confidential interval [CI] = 1.207-10.517; P = 0.016), and Stage IVA/IVB disease (OR = 5.104; 95% CI = 1.123-23.202; P = 0.021). CONCLUSION: Competing deaths is one of the multifaceted problems in locally advanced head-and-neck cancer patients. Sepsis being single most cause of early competing deaths in Stage IVA/IVB pharyngeal and laryngeal cancer.

Immobilization versus no immobilization for pelvic external beam radiotherapy.

AIM: To identify the most reproducible technique of patient positioning and immobilization during pelvic radiotherapy. BACKGROUND: Radiotherapy plays an important role in the treatment of pelvic malignancies. Errors in positioning of patient are an integral component of treatment. The present study compares two methods of immobilization with no immobilization with an aim of identifying the most reproducible method. MATERIALS AND METHODS: 65 consecutive patients receiving pelvic external beam radiotherapy were retrospectively analyzed. 30, 21 and 14 patients were treated with no-immobilization with a leg separator, whole body vacuum bag cushion (VBC) and six point aquaplast immobilization system, respectively. The systematic error, random error and the planning target volume (PTV) margins were calculated for all the three techniques and statistically analyzed. RESULTS: The systematic errors were the highest in the VBC and random errors were the highest in the aquaplast group. Both systematic and random errors were the lowest in patients treated with no-immobilization. 3D Systematic error (mm, mean ± 1SD) was 4.31 ± 3.84, 3.39 ± 1.71 and 2.42 ± 0.97 for VBC, aquaplast and no-immobilization, respectively. 3D random error (mm, 1SD) was 2.96, 3.59 and 1.39 for VBC, aquaplast and no-immobilization, respectively. The differences were statistically significant between all the three groups. The calculated PTV margins were the smallest for the no-immobilization technique with 4.56, 4.69 and 4.59 mm, respectively, in x, y and z axes, respectively. CONCLUSIONS: Among the three techniques, no-immobilization technique with leg separator was the most reproducible technique with the smallest PTV margins. For obvious reasons, this technique is the least time consuming and most economically viable in developing countries.

Analgesic and Opioid Use in Pain Associated with Head-and-Neck Radiation Therapy.

AIM: The aim of the study is to find the incidence of analgesic and opioid use in pain associated in HNC patient undergoing radiation therapy. BACKGROUND: Radiation therapy with concurrent chemotherapy has become the standard of care in head and neck cancer. Acute toxicity like mucositis and dysphagia has increased with aggressive therapy. Pain is an invariable accompaniment of oropharyngeal mucositis, which leads to decreased quality of life and treatment break. MATERIALS AND METHODS: This is a retrospective review of radiation charts of head and neck patients treated from January 2013 to June 2017 at St. John's Medical college and Hospital, Bengaluru. RESULTS: A total of 138 (92%) patients required analgesia during the radiation course. The analgesic consumption started increasing from week 2, peaked at week 5, persist for 6 weeks and started declining after week 10. 52% patients required opioids, especially from week 4 to week 8. 15% of patients required Morphine, the maximum use in week 6 to week 8. The use of chemotherapy (P = 0.031), presence of grade 3 mucositis (P = 0.010) and grade 3 dysphagia (P = 0.001) were significantly associated with severe pain (use of strong opioids). All 80 (100%) patients receiving concurrent chemotherapy required analgesia. More than 80% patients required opioids and one fourth required strong analgesic in concurrent chemotherapy group. CONCLUSION: More than 90% of all head and neck cancer patient undergoing radiation therapy experience therapy related pain for more than 6 weeks. 53% of the patients require opioids and 15% require strong opioids. The use of concurrent chemotherapy was significantly associated with severe pain.

Outcome of surgery and post-operative radiotherapy for major salivary gland carcinoma: ten year experience from a single institute.

AIMS: To determine the clinical characteristics, pathological features, local and distant failure patterns in patients with carcinoma of major salivary glands treated with surgery and postoperative radiotherapy (PORT). MATERIALS AND METHODS: We retrospectively reviewed 106 cases of major salivary gland tumor seen at our centre (1998-2008). Sixty five cases of major salivary gland carcinoma were selected for analysis (exclusions: benign, palliative, non-carcinomas). The patient population treated by surgery and PORT was divided into two groups: 1) Patients who underwent surgery and immediate PORT (Primary PORT); 2) Patients with recurrent carcinoma who underwent at least two surgeries and received PORT in the immediate post-operative period of the last performed surgery (Recurrent PORT). Recurrence free survival (RFS) was assessed using the Kaplan-Meier method. RESULTS: Median age was 35 years with a male: female ratio of 1.3:1. The majority of cancers were located in the parotid gland (86.2%) and the most common histology was mucoepidermoid carcinoma (43%). Thirty nine cases (60%) were primary while 26 (40%) were recurrent. Optimal surgery was performed in 59/65 patients (90.8%). 43 patients (66.2%) underwent neck dissection, of which 14 (32.5%) had nodal metastasis. Overall, 61 (93.8%) patients complied with the prescribed radiotherapy. Median dose of PORT was 60 Gy. Median follow-up was 13.1 months (range 2-70). Relapse free survival was 50.4% at 60 months. Some 12 cases (18.5%) recurred with a median time to recurrence of 16.9 months. CONCLUSIONS: Surgery and PORT is an effective treatment for major salivary gland carcinoma with over 90% compliance and <20% recurrence. Early treatment with postoperative radiotherapy may increase the survival rate in major salivary gland carcinoma patients.

Re-irradiation with hypo-fractionated stereotactic robotic radiotherapy for salvage in adult patients with brainstem glioma.

PURPOSE: Brainstem glioma (BSG) is often treated with definitive irradiation. However, subsequent progression and death occur as a rule rather than the exception, after varying periods of control. The outlook of patients with post-irradiation progression is dismal, and most of these patients are treated with supportive care alone. Despite the obvious risks with an area as critical as the brainstem, it is a possibility to encounter situations wherein the patients (themselves or their associates) ask for re-irradiation, with the hope of a few extra months of life. The risk of radiation-induced brainstem toxicity may be justifiable under the strict assumption that the patients stand a chance of benefiting from re-irradiation but still may not live long enough to manifest brainstem toxicity. METHODS: Five adult BSG patients were treated with re-irradiation using robotic-arm stereotactic radiation therapy (SRT) between September 2009 and July 2012, primarily at the request of the concerned patient parties. Re-irradiation doses ranged from 16 to 25 Gray (Gy) delivered by robotic arm stereotactic irradiation in 2-5 fractions. RESULTS: Four out of five patients enjoyed a prolongation of survival in the order of months (three, five, six, and 14 months), which was very significant given that all patients had severe neurological compromise and poor performance status prior to re-irradiation. One patient has survived 36 months after re-irradiation and thus has lived long enough to manifest late radiation-induced brainstem toxicity. CONCLUSION: Despite the obvious risks of brainstem toxicity associated with the use of re-irradiation for BSG, the use of fractionated stereotactic re-irradiation seems to offers prospects of additional periods of local control and augments duration of life.

Clinical audit in radiation oncology: results from one academic centre in Delhi, India.

The objective was to analyze the radiotherapy (RT) practice at the cancer centre of a tertiary academic medical institution in Delhi. This audit from an Indian public institution covered patient care processes related to cancer diagnosis, integration of RT with other anti-cancer modalities, waiting time, overall treatment time, and compliance with RT. Over a period of one year, all consecutively registered patients in radiotherapy were analyzed for the audit cycle. Analysis of 1,030 patients showed median age of 49.6 years, with presentation as stage I and II in 14.2%, stage III and IV in 71.2% and unknown stage in 14.6%. A total of 974 (95%) were advised for RT appointment; 669 (68.6%) for curative intent and 31.4% for palliation. Mean times for diagnostic workup and from registration at cancer centre to radiotherapy referral were 33 and 31 days respectively. Median waiting time to start of RT course was 41 days. Overall RT compliance was 75% and overall duration for a curative RT course ranged from 50 days to 61 days. Non-completion and interruption of RT course were observed in 12% and 13% respectively. Radiotherapy machine burden in a public cancer hospital in India increases the waiting time and 25% of advised patients do not comply with the prescribed treatment. Infrastructure, machine and manpower constraints lead to more patients being treated on cobalt (74%) and by two-dimensional (78%) techniques.

Multicentric sinus histicytosis (Rosai-Dorfman Disease): Computed tomography, magnetic resonance imaging findings.

Sinus histicytosis (Rosai-Dorfman disease) is a rare, benign granulomatous disease that typically presents with massive cervical lymphadenopathy. Extranodal involvement along with concomitant nodal disease occurs in about 43% of cases. We present a unique case of a 30-year-old male with cervical, retroperitoneal lymphadenopathy, associated with renal and pituitary sellar masses.

Radiation therapy in paediatric gliomas: our institutional experience.

BACKGROUND AND PURPOSE: The aim of our retrospective study was to analyze the clinical outcome of paediatric glioma patients treated with radiation therapy (RT) in our institution. MATERIAL AND METHODS: We retrieved the case records of all children with gliomas (age < 18 years) who received RT in our department between 2004 and 2007. We analyzed the information regarding patients' demography, clinical details, treatment given, RT details, and survival. The event-free survival (EFS), the period from the date of completion of RT to the date of the event, i.e. death/recurrence, was calculated with respect to age, sex, location of tumour (brainstem vs. non-brainstem), histopathology (low grade vs. high grade), extent of surgical resection, dose and duration of RT, and use of chemotherapy. RESULTS: A total of 70 children with glioma received RT during the above-mentioned period. The 3-year EFS rate for all patients was 44% and the median EFS period was 18 months. The 3-year EFS in patients who underwent surgical decompression and no surgery was 58% and 25%, respectively (p < 0.05). Patients with brainstem lesions had statistically significantly lower 3-year EFS to non-brainstem gliomas (28% vs. 56%, p < 0.01). Chemotherapy use showed no statistically significant trend towards better survival. CONCLUSIONS: RT is an effective modality of treatment in paediatric glioma patients in our setup. Early use of RT in incompletely resected low-grade gliomas is worth revisit-ing. Results of chemotherapy in high-grade glioma and brainstem gliomas are encouraging.

Non-Hodgkin lymphoma following temozolomide.

Temozolomide (TMZ) is an oral alkylating agent with significant activity against glioblastoma multiforme (GBM) and melanoma. It increases survival by 2.5 months when used in combination with radiotherapy as an adjuvant therapy in GBM. Secondary MDS/AML or non-Hodgkin lymphoma attributed to TMZ exposure has been reported. We report a case of non-Hodgkin lymphoma secondary to temozolomide in a 20-year-old female who was treated for GBM with concurrent TMZ and radiotherapy. She developed lymphoma 2 months after completing chemoradiotherapy. Although she was treated with combination chemotherapy for lymphoma, she died of progressive GBM.