Stigmatizing Language Expressed Towards Individuals With Current or Previous OUD Who Have Pain and Cancer: A Qualitative Study.

CONTEXT: Stigma is known to impact the care of patients with opioid use disorder (OUD). OBJECTIVES: This qualitative study seeks to understand how stigma is expressed in the medical chart by healthcare workers towards patients with cancer pain and OUD treated at an academic medical center. METHODS: This descriptive qualitative study utilized a thematic analysis approach to analyze the medical charts of 25 hospitalized patients with current or previous opioid use disorder and cancer with respect to their pain care in forty pain-related hospital admissions to a tertiary academic center from 2015 to 2020. The codebook utilized a well-characterized stigma framework and emerging themes were identified through an iterative, comparative method. COREQ guidelines were followed. RESULTS: Evidence of stigma marking was present in the medical chart aligning with several intersecting stigmas. Drivers such as blame and stereotypes impeded pain care, while facilitators such as legal or policy influences and non-care advocates could be either positive or negative determinants to pain care. Care by known providers within the healthcare environment was largely a facilitator of improved pain care. CONCLUSIONS: Healthcare provider stigma must be addressed as its effects are both quantitatively and qualitatively affecting patient care; in particular access to pain treatment. Continuity of care by known care providers may improve pain care for patients with cancer and OUD who are acutely hospitalized.

Photobiomodulation During Chemoradiation for Head and Neck Cancer: Effect on Mucositis, Weight Loss, and Feeding Tube Dependence.

Purpose: The standard therapeutic approach in head and neck cancer (HNC) involves multimodality therapy, including surgery, radiation therapy (RT), or chemoradiation therapy (CRT). Treatment complications (mucositis, weight loss, and feeding tube dependence [FTD]) can result in treatment delays, incomplete treatment, and decreased quality of life. Studies on photobiomodulation (PBM) have shown promising reductions in mucositis severity but with little quantitative supporting data. We compared complications for patients with HNC receiving PBM with those in patients who did not, hypothesizing that PBM improves mucositis severity, weight loss, and FTD. Methods and Materials: Medical records of 44 patients with HNC treated with CRT or RT from 2015 to 2021 were reviewed (22 PBM, 22 controls; median age, 63.5 years; range, 45-83 years). Between-group outcomes of interest included maximum mucositis grade, weight loss, and FTD 100 days after initiation of treatment. Results: Median RT doses were 60 Gy (PBM) and 66 Gy (control). Eleven patients treated with PBM received CRT; 11 received RT alone (median of 22 PBM sessions [range, 6-32]). Sixteen control group patients received CRT; 6 received RT alone. Median maximal mucositis grades were 1 in the PBM group and 3 in the control group (P < .0001). The adjusted odds of higher mucositis grade were only 0.024% (P < .0001; 95% confidence interval, 0.004-0.135) in PBM compared with the control group. Conclusions: PBM may have a role in decreasing complications related to RT and CRT for HNC, mainly mucositis severity.

Tailored Mentorship for the Underrepresented and Allies in Radiation Oncology: The Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee Mentorship Experience.

PURPOSE: There are limited opportunities for mentorship for underrepresented in medicine (URM) trainees and physicians in radiation oncology (RO). The purpose of this study was to create and evaluate a formal mentorship program open to URMs and allies with interests in diversity, equity, and inclusion. METHODS AND MATERIALS: A mentorship program incorporating a virtual platform was designed by the Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee. It was structured to include 6 sessions over 6 months with matched mentor-mentee pairs based on responses to a publicized online interest form. A compilation of evidence-based guidelines was provided to optimize the mentorship relationship. Linked pre- and postprogram surveys were administered to collect demographic data, define baseline goals and level of support, and evaluate program satisfaction. RESULTS: Thirty-five mentor-mentee pairs were matched; 31 mentees completed the preprogram survey and 17 completed the postprogram survey. Preprogram, only 3 mentees (9.7%) reported satisfaction with current mentorship and 5 (16%) reported mechanisms or mentorship in place at their program to support URMs. On the postprogram survey, mentees reported high satisfaction with areas of mentorship, mentor attributes, and the program overall. Opportunities for improvement include implementation of mechanisms to enhance communication with mentor-mentee pairs and maintain longitudinal engagement. CONCLUSIONS: In the first tailored mentorship program in RO for URMs and those with diversity, equity, and inclusion interests, our results demonstrate that there is self-reported interest for better mentorship for URMs in RO, and that a nationwide structured mentorship program can address participants' goals with high satisfaction. Program expansion could provide URMs and allies in RO more opportunities for career development and promote a greater sense of community and inclusion within the field.

Predictors of Pathologic Response After Total Neoadjuvant Therapy in Patients With Rectal Adenocarcinoma: A National Cancer Database Analysis.

Purpose/objectives Induction chemotherapy followed by chemoradiation and surgical resection in rectal cancer, known as total neoadjuvant therapy (TNT), is associated with improved pathologic complete response (pCR) rates. The National Cancer Database was utilized to identify factors associated with pCR and survival following treatment with TNT compared to standard neoadjuvant chemoradiation (nCRT). Materials/methods The National Cancer Database was queried from 2004 to 2015 for patients with locally advanced, non-metastatic rectal cancer. We identified 16,299 patients receiving neoadjuvant chemotherapy and radiation followed by definitive surgical resection. Patients were stratified by treatment received, either TNT (n=350) or nCRT (n=15,949). Multivariate binomial regression analysis and propensity matching were used to evaluate predictors of pCR. Kaplan-Meier and Cox multivariate analysis of survival were performed. Results Median follow-up was 38 months vs 53 months in the TNT vs nCRT groups, respectively. There were more patients with T4 or node-positive disease in the TNT group. There was a trend towards improved pCR in the TNT group (p=0.053). Patients achieving pCR had improved 5-year overall survival (OS) of 85.1%. The 5-year OS was not improved for TNT (76.2%) over nCRT (69.9%) (p=0.19). Pelvic nodal pCR was significantly higher in the TNT group (72%). When stratified by clinical stage, patients with cT3 (p=0.038) or cN1 (p=0.049) disease had improved OS with TNT. Conclusions Compared to nCRT, TNT is correlated with higher rates of complete pelvic nodal clearance in patients with locally advanced rectal adenocarcinoma. The use of TNT showed improved survival in patients with cT3 and cN1 disease, indicating a potential benefit for patients with less advanced disease.

Radiographic and Tumor Biomarker Response to Radiotherapy for Recurrent Granulosa Cell Tumor of the Ovary.

Granulosa cell tumors (GCTs) of the ovary are rare, comprising less than 5% of all malignant ovarian neoplasms. While generally considered indolent, GCTs have a tendency for metastasis and delayed relapse, with recurrence developing in 20%-50%. Recurrent or metastatic disease is associated with aggressive behavior and a poor prognosis, as nearly 70% of patients developing recurrence will eventually succumb to their disease. The optimal management of relapsed disease is controversial. Initial salvage therapy typically involves surgical debulking followed by cisplatin-based chemotherapy. Unfortunately, tumor responses are durable for less than half of patients treated with this regimen. Radiation therapy is an attractive option for providing rapid palliation and improving local control without the morbidity of additional surgery or chemotherapy. Here we describe a case of multiply recurrent, rapidly growing intraperitoneal GCT refractory to repeated surgical debulking and several lines of systemic therapy. The patient was treated with two courses of palliative radiotherapy and achieved rapid symptomatic relief, achieving over a 90% reduction in tumor volume. Serum concentration of inhibin B, often inappropriately elevated in patients with GCT, decreased by 98% following irradiation with no interim systemic therapy. At one-year follow-up, the patient has no evidence of radiographic or biochemical recurrence.

Radiation Toxicity in Patients With Collagen Vascular Disease: A Meta-Analysis of Case-Control Studies.

PURPOSE: Several retrospective series have reported that patients with collagen vascular disease (CVD) are at increased risk of radiation (RT) toxicity. However, the evidence is mixed, and many series lack control groups. We performed a meta-analysis including only case-cohort or randomized studies that examined the risk of RT toxicity for patients with CVD compared with controls. METHODS AND MATERIALS: Meta-analysis of Observational Studies in Epidemiology guidelines were used to perform a comprehensive search identifying case-control or randomized studies reporting RT toxicity outcomes for patients with CVD versus controls. Data were synthesized from studies reporting grade 2 to 3 or more (G2/3 +) acute and late RT toxicities. Results were analyzed with fixed effects meta-analysis on the random-effects model for between-study heterogeneity; otherwise, the fixed-effects model was used. Hazard ratio or odds ratio (OR) were the effect-size estimators, as appropriate. RESULTS: Ten studies were included, with 4028 patients (CVD: 406, control: 3622). Patients with CVD had higher rates of acute G2/3 + toxicity (26.2% vs 16.5%, OR [odds ratio] 2.01; P < .001) and late G2/3 + toxicity (18.4% vs 10.1%, OR 2.37; P < .001). Higher rates of late G2/3 + toxicity were observed for CVD patients with systemic lupus erythematous (21% vs 9.7%; OR 2.55, P = .03), systemic scleroderma (31.8% vs 9.7%, OR 3.85; P = .03), rheumatoid arthritis (11.7% vs 8.4%, OR = 2.56; P = .008), and those irradiated to the pelvis/abdomen (32.2% vs 11.9%, OR 3.29; P = .001), breast (14.7% vs 4.4%, OR 3.51; P = .003), thorax (12.5% vs 8.7%, OR 3.46; P < .001), and skin (14.6% vs 5.2%, OR 2.59; P = .02). Late grade 5 toxicities were significantly higher for patients with CVD, although absolute rates were low (3.9% vs 0.6%, OR = 7.81; P = .01). CONCLUSIONS: Moderate and severe toxicities are more likely in patients with CVD, with variable risk depending on toxicity grade, CVD subtype, treatment site, and dose. Severe toxicities are uncommon. These factors should be considered when informing patients of treatment-related risks and monitoring for morbid treatment sequelae.

Compassion Inequities and Opioid Use Disorder: A Matched Case-Control Analysis Examining Inpatient Management of Cancer-Related Pain for Patients With Opioid Use Disorder.

CONTEXT: The opioid epidemic spurred guidelines intended to reduce inappropriate prescribing. Although acute cancer-related pain was excluded from these recommendations, studies demonstrate reduced opioid prescribing for patients hospitalized with advanced cancer. OBJECTIVES: We performed a matched case-control analysis to determine how a history of opioid use disorder (OUD) affects inpatient management of cancer pain. METHODS: Charts of patients with OUD admitted for cancer pain from 2015-2020 were retrospectively reviewed. Hospitalizations were matched 1:1 by patient age and sex. Home milligram-morphine equivalent per day (MME/day) was calculated from the home medication list. Admission MME/day was the average MME/day administered during hospitalization. RESULTS: A total of 80 hospitalizations (40:40) were matched for 25 patients with a history of OUD and 31 patients with no history of OUD. Cancer was metastatic/relapsed for 70% of admissions. The median overall survival was 2.3 months (95% CI 0-5.21, P = 0.13). Patients with OUD had a significantly lower change from Home to Admission MME/day (-3 vs. 37, P < 0.01) and were less likely to have any increase in Admission MME/day (OR 0.1, 95% CI 0.02-0.43, P < 0.01). When considering opioids administered after pain specialty consultation, there was no difference between groups. CONCLUSION: Our results suggest that patients with OUD receive lower quality inpatient management of cancer-related pain. Provider education and early involvement of pain specialists are crucial in delivering equitable and compassionate end-of-life care for patients with OUD.

Impact of Systemic Therapy Type and Timing on Intracranial Tumor Control in Patients with Brain Metastasis from Non-Small-Cell Lung Cancer Treated With Stereotactic Radiosurgery.

OBJECTIVE: Stereotactic radiosurgery (SRS) can effectively control brain metastasis (BRM) from non-small-cell lung cancer (NSCLC), although intracranial recurrence from untreated micrometastatic tumor deposits is common without whole-brain radiotherapy. Our goal was to determine if immunotherapy improves distant intracranial progression-free survival (DI-PFS) compared with other systemic therapies in patients treated with SRS. METHODS: All patients from 2011 to 2019 treated with SRS without previous whole-brain radiotherapy for NSCLC BRM were reviewed. DI-PFS for the entire cohort, and subgroups of patients, was estimated and compared using the Kaplan-Meier/log-rank method. RESULTS: One hundred and thirty-six SRS sessions used to treat 99 patients were reviewed; 98 (72%) for previously untreated BRM and 38 (28%) for recurrent BRM. 35% received immunotherapy (77% concurrent with SRS), 46% received chemotherapy (75% concurrent), and 18% received epidermal growth factor receptor/anaplastic lymphoma kinase (ALK) targeted therapy (85% concurrent). At median follow-up of 13.7 months, 49% developed distant intracranial recurrence. One-year DI-PFS was improved with any use of immunotherapy (58% vs. 39%; P = 0.03) and concurrent immunotherapy versus chemotherapy or targeted therapy (67% vs. 37% vs. 39%, respectively; P = 0.01). In the immunotherapy cohort, 1-year DI-PFS was improved for programmed death-ligand 1 expression ≥50% versus 1%-49% versus 0% (80% vs. 49% vs. 19%, respectively; P < 0.01), and Lung Immune Prognostic Index 0-1 versus 2 (63% vs. 34%; P = 0.03). CONCLUSIONS: Immunotherapy concurrent with SRS, particularly in patients with high programmed death-ligand 1 expression or low Lung Immune Prognostic Index, is associated with improved DI-PFS and no increased risk of radiation necrosis compared with other systemic therapies for NSCLC.