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INTRODUCTION: Family planning among female physicians is harmed by high risks of infertility, workload burden, poor family leave policies, and gender discrimination. Many women report feeling unsupported in the workplace, despite national policies to protect against unfair treatment. METHODS: This secondary analysis applied a modified version of the rigorous and accelerated data reduction technique to conduct a thematic analysis of comments to an open-ended prompt. Comments were coded by multiple trained researchers then grouped and merged into illustrative themes via qualitative techniques. RESULTS: Of 1004 responses to the quantitative survey, 162 physicians completed the open-ended prompt. Initial codes (n = 16) were combined into eight groups including, from which three overarching themes were identified. Institutional barriers were highlighted with comments discussing the increased need for parental leave, part-time options and the concern for academic or professional punishment for being pregnant and/or having children. Departmental barriers were explored with comments grouped around codes of discrimination/negative culture and challenges with breastfeeding/pumping and childcare. Personal barriers were discussed in themes highlighting the difficulties that female physicians faced around the timing of family planning, challenges with reproductive health and assistance, and alternative circumstances and/or decisions against family planning. CONCLUSION: Barriers to family planning in oncology exist across career domains from dysfunctional maternity leave to poor education on infertility risk. Solutions include improving institutional support, expanding parental leave, and general cultural change to improve awareness and promotion of family and career balance.
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OBJECTIVE: To optimize the use of confirmatory endoscopic exams (cystoscopy/proctoscopy) in the staging of locally advanced cervical cancer (LACC), the present study evaluates the predictive value of radiological exams (CT and MRI) to detect bladder/rectum invasion. METHODS: A systematic search of databases (PubMed and EMBASE) was performed (CRD42021270329). The inclusion criteria were: a) cervix cancer diagnosis; b) staging CT and/or MRI (index test); c) staging cystoscopy and/or proctoscopy (standard test); and d) numbers of true positives (TP), true negatives (TN), false positives (FP), and false negatives (FN) provided. A random-effects bivariate meta-analysis of positive predictive value (PPV) and negative predictive value (NPV) was performed with moderator analyses by imaging modality (CT and MRI) and prevalence. RESULTS: Nineteen studies met the inclusion criteria, totaling 3480 and 1641 patients for bladder and rectum analyses, respectively. For bladder invasion (prevalence ranged from 0.9% to 34.5%), the overall PPV was 45% (95% confidence interval, 33%-57%, based on 19 studies). Per subgroup, the PPV was 31% for MRI/prevalence ≤6%, 33% for CT/prevalence ≤6%, and 69% for CT/prevalence >6%. For rectal invasion (prevalence ranged from 0.4% to 20.0%), the overall PPV was 30% (95% confidence interval, 17%-47%, based on 8 studies). Per subgroup, the PPV was 36% for MRI/prevalence ≤1%, 17% for MRI/prevalence >1%, and 38% for CT/prevalence >1%. The overall NPV for bladder invasion and rectal invasion were 98% (95% confidence interval, 97%-99%) and 100% (95% confidence interval, 99%-100%), respectively. Considering prevalence and radiological modality, the point estimate of NPV varied from 95% to 100% for bladder invasion and from 99% to 100% for rectum invasion. CONCLUSIONS: Due to low PPV (<50%) of radiological staging, endoscopic exams may be necessary to correctly assess radiological stage IVA LACC. However, they are not necessary after negative radiological exam (NPV ≥95%).
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Neoplasias do Colo do Útero , Algoritmos , Cistoscopia , Feminino , Humanos , Imageamento por Ressonância Magnética/métodos , Estadiamento de Neoplasias , Radiografia , Neoplasias do Colo do Útero/patologiaRESUMO
INTRODUCTION: The current literature is insufficient to guide care for patients with cervical cancer ineligible for brachytherapy. Stereotactic ablative radiotherapy boost is a clinical necessity for these patients, but highly debated among radiation oncologists. OBJECTIVE: To report toxicity and survival outcomes in a large cohort of patients with locally advanced cervical cancer treated with a non-invasive stereotactic ablative radiotherapy boost instead of brachytherapy METHODS: Patients with locally advanced cervical cancer were entered, between January 2008 and December 2018, who were recommended definitive intent external boost after pelvic radiotherapy to 45-50.4 Gy concurrent with weekly cisplatin and simultaneous/sequential nodal boost up to 55-66 Gy. Simulation CT was facilitated using radio-opaque fiducials, empty rectum, dedicated bladder filling, and whole body vaculoplastic immobilization. Kaplan-Meier survival estimates were used to report local/regional recurrences, distant metastases, cancer-specific survival, and overall survival. RESULTS: A total of 25 patients were analyzed. Median follow-up was 25 months (range 6-54). Patients received stereotactic ablative radiotherapy due to refusal of brachytherapy (9/25, 36%), medical co-morbidities limiting implantation (9/25, 36%), or technical infeasibility (7/25, 28%). Typical fractionation was 24-30 Gy in 4-5 fractions (24/25, 96%). The most common long-term toxicity was grade 1-2 vaginal dryness, discomfort, stenosis, and/or dyspareunia (4/25, 16%). One patient had new post-treatment grade 4 fistula in an area of previous tumor erosion (1/25, 4%). Overall survival, cancer specific survival, loco-regional control, and distant control were 95.5%, 100%, 95.5%, and 89.1%, respectively, at 2 years. CONCLUSION: Further study of stereotactic ablative radiotherapy boost for cervical cancer is needed; a brachytherapy-similar approach portends clinical success with 95.5% overall survival and loco-regional control at 2 years.
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Carcinoma de Células Escamosas/terapia , Radiocirurgia/métodos , Neoplasias do Colo do Útero/terapia , Adulto , Idoso , Antineoplásicos/administração & dosagem , Braquiterapia/efeitos adversos , Carcinoma de Células Escamosas/patologia , Quimiorradioterapia/métodos , Cisplatino/administração & dosagem , Fracionamento da Dose de Radiação , Feminino , Humanos , Pessoa de Meia-Idade , Radiocirurgia/efeitos adversos , Estudos Retrospectivos , Neoplasias do Colo do Útero/patologiaRESUMO
OBJECTIVE: To evaluate the efficacy, feasibility and safety of image-based, inversely and adaptively planned high-dose rate interstitial brachytherapy (HDR-ISBT) to treat advanced primary or recurrent gynecologic malignancy in a single implant, three-consecutive-day regimen. METHODS: Clinical demographics and outcome data were abstracted from all patients with primary and recurrent gynecologic malignancies who received HDR-ISBT boost from 2014 to 2017. Treatment consisted of a single implant (~7â¯Gyâ¯×â¯4 fractions) of interstitial needles using the Syed-Neblett template over a three-day hospital admission. CT-based (3D) simulation with inverse and adaptive planning was utilized for each fraction. MR prior to and MR immediately after external beam therapy were fused for HDR-ISBT target delineation. RESULTS: Forty women with an overall median follow-up of 18â¯months (range: 6-54â¯months) received an HDR-ISBT boost. Of the 30 primary cases (83% cervix, 10% vaginal, 7% uterine), 44% had organ invasion (bladder, rectal or both) on MRI. Median coverage and dose are reported (V100: 98%, HR-CTV EQD2: 85.1â¯Gy, D90: 92â¯Gy). A significant association existed between rectal doses exceeding GEC-ESTRO recommendations (D2ccâ¯<â¯75â¯Gy) and the development of grade 3 gastrointestinal toxicity with a relative risk of 1.4 [1.1-1.8] (pâ¯=â¯.046). Actuarial two-year overall survival (OS), local control (LC) and progression-free survival (PFS) were 81%, 81% and 64%, respectively. CONCLUSIONS: A four fraction, inversely and adaptively planned, single-implant approach of image-based HDR-ISBT provides excellent coverage, minimal toxicity and effective local control in patients with advanced and recurrent disease.
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Braquiterapia/métodos , Neoplasias dos Genitais Femininos/radioterapia , Adulto , Idoso , Feminino , Neoplasias dos Genitais Femininos/diagnóstico por imagem , Neoplasias dos Genitais Femininos/patologia , Humanos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/patologia , Recidiva Local de Neoplasia/radioterapia , Planejamento da Radioterapia Assistida por Computador , Radioterapia Guiada por Imagem/métodos , Estudos RetrospectivosRESUMO
OBJECTIVE: Although locally advanced cervical cancer can be cured, patients with stage IVB disease have poor prognosis with limited treatment options. Our aim was to describe the pattern of care and analyze health disparity variables that may account for differences in treatment modalities and survival in this population. METHODS: The National Cancer Database was queried for patients diagnosed between 2004 and 2013 with metastatic squamous cell carcinoma or adenocarcinoma of the cervix. Codes representing parenchymal and lymphatic metastasis (beyond the para-aortic radiation fields) were used to identify the cohort. Variables included age, race, insurance status, comorbidity, treatment modality, and outcomes. We used Kaplan-Meier methods to compare survival curves and Cox proportional hazards to estimate the association between variables and overall survival (OS). Log-rank method was used to compare Kaplan-Meier curves. RESULTS: There were 4576 patients identified. The majority was white (59.7%); 19.5% were Hispanic, and 9.6% were black. Fifty-one percent had Medicare/Medicaid; 33.7% had private, and 12.5% had no insurance. The majority (56.3%) received chemotherapy (CMT) alone or in combination with radiation therapy (RT) and/or surgery. Median follow-up was 7.3 months (0-124.8 months). Median OS was 11.5 months (10.5-12.5 months). Higher probability of receiving CMT and RT was associated with having private insurance (P < 0.001). Significant prognostic values positively affecting survival on multivariate analysis included black and Asian race, private insurance, comorbidity index of 0, metastatic site at initial presentation (lung), and treatment modality. Patients treated with CMT + RT with or without surgery had significantly better median OS (12 months) compared with those treated with CMT alone (8.3 months), RT alone (4.8 months), or those untreated (2.3 months) (P < 0.001). CONCLUSIONS: Insurance status influences treatment options in patients with distant metastatic cervical cancer. Race, comorbidity index, metastatic site, and suboptimal treatment appear to affect survival outcomes. Regardless of treatment, survival was extremely limited.
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Adenocarcinoma/terapia , Carcinoma de Células Escamosas/terapia , Disparidades em Assistência à Saúde , Neoplasias do Colo do Útero/terapia , Adenocarcinoma/mortalidade , Carcinoma de Células Escamosas/mortalidade , Feminino , Humanos , Estudos Retrospectivos , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Neoplasias do Colo do Útero/mortalidadeRESUMO
BACKGROUND AND PURPOSE: Our objective was to determine whether stereotactic body radiotherapy (SBRT), intensity-modulated radiation therapy (IMRT), and brachytherapy boost techniques have comparable overall survival in treating cervical cancer when adjusted for known prognostic factors. MATERIALS AND METHODS: We used the National Cancer Database to study women with invasive cervical cancer who were treated with radiation between 2004 and 2013. A logistic regression model was built to identify factors associated with the receipt of SBRT and IMRT. Outcomes were compared using Kaplan-Meier and propensity score matching. RESULTS: Of all 15,905 patients, 14,394 (90.5%) received brachytherapy, 42 (0.8%) received SBRT, and 1468 (9.2%) received IMRT. After propensity score matching, there was no significant difference in overall survival (OS) for patients who received SBRT boost versus brachytherapy boost (hazard ratio = 1.477, 95% confidence interval = 0.746-2.926, P = 0.263) but a significant OS detriment in patients who received IMRT boost versus brachytherapy boost (hazard ratio = 1.455, 95% confidence interval = 1.300-1.628, P < 0.001). CONCLUSIONS: In a propensity-matched analysis, those who received SBRT boost had equal OS when compared with brachytherapy, but those who received IMRT boost had worse OS when compared with brachytherapy.
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Braquiterapia/estatística & dados numéricos , Radiocirurgia/estatística & dados numéricos , Radioterapia de Intensidade Modulada/estatística & dados numéricos , Neoplasias do Colo do Útero/mortalidade , Neoplasias do Colo do Útero/radioterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Braquiterapia/métodos , Bases de Dados Factuais , Feminino , Humanos , Modelos Logísticos , Pessoa de Meia-Idade , Invasividade Neoplásica , Estadiamento de Neoplasias , Pontuação de Propensão , Radiocirurgia/métodos , Radioterapia de Intensidade Modulada/métodos , Análise de Sobrevida , Resultado do Tratamento , Estados Unidos/epidemiologia , Neoplasias do Colo do Útero/patologia , Adulto JovemRESUMO
OBJECTIVE: The aim of the study was to determine whether patient characteristics are associated with radiation treatment noncompliance. METHODS/MATERIALS: We retrospectively studied 244 patients with cervical cancer treated with chemoradiation between May 2006 and August 2015 at a safety net health center. Compliance with treatment was defined as missing less than 2 days of scheduled radiation. RESULTS: Treatment records revealed a compliance rate of 50.8% in this population. Factors associated with noncompliance were younger age (hazard ratio [HR], 1.037; P = 0.004), presence of psychiatric diagnosis (HR, 0.581; P = 0.044), and having insurance (HR, 0.484; P = 0.022). Noncompliance was associated with a decrease in disease-free survival (HR, 0.555; P = 0.042) but was not associated with overall survival. International Federation of Gynecology and Obstetrics stage was associated with detriment in overall survival on multivariate analysis (HR, 2.034; P = 0.001). CONCLUSIONS: Younger patients, those with psychiatric illness, and those with insurance define a group that is more likely to be noncompliant with treatment and hence may require up-front intervention to improve outcomes.
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Cooperação do Paciente/estatística & dados numéricos , Neoplasias do Colo do Útero/radioterapia , Fatores Etários , Quimiorradioterapia , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Pessoa de Meia-Idade , Cooperação do Paciente/psicologia , Estudos Retrospectivos , Neoplasias do Colo do Útero/tratamento farmacológico , Neoplasias do Colo do Útero/psicologiaRESUMO
BACKGROUND: To determine whether the effect of androgen deprivation therapy (ADT) on the risk of biochemical failure varies at different doses of radiation in patients treated with definitive external beam radiation for intermediate risk prostate cancer (IRPC). METHODS: This study included 1218 IRPC patients treated with definitive external beam radiation therapy to the prostate and seminal vesicles from June 1987 to January 2009 at our institution. Patient, treatment, and tumor information was collected, including age, race, Gleason score, radiation dose, PSA, T-stage, and months on ADT. RESULTS: The median follow-up was 6 years. A total of 421(34.6%) patients received ADT, 211 (17.3%) patients experienced a biochemical failure, and 38 (3.1%) developed distant metastasis. On univariable analyses, higher PSA, earlier year of diagnosis, higher T-stage, lower doses of radiation, and the lack of ADT were associated with an increased risk of biochemical failure. No difference in biochemical failure was seen among different racial groups or with the use of greater than 6 months of ADT compared with less than 6 months. On multivariate analysis, the use of ADT was associated with a lower risk of biochemical failure than no ADT (HR, 0.599; 95% CI, 0.367-0.978; P<0.04) and lower risk of distant metastasis (HR, 0.114; 95% CI, 0.014-0.905; P=0.04). CONCLUSIONS: ADT reduced the risk of biochemical failure and distant metastasis in both low- and high dose radiation groups among men with intermediate-risk PCa. Increasing the duration of ADT beyond 6 months did not reduce the risk of biochemical failures. Better understanding the benefit of ADT in the era of dose escalation will require a randomized clinical trial.
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Adenocarcinoma/terapia , Antagonistas de Androgênios/uso terapêutico , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/patologia , Neoplasias da Próstata/terapia , Dosagem Radioterapêutica , Adenocarcinoma/secundário , Idade de Início , Idoso , Quimiorradioterapia , Intervalo Livre de Doença , Humanos , Masculino , Gradação de Tumores , Estadiamento de Neoplasias , Modelos de Riscos Proporcionais , Neoplasias da Próstata/sangue , Radioterapia de Intensidade Modulada , Estudos RetrospectivosRESUMO
OBJECTIVE: This study aims to assess treatment compliance among women undergoing definitive chemoradiation with weekly cisplatin for cervical cancer within a safety net health system and to quantify the impact of chemotherapy compliance on outcomes. MATERIALS AND METHODS: All women who were treated for International Federation of Gynecology and Obstetrics stage IB2 to stage IVA cervical cancer between April 2008 and May 2014 were identified. Treatment delays were attributed to toxicity, comorbid conditions, or system issues, or categorized as patient-initiated. Disease-free survival and overall survival of women who received fewer than 6 versus 6 or more doses of weekly cisplatin 40 mg/m were compared using Kaplan-Meier analyses. RESULTS: One hundred nineteen women (mean [SD] age, 48.5 [11.8] years) were identified. Most women (n = 112; 94.1%) completed definitive radiotherapy, requiring a mean (SD) of 56.5 (20.1) days. Sixty-four women (57.1%) completed definitive radiotherapy in 56 days or less. Only 44 women (36.4%) received 6 or more cycles of cisplatin. Of 122 delayed cycles, reasons for delay were as follows: grade 2 or higher toxicity (n = 70; 57.4%), medical comorbidity (n = 12; 9.8%), system issues (n = 9; 7.4%), and patient-initiated (n = 14; 11.5%). Multiple issues complicated treatment for 3 doses (2.5%). Reasons for delay were not documented in 14 doses (11.5%). Among patients who received 6 or more cycles, disease-free survival improved by 17.4 months (mean [SD], 61.1 [3.7] vs 43.7 [4.3] months, P = 0.002) and overall survival improved by 8.6 months (mean [SD], 68.7 [2.3] vs 60.1 [3.7] months, P = 0.011). CONCLUSIONS: Higher rates of toxicity and psychosocial barriers to chemotherapy compliance adversely impact survival among women who seek care in low-resource settings. In our population, administration of all 6 cycles of cisplatin was necessary for optimal survival benefit. Future efforts to improve cervical cancer outcomes should address preventable reasons for treatment delays among underinsured or uninsured individuals.
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Carcinoma/patologia , Carcinoma/terapia , Cooperação do Paciente/estatística & dados numéricos , Provedores de Redes de Segurança , Neoplasias do Colo do Útero/patologia , Neoplasias do Colo do Útero/terapia , Adulto , Antineoplásicos/uso terapêutico , Braquiterapia , Quimiorradioterapia/efeitos adversos , Cisplatino/uso terapêutico , Intervalo Livre de Doença , Fracionamento da Dose de Radiação , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
The use of stereotactic body radiation therapy (SBRT) is not well studied or reported in the treatment of gynecologic malignancies, despite its success in the definitive management of other cancer sites. This report describes a rigorous quality assurance process for patients to undergo dose escalation to the pelvis via stereotactic photon beam irradiation. Patients who receive SBRT must be ineligible for conventional brachytherapy boost and undergo comprehensive informed consent. Fiducial placement, bowel prep, Foley catheter placement with standardized bladder filling, computerized tomography (CT) simulation with whole-body immobilization, magnetic resonance imaging (MRI)-assisted target delineation, planning aims based on the established brachytherapy literature, and physics consultation for SBRT plan optimization are necessary. Prior to each fraction, the simulation position is reproduced and verified with on-table cone beam CT, and the position is maintained with whole-body immobilization. Following treatment, the treating physician is active in survivorship and toxicity management. Gynecologic SBRT is an ongoing area of study, and preliminary successes in delivering high-quality stereotactic dose escalation suggest prospective investigation is warranted. By adhering to strict quality control measures and following a pre-defined best standard of practice, patients with gynecologic malignancies who are ineligible for traditional brachytherapy procedures can be safely treated with SBRT.
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BACKGROUND: Diffusion-weighted magnetic resonance imaging (DWI) provides a measurement of tumor cellularity. We evaluated the potential of apparent diffusion coefficient (ADC) values obtained from post-external beam radiation therapy (EBRT) DWI and prior to brachytherapy (BT) to predict for complete metabolic response (CMR) in bulky cervical cancer. METHODS: Clinical and DWI (b value = 500 s/mm2) data were obtained from patients undergoing interstitial BT with high-risk clinical target volumes (HR-CTVs) > 30 cc. Volumes were contoured on co-registered T2 weighted images and 90th percentile ADC values were calculated. Patients were stratified by CMR (defined by PET-CT at three months post-BT). Relation of CMR with 90th percentile ADC values and other clinical factors (International Federation of Gynecology and Obstetrics (FIGO) stage, histology, tumor and HR-CTV size, pre-treatment hemoglobin, and age) was assessed both in univariate and multivariate logistic regression analyses. Youden's J statistic was used to identify a threshold value. RESULTS: Among 45 patients, twenty-eight (62%) achieved a CMR. On univariate analysis for CMR, only 90th percentile ADC value was significant (p = 0.029) while other imaging and clinical factors were not. Borderline significant factors were HR-CTV size (p = 0.054) and number of chemotherapy cycles (p = 0.078). On multivariate analysis 90th percentile ADC (p < 0.0001) and HR-CTV size (p < 0.003) were highly significant. Patients with 90th percentile ADC values above 2.10 × 10- 3 mm2/s were 5.33 (95% CI, 1.35-24.4) times more likely to achieve CMR. CONCLUSIONS: Clinical DWI may serve to risk-stratify patients undergoing interstitial BT for bulky cervical cancer.
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Braquiterapia , Neoplasias do Colo do Útero , Feminino , Humanos , Neoplasias do Colo do Útero/diagnóstico por imagem , Neoplasias do Colo do Útero/radioterapia , Neoplasias do Colo do Útero/patologia , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Braquiterapia/métodos , Imagem de Difusão por Ressonância Magnética/métodosRESUMO
PURPOSE: Radiotherapy affects the functioning of pacemakers. Guidelines based on dosimetric data exist regarding tolerable doses to pacemakers. Little is known about the effects of radiation on implantable drug delivery systems (IDDS). The objective of our study is to evaluate the safety of radiation treatment delivered to patients with IDDS. METHODS AND MATERIALS: We evaluated patients who received external beam radiation therapy in our department after implantation of an IDDS between January 1, 2000 and November 30, 2011. Information was collected on IDDS function, treatment goals, treatment fields, prescribed doses, treatment energies, and cumulative radiation doses to the pump and the catheter. RESULTS: A total of 39 patients received 60 separate courses of radiation therapy, of which 12 patients received radiation with either the pump or the catheter in the field. The remaining patients received scatter radiation only. The goal of radiation was palliative in all but one of the patients. Cumulative pump doses ranged from 5 to 36 Gy, and catheter doses ranged from 15 to 45 Gy. Beam energies ranged from 6 to 18 MV photons. All devices were checked after the completion of radiotherapy with a median follow-up of 4.5 months, and all were found to be in good working condition. CONCLUSIONS: IDDS failures related to external beam radiation therapy seem to represent a rare occurrence. While we do not see reason to limit radiotherapy in patients with IDDS, we recommend device check after the completion of radiotherapy as well as if the patient has an increase in pain or analgesic requirement.
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Analgésicos Opioides/uso terapêutico , Bombas de Infusão Implantáveis , Neoplasias/radioterapia , Dor/tratamento farmacológico , Falha de Equipamento , Feminino , Humanos , Infusão Espinal , Masculino , Pessoa de Meia-Idade , Neoplasias/complicações , Dor/etiologia , Manejo da Dor/instrumentação , Radioterapia/efeitos adversos , Estudos RetrospectivosRESUMO
PURPOSE: Outcomes for patients undergoing chemoradiation for cervical cancer are dependent on adherence to radiation therapy (RT). In other diseases, quality of life (QoL) is associated with treatment adherence, but the association between QoL and RT adherence for patients with cervical cancer remains unclear. METHODS AND MATERIALS: This prospective study included patients undergoing RT for cervical cancer from 2017 to 2021 at an urban safety net hospital. The Functional Assessment of Cancer Therapy-Cervical Cancer Version 4 was used to assess QoL based on 5 subscales (physical, functional, social and emotional, and cervical-cancer specific). The survey was administered at radiation consult, then weekly during RT and at follow-up. Patient information was abstracted from the medical record. Radiation nonadherence was defined as missing ≥2 days of external beam RT. The Functional Assessment of Cancer Therapy-Cervical Cancer Version 4 total and subscale scores were compared between adherent and nonadherent patients. Multivariable logistic regression was performed to control for confounding variables. RESULTS: Ninety-three patients were enrolled, completing 522 surveys. Median age at diagnosis was 46 years (interquartile range, 40-51); 76% of patients were Hispanic, and 12% were Black. Only 30% of patients were nonadherent with RT. A psychiatric comorbidity (P = .012) and symptomatic presentation (P = .027) were associated with decreased adherence. Baseline total QoL was higher in treatment-adherent than in nonadherent patients (median, 124.86; range, 48-160; 108.9, 46-150; P = .01). Higher baseline functional and physical subscale scores were associated with adherence (P < .05). Change from baseline to lowest score during treatment in the emotional subscale was also associated with patient adherence (P < .05). In multivariable analysis, higher baseline physical score, baseline total score, and change in emotional subscale score were associated with adherence (P < .05). CONCLUSIONS: Poor QoL during chemoradiation for cervical cancer is associated with missed treatments. Physician assessment of a patient's well-being while they are undergoing RT is of utmost importance to improve adherence to treatment.
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Qualidade de Vida , Neoplasias do Colo do Útero , Feminino , Humanos , Pessoa de Meia-Idade , Emoções , Hispânico ou Latino , Estudos Prospectivos , Qualidade de Vida/psicologia , Neoplasias do Colo do Útero/tratamento farmacológico , Neoplasias do Colo do Útero/epidemiologia , Neoplasias do Colo do Útero/etnologia , Neoplasias do Colo do Útero/radioterapia , População Urbana , Cooperação e Adesão ao Tratamento , Provedores de Redes de Segurança , Adulto , Negro ou Afro-Americano , QuimiorradioterapiaRESUMO
The purpose of this report is to design, develop, and evaluate a cost-effective applicator for interstitial brachytherapy (ISBT) to minimize patient morbidity and facilitate access to curative radiation treatment for gynecologic cancers, especially in low-resource settings. A computer-aided design and prototype were developed of a proposed applicator that incorporates 44 slotted channels to gently guide needles, with or without a tandem, through the vaginal canal, effectively eliminating the need for transcutaneous needle insertions typically employed during ISBT of advanced gynecologic cancer and thus reducing the risk of vaginal laceration and bladder or rectal injury. The tested prototype was developed using AutoCAD software (Autodesk, San Francisco, CA) and 3D printed in Accura Xtreme Gray material using stereolithography. Small-scale iterative tests using a gelatin phantom were conducted on this prototype to confirm the efficacy of the applicator through inter-operator usability, needle stability, and needle arrangement. A promising prototype was developed aimed at addressing key issues with traditional perineum-based templates to facilitate ISBT, including being able to cover bulky tumors with parametrial extension reliably, decrease the risk of tissue or organ injury, and treat women with a prior hysterectomy. Results of preclinical testing demonstrated that the applicator met its purpose, suggesting that it may facilitate ISBT without the morbidity typically associated with the procedure, especially by addressing concerns associated with implementing the procedure in low-resource settings. The applicator shows substantial promise in the treatment of advanced gynecologic cancer. While further testing remains necessary to confirm its translatability to the clinical setting, the applicator appears capable of meeting its design objectives, representing its potential for improving upon current methods.
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Radiation oncology clinical trials lack full representation of the ethnic and racial diversity present in the general United States and in the cancer patient population. There are low rates of both recruitment and enrollment of individuals from underrepresented ethnic and racial backgrounds, especially Black and Hispanic patients, people with disabilities, and patients from underrepresented sexual and gender groups. Even if approached for enrollment, barriers such as mistrust in medical research stemming from historical abuse and contemporary biased systems, low socioeconomic status, and lack of awareness prohibit historically marginalized populations from participating in clinical trials. In this review, we reflect on these specific barriers and detail approaches to increase diversity of the patient population in radiation oncology clinical trials to better reflect the communities we serve. We hope that implementation of these approaches will increase the diversity of clinical trials patient populations in not only radiation oncology but also other medical specialties.
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Ensaios Clínicos como Assunto , Diversidade Cultural , Neoplasias , Radioterapia (Especialidade) , Humanos , Hispânico ou Latino , Grupos Minoritários , Neoplasias/etnologia , Neoplasias/radioterapia , Grupos Raciais , Estados Unidos , Negro ou Afro-AmericanoRESUMO
PURPOSE: The aim of this study was to quantify the effect of four image registration methods on lung texture features extracted from serial computed tomography (CT) scans obtained from healthy human subjects. METHODS: Two chest CT scans acquired at different time points were collected retrospectively for each of 27 patients. Following automated lung segmentation, each follow-up CT scan was registered to the baseline scan using four algorithms: (1) rigid, (2) affine, (3) B-splines deformable, and (4) demons deformable. The registration accuracy for each scan pair was evaluated by measuring the Euclidean distance between 150 identified landmarks. On average, 1432 spatially matched 32 × 32-pixel region-of-interest (ROI) pairs were automatically extracted from each scan pair. First-order, fractal, Fourier, Laws' filter, and gray-level co-occurrence matrix texture features were calculated in each ROI, for a total of 140 features. Agreement between baseline and follow-up scan ROI feature values was assessed by Bland-Altman analysis for each feature; the range spanned by the 95% limits of agreement of feature value differences was calculated and normalized by the average feature value to obtain the normalized range of agreement (nRoA). Features with small nRoA were considered "registration-stable." The normalized bias for each feature was calculated from the feature value differences between baseline and follow-up scans averaged across all ROIs in every patient. Because patients had "normal" chest CT scans, minimal change in texture feature values between scan pairs was anticipated, with the expectation of small bias and narrow limits of agreement. RESULTS: Registration with demons reduced the Euclidean distance between landmarks such that only 9% of landmarks were separated by ≥1 mm, compared with rigid (98%), affine (95%), and B-splines (90%). Ninety-nine of the 140 (71%) features analyzed yielded nRoA > 50% for all registration methods, indicating that the majority of feature values were perturbed following registration. Nineteen of the features (14%) had nRoA < 15% following demons registration, indicating relative feature value stability. Student's t-tests showed that the nRoA of these 19 features was significantly larger when rigid, affine, or B-splines registration methods were used compared with demons registration. Demons registration yielded greater normalized bias in feature value change than B-splines registration, though this difference was not significant (p = 0.15). CONCLUSIONS: Demons registration provided higher spatial accuracy between matched anatomic landmarks in serial CT scans than rigid, affine, or B-splines algorithms. Texture feature changes calculated in healthy lung tissue from serial CT scans were smaller following demons registration compared with all other algorithms. Though registration altered the values of the majority of texture features, 19 features remained relatively stable after demons registration, indicating their potential for detecting pathologic change in serial CT scans. Combined use of accurate deformable registration using demons and texture analysis may allow for quantitative evaluation of local changes in lung tissue due to disease progression or treatment response.
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Pulmão/diagnóstico por imagem , Pulmão/patologia , Intensificação de Imagem Radiográfica/métodos , Tomografia Computadorizada por Raios X/métodos , Adolescente , Adulto , Idoso , Algoritmos , Feminino , Análise de Fourier , Fractais , Humanos , Masculino , Pessoa de Meia-Idade , Padrões de Referência , Reprodutibilidade dos Testes , Estudos Retrospectivos , SoftwareRESUMO
Clinical trials are considered the gold standard of clinical research and are sought in the medical literature for the goal of providing quality care. To identify factors associated with successful or unsuccessful publication of clinical trials in radiation oncology, data on trial characteristics were collected from the National Institutes of Health database on clinicaltrials.gov. To assess studies that had adequate time to accrue, trials between 2000 and 2005 were extracted by filtering for "radiation oncology". Studies were excluded if they were incomplete, observational, Phase 4, or lacked sufficient method descriptions. Included studies underwent independent samples t-tests and Pearson Chi-Square bivariate analyses. 538 studies were candidates for analysis of clinical trial characteristics. United States (US) origin, multi-center sites, government funding, Phase III status, and randomized allocation were factors associated with increased publication rate. The number of study arms, study length, and number of participants were significantly greater in published trials. The review's results demonstrate potential barriers or facilitators to publication, and they suggest that publication status may be influenced by geographic, financial, and temporal characteristics of clinical trials. Understanding trial background factors that may impact publication improve data visibility and clinical advancements for all.
RESUMO
Management of triple negative breast cancer (TNBC) that is resistant to chemotherapy remains a challenge. Many studies have investigated the unconventional approach of concurrent chemotherapy with radiation in management of TNBC that is resistant to neoadjuvant anthracycline and taxane containing chemotherapy. Various chemotherapies have been used as radiosensitizers. In this report we summarize the published literature and highlight clinical trials that pertain to management of TNBC.
Assuntos
Neoplasias da Mama , Neoplasias de Mama Triplo Negativas , Antraciclinas/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Feminino , Humanos , Terapia Neoadjuvante , Neoplasias de Mama Triplo Negativas/tratamento farmacológico , Neoplasias de Mama Triplo Negativas/patologiaRESUMO
Importance: Female oncologists often spend their childbearing years in training and establishing careers, with many later experiencing fertility issues when starting a family. Physician fertility and family planning are rarely discussed during training. Attitudes among female oncologists regarding family planning are unknown. Objectives: To understand barriers to family planning as well as the association of fertility treatment with career decisions and to assess experiences of pregnancy-based discrimination among female oncologists. Design, Setting, and Participants: In this survey study, a novel 39-item questionnaire was distributed to US female oncologists from May 7 to June 30, 2020, via email and social media channels. Questions regarding factors associated with family planning, maternity leave, and discrimination were included. Main Outcomes and Measures: The distribution of survey responses was compared by oncology subspecialty. Multivariable logistic regression was performed to determine independent variables for discrimination experienced during maternity leave. Results: Responses were collected from 1004 female oncologists. Most respondents (847 [84.4%]) were married, and 713 (71.0%) were currently working full-time. A total of 351 oncologists (35.0%) worked in radiation oncology, 344 (34.3%) in medical oncology, 186 (18.4%) in surgical oncology, and 91 (9.1%) in pediatric oncology. A total of 768 respondents (76.5%) had children, and of these, 415 (41.3%) first gave birth during postgraduate training, and 275 (27.4%) gave birth in years 1 to 5 as an attending physician. Almost all respondents (951 [94.7%]) stated that their career plans were at least somewhat associated with the timing of when to start a family. Having a supportive partner was the most commonly cited positive association with family planning (802 [79.9%]), while long work hours and heavy workload (669 [66.6%]) were the most common negative factors. One-third (318 [31.7%]) had miscarried, and 315 (31.4%) reported difficulty with infertility that required fertility counseling and/or treatment; 660 (65.7%) thought fertility preservation should be discussed with women during medical school and/or residency. One-third (312 [31.1%]) reported experiencing discrimination during pregnancy, and 332 (33.1%) stated they experienced discrimination for taking maternity leave. On multivariable logistic regression, having more than 1 child was associated with increased likelihood of experiencing discrimination during maternity leave (2 children: odds ratio, 1.62 [95% CI, 1.10-2.39]; P = .02; ≥3 children: odds ratio, 1.84 [95% CI, 1.14-2.95; P = .01). Conclusions and Relevance: In this survey study of female oncologists, 1 in 3 reported experiencing infertility and 1 in 3 stated they experienced discrimination during pregnancy and/or for taking maternity leave. Systemic changes are necessary to ensure women are supported and able to advance equitably in the field.