Serum erythropoietin levels, breast cancer and breast cancer-initiating cells.

BACKGROUND: Cancer is frequently associated with tumor-related anemia, and many chemotherapeutic agents impair hematopoiesis, leading to impaired quality of life for affected patients. The use of erythropoiesis-stimulating agents has come under scrutiny after prospective clinical trials using recombinant erythropoietin to correct anemia reported increased incidence of thromboembolic events and cancer-related deaths. Furthermore, previous preclinical reports indicated expansion of the pool of breast cancer-initiating cells when erythropoietin was combined with ionizing radiation. METHODS: Using four established breast cancer cell lines, we test the effects of recombinant human erythropoietin and the number of breast cancer-initiating cells in vitro and in vivo and study if recombinant human erythropoietin promotes the phenotype conversion of non-tumorigenic breast cancer cells into breast cancer-initiating cells. In a prospective study, we evaluate whether elevated endogenous serum erythropoietin levels correlate with increased numbers of tumor-initiating cells in a cohort of breast cancer patients who were scheduled to undergo radiation treatment. RESULTS: Our results indicate that recombinant erythropoietin increased the number of tumor-initiating cells in established breast cancer lines in vitro. Irradiation of breast cancer xenografts caused a phenotype conversion of non-stem breast cancer cells into induced breast cancer-initiating cells. This effect coincided with re-expression of the pluripotency factors c-Myc, Sox2, and Oct4 and was enhanced by recombinant erythropoietin. Hemoglobin levels were inversely correlated with serum erythropoietin levels, and the latter were correlated with disease stage. However, tumor sections revealed a negative correlation between serum erythropoietin levels and the number of ALDH1A3-positive cells, a marker for breast cancer-initiating cells. CONCLUSIONS: We conclude that physiologically slow-rising serum erythropoietin levels in response to tumor-related or chemotherapy-induced anemia, as opposed to large doses of recombinant erythropoietin, do not increase the pool of breast cancer-initiating cells.

The patient's perspective on breast radiotherapy: Initial fears and expectations versus reality.

BACKGROUND: Although the efficacy and toxicity of breast radiotherapy (RT) has been studied extensively, to the authors' knowledge little is known regarding the patient's perspective on the modern breast RT experience. To better inform future patients and providers, the authors explored patient perceptions of their RT experience. METHODS: Consecutive patients who were free of disease recurrence and who had been treated between 2012 and 2016 were surveyed regarding their original fears, how short-term and long-term toxicities compared with initial expectations, and how pretreatment beliefs concerning RT compared with the actual experience. RESULTS: A total of 502 patients were surveyed, with a response rate of 65% (327 patients). The median patient age and posttreatment follow-up was 59 years and 31 months, respectively. Approximately 83% of patients (269 patients) underwent breast conservation therapy. Although approximately 68% of patients (221 patients) endorsed that they initially had little to no knowledge regarding RT, approximately 47% (152 patients) reported that they had heard frightening stories. Approximately 2% of patients (6 patients) agreed that the negative stories they previously heard about RT were actually true. Approximately 92% of patients treated with breast conservation (247 patients) and 81% of patients who underwent mastectomy (47 patients) agreed with the statement "If future patients knew the real truth about RT, they would be less scared about treatment." Approximately 83% (272 patients) and 84% (274 patients), respectively, of all patients reported the overall severity of short-term and long-term side effects to be better than or as expected. CONCLUSIONS: Breast RT is associated with misconceptions and fears. Patients' experiences with modern breast RT appear to be superior to expectations, and the majority of patients in the current study agreed that their initial negative impressions were unfounded. Cancer 2018;124:1673-81. © 2018 American Cancer Society.

Predictors associated with MRI surveillance screening in women with a personal history of unilateral breast cancer but without a genetic predisposition for future contralateral breast cancer.

PURPOSE: For women with a personal history of breast cancer (PHBC), no validated mechanisms exist to calculate future contralateral breast cancer (CBC) risk. The Manchester risk stratification guidelines were developed to evaluate CBC risk in women with a PHBC, primarily for surgical decision making. This tool may be informative for the use of MRI screening, as CBC risk is an assumed consideration for high-risk surveillance. METHODS: Three hundred twenty-two women with a PHBC were treated with unilateral surgery within our multidisciplinary breast clinic. We calculated lifetime CBC risk using the Manchester tool, which incorporates age at diagnosis, family history, genetic mutation status, estrogen receptor positivity, and endocrine therapy use. Univariate and multivariate logistic regression analyses (UVA/MVA) were performed, evaluating whether CBC risk predicted MRI surveillance. RESULTS: For women with invasive disease undergoing MRI surveillance, 66% had low, 23% above-average, and 11% moderate/high risk for CBC. On MVA, previous mammography-occult breast cancer [odds ratio (OR) 18.95, p < 0.0001], endocrine therapy use (OR 3.89, p = 0.009), dense breast tissue (OR 3.69, p = 0.0007), mastectomy versus lumpectomy (OR 3.12, p = 0.0041), and CBC risk (OR 3.17 for every 10% increase, p = 0.0002) were associated with MRI surveillance. No pathologic factors increasing ipsilateral breast cancer recurrence were significant on MVA. CONCLUSIONS: Although CBC risk predicted MRI surveillance, 89% with invasive disease undergoing MRI had <20% calculated CBC risk. Concerns related to future breast cancer detectability (dense breasts and/or previous mammography-occult disease) predominate decision making. Pathologic factors important for determining ipsilateral recurrence risk, aside from age, were not associated with MRI surveillance.

Increasing Appropriate BRCA1/2 Mutation Testing: The Role of Family History Documentation and Genetic Counseling in a Multidisciplinary Clinic.

BACKGROUND: Findings show that 5-10 % of women with a diagnosis of breast cancer (BCa) have actionable genetic mutations. The National Comprehensive Cancer Network guidelines for testing to detect BRCA1/2 mutations include personal history (PH) variables such as age of 45 years or younger and a family history (FH) variables. Rates of FH documentation and overall rates of appropriate referral for genetic testing are low, ranging from about 30 to 60 %. The authors hypothesized that an upfront FH documentation and inclusion of a genetics counselor in a multidisciplinary clinic (MDC) setting would increase rates of appropriate referral for genetic testing. METHODS: The study enrolled 609 consecutive women with non-metastatic BCa seen in consultation between June 2012 and December 2015 at a multidisciplinary clinic. Rates of FH documentation and referral for genetic testing to detect BRCA1/2 mutations were assessed before and after inclusion of a genetic counselor in the MDC. RESULTS: The rates of FH documentation and appropriate referral were 100 and 89 %, respectively. Half (50 %) of the patients had only FH-based indications for testing. All the patients with PH-based indications were referred. The inclusion of a genetic counselor significantly increased appropriate referral rates among those with only FH-based indications (62 vs. 92 %) and overall (80 vs. 96 %) (p < 0.0001 for both). Among the 12 % of the patients with actionable mutations, 60 % were 45 years of age or younger, whereas 30 % had only FH-based testing indications. CONCLUSIONS: This report shows substantially higher FH documentation and appropriate genetic testing rates than prior reports. Many patients with indications for genetic testing may have only FH-based indications for testing, and this subset may account for the sizable proportion of patients with newly diagnosed BCa who have actionable mutations.

The role of radiation therapy after nipple-sparing mastectomy.

PURPOSE: The aim of this review was to examine the incidence of nipple-areola complex (NAC) involvement, the rates of NAC recurrence, and the data regarding the role of radiation therapy (RT) following nipple-sparing mastectomy (NSM). METHODS: A literature review was performed using the PubMed search engine, with articles selected based on standardized criteria. Additional articles included those known to the authors and those obtained by review of references from key studies. RESULTS: The reported incidence of NAC involvement ranges from 0 to 58 %. The most commonly associated factors with NAC involvement include tumor-to-NAC distance, tumor size, central location of the primary tumor, multicentricity/multifocality, and positive axillary lymph nodes. Following NSM, in the setting of proper patient selection, rates of NAC recurrence are generally low, with the majority of studies reporting rates ranging from 0 to 4 %. There is a paucity of data evaluating the role of RT after NSM and a lack of level I evidence, with the largest series documenting low rates of local recurrence with RT but failing to provide a control arm without radiotherapy. CONCLUSIONS: Optimal preoperative patient selection for NSM and intraoperative assessment of the NAC result in acceptably low rates of NAC involvement/recurrence. NSM alone is not adequate justification for post-mastectomy radiation. NSM should be taken into consideration to inform radiation decision making only when preoperative imaging, clinical features, or pathologic findings suggest higher risk for NAC involvement.

Pretreatment weight status and weight loss among head and neck cancer patients receiving definitive concurrent chemoradiation therapy: implications for nutrition integrated treatment pathways.

PURPOSE: The purpose was to examine the effect of pretreatment weight status on loco-regional progression for patients with squamous cell carcinoma of the head and neck (SCCHN) after receiving definitive concurrent chemoradiation therapy (CCRT). METHODS: In an expanded cohort of 140 patients, we retrospectively reviewed weight status and loco-regional progression of SCCHN patients treated with CCRT between 2004 and 2010. RESULTS: Pretreatment ideal body weight percentage (IBW%) was statistically significantly different for patients with disease progression than for those without progression (p = 0.02) but was not an independent predictor of progression. Median pretreatment IBW% was 118 (72-193) for the progression-free group and was 101.5 (73-163) for the group with progression. Both groups suffered clinically severe weight loss of approximately 9 % from baseline to end treatment. CONCLUSIONS: Pretreatment weight status, a very crude indicator of nutrition status, may have prognostic value in patients with SCCHN undergoing definitive CCRT. Inadequate nutritional status in these patients has been associated with poor clinical outcomes and decreased quality of life. Based on this report and others, the best next steps include routine validated malnutrition screening and the testing of evidence-based nutrition care protocols with the goals of minimizing weight loss and improvement of quality of life.

Established and new horizons in radiotherapy for breast cancer.

Modern advances in diagnostics, surgery, systemic therapies, and radiotherapy (RT) have drastically revolutionized treatment strategies for breast cancer. This review outlines current and evolving treatment paradigms for RT in the breast-conserving therapy and post-mastectomy setting. In early-stage breast cancer, there is active investigation in expanding eligibility for omission of RT in women with more biologically favorable tumors and growing options to effectively irradiate less breast tissue and shorten RT treatment courses. For locally advanced breast cancer, we discuss several patient cohorts in which the necessity of post-mastectomy RT (PMRT) is commonly debated. Ongoing efforts to better refine indications for PMRT and evaluate the feasibility of hypofractionated PMRT are being studied. Metastasis-directed therapy with ablative RT is an emerging topic of interest in many cancers, including its role and impact in oligometastatic breast cancer. In this review, we will discuss the rationale for current standard of care and address in greater detail the aforementioned concepts.

De-escalation of surgery for occult breast cancer with axillary metastasis.

Occult breast cancer presenting as axillary metastasis is rare and remains a diagnostic and therapeutic challenge. Evidence to guide clinical management is limited, and locoregional treatment remains nonstandardized and highly varied nationally. Historically, occult breast cancer was managed with modified radical mastectomy ± radiotherapy; however, equivalent local control and survival are observed with breast preservation and adjuvant whole breast radiotherapy. Axillary lymph node dissection remains the standard surgical approach to the axilla for occult breast cancer patients. De-escalating axillary surgery in a subset of occult breast cancer patients treated with neoadjuvant chemotherapy with good response to treatment may be appropriate, similar to the management of clinically node-positive patients in a known primary setting. As in other clinically node-positive breast cancer cases, thoughtful integration and tailoring of axillary surgery and regional nodal radiotherapy (for the varying extent of nodal burden) is an area of continued controversy and active investigation.

Predictors of continuous positive airway pressure use during the first week of treatment.

This study aimed to identify pre-treatment and immediate early treatment factors predicting continuous positive airway pressure (CPAP) use during the first week of therapy, when the pattern of non-adherence is established. Four domains of potential predictors were examined: pre-treatment demographic and clinical factors, patients' perceived self-efficacy, treatment delivery (mask leak and bothering side effects) and immediate disease reduction (residual respiratory events and flow limitation). The Autoset™ Clinical System objectively documented daily CPAP use, mask leak, residual respiratory events and flow limitation. Ninety-one CPAP-naive patients with newly diagnosed obstructive sleep apnea were followed for 1week after treatment initiation. Mean CPAP daily use during the first week was 3.4±2.7h, with significantly lower use observed in black than non-black participants (2.7 versus 4.4h, respectively, P=0.002). Less intimacy with partners caused by CPAP was the only treatment side effect correlated with CPAP use (r=-0.300, P=0.025). Reduced CPAP use during the first week was associated simultaneously with being black, higher residual apnea-hypopnea index and the treatment side effect of less intimacy with partners. The three factors together accounted for 25.4% of the variance in the CPAP use (R(2) =0.254, P<0.01). These data suggest the need to assess the impact of CPAP on intimacy and troubleshooting aspects of the treatment that interfere with sexual relationships. Assessing the presence of residual respiratory events may be important in promoting CPAP adherence. The association of race and CPAP use needs to be explored further by including more socioeconomic information.

Delivering affordable cancer care in high-income countries.

The burden of cancer is growing, and the disease is becoming a major economic expenditure for all developed countries. In 2008, the worldwide cost of cancer due to premature death and disability (not including direct medical costs) was estimated to be US$895 billion. This is not simply due to an increase in absolute numbers, but also the rate of increase of expenditure on cancer. What are the drivers and solutions to the so-called cancer-cost curve in developed countries? How are we going to afford to deliver high quality and equitable care? Here, expert opinion from health-care professionals, policy makers, and cancer survivors has been gathered to address the barriers and solutions to delivering affordable cancer care. Although many of the drivers and themes are specific to a particular field-eg, the huge development costs for cancer medicines-there is strong concordance running through each contribution. Several drivers of cost, such as over-use, rapid expansion, and shortening life cycles of cancer technologies (such as medicines and imaging modalities), and the lack of suitable clinical research and integrated health economic studies, have converged with more defensive medical practice, a less informed regulatory system, a lack of evidence-based sociopolitical debate, and a declining degree of fairness for all patients with cancer. Urgent solutions range from re-engineering of the macroeconomic basis of cancer costs (eg, value-based approaches to bend the cost curve and allow cost-saving technologies), greater education of policy makers, and an informed and transparent regulatory system. A radical shift in cancer policy is also required. Political toleration of unfairness in access to affordable cancer treatment is unacceptable. The cancer profession and industry should take responsibility and not accept a substandard evidence base and an ethos of very small benefit at whatever cost; rather, we need delivery of fair prices and real value from new technologies.

Developing a Mobile Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events Administration System to Capture Postradiation Toxicity in Oncology: Usability and Feasibility Study.

BACKGROUND: Accurate self-reported symptomatic toxicity documentation via the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) is essential throughout cancer treatment to ensure safety and understand therapeutic efficacy. However, the capture of accurate toxicities from patients undergoing radiation therapy is challenging because this is generally provided only at the time of scheduled visits. OBJECTIVE: This study seeks to establish the usability and feasibility of a mobile PRO-CTCAE Administration System (mPROS) to capture toxicities related to radiation therapy. METHODS: English-speaking adult patients who were undergoing radiation therapy for cancer were enrolled and given a brief demonstration of the Say All Your Symptoms (SAYS) and Symptom Tracking Entry Program (STEP) interfaces of the mPROS app, followed by a patient-use phase where patient actions were observed as they navigated mPROS to enter toxicities. Patient feedback was captured via a semistructured interview and brief questionnaire. RESULTS: We enrolled 25 patients (age: mean 60.7 years; females: n=13, 52%; White patients: n=13; 52%; non-Hispanic patients: n=19, 76%; college graduates: n=17, 68%). Patients almost equally preferred the SAYS (n=14, 56%) or STEP (n=11, 44%) interfaces, with 21 patients (84%) agreeing that they would use mPROS to report their symptoms to their health care team and 19 patients (76%) agreeing that they would recommend mPROS to others. CONCLUSIONS: The mPROS app is usable and feasible for facilitating the patient reporting of radiation therapy-related symptomatic toxicities. A revised version of mPROS that incorporates patient input and includes electronic health record integration is being developed and validated as part of a multicenter trial.

Germline biomarkers predict toxicity to anti-PD1/PDL1 checkpoint therapy.

BACKGROUND: There is great interest in finding ways to identify patients who will develop toxicity to cancer therapies. This has become especially pressing in the era of immune therapy, where toxicity can be long-lasting and life-altering, and primarily comes in the form of immune-related adverse effects (irAEs). Treatment with the first drugs in this class, anti-programmed death 1 (anti-PD1)/programmed death-ligand 1 (PDL1) checkpoint therapies, results in grade 2 or higher irAEs in up to 25%-30% of patients, which occur most commonly within the first 6 months of treatment and can include arthralgias, rash, pruritus, pneumonitis, diarrhea and/or colitis, hepatitis, and endocrinopathies. We tested the hypothesis that germline microRNA pathway functional variants, known to predict altered systemic stress responses to cancer therapies, would predict irAEs in patients across cancer types. METHODS: MicroRNA pathway variants were evaluated for an association with grade 2 or higher toxicity using four classifiers on 62 patients with melanoma, and then the panel's performance was validated on 99 patients with other cancer types. Trained classifiers included classification trees, LASSO-regularized logistic regression, boosted trees, and random forests. Final performance measures were reported on the training set using leave-one-out cross validation and validated on held-out samples. The predicted probability of toxicity was evaluated for its association, if any, with response categories to anti-PD1/PDL1 therapy in the melanoma cohort. RESULTS: A biomarker panel was identified that predicts toxicity with 80% accuracy (F1=0.76, area under the curve (AUC)=0.82) in the melanoma training cohort and 77.6% accuracy (F1=0.621, AUC=0.778) in the pan-cancer validation cohort. In the melanoma cohort, the predictive probability of toxicity was not associated with response categories to anti-PD1/PDL1 therapy (p=0.70). In the same cohort, the most significant biomarker of toxicity in RAC1, predicting a greater than ninefold increased risk of toxicity (p<0.001), was also not associated with response to anti-PD1/PDL1 therapy (p=0.151). CONCLUSIONS: A germline microRNA-based biomarker signature predicts grade 2 and higher irAEs to anti-PD1/PDL1 therapy, regardless of tumor type, in a pan-cancer manner. These findings represent an important step toward personalizing checkpoint therapy, the use of which is growing rapidly.

Roles and types of radiation in breast cancer treatment: early breast cancer, locoregionally advanced, and metastatic disease.

PURPOSE OF REVIEW: To describe the current role of radiation therapy and specific types of radiation therapy used in the management of early stage, locoregionally advanced, and metastatic breast cancer. RECENT FINDINGS: The role of radiation therapy in the management of breast cancer has not changed in recent decades, however methods of treatment delivery have advanced considerably. Hypofractionation and accelerated partial breast irradiation, which substantially reduce radiation treatment duration, have emerged as appropriate alternatives to conventional whole breast radiation in select patient subsets, and intensity modulated radiation therapy, breathing-adapted radiation therapy, and prone-positioning technique address challenging anatomic issues and reduce treatment-associated toxicity. Stereotactic radiosurgery and stereotactic body radiation therapy continue to advance the management of distant metastatic disease. SUMMARY: Radiation therapy plays a significant role in the management of early stage, locoregionally advanced, and metastatic breast cancer. Technological advances are allowing for greater patient convenience and comfort in locoregional radiation therapy delivery and for expanded radiation therapy indications in the setting of metastatic disease.

The Declining Residency Applicant Pool: A Multi-Institutional Medical Student Survey to Identify Precipitating Factors.

PURPOSE: The purpose of our study was to better understand and identify concerns that may be responsible for the declining radiation oncology (RO) residency applicant pool. METHODS AND MATERIALS: All RO residency programs affiliated with a US medical school were asked to participate in the study survey. An optional and anonymous survey consisting of 12 questions was emailed to all graduating medical students in 2020 at the 12 allopathic medical schools that agreed to survey administration. Survey responses were collected from March to May 2020. RESULTS: The study consisted of 265 survey responses out of 1766 distributed to eligible medical students, resulting in a response rate of 15.0%. The majority of students reported no exposure to RO (60.8%) and never considered it as a career option (63.8%). Neutral perceptions of the field were more common (54.3%) than positive (39.6%) and negative (6.0%). The top factors attracting medical students to RO were perceptions of high salary, favorable lifestyle and workload, and technological focus. The top negative factors were the field's interplay with physics, competitive United States Medical Licensing Examination board scores for matched applicants, and the focus placed on research during medical school. In the subgroup of students who were interested in RO but ultimately applied to another specialty, the job market was the most salient concern. CONCLUSIONS: Finding a place for RO in medical school curricula remains a challenge, with most surveyed students reporting no exposure during their education. Concern over the job market was the primary deterrent for medical students interested in pursuing RO. For disinterested students who had not considered RO as a career option, the required physics knowledge was the main deterrent.

A Practical Guide for Navigating the Design, Build, and Clinical Integration of Electronic Patient-Reported Outcomes in the Radiation Oncology Department.

The development and integration of electronic patient-reported outcomes (ePROs) into the radiation oncology clinic workflow provide novel opportunities, accompanied by unique design considerations and implementation challenges. The processes required for implementation of ePROs are entirely distinct from standard paper-based surveys, with the majority of time devoted to conception and design before initiating questionnaire build, detailed workflow process mapping including development of new workflows, comprehensive communication of the vision between providers and the information technology team, and quality assurance. Based on our experience with implementation of ePROs in our radiation oncology department, we developed a stepwise framework for approaching ePRO conceptual design, build, workflow integration, and the electronic health record interface. Here, we provide a guide for the numerous considerations, decision points, and solutions associated with the implementation of ePROs in the radiation oncology department setting. Although various ePRO tools and electronic health record capabilities impose different requirements, opportunities, and limitations, the conceptual processes and many of the electronic build considerations are broadly applicable.

Development and Pilot Implementation of a Remote Monitoring System for Acute Toxicity Using Electronic Patient-Reported Outcomes for Patients Undergoing Radiation Therapy for Breast Cancer.

PURPOSE: We aimed to develop and study the implementation of a remote system for toxicity assessment and management of acute side effects of breast radiation using electronic patient-reported outcomes (ePROs). METHODS AND MATERIALS: A response-adapted Patient-Reported Outcomes Common Terminology Criteria for Adverse Events-based assessment for breast radiation toxicity was administered weekly during and for 8 weeks after radiation from June 2019 to July 2020. The care team received alerts when "severe" symptoms were reported by patients, who were then contacted. Treatment, clinic, and sociodemographic characteristics were abstracted from patient records. A subsample of patients and care team members was qualitatively interviewed at follow-up. RESULTS: Overall, 5787 assessments were sent to 678 patients, of whom 489 (72%) completed 2607 assessments (45%). Moderate or greater toxicity was reported by 419 responders (86%; 95% CI, 82%-89%). Clinician alerts for severe toxicity were generated for 264 assessments among 139 unique patients, of which 83% occurred posttreatment. The proportion of surveys that prompted an alert was significantly higher after treatment (219 [13%]) than during treatment (45 [5%]) (P < .001). Survey completion rates in the posttreatment period were higher among patients undergoing partial breast irradiation than postmastectomy radiation (incidence rate ratio, 0.70; 95% CI, 0.60-0.81) (P < .001) despite these patients experiencing less severe toxicity. Interviews (15) found that patients had a positive experience with ePROs, although many thought the primary purpose was for research rather than symptom management. CONCLUSIONS: With the majority of toxicity occurring after breast radiation has ended, remote symptom monitoring with ePROs appears to fill a gap in clinical practice, particularly for patients undergoing shorter courses of radiation. It is important to properly onboard patients and explain that the purpose of ePROs is to aid clinical care. Further research is needed to determine whether the costs associated with ePROs can be offset by reducing routine clinic visits and whether this approach is acceptable and appropriate.

Adjuvant vaginal brachytherapy alone for high risk localized endometrial cancer as defined by the three major randomized trials of adjuvant pelvic radiation.

OBJECTIVE: Controversy exists regarding optimal management of high risk localized endometrial cancer. Given that vaginal brachytherapy (VB) alone is used routinely at our institution, we retrospectively reviewed our outcomes among high risk patients defined according to the PORTEC, GOG 99, and/or Aalders randomized trials of pelvic radiation versus observation to determine if acceptable rates of locoregional control could be achieved with vaginal brachytherapy alone in this highest risk patient population. METHODS: The Roswell Park Cancer Institute hospital tumor registry was used to identify all patients with Stage I or IIA endometrial cancer treated between January 1992 and June 2006. A total of 464 patients were identified. Of 261 patients who received post-operative RT, 225 received VB alone. Of those 225, 87 met the high risk criteria as designated by PORTEC (at least 2 of the following high risk features: age>60, Grade 3, and/or myometrial invasion >or=Occurrences of the mathematical operator' (='were changed to 'OE'. Please check.-->50%), GOG 99 (any age with 3 high risk features: Grade 2-3, >66% myometrial invasion, and/or LVSI; age >or=50 with 2 high risk features; or age >or=70 with 1 high risk feature), and/or Aalders (Stage IC, Grade 3). Descriptive recurrence statistics are provided. RESULTS: Among 87 high risk patients treated with VB alone, 36, 77, and 14 were high risk per PORTEC, GOG 99, and Aalders respectively. Forty (46%) underwent pelvic lymph node dissection. With a median follow-up of 52 months, 3 (3.4%) pelvic recurrences were observed including 1 vaginal recurrence, 1 pelvic recurrence, and 1 local recurrence involving both the vagina and pelvis. All 3 local recurrences were successfully salvaged with pelvic RT+/-surgery. CONCLUSIONS: This represents one of the largest known series of high risk localized endometrial cancer treated with VB alone. The observed 3.4% locoregional recurrence compares favorably with the 5% locoregional recurrence noted among the highest risk patients receiving pelvic RT in the PORTEC, GOG 99, and Aalders randomized trials. In this single institution experience, the 3 local recurrences were salvaged. Based on these findings, we will continue to use VB alone in the adjuvant setting for patients with high risk localized endometrial cancer.

Treatment of early-stage uterine papillary serous carcinoma at Roswell Park Cancer Institute, 1992-2006.

OBJECTIVE: Optimal management of early-stage uterine papillary serous carcinoma (UPSC) remains controversial. We reviewed our outcomes in this patient population. METHODS: The Roswell Park Cancer Institute (RPCI) tumor registry identified all patients with Stages I and IIA UPSC treated between January 1992 and June 2006. The Fisher's exact test was used to compare recurrence rates by adjuvant therapy received. Overall survival (OS) estimates were made using the Kaplan-Meier method. RESULTS: Fifty-eight patients with Stage I or IIA UPSC underwent surgery. Thirty-four patients (59%) were surgically staged. Among 21 patients with Stage IA disease, 15 received adjuvant therapy. With a median follow-up of 44.7 months, only one recurrence was observed in a patient who received adjuvant brachytherapy. The 5-year OS was 66%. Among 37 patients with Stages IB-IIA, 30 patients received adjuvant therapy. With a median follow-up of 29 months, there were 7 recurrences. The 5-year OS was 60%. Although there were no significant differences in recurrence by adjuvant therapy received, a significant OS benefit was found in those who received radiation. There was no significant difference in OS distributions of those patients who received Carboplatin/Paclitaxel chemotherapy. CONCLUSIONS: Despite the limitations of our retrospective study, we have shown that even comprehensively staged early-stage UPSC patients are still at risk for recurrence despite adjuvant therapy received. Hence, all patients with this histologic diagnosis should be considered at high risk for recurrence and counseled appropriately regarding the risks and benefits of adjuvant therapy.

Nationwide Survey of Patients' Perspectives Regarding Their Radiation and Multidisciplinary Cancer Treatment Experiences.

PURPOSE: The perspectives of patients with cancer about their treatment can inform interventions to improve the approaches of treating oncologists and experiences of future patients. We sought to identify areas where current toxicity management, informed consent processes, and physician-patient communication merit improvement. METHODS: In a Web-based survey administered from March to May 2018 using quota-based sampling to draw a nationwide sample of US patients with cancer treated with radiotherapy within the past 5 years, we evaluated patient perceptions of adequacy of information about adverse effects, severity of actual adverse effects experienced, and experiences divergent from expectations. RESULTS: Among 403 respondents, 18% felt inadequately informed about what adverse effects to expect from radiotherapy, and 37% experienced radiation adverse effects that they wished they had known more about. Similar proportions of patients treated with chemotherapy (36%) and surgery (34%) experienced toxicities related to those treatments that they wished they had known more about. Patients who noted their adverse effects to be minimal versus severe were significantly more likely to feel informed about radiotherapy adverse effects (odds ratio, 13.05; 95% CI, 5.6 to 30.38; P < .001). Across all evaluated measures, a majority of patients indicated that they did not experience the potentially anticipated radiotherapy adverse effect or that it was the same as or better than expected. CONCLUSION: This study suggests that experiences with radiation adverse effects generally are congruent with expectations. Nevertheless, improvement of pretreatment counseling across all cancer therapy modalities seems warranted to improve informed decision making and treatment experiences.

Impact of Open Access to Physician Notes on Radiation Oncology Patients: Results from an Exploratory Survey.

PURPOSE: There is an increasing effort to allow patients open access to their physician notes through electronic medical record portals. However, limited data exist on the impact of such access on oncology patients, and concerns remain regarding potential harms. Therefore, we determined the baseline perceptions and impact of open access to oncology notes on radiation oncology patients. METHODS AND MATERIALS: Patients receiving radiation therapy were provided instructional materials on accessing oncology notes at the time of their initial evaluation. Patients were prospectively surveyed to evaluate baseline interest and expectations before access and to determine the actual usage and impact at the end of their radiation treatment course. RESULTS: A total of 220 patients were surveyed; 136 (62%) completed the baseline survey, of which 88 (40%) completed the final survey. The majority of participants were age >60 years (n = 83; 61%), and 70 were male (51%). Before accessing the notes, the majority of patients agreed that open access to oncology notes would improve understanding of diagnosis (99%), understanding of treatment side effects (98%), reassurance about treatment goals (96%), and communication with family (99%). All patients who accessed the notes found them to be useful. After accessing the notes, approximately 96%, 94%, and 96% of patients reported an improved understanding of their diagnosis, an improved understanding of treatment side effects, and feeling more reassured about their treatment, respectively. Approximately 11%, 6%, and 4% of patients noted increased worry, increased confusion, and finding information they now regret reading, respectively. Patient age, sex, and specific cancer diagnoses were not predictive of experiencing negative effects from accessing the notes. CONCLUSIONS: Radiation oncology patients have a strong interest in open access to their physician notes, and the majority of patients expect and actually report meaningful benefits. These data support strategies to allow more patients with cancer access to their physicians' notes.