Your browser doesn't support javascript.
loading
Show: 20 | 50 | 100
Results 1 - 20 de 40
Filter
1.
Gynecol Oncol ; 180: 55-62, 2024 Jan.
Article in English | MEDLINE | ID: mdl-38052109

ABSTRACT

PURPOSE: Curative-intent radiotherapy for locally advanced and select early stage cervical cancer in the US includes external beam radiotherapy (EBRT) with brachytherapy. Although there are guidelines for brachytherapy dose and fractionation regimens, there are limited data on practice patterns. This study aims to evaluate the contemporary utilization of cervical cancer brachytherapy in the US and its association with patient demographics and facility characteristics. METHODS: We retrospectively analyzed clinical covariates of cervical cancer patients diagnosed and treated in 2018-2020 with curative-intent radiotherapy from the 2020 National Cancer Database. Associations between patient and institutional factors with the number of brachytherapy fractions were identified with logistic regression. Factors with association (p < 0.10) were then included in a multivariable logistic regression model. All tests were two-sided with significance <0.05 unless specified otherwise. RESULTS: Among the eligible 2517 patients, 97.3% received HDR or LDR and is further analyzed. More patients received HDR than LDR brachytherapy (98.9% vs 1.1%) and intracavitary than interstitial brachytherapy (86.4% vs 13.6%). The most common number of HDR fractions prescribed were 5 (51.0%), 4 (32.9%), and 3 (8.6%). After adjusting for the other variables in the model, ethnicity, private insurance status, overall insurance status, and facility type were the only factors that were significantly associated with the number of brachytherapy factions (p < 0.0001, p = 0.028, p = 0.001, and p < 0.0001, respectively, n = 2184). CONCLUSIONS: In the US, various HDR brachytherapy regimens are utilized depending on patient and institutional factors. Future research may optimize cervical cancer brachytherapy by correlating specific dose and fractionation regimens with patient outcomes.


Subject(s)
Brachytherapy , Uterine Cervical Neoplasms , Female , Humans , Brachytherapy/adverse effects , Radiotherapy Dosage , Uterine Cervical Neoplasms/drug therapy , Retrospective Studies , Dose Fractionation, Radiation
2.
Holist Nurs Pract ; 37(6): 330-336, 2023.
Article in English | MEDLINE | ID: mdl-37851349

ABSTRACT

This study evaluated the effectiveness of traditional Chinese medicine-based therapeutic acupuncture (TA) in reducing the severity of hot flashes (HFs) in breast cancer patients and compared the effectiveness of TA to "sham" placebo acupuncture (SA). Subjects experiencing more than 10 episodes of HF/week were randomly assigned to TA or SA. The response was assessed by the Menopause-specific Quality of Life (MenQoL) scale, scoring the subject's perception of the severity of HFs. HFs were scored at baseline, after treatment, and 1-month follow-up. A total of 54 subjects enrolled (28 TA and 26 SA). Seven women withdrew from the study. A hot flash diary documented the number of HFs a subject experienced. Analysis included 47 subjects (27 TA and 20 SA). A statistically significant response in HF scores was noted in the TA group compared with the SA group (P = .0064.) On average HF scores dropped by 1.89 with TA, and only 0.16 with SA. At follow-up, TA subjects had a sustained response. TA is effective in reducing the intensity and severity of HF. With SA, no relative response/change in HF scores was noted. Larger studies and longer follow-up to assess durability of response to TA are needed.


Subject(s)
Acupuncture Therapy , Breast Neoplasms , Humans , Female , Hot Flashes/drug therapy , Breast Neoplasms/complications , Breast Neoplasms/therapy , Quality of Life , Single-Blind Method , Treatment Outcome , Menopause
3.
Breast Cancer Res Treat ; 182(2): 355-365, 2020 Jul.
Article in English | MEDLINE | ID: mdl-32468336

ABSTRACT

PURPOSE: We performed a cost-effectiveness analysis of three strategies for the adjuvant treatment of early breast cancer in women age 70 years or older: an aromatase inhibitor (AI-alone) for 5 years, a 5-fraction course of accelerated partial-breast irradiation using intensity-modulated radiation therapy (APBI-alone), or their combination. METHODS: We constructed a patient-level Markov microsimulation from the societal perspective. Effectiveness data (local recurrence, distant metastases, survival), and toxicity data were obtained from randomized trials when possible. Costs of side effects were included. Costs were adjusted to 2019 US dollars and extracted from Medicare reimbursement data. Quality-adjusted life-years (QALY) were calculated using utilities extracted from the literature. RESULTS: The strategy of AI-alone ($12,637) was cheaper than both APBI-alone ($13,799) and combination therapy ($18,012) in the base case. All approaches resulted in similar QALY outcomes (AI-alone 7.775; APBI-alone 7.768; combination 7.807). In the base case, AI-alone was the cost-effective strategy and dominated APBI-alone, while combined therapy was not cost-effective when compared to AI-alone ($171,451/QALY) or APBI-alone ($107,932/QALY). In probabilistic sensitivity analyses, AI-alone was cost-effective at $100,000/QALY in 50% of trials, APBI-alone in 28% and the combination in 22%. Scenario analysis demonstrated that APBI-alone was more effective than AI-alone when AI compliance was lower than 26% at 5 years. CONCLUSIONS: Based on a Markov microsimulation analysis, both AI-alone and APBI-alone are appropriate options for patients 70 years or older with early breast cancer with small cost differences noted. A prospective trial comparing the approaches is warranted.


Subject(s)
Aromatase Inhibitors/economics , Breast Neoplasms/therapy , Cost-Benefit Analysis/methods , Neoplasm Recurrence, Local/epidemiology , Radiotherapy, Intensity-Modulated/economics , Age Factors , Aged , Aged, 80 and over , Aromatase Inhibitors/administration & dosage , Aromatase Inhibitors/adverse effects , Breast Neoplasms/economics , Breast Neoplasms/mortality , Chemoradiotherapy, Adjuvant/adverse effects , Chemoradiotherapy, Adjuvant/economics , Chemoradiotherapy, Adjuvant/methods , Dose Fractionation, Radiation , Female , Humans , Markov Chains , Medicare/economics , Medicare/statistics & numerical data , Models, Economic , Neoplasm Recurrence, Local/prevention & control , Patient Compliance/statistics & numerical data , Prospective Studies , Quality-Adjusted Life Years , Radiotherapy, Intensity-Modulated/adverse effects , Randomized Controlled Trials as Topic , United States/epidemiology
4.
Breast Cancer Res Treat ; 177(3): 611-618, 2019 Oct.
Article in English | MEDLINE | ID: mdl-31302854

ABSTRACT

PURPOSE: Adjuvant therapy decisions may in part be based on results of Oncotype DX Breast Recurrence Score® (RS) testing of primary tumors. When necessary, lymph node metastases may be considered as a surrogate. Here we evaluate the concordance in gene expression between primary breast cancers and synchronous lymph node metastases, based on results from quantitative RT-PCR-based RS testing between matched primary tumors and synchronous nodal metastases. METHODS: This retrospective, exploratory study included patients (≥ 18 years old) treated at our center (2005-2009) who had ER+ , HER2-negative invasive breast cancer and synchronous nodal metastases with available tumor blocks from both sites. Paired tissue blocks underwent RS testing, and RS and single-gene results for ER, PR, and HER2 were explored between paired samples. RESULTS: A wide distribution of RS results in tumors and in synchronous nodal metastases were modestly correlated between 84 paired samples analyzed (Pearson correlation 0.69 [95% CI 0.55-0.78]). Overall concordance in RS group classification between samples was 63%. ER, PR, and HER2 by RT-PCR between the primary tumor and lymph node were also modestly correlated (Pearson correlation [95% CI] 0.64 [0.50-0.75], 0.64 [0.49-0.75], and 0.51 [0.33-0.65], respectively). Categorical concordance (positive or negative) was 100% for ER, 77% for PR, and 100% for HER2. CONCLUSIONS: There is modest correlation in continuous gene expression, as measured by the RS and single-gene results for ER, PR, and HER2 between paired primary tumors and synchronous nodal metastases. RS testing for ER+ breast cancer should continue to be based on analysis of primary tumors.


Subject(s)
Biomarkers, Tumor , Breast Neoplasms/diagnosis , Breast Neoplasms/genetics , Genomics , Lymph Nodes/pathology , Adult , Aged , Aged, 80 and over , Biopsy , Female , Genomics/methods , Humans , Lymphatic Metastasis , Middle Aged , Neoplasm Recurrence, Local , Neoplasm Staging , Retrospective Studies , Young Adult
5.
Int J Gynecol Cancer ; 28(5): 882-889, 2018 06.
Article in English | MEDLINE | ID: mdl-29538253

ABSTRACT

OBJECTIVES: Randomized trials have shown a local control benefit with adjuvant radiotherapy (RT) in high-intermediate-risk endometrial cancer patients, although not all such patients receive RT. We reviewed the National Cancer Data Base to investigate which patient/tumor-related factors are associated with delivery of adjuvant RT. METHODS: The National Cancer Data Base was queried for patients diagnosed with International Federation of Gynecology and Obstetrics 2009 stage I endometrioid adenocarcinoma from 1998 to 2012 who underwent surgery +/- adjuvant RT. Exclusion criteria were unknown stage/grade, nonsurgical primary therapy, less than 30 days' follow-up, RT of more than 6 months after surgery, or palliative treatment. High-intermediate risk was defined based on Post Operative Radiation Therapy in Endometrial Carcinoma 2 criteria: older than 60 years with stage IA grade 3 or stage IB grade 1-2. RESULTS: Seventeen thousand five hundred twenty-four met inclusion criteria, and the 13,651 patients with complete data were subjected to a multiple logistic regression analysis; 7814 (57.2%) received surgery alone, and 5837 (42.8%) received surgery + RT. Receipt of adjuvant RT was more likely among black women and women with higher income, Northeastern residence, diagnosis after 2010, greater than 50% myometrial invasion, and receipt of adjuvant chemotherapy (P < 0.05). Patients older than 80 years or those undergoing lymph node dissection were less likely to receive adjuvant RT (P < 0.05). Of those treated with RT, 44.0% received external beam therapy, 54.8% received vaginal cuff brachytherapy, and 0.6% received both. Among irradiated women, patients older than 80 years and those with Northeastern residence, treatment at academic facilities, diagnosis after 2004, and lymph node dissection were more likely to undergo brachytherapy over external beam radiation therapy (P < 0.05). Overall use of adjuvant RT was 28.8% between 1998 and 2004, 42.0% between 2005 and 2010, and 43.4% between 2011 and 2012; the difference between 1998-2004 and 2005-2010 was not statistically significant. CONCLUSIONS: Fewer than half of patients with high-intermediate-risk endometrial cancer by Post Operative Radiation Therapy in Endometrial Carcinoma 2 criteria received adjuvant RT despite evidence demonstrating improved local control. Both patient- and tumor-related factors are associated with delivery of adjuvant RT and the modality selected.


Subject(s)
Carcinoma, Endometrioid/radiotherapy , Endometrial Neoplasms/radiotherapy , Radiotherapy, Adjuvant/statistics & numerical data , Aged , Aged, 80 and over , Carcinoma, Endometrioid/surgery , Endometrial Neoplasms/surgery , Female , Humans , Middle Aged , Radiotherapy, Adjuvant/methods , Retrospective Studies
6.
Int J Gynecol Cancer ; 27(1): 85-92, 2017 01.
Article in English | MEDLINE | ID: mdl-27759595

ABSTRACT

OBJECTIVES: High-risk histology including UPSC, CC, and high-grade (G3) endometrioid adenocarcinoma (EAC) have a worse prognosis compared to G1-2 EAC. It is unknown whether G3EAC outcomes are more similar to UPSC/CC or to G1-2 EAC. The purpose of this study was to compare overall survival (OS) among UPSC, CC, and G1-3 EAC, for International Federation of Gynecology and Obstetrics stages I to III. METHODS: The National Cancer Data Base was queried for patients diagnosed with International Federation of Gynecology and Obstetrics (1988 classification) Stage I-III UPSC, CC, and EAC from 1998 to 2012 who underwent surgery as definitive treatment. Patients with unknown grade/stage, nonsurgical primary therapy, other histologies, and less than 30-day follow-up were excluded. Overall survival was calculated using the Kaplan-Meier product-limit method and compared using log-rank tests. RESULTS: 219,934 patients met our inclusion criteria. For patients with stage I disease (n = 174,361), 5-year OS was for 92.4% for G1EAC, 87.8% for G2EAC, 77.5% for G3EAC, 74.9% for CC, and 74.6% for UPSC. For stage II patients (n = 17,361), 5-year OS was 86.7% for G1EAC, 80.2% for G2EAC, 62.7% for G3EAC, 64.3% for CC, and 56.7% for UPSC. For stage III patients (n = 28,212), 5-year OS was 79.7% for G1EAC, 68.9% for G2EAC, 49.6% for G3EAC, 40.2% for CC, and 35.7% for UPSC (P <0.0001). On multivariate analysis, black race, age 60 years and older, higher stage, higher grade, high-risk histologies, receiving chemotherapy, and higher comorbidity scores were all significantly (P < 0.0001) predictive of death while receiving radiation therapy was protective (hazards ratio, 0.7; 95% confidence interval, 2.6-2.9). CONCLUSIONS: The results suggest that G3 EAC has a slightly more favorable survival than UPSC and CC but predictably does poorer than G1-2 EAC. Further research is warranted to determine if G3 EAC should be reclassified as a type II cancer.


Subject(s)
Adenocarcinoma, Clear Cell/mortality , Carcinoma, Endometrioid/mortality , Cystadenocarcinoma, Papillary/mortality , Cystadenocarcinoma, Serous/mortality , Endometrial Neoplasms/mortality , Adenocarcinoma, Clear Cell/pathology , Aged , Carcinoma, Endometrioid/pathology , Cystadenocarcinoma, Papillary/pathology , Cystadenocarcinoma, Serous/pathology , Databases, Factual , Endometrial Neoplasms/pathology , Female , Humans , Middle Aged , Neoplasm Staging , Registries , SEER Program , United States/epidemiology
7.
Oncology (Williston Park) ; 29(6): 446-58, 460-1, 2015 Jun.
Article in English | MEDLINE | ID: mdl-26089220

ABSTRACT

Ductal carcinoma in situ (DCIS) is a breast neoplasm with potential for progression to invasive cancer. Management commonly involves excision, radiotherapy, and hormonal therapy. Surgical assessment of regional lymph nodes is rarely indicated except in cases of microinvasion or mastectomy. Radiotherapy is employed for local control in breast conservation, although it may be omitted for select low-risk situations. Several radiotherapy techniques exist beyond standard whole-breast irradiation (ie, partial-breast irradiation [PBI], hypofractionated whole-breast radiation); evidence for these is evolving. We present an update of the American College of Radiology (ACR) Appropriateness Criteria® for the management of DCIS. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions, which are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review includes an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi technique) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.


Subject(s)
Breast Neoplasms/therapy , Carcinoma, Intraductal, Noninfiltrating/therapy , Antineoplastic Agents, Hormonal/therapeutic use , Breast Neoplasms/pathology , Carcinoma, Intraductal, Noninfiltrating/pathology , Carcinoma, Lobular/pathology , Carcinoma, Lobular/therapy , Female , Humans , Magnetic Resonance Imaging , Mammography , Mastectomy , Mastectomy, Segmental , Neoplasm Invasiveness , Radiotherapy Dosage , Radiotherapy, Adjuvant , Sentinel Lymph Node Biopsy , Tamoxifen/therapeutic use
8.
Article in English | MEDLINE | ID: mdl-38432284

ABSTRACT

PURPOSE: The optimal adjuvant therapy (antiestrogen therapy [ET] + radiation therapy or ET alone, or in some reports radiation therapy alone) in older women with early-stage breast cancer has been highly debated. However, granular details on the role of insurance in the out-of-pocket cost for patients receiving ET with or without radiation therapy are lacking. This project disaggregates out-of-pocket costs by insurance plans to increase treatment cost transparency. METHODS AND MATERIALS: Several radiation therapy schedules are accepted standards as per the National Comprehensive Cancer Network guidelines. For our financial estimate model, we used the 5-fraction and 15-fraction radiation therapy and ET prescribed over a 5-year duration. The total aggregate out-of-pocket costs were determined from the sum of treatment costs, deductibles, and copays/coinsurance based on Medicaid, Original Medicare, Medigap Plan G, and Medicare Part D Rx plans. The model assumes a Medicare- and/or Medicaid-eligible patient ≥70 years of age with node-negative, early-stage estrogen-receptor-positive breast cancer. Patient out-of-pocket costs were estimated from publicly available insurance data from plan-specific benefit coverage materials using a 5-year time horizon. RESULTS: Original Medicare beneficiaries face a total out-of-pocket treatment charge of $2738.52 for ET alone, $2221.26 for 5-fraction radiation therapy alone, $2573.92 for 15-fraction radiation therapy alone, $3361.26 for combined ET+ 5-fraction radiation therapy, and $3713.92 for combined ET + 15-fraction radiation therapy. Medigap Plan G beneficiaries have an out-of-pocket charge of $1130.00 with radiation therapy alone and face an out-of-pocket of $2270.00 for ET alone and combined ET+ radiation therapy. For Medicaid beneficiaries, all treatments approved by Medicaid are covered without limit, resulting in no out-of-pocket expense for either adjuvant treatment option. CONCLUSIONS: This model (based on actual cost estimates per insurance plan rather than claims data), by estimating expenses within Medicare and Medicaid plans, provides a level of transparency to patient cost. With knowledge of the costs borne by patients themselves, treatment decisions informed by patients' individual priorities and preferences may be further enhanced.

9.
Int J Radiat Oncol Biol Phys ; 118(2): 458-465, 2024 Feb 01.
Article in English | MEDLINE | ID: mdl-37478956

ABSTRACT

PURPOSE: To conduct an appropriate use criteria expert panel update on clinical topics relevant to current clinical practice regarding postmastectomy radiation therapy (PMRT). METHODS AND MATERIALS: An analysis of the medical literature from peer-reviewed journals was conducted from May 4, 2010 to May 4, 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to search the PubMed database to retrieve a comprehensive set of relevant articles. A well-established methodology (modified Delphi) was used by the expert panel to rate the appropriate use of procedures. RESULTS: Evidence for key questions in PMRT regarding benefit in special populations and technical considerations for delivery was examined and described. Risk factors for local-regional recurrence in patients with intermediate-risk disease that indicate benefit of PMRT include molecular subtype, age, clinical stage, and pathologic response to neoadjuvant chemotherapy. Use of hypofractionated radiation in PMRT has been examined in several recent randomized trials and is under investigation for patients with breast reconstruction. The use of bolus varies significantly by practice region and has limited evidence for routine use. Adverse effects occurred with both PMRT preimplant and postimplant exchange in 2-staged breast reconstruction. CONCLUSIONS: Most patients with even limited nodal involvement will likely benefit from PMRT with significant reduction in local-regional recurrence and potential survival. Patients with initial clinical stage III disease and/or any residual disease after neoadjuvant chemotherapy should be strongly considered for PMRT. Growing evidence supports the use of hypofractionated radiation for PMRT with equivalent efficacy and decreased acute side effects, but additional evidence is needed for special populations. There is limited evidence to support routine use of bolus in all patients. Timing of PMRT regarding completion of 2-staged breast reconstruction requires a discussion of increased risks with radiation postimplant exchange compared with increased risk of failure of reconstruction or surgical complications with radiation preimplant exchange.


Subject(s)
Breast Neoplasms , Mammaplasty , Radium , Humans , United States , Female , Mastectomy/methods , Breast Neoplasms/radiotherapy , Breast Neoplasms/surgery , Mammaplasty/methods , Risk Factors , Radiotherapy, Adjuvant/adverse effects , Radiotherapy, Adjuvant/methods
10.
Cancers (Basel) ; 16(7)2024 Mar 29.
Article in English | MEDLINE | ID: mdl-38611024

ABSTRACT

Endometrial cancer is the most common gynecologic cancer in the United States and it contributes to the second most gynecologic cancer-related deaths. With upfront surgery, the specific characteristics of both the patient and tumor allow for risk-tailored treatment algorithms including adjuvant radiotherapy and systemic therapy. In this narrative review, we discuss the current radiation treatment paradigm for endometrial cancer with an emphasis on various radiotherapy modalities, techniques, and dosing regimens. We then elaborate on how to tailor radiotherapy treatment courses in combination with other cancer-directed treatments, including chemotherapy and immunotherapy. In conclusion, this review summarizes ongoing research that aims to further individualize radiotherapy regimens for individuals in an attempt to improve patient outcomes.

11.
Ann Plast Surg ; 71(3): 250-4, 2013 Sep.
Article in English | MEDLINE | ID: mdl-23945528

ABSTRACT

INTRODUCTION: Patients with node positive or locally advanced breast cancer desiring deep inferior epigastric perforator (DIEP) flap reconstruction frequently require postmastectomy radiation therapy (PMRT). To avoid the deleterious effects of PMRT, surgeons will often delay reconstruction until after PMRT is complete. Drawbacks to this approach include additional surgery, recuperation, cost, and an extended reconstructive process. Even if a tissue expander is used to preserve the skin envelope during irradiation, the post-PMRT breast pocket is often distorted or constricted necessitating some skin replacement, resulting in a compromised aesthetic outcome. Therefore, a systematic approach to mitigate the deleterious effects of PMRT was developed, and primary DIEP flap reconstruction was offered to patients requiring PMRT. This study evaluates the outcome of this approach in a cohort of patients undergoing immediate bilateral DIEP flap reconstruction with unilateral PMRT, allowing comparison between irradiated and nonirradiated flaps. METHODS: One hundred twenty-five patients who underwent immediate DIEP reconstruction between 2009 and 2011 were identified. Eleven consecutive patients had bilateral DIEP reconstructions by a single surgeon and received unilateral PMRT. Preoperative, intraoperative, and postoperative steps were taken in all patients to ensure flap vascularity, prevent uncontrolled contracture, and limit radiation damage to the breast mound. Results were documented photographically and the irradiated and nonirradiated breasts were compared. The complication rates, incidence of clinically significant fat necrosis, and need for reoperation were examined. RESULTS: Median follow-up was 18 months (range, 8-21 months). Complications were minor and did not require readmission to the hospital or reoperation. There was no incidence of clinically significant fat necrosis in either the irradiated or nonirradiated DIEP flaps. Four operative revisions for breast symmetry were required in 3 of 11 patients. Aesthetic outcomes were deemed satisfactory in all patients. CONCLUSIONS: Primary reconstruction with DIEP flaps can be performed successfully in patients who require PMRT if steps are taken to ensure flap vascularity, minimize fibrosis, optimize contour, and modulate radiation dosing.


Subject(s)
Breast Neoplasms/radiotherapy , Mammaplasty/methods , Mastectomy , Perforator Flap , Radiotherapy, Conformal , Adult , Breast Neoplasms/surgery , Female , Follow-Up Studies , Humans , Middle Aged , Patient Satisfaction , Postoperative Complications/etiology , Radiotherapy, Adjuvant , Radiotherapy, Conformal/adverse effects , Reoperation , Treatment Outcome
12.
Int J Radiat Oncol Biol Phys ; 116(3): 617-626, 2023 07 01.
Article in English | MEDLINE | ID: mdl-36586492

ABSTRACT

PURPOSE: The optimal management of early-stage, low-risk, hormone-positive breast cancer in older women remains controversial. Recent trials have shown that 5-fraction ultrahypofractionated whole-breast irradiation (U-WBI) has similar outcomes to longer courses, reducing the cost and inconvenience of treatment. We performed a cost-utility analysis to compare U-WBI to hormone therapy alone or their combination. METHODS AND MATERIALS: We simulated 3 different treatment approaches for women age 65 years or older with pT1-2N0 ER-positive invasive ductal carcinoma treated with lumpectomy with negative margins using a Markov microsimulation model. The strategies were U-WBI performed with a 3-dimensional conformal technique over 5 fractions without a boost ("radiation therapy [RT] alone"), adjuvant hormone therapy (anastrozole for 5 years) without RT ("aromatase-inhibitor [AI] alone"), or the combination of the 2. The combination strategy was calibrated to match trial results, and the relative effectiveness of the RT alone and AI alone strategies were inferred from previous randomized trials. The primary endpoint was the cost-effectiveness of the 3 strategies over a lifetime horizon as measured by the incremental cost-effectiveness ratio (ICER), with a value of $100,000/quality-adjusted life-year deemed "cost-effective." RESULTS: The model results compared with the prespecified target outcomes. On average, RT alone was the least expensive strategy ($14,775), with AI alone slightly more ($14,998), and combination therapy the costliest ($19,802). RT alone dominated AI alone (the incremental cost-effectiveness ratio [ICER] -$5089). Combination therapy, compared with RT alone, was slightly more expensive than our definition of cost-effective (ICER $113,468) but was cost-effective compared with AI alone (ICER $54,451). Probabilistic sensitivity analysis demonstrated RT alone to be cost-effective in 50% of trials, with combination therapy in 36% and AI alone in 14%. CONCLUSIONS: U-WBI alone appears the more cost-effective de-escalation strategy for these low-risk patients, compared with AI alone. Combining U-WBI and AI appears more costly but may be preferred by some patients.


Subject(s)
Breast Neoplasms , Female , Humans , Aged , Breast Neoplasms/radiotherapy , Breast Neoplasms/pathology , Cost-Effectiveness Analysis , Anastrozole , Breast/pathology , Aromatase Inhibitors , Cost-Benefit Analysis , Hormones
13.
Int J Radiat Oncol Biol Phys ; 112(1): 40-51, 2022 01 01.
Article in English | MEDLINE | ID: mdl-33974886

ABSTRACT

PURPOSE: The omission of radiation therapy (RT) in older women with stage 1 estrogen-receptor-positive (ER+) breast cancer receiving endocrine therapy (ET) is an acceptable strategy based on randomized trial data. Less is known about the omission of ET with or without RT. METHODS AND MATERIALS: We analyzed surveillance, epidemiology, and end results (SEER)-Medicare data for 13,321 women age 66 years or older with stage I ER+ breast cancer from 2007 to 2012 who underwent breast-conserving surgery. Patients were classified into 4 groups: (1) ET + RT (reference); (2) ET alone; (3) RT alone; and (4) neither RT nor ET (NT). Second breast cancer events (SBCEs) were captured using the Chubak high-specificity algorithm. We used χ2 tests for descriptive statistics, multivariable multinomial logistic regression to estimate relative risk of undergoing a treatment, and multivariable, propensity-weighted competing-risks survival regression to estimate standardized hazard ratio (SHR) of SBCE. We set significance at P ≤ .01. RESULTS: Most women underwent both treatments, with 44% undergoing ET + RT, 41% RT alone, 6.6% ET alone, and 8.6% NT, but practice patterns varied over time. From 2007 to 2012, RT decreased from 49% to 30%, whereas ET alone and ET + RT increased (ET alone, 5.4%-9.6%; ET + RT, 38%-51%). Compared with patients age 66 to 69 years, patients age 80 to 85 years were more likely to receive NT (odds ratio [OR], 8.9), RT (OR, 1.9), or ET (OR, 8.8) versus ET + RT (P < .01). Three percent of subjects had an SBCE (2.2% ET + RT, 3.0% RT alone, 3.2% ET alone, 7.0% NT). Relative to ET + RT, NT and ET alone were associated with higher SBCE (NT: SHR, 3.7, P < .001; ET alone: SHR, 2.2, P = .008), whereas RT was not associated with a higher SBCE (SHR 1.21; P = .137). Clinical factors associated with higher SBCE were HER2 positivity and pT1c (SHR, 1.7; P = .006). CONCLUSIONS: Treatment with RT alone in older women with stage I ER+ disease is decreasing. RT alone is not associated with an increased risk for SBCE. By contrast, NT and ET are both associated with higher SBCE in multivariable analysis with propensity weighting. Further study of the omission of endocrine therapy in this patient population is warranted.


Subject(s)
Breast Neoplasms , Aged , Aged, 80 and over , Breast Neoplasms/pathology , Estrogens/therapeutic use , Female , Humans , Mastectomy, Segmental , Medicare , Neoplasm Staging , Radiotherapy, Adjuvant/methods , Treatment Outcome , United States/epidemiology
14.
Curr Oncol ; 30(1): 184-195, 2022 12 23.
Article in English | MEDLINE | ID: mdl-36661664

ABSTRACT

Radiotherapy omission is increasingly considered for selected patients with early-stage breast cancer. However, with emerging data on the safety and efficacy of radiotherapy de-escalation with partial breast irradiation and accelerated treatment regimens for low-risk breast cancer, it is necessary to move beyond an all-or-nothing approach. Here, we review existing data for radiotherapy omission, including the use of age, tumor subtype, and multigene profiling assays for selecting low-risk patients for whom omission is a reasonable strategy. We review data for de-escalated radiotherapy, including partial breast irradiation and acceleration of treatment time, emphasizing these regimens' decreasing biological and financial toxicities. Lastly, we review evidence of omission of endocrine therapy. We emphasize ongoing research to define patient selection, treatment delivery, and toxicity outcomes for de-escalated adjuvant therapies better and highlight future directions.


Subject(s)
Breast Neoplasms , Humans , Female , Breast Neoplasms/pathology , Mastectomy, Segmental , Combined Modality Therapy , Patient Selection
15.
J Assoc Physicians India ; 59: 52-4, 2011 Jan.
Article in English | MEDLINE | ID: mdl-21751668

ABSTRACT

We present a case of 16 year old female admitted with complaints of influenza like symptoms followed by convulsions and sudden impairment of consciousness. Magnetic resonance imaging abnormalities were found in bilateral thalami including cerebellum. Diagnosis of influenza associated acute necrotizing encephalopathy was made on the basis of clinical features, neuroimaging findings and isolation of influenza A(H3N2) virus from throat swab. This is probably first case of Influenza associated acute necrotizing encephalopathy reported in India in 2009.


Subject(s)
Influenza A Virus, H3N2 Subtype/isolation & purification , Influenza, Human/complications , Leukoencephalitis, Acute Hemorrhagic/etiology , Adolescent , Coma/etiology , Fatal Outcome , Female , Humans , Influenza, Human/diagnosis , Influenza, Human/virology , Leukoencephalitis, Acute Hemorrhagic/diagnosis , Magnetic Resonance Imaging , Seizures/etiology , Thalamus/pathology
16.
JCO Oncol Pract ; 17(8): e1055-e1074, 2021 08.
Article in English | MEDLINE | ID: mdl-33970684

ABSTRACT

PURPOSE: Adjuvant therapy in patients with ductal carcinoma in situ who undergo partial mastectomy remains controversial, particularly for low-risk patients (60 years or older, estrogen-positive, tumor extent < 2.5 cm, grade 1 or 2, and margins ≥ 3 mm). We performed a cost-effectiveness analysis comparing three strategies: no adjuvant treatment after surgery, a five-fraction course of accelerated partial breast irradiation using intensity-modulated radiation therapy (accelerated partial breast irradiation [APBI]-alone), or APBI plus an aromatase inhibitor for 5 years. MATERIALS AND METHODS: Outcomes including local recurrence, distant metastases, and survival as well as toxicity data were modeled by a patient-level Markov microsimulation model, which were validated against trial data. Costs of treatment and possible adverse events were included from the societal perspective over a lifetime horizon, adjusted to 2019 US dollars and extracted from Medicare reimbursement data. Quality-adjusted life-years (QALYs) were calculated based on utilities extracted from the literature. RESULTS: No adjuvant therapy was the least costly approach ($5,744), followed by APBI-alone ($11,070); combined therapy was costliest ($16,052). Adjuvant therapy resulted in slightly higher QALYs (no adjuvant, 11.320; APBI-alone, 11.343; and combination, 11.381). In the base case, no treatment was the cost-effective strategy, with an incremental cost-effectiveness ratio of $239,109/QALY for APBI-alone and $171,718/QALY for combined therapy. The incremental cost-effectiveness ratio for combined therapy compared with APBI-alone was $131,949. Probabilistic sensitivity analyses found that no therapy was cost effective (defined as $100,000/QALY of lower) in 63% of trials, APBI-alone in 19%, and the combination in 18%. CONCLUSION: No adjuvant therapy represents the most cost-effective approach for postmenopausal women 60 years or older who receive partial mastectomy for low-risk ductal carcinoma in situ.


Subject(s)
Breast Neoplasms , Carcinoma, Intraductal, Noninfiltrating , Aged , Breast Neoplasms/radiotherapy , Carcinoma, Intraductal, Noninfiltrating/radiotherapy , Cost-Benefit Analysis , Female , Humans , Mastectomy , Medicare , Middle Aged , Neoplasm Recurrence, Local , United States
17.
Gynecol Oncol ; 119(2): 295-8, 2010 Nov.
Article in English | MEDLINE | ID: mdl-20673973

ABSTRACT

OBJECTIVE: Gynecologic oncologists have sought to define adequate lymphadenectomy. The purpose of this study is to determine the probability of detecting lymph node metastasis by lymph node count compared to number of nodal stations sampled. METHODS: This is a clinicopathologic review of surgically staged endometrial carcinoma patients from 2000 to 2008. Information was extracted from patients' medical records. Student t-test, Wilcoxon rank sum test, Chi-square and Fisher exact tests were used. Elimination logistic regression was performed to identify independent significant predictors of lymph node metastasis. p<.05 was considered significant for all tests. RESULTS: The study population consisted of 352 patients with a mean age of 65. Forty patients (11.36%) had lymph node metastasis. Number of nodes sampled was not associated with lymph node status on univariate analyses. Patients with lymph node metastases detected was increased when 8 or more nodal stations were sampled compared to less than 8 (19.4% vs. 9.8%, p=.04). More significance was seen when 9 or more stations were sampled (32% vs. 9.8%, p=.004). Multivariate logistic regression analysis, controlling for age, grade, depth of myometrial invasion, number of nodes sampled, and number of nodal stations sampled, found only grade (p=.002), depth of myometrial invasion (p<.0003), and sampling of 9 or more nodal stations (p=.03) to be independent predictors of node status. CONCLUSIONS: Lymph node count did not accurately predict risk of lymph node metastasis. Number of nodal stations sampled was a more precise predictor of lymph node metastases.


Subject(s)
Carcinoma, Endometrioid/pathology , Endometrial Neoplasms/pathology , Lymph Nodes/pathology , Aged , Female , Humans , Logistic Models , Lymphatic Metastasis , Middle Aged , Multivariate Analysis , Retrospective Studies
18.
Indian J Cancer ; 57(4): 457-462, 2020.
Article in English | MEDLINE | ID: mdl-32769296

ABSTRACT

BACKGROUND: In India, where the annual incidence of cancer is projected to reach 1.7 million by 2020, the need for clinical research to establish the most effective, resource-guided, and evidence-based care is paramount. In this study, we sought to better understand the research training needs of radiation oncologists in India. METHODS: A 12 item questionnaire was developed to assess research training needs and was distributed at the research methods course jointly organized by Indian College of Radiation Oncology, the American Brachytherapy Society, and Education Committee of the American Society of Therapeutic Radiation Oncology during the Indian Cancer Congress, 2017. RESULTS: Of 100 participants who received the questionnaire, 63% responded. Ninety percent (56/63) were Radiation Oncologists. Forty-two percent (26/63) of respondents had previously conducted research. A longer length of practice (>10 years) was significantly associated with conducting research (odds ratio (OR) 6.99, P = 0.031) and having formal research training trended toward significance (OR 3.03, P = 0.058). The most common reason for not conducting research was "lack of training" (41%, 14/34). The most common types of research conducted were Audits and Retrospective studies (62%, 16/26), followed by a Phase I/II/III Trial (46%, 10/26). Having formal research training was a significant factor associated with writing a protocol (OR 5.53, P = 0.016). Limited training in research methods (54%, 13/24) and lack of mentorship (42%, 10/24) were cited as reasons for not developing a protocol. Ninety-seven percent (57/59) of respondents were interested in a didactic session on research, specifically focusing on biostatistics. CONCLUSIONS: With research training and mentorship, there is a greater likelihood that concepts and written protocols will translate into successfully completed studies in radiation therapy.


Subject(s)
Biomedical Research/standards , Needs Assessment/standards , Neoplasms/radiotherapy , Radiation Oncologists/standards , Radiation Oncology/standards , Research Design/standards , Biomedical Research/organization & administration , Humans , Neoplasms/pathology , Prognosis , Radiation Oncologists/education , Radiation Oncologists/statistics & numerical data , Surveys and Questionnaires
19.
Oncology (Williston Park) ; 23(11): 933-40, 2009 Oct.
Article in English | MEDLINE | ID: mdl-19947343

ABSTRACT

Over the past 30 years, lumpectomy and radiation therapy (breast-conservation therapy, or BCT) has been the preferred treatment for early-stage breast cancer. With accumulating follow-up, we have an ever-expanding pool of patients with history of an irradiated intact breast. Routine use of every-6-month or annual screening in this population has identified an emerging clinical dilemma with respect to managing a small recurrence or a second primary tumor in the treated breast. Most women diagnosed with a second cancer in a previously irradiated breast are advised to undergo mastectomy. More recently, with an improved understanding of the patterns of in-breast failure, and with advances in the delivery of conformal radiation dose there is an opportunity to reevaluate treatment alternatives for managing a small in-breast recurrence. A limited number of publications have reported on patient outcomes after a second lumpectomy and radiation therapy for this clinical scenario. In this report, we review the controversial subject of a second chance at breast conservation for women with a prior history of breast irradiation.


Subject(s)
Breast Neoplasms/pathology , Breast Neoplasms/radiotherapy , Breast Neoplasms/surgery , Neoplasm Recurrence, Local/radiotherapy , Neoplasm Recurrence, Local/surgery , Breast Neoplasms/therapy , Clinical Trials as Topic , Combined Modality Therapy , Female , Humans , Mastectomy , Mastectomy, Segmental , Neoplasms, Second Primary/radiotherapy , Neoplasms, Second Primary/surgery , Radiotherapy
20.
Breast J ; 15(2): 140-5, 2009.
Article in English | MEDLINE | ID: mdl-19292799

ABSTRACT

Treating recurrent disease in the axilla is a challenging and complex clinical problem. Several reports in the literature suggest better outcomes with the combination of both surgery and radiation therapy than either modality alone. However, the available options for re-treatment are limited by the extent of disease at relapse, and the prior therapy that the patient has already received. The choice of re-irradiation using conventional external beam therapy is generally limited because of the risk of exceeding the radiation tolerance of the brachial plexus. In lieu of our concerns regarding excessive morbidity from re-irradiation with external radiation therapy when treating an axillary relapse, we applied intraoperative high-dose-rate brachytherapy (HDR-IORT) at the time of surgical resection +/- a modest dose of postoperative external beam radiation therapy. In this paper, we describe the feasibility of HDR-IORT technique in three patients presenting with recurrent disease in the axilla.


Subject(s)
Brachytherapy/methods , Breast Neoplasms/radiotherapy , Breast Neoplasms/surgery , Adult , Brachytherapy/instrumentation , Breast Neoplasms/drug therapy , Breast Neoplasms/pathology , Combined Modality Therapy , Estrogen Receptor Modulators/therapeutic use , Estrogen Replacement Therapy , Female , Humans , Intraoperative Period , Mastectomy, Segmental , Neoplasm Recurrence, Local/radiotherapy , Neoplasm Staging
SELECTION OF CITATIONS
SEARCH DETAIL