Cancer-specific survival after radical prostatectomy versus external beam radiotherapy in high-risk and very high-risk African American prostate cancer patients.

BACKGROUND: To test for differences in cancer-specific mortality (CSM) rates between radical prostatectomy (RP) vs external beam radiotherapy (EBRT) in National Comprehensive Cancer Network (NCCN) high-risk African American patients, as well as Johns Hopkins University (JHU) high-risk and very high-risk patients. MATERIALS AND METHODS: Within the Surveillance, Epidemiology, and End Results database (2010-2016), we identified 4165 NCCN high-risk patients, of whom 1944 (46.7%) and 2221 (53.3%) patients qualified for JHU high-risk or very high-risk definitions. Of all 4165 patients, 1390 (33.5%) were treated with RP versus 2775 (66.6%) with EBRT. Cumulative incidence plots and competing risks regression models addressed CSM before and after 1:1 propensity score matching between RP and EBRT NCCN high-risk patients. Subsequently, analyses were repeated separately in JHU high-risk and very high-risk subgroups. Finally, all analyses were repeated after landmark analyses were applied. RESULTS: In the NCCN high-risk cohort, 5-year CSM rates for RP versus EBRT were 2.4 versus 5.2%, yielding a multivariable hazard ratio of 0.50 (95% confidence interval [CI] 0.30-0.84, p = 0.009) favoring RP. In JHU very high-risk patients 5-year CSM rates for RP versus EBRT were 3.7 versus 8.4%, respectively, yielding a multivariable hazard ratio of 0.51 (95% CI: 0.28-0.95, p = 0.03) favoring RP. Conversely, in JHU high-risk patients, no significant CSM difference was recorded between RP vs EBRT (5-year CSM rates: 1.3 vs 1.3%; multivariable hazard ratio: 0.55, 95% CI: 0.16-1.90, p = 0.3). Observations were confirmed in propensity score-matched and landmark analyses adjusted cohorts. CONCLUSIONS: In JHU very high-risk African American patients, RP may hold a CSM advantage over EBRT, but not in JHU high-risk African American patients.

Radiotherapy resources in Africa: an International Atomic Energy Agency update and analysis of projected needs.

The number of patients with cancer in Africa has been predicted to increase from 844 279 in 2012 to more than 1·5 million in 2030. However, many countries in Africa still lack access to radiotherapy as a part of comprehensive cancer care. The objective of this analysis is to present an updated overview of radiotherapy resources in Africa and to analyse the gaps and needs of the continent for 2030 in the context of the UN Sustainable Development Goals. Data from 54 African countries on teletherapy megavoltage units and brachytherapy afterloaders were extracted from the Directory for Radiotherapy Centres, an electronic, centralised, and continuously updated database of radiotherapy centres. Cancer incidence and future predictions were taken from the GLOBOCAN 2018 database of the International Agency for Research on Cancer. Radiotherapy need was estimated using a 64% radiotherapy utilisation rate, while assuming a machine throughput of 500 patients per year. As of March, 2020, 28 (52%) of 54 countries had access to external beam radiotherapy, 21 (39%) had brachytherapy capacity, and no country had a capacity that matched the estimated treatment need. Median income was an important predictor of the availability of megavoltage machines: US$1883 (IQR 914-3269) in countries without any machines versus $4485 (3079-12480) in countries with at least one megavoltage machine (p=0·0003). If radiotherapy expansion continues at the rate observed over the past 7 years, it is unlikely that the continent will meet its radiotherapy needs. This access gap might impact the ability to achieve the Sustainable Development Goals, particularly the target to reduce preventable, premature mortality by a third, and meet the target of the cervical cancer elimination strategy of 90% with access to treatment. Urgent, novel initiatives in financing and human capacity building are needed to change the trajectory and provide comprehensive cancer care to patients in Africa in the next decade.

Liver function after combined selective internal radiation therapy or sorafenib monotherapy in advanced hepatocellular carcinoma.

BACKGROUND & AIMS: SORAMIC is a previously published randomised controlled trial assessing survival in patients with advanced hepatocellular carcinoma who received sorafenib with or without selective internal radiation therapy (SIRT). Based on the per-protocol (PP) population, we assessed whether the outcome of patients receiving SIRT+sorafenib vs. sorafenib alone was affected by adverse effects of SIRT on liver function. METHODS: The PP population consisted of 109 (SIRT+sorafenib) vs. 173 patients (sorafenib alone). Comparisons were made between subgroups who achieved a significant survival benefit or trend towards improved survival with SIRT and the inverse group without a survival benefit: <65 years-old vs. ≥65 years-old, Child-Pugh 5 vs. 6, no transarterial chemoembolisation (TACE) vs. prior TACE, no cirrhosis vs. cirrhosis, non-alcohol- vs. alcohol-related aetiology. The albumin-bilirubin (ALBI) score was used to monitor liver function over time during follow-up. RESULTS: ALBI scores increased in all patient groups during follow-up. In the PP population, ALBI score increases were higher in the SIRT+sorafenib than the sorafenib arm (p = 0.0021 month 4, p <0.0001 from month 6). SIRT+sorafenib conferred a survival benefit compared to sorafenib alone in patients aged <65 years-old, those without cirrhosis, those with Child-Pugh 5, and those who had not received TACE. A higher increase in ALBI score was observed in the inverse subgroups in whom survival was not improved by adding SIRT (age ≥65 years-old, p <0.05; cirrhosis, p = 0.07; Child-Pugh 6, p <0.05; prior TACE, p = 0.08). CONCLUSION: SIRT frequently has a negative, often subclinical, effect on liver function in patients with hepatocellular carcinoma, which may impair prognosis after treatment. Careful patient selection for SIRT as well as prevention of clinical and subclinical liver damage by selective treatments, high tumour uptake ratio, and medical prophylaxis could translate into better efficacy. CLINICAL TRIAL NUMBER: EudraCT 2009-012576-27, NCT01126645 LAY SUMMARY: This study of treatments in patients with hepatocellular carcinoma found that selective internal radiation therapy (SIRT) has an adverse effect on liver function that may affect patient outcomes. Patients should be carefully selected before they undergo SIRT and the treatment technique should be optimised for maximum protection of non-target liver parenchyma.

Comparison of Multimodal Therapies and Outcomes Among Patients With High-Risk Prostate Cancer With Adverse Clinicopathologic Features.

Importance: The optimal management strategy for high-risk prostate cancer and additional adverse clinicopathologic features remains unknown. Objective: To compare clinical outcomes among patients with high-risk prostate cancer after definitive treatment. Design, Setting, and Participants: This retrospective cohort study included patients with high-risk prostate cancer (as defined by the National Comprehensive Cancer Network [NCCN]) and at least 1 adverse clinicopathologic feature (defined as any primary Gleason pattern 5 on biopsy, clinical T3b-4 disease, ≥50% cores with biopsy results positive for prostate cancer, or NCCN ≥2 high-risk features) treated between 2000 and 2014 at 16 tertiary centers. Data were analyzed in November 2020. Exposures: Radical prostatectomy (RP), external beam radiotherapy (EBRT) with androgen deprivation therapy (ADT), or EBRT plus brachytherapy boost (BT) with ADT. Guideline-concordant multimodal treatment was defined as RP with appropriate use of multimodal therapy (optimal RP), EBRT with at least 2 years of ADT (optimal EBRT), or EBRT with BT with at least 1 year ADT (optimal EBRT with BT). Main Outcomes and Measures: The primary outcome was prostate cancer-specific mortality; distant metastasis was a secondary outcome. Differences were evaluated using inverse probability of treatment weight-adjusted Fine-Gray competing risk regression models. Results: A total of 6004 men (median [interquartile range] age, 66.4 [60.9-71.8] years) with high-risk prostate cancer were analyzed, including 3175 patients (52.9%) who underwent RP, 1830 patients (30.5%) who underwent EBRT alone, and 999 patients (16.6%) who underwent EBRT with BT. Compared with RP, treatment with EBRT with BT (subdistribution hazard ratio [sHR] 0.78, [95% CI, 0.63-0.97]; P = .03) or with EBRT alone (sHR, 0.70 [95% CI, 0.53-0.92]; P = .01) was associated with significantly improved prostate cancer-specific mortality; there was no difference in prostate cancer-specific mortality between EBRT with BT and EBRT alone (sHR, 0.89 [95% CI, 0.67-1.18]; P = .43). No significant differences in prostate cancer-specific mortality were found across treatment cohorts among 2940 patients who received guideline-concordant multimodality treatment (eg, optimal EBRT alone vs optimal RP: sHR, 0.76 [95% CI, 0.52-1.09]; P = .14). However, treatment with EBRT alone or EBRT with BT was consistently associated with lower rates of distant metastasis compared with treatment with RP (eg, EBRT vs RP: sHR, 0.50 [95% CI, 0.44-0.58]; P < .001). Conclusions and Relevance: These findings suggest that among patients with high-risk prostate cancer and additional unfavorable clinicopathologic features receiving guideline-concordant multimodal therapy, prostate cancer-specific mortality outcomes were equivalent among those treated with RP, EBRT, and EBRT with BT, although distant metastasis outcomes were more favorable among patients treated with EBRT and EBRT with BT. Optimal multimodality treatment is critical for improving outcomes in patients with high-risk prostate cancer.

Co-treatment with Ginsenoside 20(S)-Rg3 and Curcumin increases Radiosensitivity of MDA-MB-231 Cancer Cell Line.

Background: Breast cancer is the second most common cancer in women worldwide. Developing drugs increase the radiosensitivity effect of tumoral tissue, while protecting normal tissues has gained much attention. Ginsenoside Rg3, one of the active components of ginseng, has been shown to possess various pharmacological effects and antiproliferation activity on cancer cell lines. In this study, we assessed the anti-cancer effect of co-treatment with ginsenoside 20(S)-Rg3 and curcumin on MDA-MB-231 breast cancer cells with and without radiotherapy. Methods: MTT assay was applied using different concentrations of ginsenoside 20(S)-Rg3 (0, 10, 80, 150 µmol/l) and curcumin (0, 10, 30, 50, 90 µg/mL). The inhibitory effect of co-treatment with these herbal drugs with and without 4 Gy radiotherapy on the MDA-MB-231 cell line was examined. Flow cytometry was applied to measure the effect of co-treatment of the drugs on radiation-induced apoptosis. The data were analyzed using ANOVA and Kruskal-Wallis tests. P values<0.05 were considered statistically significant. Results: The results of the MTT assay showed that ginsenoside 20(S)-Rg3 and curcumin had an inhibitory effect on the MDA-MB-231 cell line in a concentration-dependent manner. Ginsenoside 20(S)-Rg3 and curcumin inhibited tumor cell development and proliferation at concentrations of 80 µmol/L and 30 µg/mL, respectively, with 50% cell viability (P=0.018, P=0.01, respectively) at 48 hour incubation time. Conclusion: Ginsenoside 20(S)-Rg3 and curcumin inhibited MDA-MB-231 cell growth in a dose- and time-dependent manner and increased the radiosensitivity of cancer cells. These herbal drugs can be considered as a radiosensitizer in radiotherapy.

Implications of Radiotherapy Utilization in Korea from 2010 to 2019.

BACKGROUND: This study was to assess the rate of radiotherapy (RT) utilization according to the modality in South Korea to identify the implications of contemporary RT patterns. METHODS: We collected information from claims and reimbursement records of the National Health Insurance Service from 2010 to 2019. We classified the location of each institution as capital (Seoul, Incheon, and Gyeonggi-do) and non-capital areas. RESULTS: The rate of RT utilization in total cancer patients nationwide was 24.5% in 2010, which consistently has increased to 36.1% in 2019 (annual increase estimate [AIE], 4.5%). There was an abrupt increase in patients receiving intensity-modulated RT (IMRT), with an AIE of 33.5%, and a steady decline in patients receiving three-dimensional conformal RT (3DCRT), with an AIE of -7.1%. The commonest RT modality was IMRT (44.5%), followed by 3DCRT and stereotactic RT (SRT) (37.2% and 13.5%) in 2019. An increasing trend of advanced RT (such as IMRT and SRT) utilization was observed regardless of the region, although the AIE in the capital areas was slightly higher than that in non-capital areas. CONCLUSION: The utilization of overall RT application and especially of advanced modalities remarkably increased from 2010 to 2019. We also found gaps in their AIEs between capital and non-capital areas. We should ensure that advanced RT is accessible to all cancer patients across South Korea.

Active Surveillance for Men with Intermediate Risk Prostate Cancer.

PURPOSE: Optimal treatment of intermediate risk prostate cancer remains unclear. National Comprehensive Cancer Network® guidelines recommend active surveillance, prostatectomy or radiotherapy. Recent trials demonstrated no difference in prostate cancer specific mortality for men undergoing active surveillance for low risk prostate cancer compared to prostatectomy or radiotherapy. The use of active surveillance for intermediate risk prostate cancer is less clear. In this study we characterize U.S. national trends for demographic, clinical and socioeconomic factors associated with active surveillance for men with intermediate risk prostate cancer. MATERIALS AND METHODS: This retrospective cohort study examined 176,122 men diagnosed with intermediate risk prostate cancer from 2010 to 2016 in the National Cancer Database. Temporal trends in demographic, clinical and socioeconomic factors among men with intermediate risk prostate cancer and association with the use of active surveillance were characterized. The analysis was performed in April 2020. RESULTS: In total, 176,122 men were identified with intermediate risk prostate cancer from 2010 to 2016. Of these men 57.3% underwent prostatectomy, 36.4% underwent radiotherapy and 3.2% underwent active surveillance. Active surveillance nearly tripled from 1.6% in 2010 to 4.6% in 2016 (p <0.001). On multivariate analysis use of active surveillance was associated with older age, diagnosis in recent years, lower Gleason score and tumor stage, type of insurance, treatment at an academic center and proximity to facility, and attaining higher education (p <0.05). Race and comorbidities were not associated with active surveillance. CONCLUSIONS: Our findings highlight increasing active surveillance use for men with intermediate risk prostate cancer demonstrating clinical and socioeconomic disparities. Prospective data and improved risk stratification are needed to guide optimal treatment for men with intermediate risk prostate cancer.

Socioeconomic disparity trends in diagnostic imaging, treatments, and survival for non-small cell lung cancer 2007-2016.

Socioeconomic status (SES) has led to treatment and survival disparities; however, limited data exist for non-small cell lung cancer (NSCLC). This study investigates the impact of SES on NSCLC diagnostic imaging, treatment, and overall survival (OS), and describes temporal disparity trends. The Ontario Cancer Registry was used to identify NSCLC patients diagnosed between 2007 and 2016. Through linkage to administrative datasets, patients' demographics, imaging, treatment, and survival were obtained. Based on median household neighborhood income, the Ontario population was divided into five income quintiles (Q1-Q5; Q1 = lowest income). Multivariable regressions assessed SES association with OS, imaging, treatment receipt, and treatment delay, and their interaction with year of diagnosis to understand temporal trends. Endpoints were adjusted for demographics, stage and comorbidities, along with treatments and imaging for OS. A total of 50 542 patients were identified. Higher SES patients (Q5 vs. Q1) showed improved 5-year OS (hazard ratio, 0.89; 95% confidence interval [CI], 0.87-0.92; P < .0001) and underwent greater magnetic resonance imaging head (stages IA-IV; odds ratio [OR], 1.24; 95% CI, 1.16-1.32; P < .0001), lung resection (IA-IIIA; OR, 1.58; 95% CI, 1.43-1.74; P < .0001), platinum-based vinorelbine adjuvant chemotherapy (IB-IIIA; OR, 1.63; 95% CI, 1.39-1.92; P < .0001), palliative radiation (IV; OR, 1.14; 95% CI, 1.05-1.25; P = .023), and intravenous chemotherapy (IV; OR, 1.45; 95% CI, 1.32-1.60; P < .0001). Lower SES patients underwent greater thoracic radiation (IA-IIIB; OR, 0.86; 95% CI, 0.79-0.94; P = .0003). Across 2007-2016, socioeconomic disparities remain largely unchanged (interaction P > .05) despite widening income inequality.

[Analytical study of the breast cancer patient flow network in Brazil from 2014 to 2016]. / Estudo de análise de rede do fluxo de pacientes de câncer de mama no Brasil entre 2014 e 2016.

This study aims to analyze the flow of breast cancer patients treated outside of their municipality of residence, based on hospital admissions and chemotherapy and radiotherapy in the Brazilian Unified National Health System (SUS) from 2014 to 2016. Network analysis was used, considering the municipality of residence and of treatment as nodes in a graph, thus consisting of a "health system organizational network study". In addition, highway distances and travel time were estimated via the best feasible route according to the Open Street Maps highway project. According to the results, 51.34% of breast cancer patients in Brazil were treated outside their municipality of residence, following regionalized flows that respect state borders, generally towards the state capital or other large cities. The results also point to specific exceptions, where some municipalities occupy outstanding positions that extrapolate state borders. Median travel time from the municipality of residence to the municipality of care was nearly 3 hours, and 75% of trips totaled 324km for chemotherapy, 287km for radiotherapy, and 282km for hospitalizations. These results are indicative of the difficulties in access to oncology services, potentially aggravating the illness experience with cancer in terms of impact on the individuals and their families.

Este estudo busca analisar o fluxo de pacientes oncológicos de mama que são atendidos fora de seu domicílio de residência. Foram considerados as internações hospitalares e os tratamentos por quimioterapia e radioterapia para neoplasias malignas na mama, no âmbito do Sistema Único de Saúde, entre os anos de 2014 e 2016. Foi empregado o método de análise de redes, considerando o município de residência e de tratamento como nós de um grafo, que consiste em um "estudo de redes organizacionais de sistemas de saúde". Além disso, distância e tempo de deslocamento foram estimados por meio da melhor rota viável, segundo a malha rodoviária do projeto Open Street Maps. Os resultados apontam que 51,34% dos pacientes de câncer de mama no Brasil foram atendidos fora de seu município de residência, seguindo fluxos que são regionalizados e que preservam fronteiras estaduais, em geral, em direção a capitais ou a cidades de grande porte. Por outro lado, os resultados também apontam exceções específicas, visto que alguns municípios detêm um grau de proeminência que supera os limites estaduais. O tempo de deslocamento entre município de residência e município de atendimento apresentou medianas próximas a três horas, e 75% dos deslocamentos se dão em até 324km para tratamento por quimioterapia, 287km para tratamento por radioterapia e 282km para internações. Esses resultados são indicativos das dificuldades de acesso aos serviços de oncologia, o que potencialmente agrava a experiência do adoecimento oncológico em termos de impacto no indivíduo e em sua família.

El objetivo de este estudio fue analizar el flujo de pacientes oncológicos con cáncer de mama que son atendidos fuera de su domicilio de residencia. Se consideraron internamientos hospitalarios, tratamientos por quimioterapia y radioterapia para neoplasias malignas de mama, dentro del ámbito del Sistema Único de Salud brasileño, entre los años de 2014 a 2016. Se empleó el método de análisis de redes, considerando como nudos de un grafo el municipio de residencia y el del tratamiento, formándose de esta forma un "estudio de redes organizativas de sistemas de salud". Asimismo, se estimaron las distancias viales y el tiempo de desplazamiento, a través de la mejor ruta de carreteras, según la red de carreteras del proyecto Open Street Maps. Los resultados apuntan que un 51,34% de los pacientes con cáncer de mama en Brasil fueron atendidos fuera de su municipio de residencia, siguiendo flujos regionalizados y dentro de sus fronteras estatales, en general, en dirección a las capitales de las mismas o grandes ciudades. Por otro lado, los resultados también muestran excepciones específicas, donde algunos municipios detentan un grado de relevancia superando las fronteras estatales. El tiempo de desplazamiento entre el municipio de residencia y el municipio de atención presentó unas medias cercanas a las 3 horas, y en un 75% de los desplazamientos se recorrieron hasta 324km para recibir tratamiento de quimioterapia, 287km para el tratamiento de radioterapia y 282km para internamientos. Estos resultados son indicativos de las dificultades de acceso a los servicios de oncología, lo que agrava potencialmente la experiencia de la enfermedad oncológica en términos de impacto en el individuo y su familia.

Estudo de análise de rede do fluxo de pacientes de câncer de mama no Brasil entre 2014 e 2016 / Analytical study of the breast cancer patient flow network in Brazil from 2014 to 2016 / Estudio de análisis de red del flujo de pacientes con cáncer de mama en Brasil entre 2014 y 2016

Resumo: Este estudo busca analisar o fluxo de pacientes oncológicos de mama que são atendidos fora de seu domicílio de residência. Foram considerados as internações hospitalares e os tratamentos por quimioterapia e radioterapia para neoplasias malignas na mama, no âmbito do Sistema Único de Saúde, entre os anos de 2014 e 2016. Foi empregado o método de análise de redes, considerando o município de residência e de tratamento como nós de um grafo, que consiste em um "estudo de redes organizacionais de sistemas de saúde". Além disso, distância e tempo de deslocamento foram estimados por meio da melhor rota viável, segundo a malha rodoviária do projeto Open Street Maps. Os resultados apontam que 51,34% dos pacientes de câncer de mama no Brasil foram atendidos fora de seu município de residência, seguindo fluxos que são regionalizados e que preservam fronteiras estaduais, em geral, em direção a capitais ou a cidades de grande porte. Por outro lado, os resultados também apontam exceções específicas, visto que alguns municípios detêm um grau de proeminência que supera os limites estaduais. O tempo de deslocamento entre município de residência e município de atendimento apresentou medianas próximas a três horas, e 75% dos deslocamentos se dão em até 324km para tratamento por quimioterapia, 287km para tratamento por radioterapia e 282km para internações. Esses resultados são indicativos das dificuldades de acesso aos serviços de oncologia, o que potencialmente agrava a experiência do adoecimento oncológico em termos de impacto no indivíduo e em sua família.

Abstract: This study aims to analyze the flow of breast cancer patients treated outside of their municipality of residence, based on hospital admissions and chemotherapy and radiotherapy in the Brazilian Unified National Health System (SUS) from 2014 to 2016. Network analysis was used, considering the municipality of residence and of treatment as nodes in a graph, thus consisting of a "health system organizational network study". In addition, highway distances and travel time were estimated via the best feasible route according to the Open Street Maps highway project. According to the results, 51.34% of breast cancer patients in Brazil were treated outside their municipality of residence, following regionalized flows that respect state borders, generally towards the state capital or other large cities. The results also point to specific exceptions, where some municipalities occupy outstanding positions that extrapolate state borders. Median travel time from the municipality of residence to the municipality of care was nearly 3 hours, and 75% of trips totaled 324km for chemotherapy, 287km for radiotherapy, and 282km for hospitalizations. These results are indicative of the difficulties in access to oncology services, potentially aggravating the illness experience with cancer in terms of impact on the individuals and their families.

Resumen: El objetivo de este estudio fue analizar el flujo de pacientes oncológicos con cáncer de mama que son atendidos fuera de su domicilio de residencia. Se consideraron internamientos hospitalarios, tratamientos por quimioterapia y radioterapia para neoplasias malignas de mama, dentro del ámbito del Sistema Único de Salud brasileño, entre los años de 2014 a 2016. Se empleó el método de análisis de redes, considerando como nudos de un grafo el municipio de residencia y el del tratamiento, formándose de esta forma un "estudio de redes organizativas de sistemas de salud". Asimismo, se estimaron las distancias viales y el tiempo de desplazamiento, a través de la mejor ruta de carreteras, según la red de carreteras del proyecto Open Street Maps. Los resultados apuntan que un 51,34% de los pacientes con cáncer de mama en Brasil fueron atendidos fuera de su municipio de residencia, siguiendo flujos regionalizados y dentro de sus fronteras estatales, en general, en dirección a las capitales de las mismas o grandes ciudades. Por otro lado, los resultados también muestran excepciones específicas, donde algunos municipios detentan un grado de relevancia superando las fronteras estatales. El tiempo de desplazamiento entre el municipio de residencia y el municipio de atención presentó unas medias cercanas a las 3 horas, y en un 75% de los desplazamientos se recorrieron hasta 324km para recibir tratamiento de quimioterapia, 287km para el tratamiento de radioterapia y 282km para internamientos. Estos resultados son indicativos de las dificultades de acceso a los servicios de oncología, lo que agrava potencialmente la experiencia de la enfermedad oncológica en términos de impacto en el individuo y su familia.

Patient Reported Outcomes in NRG Oncology RTOG 0938, Evaluating Two Ultrahypofractionated Regimens for Prostate Cancer.

PURPOSE: There is considerable interest in very short (ultrahypofractionated) radiation therapy regimens to treat prostate cancer based on potential radiobiological advantages, patient convenience, and resource allocation benefits. Our objective is to demonstrate that detectable changes in health-related quality of life measured by the bowel and urinary domains of the Expanded Prostate Cancer Index Composite (EPIC-50) were not substantially worse than baseline scores. METHODS AND MATERIALS: NRG Oncology's RTOG 0938 is a nonblinded randomized phase 2 study of National Comprehensive Cancer Network low-risk prostate cancer in which each arm is compared with a historical control. Patients were randomized to 5 fractions (7.25 Gy in 2 weeks) or 12 fractions (4.3 Gy in 2.5 weeks). The co-primary endpoints were the proportion of patients with a change in EPIC-50 bowel score at 1 year (baseline to 1 year) >5 points and in EPIC-50 urinary score >2 points tested with a 1-sample binomial test. RESULTS: The study enrolled 127 patients to 5 fractions (121 analyzed) and 128 patients to 12 fractions (125 analyzed). Median follow-up for all patients at the time of analysis was 3.8 years. The 1-year frequency for >5 point change in bowel score were 29.8% (P < .001) and 28.4% (P < .001) for 5 and 12 fractions, respectively. The 1-year frequencies for >2 point change in urinary score were 45.7% (P < .001) and 42.2% (P < .001) for 5 and 12 fractions, respectively. For 5 fractions, 32.9% of patients had a drop in 1-year EPIC-50 sexual score of ≥11 points (P = .34); for 12 fractions, 30.9% of patients had a drop in 1-year EPIC-50 sexual score of ≥ 11 points (P = .20). Disease-free survival at 2 years is 99.2% (95% confidence interval: 97.5-100) in the 5-fraction arm and 97.5% (95% confidence interval: 94.6-100) in the 12-fraction arm. There was no late grade 4 or 5 treatment-related urinary or bowel toxicity. CONCLUSIONS: This study confirms that, based on changes in bowel and urinary domains and toxicity (acute and late), the 5- and 12-fraction regimens are well tolerated. These ultrahypofractionated approaches need to be compared with current standard radiation therapy regimens.

Impact of insurance status and race on receipt of treatment for acoustic neuroma: A national cancer database analysis.

Acoustic neuroma (AN) management involves surgery, radiation, or observation. Previous studies have demonstrated that patient race and insurance status impact in-hospital morbidity/mortality following surgery; however the nationwide impact of these demographics on the receipt of each treatment modality has not been examined. The National Cancer Data Base (NCDB) from 2004 to 2013 identified AN patients. Multivariate analysis adjusted for several variables within each treatment modality, including patient age, race, sex, income, primary payer for care, tumor size, and medical comorbidities. Patients who were African-American (OR=0.7; 95%CI=0.5-0.9; p=0.01), elderly (minimum age 65) (OR=0.4; 95%CI=0.4-0.6; p<0.0001), on Medicare (OR=0.6; 95% CI=0.4-0.7; p=0.0005), or treated at a community hospital (OR=0.4; 95%CI=0.2-0.7; p=0.007) were less likely to receive surgery. Patients on Medicaid (OR=1.2; 95%CI=0.8-1.8; p=0.04) or treated at an integrated network (OR=1.2; 95%CI=0.9-1.6; p=0.0004) were more likely to receive surgery. Patients who were elderly (OR=2.2; 95%CI=1.7-2.9; p<0.0001) or treated in a comprehensive cancer center (OR=1.5; 95%CI=1.3-1.9; p=0.02) were more likely and Medicaid patients (OR=0.8; 95%CI=0.5-1.2; p=0.04) were less likely to receive radiation. Patients who were elderly (OR=2.2; 95%CI=1.7-2.7; p<0.0001), African-American (OR=1.5; 95%CI=1.1-2.0; p=0.01), on Medicare (OR=1.8; 95%CI=1.4-2.3; p=0.0003), or treated in a community hospital (OR=3.0; 95%CI=1.6-5.6; p=0.0007) were more likely to receive observation. Patients on Medicaid (OR=0.8; 95%CI=0.5-1.2; p=0.04) or treated in an integrated network (OR=0.8; 95%CI=0.6-1.0; p=0.0001) were less likely to receive observation. African-American race, elderly age, and community hospital treatment triaged towards observation/away from surgery; age also triaged towards radiation. Conversely, integrated networks triaged towards surgery/away from observation; comprehensive cancer centers triaged towards radiation. Medicaid insurance triaged towards surgery/away from radiation/observation; this may be detrimental since lack of private insurance is a known risk factor for increased in-hospital postoperative morbidity.

Association of Hospital Volume With Racial and Ethnic Disparities in Locally Advanced Cervical Cancer Treatment.

OBJECTIVE: To evaluate racial-ethnic disparities in guideline-based care in locally advanced cervical cancer and their relationship to hospital case volume. METHODS: Using the National Cancer Database, we performed a retrospective cohort study of women diagnosed between 2004 and 2012 with locally advanced squamous or adenocarcinoma of the cervix undergoing definitive primary radiation therapy. The primary outcome was the race-ethnicity-based rates of adherence to the National Comprehensive Cancer Network guideline-based care. The secondary outcome was the effect of guideline-based care on overall survival. Multivariable models and propensity matching were used to compare the hospital risk-adjusted rates of guideline-based adherence and overall survival based on hospital case volume. RESULTS: The final cohort consisted of 16,195 patients. The rate of guideline-based care was 58.4% (95% confidence interval [CI] 57.4-59.4%) for non-Hispanic white, 53% (95% CI 51.4-54.9%) for non-Hispanic black, and 51.5% (95% CI 49.4-53.7%) for Hispanic women (P<.001). From 2004 to 2012, the rate of guideline-based care increased from 49.5% (95% CI 47.1-51.9%) to 59.1% (95% CI 56.9-61.2%) (Ptrend<.001). Based on a propensity score-matched analysis, patients receiving guideline-based care had a lower risk of mortality (adjusted hazard ratio 0.65, 95% CI 0.62-0.68). Compared with low-volume hospitals, the increase in adherence to guideline-based care in high-volume hospitals was 48-63% for non-Hispanic white, 47-53% for non-Hispanic black, and 41-54% for Hispanic women. CONCLUSION: Racial and ethnic disparities in the delivery of guideline-based care are the highest in high-volume hospitals. Guideline-based care in locally advanced cervical cancer is associated with improved survival.

Clinical and Demographic Factors Associated With Receipt of Non Guideline-concordant Initial Therapy for Nonmetastatic Prostate Cancer.

OBJECTIVES: To determine the extent to which initial therapy for nonmetastatic prostate cancer was concordant with nationally recognized guidelines using supplemented cancer registry data and what factors were associated with receipt of nonguideline-concordant care. METHODS: Initial therapy for 8229 nonmetastatic prostate cancer cases diagnosed in 2004 from cancer registries in 7 states was abstracted as part of the Centers for Disease Control's Patterns of Care Breast and Prostate Cancer study conducted during 2007 to 2009. The National Comprehensive Cancer Network clinical practice guidelines version 1.2002 was used as the standard of care based on recurrence risk group and life expectancy (LE). A multivariable model was used to determine risk factors associated with receipt of nonguideline-concordant care. RESULTS: Nearly 80% with nonmetastatic prostate cancer received guideline-concordant care for initial therapy. Receipt of nonguideline-concordant care (including receiving either less aggressive therapy or more aggressive therapy than indicated) was related to older age, African American race/ethnicity, being unmarried, rural residence, and especially to being in the high recurrence risk group where receiving less aggressive therapy than indicated occurred more often than receiving more aggressive therapy (adjusted OR=4.2; 95% CL, 3.5-5.2 vs. low-risk group). Compared with life table estimates adjusted for comorbidity, physicians tended to underestimate LE. CONCLUSIONS: Receipt of less aggressive therapy than indicated among high-risk group men with >5-year LE based on life table estimates adjusted for comorbidity was a concern. Physicians may tend to underestimate 5-year survival among this group and should be alerted to the importance of recommending aggressive therapy when warranted. However, based on more recent guidelines, among those with low-risk disease, the proportion considered to be receiving less aggressive therapy than indicated may now be lower because active surveillance is now considered appropriate.

Quality indicators for prostate radiotherapy: are patients disadvantaged by receiving treatment in a 'generalist' centre?

INTRODUCTION: The purpose of this retrospective review was to evaluate concordance with evidence-based quality indicator guidelines for prostate cancer patients treated radically in a 'generalist' (as distinct from 'sub-specialist') centre. We were concerned that the quality of treatment may be lower in a generalist centre. If so, the findings could have relevance for many radiotherapy departments that treat prostate cancer. METHODS: Two hundred fifteen consecutive patients received external beam radiotherapy (EBRT) and/or brachytherapy between 1.10.11 and 30.9.12. Treatment was deemed to be in line with evidence-based guidelines if the dose was: (i) 73.8-81 Gy at 1.8-2.0 Gy/fraction for EBRT alone (eviQ guidelines); (ii) 40-50 Gy (EBRT) for EBRT plus high-dose rate (HDR) brachytherapy boost (National Comprehensive Cancer Network (NCCN) guidelines); and (iii) 145 Gy for low dose rate (LDR) I-125 monotherapy (NCCN). Additionally, EBRT beam energy should be ≥6 MV using three-dimensional conformal RT (3D-CRT) or intensity-modulated RT (IMRT), and high-risk patients should receive neo-adjuvant androgen-deprivation therapy (ADT) (eviQ/NCCN). Treatment of pelvic nodes was also assessed. RESULTS: One hundred four high-risk, 84 intermediate-risk and 27 low-risk patients (NCCN criteria) were managed by eight of nine radiation oncologists. Concordance with guideline doses was confirmed in: (i) 125 of 136 patients (92%) treated with EBRT alone; (ii) 32 of 34 patients (94%) treated with EBRT + HDR BRT boost; and (iii) 45 of 45 patients (100%) treated with LDR BRT alone. All EBRT patients were treated with ≥6 MV beams using 3D-CRT (78%) or IMRT (22%). 84%, 21% and 0% of high-risk, intermediate-risk and low-risk patients received ADT, respectively. Overall treatment modality choice (including ADT use and duration where assessable) was concordant with guidelines for 176/207 (85%) of patients. CONCLUSION: The vast majority of patients were treated concordant with evidence-based guidelines suggesting that, within the limits of the selected criteria, prostate cancer patients are unlikely to be disadvantaged by receiving radiotherapy in this 'generalist' centre.

Treatment approach, delivery, and follow-up evaluation for cardiac rhythm disease management patients receiving radiation therapy: retrospective physician surveys including chart reviews at numerous centers.

In a 2-part study, we first examined the results of 71 surveyed physicians who provided responses on how they address the management of patients who maintained either a pacemaker or a defibrillator during radiation treatment. Second, a case review study is presented involving 112 medical records reviewed at 18 institutions to determine whether there was a change in the radiation prescription for the treatment of the target cancer, the method of radiation delivery, or the method of radiation image acquisition. Statistics are provided to illustrate the level of administrative policy; the level of communication between radiation oncologists and heart specialists; American Joint Committee on Cancer (AJCC) staging and classification; National Comprehensive Cancer Network (NCCN) guidelines; tumor site; patient׳s sex; patient׳s age; device type; manufacturer; live monitoring; and the reported decisions for planning, delivery, and imaging. This survey revealed that 37% of patient treatments were considered for some sort of change in this regard, whereas 59% of patients were treated without regard to these alternatives when available. Only 3% of all patients were identified with an observable change in the functionality of the device or patient status in comparison with 96% of patients with normal behavior and operating devices. Documented changes in the patient׳s medical record included 1 device exhibiting failure at 0.3-Gy dose, 1 device exhibiting increased sensor rate during dose delivery, 1 patient having an irregular heartbeat leading to device reprogramming, and 1 patient complained of twinging in the chest wall that resulted in a respiratory arrest. Although policies and procedures should directly involve the qualified medical physicist for technical supervision, their sufficient involvement was typically not requested by most respondents. No treatment options were denied to any patient based on AJCC staging, classification, or NCCN practice standards.

Are HIV-infected men vulnerable to prostate cancer treatment disparities?

BACKGROUND: HIV-infected (HIV(+)) men face cancer treatment disparities that impact outcome. Prostate cancer treatment and treatment appropriateness in HIV(+) men are unknown. METHODS: We used electronic chart review to conduct a retrospective cohort study of 43 HIV(+) cases with prostate cancer and 86 age- and race-matched HIV-uninfected (HIV(-)) controls with prostate cancer, ages 40 to 79 years, from 2001 to 2012. We defined treatment appropriateness using National Comprehensive Cancer Network guidelines and the Charlson comorbidity index (CCI) to estimate life expectancy. RESULTS: Median age was 59.5 years at prostate cancer diagnosis. Median CD4(+) T-cell count was 459.5 cells/mm(3), 95.3% received antiretroviral therapy, and 87.1% were virally suppressed. Radical prostatectomy was the primary treatment for 39.5% of HIV(+) and 71.0% of HIV(-) men (P = 0.004). Only 16.3% of HIV(+) versus 57.0% of HIV(-) men received open radical prostatectomy (P < 0.001). HIV(+) men received more radiotherapy (25.6% vs. 16.3%, P = 0.13). HIV was negatively associated with open radical prostatectomy (OR = 0.03, P = 0.007), adjusting for insurance and CCI. No men were undertreated. Fewer HIV(+) men received appropriate treatment (89.2% vs. 100%, P = 0.003), due to four overtreated HIV(+) men. Excluding AIDS from the CCI still resulted in fewer HIV(+) men receiving appropriate treatment (94.6% vs. 100%, P = 0.03). CONCLUSION: Prostate cancer in HIV(+) men is largely appropriately treated. Under- or overtreatment may occur from difficulties in life expectancy estimation. HIV(+) men may receive more radiotherapy and fewer radical prostatectomies, specifically open radical prostatectomies. IMPACT: Research on HIV/AIDS survival indices and etiologies and outcomes of this prostate cancer treatment disparity in HIV(+) men are needed.

Effect of self-selected music on adults' anxiety and subjective experiences during initial radiotherapy treatment: a randomised controlled trial and qualitative research.

INTRODUCTION: Patients may experience radiotherapy as anxiety provoking, especially during unfamiliar initial treatment. This study examines whether patients' use of self-selected music while undergoing first radiotherapy treatment reduces anxiety, and how patients describe their first radiotherapy experience with or without self-selected music. METHODS: Using quantitative and qualitative methods, 100 participants preparing to commence radiotherapy were assigned to the initial radiotherapy session either with self-selected music or without music. In both participant groups, the Spielberger State Anxiety Inventory measured pre- and post-radiotherapy levels, music preference questions examined future music desires during treatment and a semistructured questionnaire examined additional subjective experiences. RESULTS: Overall, participants were not highly anxious pre-radiotherapy, anxiety decreased in both music and control groups following radiotherapy (P = 0.008) and this change was not different between groups (P = 0.35). However, music group participants were significantly more likely to want music in future radiotherapy sessions (P = 0.007). Some reported a benefit from the music in terms of feeling supported, distracted or that treatment time seemed faster. Participants in both groups often commended helpful staff. Negative reactions were only occasional. CONCLUSIONS: Although preferred music does not reduce anxiety, it can support some patients undergoing initial radiotherapy and departmental staff should invite patients to bring music to radiotherapy, provide music libraries and offer to play patient selected music during treatments.

Radiation therapy at the end of life in patients with incurable nonsmall cell lung cancer.

BACKGROUND: Receipt of chemotherapy at the end of life (EOL) is considered an indicator of poor quality of care for medical oncology. The objective of this study was to characterize the use of radiotherapy (RT) in patients with nonsmall cell lung cancer (NSCLC) during the same period. METHODS: Treatment characteristics of patients with incurable NSCLC who received RT at the EOL, defined as within 14 days of death, were analyzed from the National Comprehensive Cancer Network NSCLC Outcomes Database. RESULTS: Among 1098 patients who died, 10% had received EOL RT. Patients who did and did not receive EOL RT were similar in terms of sex, race, comorbid disease, and Eastern Cooperative Oncology Group performance status. On multivariable logistic regression analysis, independent predictors of receiving EOL RT included stage IV disease (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.09-3.83) or multiorgan involvement (OR, 1.75; 95% CI, 1.08-2.84) at diagnosis, age <65 years at diagnosis (OR, 1.85; 95% CI, 1.21-2.83), and treating institution (OR, 1.24-5.94; P = .02). Nearly 50% of EOL RT recipients did not complete it, most commonly because of death or patient preference. CONCLUSIONS: In general, EOL RT was received infrequently, was delivered more commonly to younger patients with more advanced disease, and often was not completed as planned. There also was considerable variation in its use among National Comprehensive Cancer Network institutions. Next steps include expanding this research to other cancers and settings and investigating the clinical benefit of such treatment.

Mapping use of radiotherapy for patients with non-small cell lung cancer in the Netherlands between 1997 and 2008.

AIM: After the publication of several reports that the utilisation rate of radiotherapy for patients with non-small cell lung cancer (NSCLC) varies for both medical and non-medical reasons, the utilisation of radiotherapy was studied in four regions in the Netherlands. MATERIALS AND METHODS: Data from 1997-2008 were collected from the population-based cancer registries of four comprehensive cancer centres ('regions'), which represent about half of the Dutch population, resulting in 24 185 non-metastatic patients with NSCLC. Treatment had to be started or planned within 6 months of diagnosis. We evaluated the utilisation of radiotherapy according to age, gender and period for each region. RESULTS: The utilisation of radiotherapy alone decreased over time (from 35 to 19%), whereas the utilisation of radiotherapy in combination with chemotherapy increased (from 5 to 19%). The total utilisation rate remained rather stable at about 40%. The differences between the four regions remained in general no more than 15%. Elderly patients with stage I and II disease had increased odds of receiving radiotherapy (≥75 versus <50 years: odds ratio 2.6, 95% confidence interval 2.0-3.3, whereas this was the opposite for patients with stage III disease: odds ratio 0.5, 95% confidence interval 0.4-0.6). For 17-24% of all patients, especially the elderly, best supportive care was applied. CONCLUSIONS: In the Netherlands, with good accessibility to medical care and well-implemented national guidelines, variation between the four regions is limited for the treatment of non-metastatic NSCLC with radiotherapy.