Planned Dental Extractions After Radiation Therapy.

Importance: Nonrestorable teeth are recommended to be extracted prior to radiation therapy (RT). Occasionally, preradiation extractions introduce unacceptable delays in treatment initiation. Planned dental extractions immediately postradiation presents an alternative strategy, though outcomes are uncertain. Objective: To evaluate the feasibility and safety of dental extractions immediately postradiation. Design, Setting, and Participants: A prospective cohort study including patients planned for curative-intent RT but unable or unwilling to proceed with 1 or more extractions recommended pretreatment was carried out. From January 2020 to September 2022, 58 patients were screened and 50 enrolled. The dental care was performed at a single academic department and the cancer care at regional centers. Analysis took place between September 22, 2023, and June 10, 2024. Exposure: On completion of RT, patients were recommended to complete extractions as soon as feasible, and ideally within 4 months. Main Outcomes and Measures: The primary end point was the actuarial cumulative incidence of exposed alveolar bone noted by any practitioner at any time after extraction, calculated using Gray method with death as a competing risk. As a pilot study, no formal power calculation was performed; resources allowed for 50 evaluable patients. Results: Among the 50 participants enrolled, RT was nonoperative for 32 patients (64%) and postoperative for 18 patients (36%). Intensity-modulated RT (IMRT) was delivered in all patients. Of the 50 patients, 20 (40%) declined dental extractions immediately postradiation and the remaining 30 (60%) underwent a median (range) of 8.5 (1-28) extractions at a median (range) of 64.5 (13-152) days after RT. The median (IQR) follow-up for survivors without exposed bone was 26 (17-35) months from the end of RT. The 2-year cumulative incidence of any exposed bone was 27% (95% CI, 14%-40%). The 2-year incidence of exposed bone for those who underwent dental extractions immediately postradiation was 40% (95% CI, 22%-58%) and 7% (95% CI, 0%-22%) for those who did not. Of the 13 who developed exposed bone: 4 resolved, 1 was lost to follow-up, and 8 were confirmed as osteoradionecrosis. Conclusions and Relevance: This cohort study found that postradiation dental extractions incur considerable risk, even if performed within a 4-month window.

Virtual On-Treatment Visits: Implementation, Patient Perspectives, Barriers, Limitations, Benefits, and Opportunities.

PURPOSE: This study aimed to report our initial experience with weekly tele-video "virtual" on-treatment visits (vOTVs), describe the logistics of implementation, report the results of patient and physician surveys, and discuss the barriers, limitations, and benefits of vOTVs during the COVID-19 pandemic. METHODS AND MATERIALS: vOTVs were piloted at 2 centers and within 1 week were expanded to 4 additional centers. Patients participating in vOTVs were surveyed about their satisfaction with vOTVs, the quality of vOTVs, and confidence in their physician's ability to manage their care through vOTVs, as well as their support of and preferences related to vOTVs. Participating physicians were surveyed about their comfort and satisfaction with vOTVs. Medical directors at nonparticipating centers within our network were surveyed regarding their reasoning for not using vOTVs. RESULTS: In week 1, 72 of 81 patients between 2 pilot centers were seen using vOTVs. In week 2, 189 of 211 patients were seen using vOTVs at 6 centers. Patient satisfaction with and confidence in their physician's ability to address their concerns through the vOTV was high at 4.75 on a 5-point scale. Patients were overall very supportive (4.67) and found the quality of the visits to be as good as or better than their prior in-person weekly on-treatment visit (3.75). Physicians participating in the vOTVs felt very comfortable in their ability to manage patients through this platform (5.0) and on average did not report any difference in terms of efficiency of visits (3.0). CONCLUSIONS: vOTVs were easy to implement and well received by patients and participating physicians. Our experience suggests that vOTVs can be implemented rapidly using available technology and with a high degree of patient and physician satisfaction during this pandemic with similar efficiency to in-person on-treatment visits.

Hypofractionated intensity-modulated radiotherapy (70 gy at 2.5 Gy per fraction) for localized prostate cancer: long-term outcomes.

PURPOSE: To analyze the long-term relapse-free survival and toxicity rates in patients treated with hypofractionated intensity-modulated radiotherapy. METHODS AND MATERIALS: The study sample includes the first 100 consecutive localized prostate cancer patients treated to 70.0 Gy at 2.5 Gy per fraction. The median follow-up was 66 months (range, 3 to 75 months). Biochemical failure was the study endpoint, using both the ASTRO definition (A-bRFS) and the alternate "nadir + 2 ng/mL" definition (N-bRFS). RTOG scores were used to assess toxicity. RESULTS: The 5-year A-bRFS and N-bRFS rates were 85% (95%CI, 78-93%) and 88% (95%CI, 82-95%) for all cases, respectively. For low, intermediate and high-risk disease, the 5-year A-bRFS rates were 97%, 88%, and 70%. The corresponding 5-year N-bRFS rates were 97%, 93%, and 75%, respectively. The acute rectal toxicity scores were 0 in 20, 1 in 61, and 2 in 19 patients. The acute urinary toxicity scores were 0 in 9, 1 in 76, and 2 in 15 patients. The late rectal toxicity scores were 0 in 71, 1 in 19, 2 in 7, and 3 in 3 patients. The actuarial late Grade 3 rectal toxicity rate at 5 years was 3%. A number of the toxicities observed either resolved spontaneously or were corrected. At last follow-up, the rate of combined Grades 2 and 3 late rectal toxicity at 5 years was only 5%. The late urinary toxicity scores were 0 in 75, 1 in 13, 2 in 11, and 3 in 1 patients. The actuarial late Grade 3 urinary toxicity rate at 5 years was 1%. CONCLUSION: With a median follow-up of 66 months, the long-term results after high-dose hypofractionation are excellent. Late toxicity, urinary and rectal, has been limited. High-dose hypofractionation is an alternative dose escalation method in the treatment of localized prostate cancer.

Prospective study of the short-term adverse effects of gamma knife radiosurgery.

Purpose of this study is to determine the types, incidence, and severity of acute complications of intracranial stereotactic radiosurgery (SRS), specifically Gamma Knife (GK). Patients who had never had previous SRS were eligible for this prospective IRB-approved study. The questionnaire used applicable questions from CTCAE v.3.0, the Brief Pain Questionnaire (Short Form), Brief Fatigue Inventory, and the Tinnitus Handicap Inventory. Questionnaires were obtained prior to Gamma Knife (GK), 1 week, 1 month, and 2 months to assess complications. Seventy-six eligible patients (median age of 62 years) had complete data and were analyzed. Diagnoses included: 26 (34%) with brain metastases, 15 (20%) with trigeminal neuralgia, 12 (16%) with schwannoma, 10 (13%) with meningioma, 7 (9%) with arteriovenous malformation, 3 (4%) with pituitary adenoma, and 3 (4%) with other. At 1 week, 24% developed minimal scalp numbness (p =0.0004 baseline compared to 1 week). Only 13% had minimal scalp numbness at 1 month and 2% at 2 months (both p=NS compared to baseline). There was no difference in scalp tingling between baseline and the various time points. Thirteen percent developed pin site pain at 1 week with a median intensity level of 2 out of 10. By one month, only 3% had pin site pain with a median intensity level of 3 out of 10. Four percent developed pin-site infection at 1 week and none at 1 and 2 months. There was no significant difference in nausea from baseline at 1 week, but there was worsening nausea at 1 month (p =0.0114). By 1 month, 10% reported new local hair loss. 23%, 16%, and 15% complained of new/worsening fatigue at 1 week, 1 month, and 2 months, respectively, but 40% reported fatigue at baseline. Balance improved following SRS over all time periods (for all comparisons, p <0.009). 1%, 6%, and 3% developed new tinnitus at 1 week, 1 month, and 2 months, respectively, which was significant when comparing baseline to non-baseline (p =0.0269). Thirty-two patients were employed prior to SRS. Three (9%) patients did not return to work. Twenty-seven (84%) patients returned to work a median of 4 days after SRS. Two people did not report their employment status after SRS. There was no significant difference in face swelling, headache, eye pain, vomiting, seizures, or passing out at any intervals compared to baseline. This prospective study demonstrates that GK is well tolerated with few patients developing major acute effects. Many patients are able to return to work shortly after GK.

Quality of life after gamma knife radiosurgery for benign lesions: a prospective study.

This study was initiated to evaluate the impact of intracranial radiosurgery for non-malignant indications on a patient's quality of life (QOL).The study sample includes a total of 31 patients treated with single-fraction Gamma Knife radiosurgery (GKRS) for a non-malignant indication. Patients were treated at the Cleveland Clinic from 2005 through 2007 and all underwent pretreatment evaluation including screening for depression and anxiety, serum hemoglobin, hematocrit, calcium, albumin and thyroid stimulating hormone. Each patient was followed prospectively for eight weeks after treatment using a validated tool to assess fatigue and a separate questionnaire assessing quality of life. Dose and volume of GKRS were based on institutional practice and indication. The 13 question Functional Assessment of Chronic Illness Therapy Fatigue Scale (FACIT-F) was used to assess fatigue. Six additional questions assessing QOL outcomes not measured by the FACIT-F were added. Patients completed the questionnaire prior to GKRS and weekly for eight weeks. Questionnaires were scored using the FACIT scoring guidelines with a maximum score of 52. The additional questions were scored similarly with higher scores correlating with better QOL. The indications for treatment were arteriovenous malformation (5), schwannoma (12), trigeminal neuralgia (7), meningioma (4), pituitary adenoma (2), and glomus tumor (1). Median radiosurgery dose was 15 Gy (range 12-82 Gy). Doses for trigeminal neuralgia were prescribed to the 100% isodose line (IDL) while other lesions were treated to approximately the 50% IDL. Median volume of tissue treated was 2.5 cc (range 0.132-15.4 cc). Analysis of the 31 patients and 227 person-weeks of follow-up shows that GKRS does not adversely impact fatigue and QOL during the first 8 weeks after treatment. Mean FACIT-F score was 43 at baseline and 41, 43, 45, 43, 46, 44, 45, 47 at weeks 1-8 respectively after GKRS. In addition, questions assessing patients' quality of life, and ability to work and exercise showed no decline after GKRS. Mean baseline score for these questions was 13 and 18, 19, 19, 19, 20, 19, 19 and 21 at weeks 1-8 after GK. This analysis of a prospective data set indicates that Gamma Knife radiosurgery does not adversely impact levels of fatigue or quality of life during the first 8 weeks after treatment for benign indications.

Results of the 2004 Association of Residents in Radiation Oncology (ARRO) survey.

PURPOSE: The aim of this study was to document adequacy of training, career plans after residency, use of the in-service examination, and motivation for choice of radiation oncology as a specialty. METHODS AND MATERIALS: In 2004, the Association of Residents in Radiation Oncology (ARRO) conducted a nationwide survey of all radiation oncology residents in the United States. RESULTS: The survey was returned by 297 residents (response rate, 54%). Of the respondents, 29% were female and 71% male. The most popular career choice was joining an established private practice (38%), followed by a permanent academic career (29%). Residents for whom a permanent academic career was not their first choice were asked whether improvements in certain areas would have led them to be more likely to pursue an academic career. The most commonly chosen factors that would have had a strong or moderate influence included higher salary (81%), choice of geographic location (76%), faculty encouragement (68%), and less time commitment (68%). Of respondents in the first 3 years of training, 78% believed that they had received adequate training to proceed to the next level of training. Of those in their fourth year of training, 75% believed that they had received adequate training to enter practice. CONCLUSIONS: Multiple factors affect the educational environment of physicians in training. Data describing concerns unique to resident physicians in radiation oncology are limited. The current survey was designed to explore a variety of issues confronting radiation oncology residents. Training programs and the Residency Review Committee should consider these results when developing new policies to improve the educational experiences of residents in radiation oncology.