Late Toxicity of Prostate Ultrahypofractionated Radiation Therapy Compared With Moderate Hypofractionation in a Randomized Trial.

PURPOSE: We report late toxicity, quality of life (QOL), and urinary symptom score with prostate cancer radiation therapy in a randomized trial comparing moderate hypofractionation and ultrahypofrationation. METHODS AND MATERIALS: Patients with intermediate and high-risk prostate cancer were randomized to either Arm 1 (70 Gy/28 fractions) or Arm 2 (36.25 Gy/5 weekly fractions). Late toxicity was evaluated using the Common Terminology Criteria for Adverse Events and Radiation Therapy Oncology Group/Subjective, Objective, Management, Analytical scales. QOL was assessed with the Expanded Prostate Inventory Composite-26 Short Form and urinary function with the International Prostate Symptom Score. RESULTS: Eighty participants were randomized. Two from Arm 1 withdrew, leaving 36 patients in Arm 1 and 42 in Arm 2. There were no significant differences in baseline characteristics, except for worse International Prostate Symptom Score in Arm 2. No difference was observed in freedom from grade 3 or worse toxicity between treatments (P = .921), with only a single grade 3 event in each arm. There was no significant difference in freedom from grade 2 or worse toxicity (P = .280). No difference was observed in freedom from grade 2 or worse genitorurinary toxicity, with cumulative probabilities of 69.0% and 87.0% at 5 years for Arms 1 and 2, respectively (0.132). No difference was observed in freedom from grade 2 or worse gastrointestinal toxicity, with cumulative probabilities of 74.0% in Arm 1 and 80.0% in Arm 2 (P = .430). There were no significant differences in Expanded Prostate Inventory Composite-26 Short Form QOL between arms. CONCLUSIONS: Ultrahypofrationation, delivered weekly, is well tolerated with no significant differences in freedom from late toxicity compared with moderate hypofractionation.

Acute Toxicity of Ultrahypofractionation Compared With Moderate Hypofractionation in Prostate Cancer Treatment: A Randomized Trial.

PURPOSE: We report on the early toxic effects and quality of life of localized prostate cancer radiation therapy in a randomized trial comparing moderate hypofractionation (MHF) with ultrahypofractionation (UHF). METHODS AND MATERIALS: We randomized patients with intermediate- to high-risk localized prostate cancer to radiation therapy with MHF (70 Gy in 28 daily fractions) or UHF (36.25 Gy in 5 weekly fractions). We analyzed early toxic effects (using Common Terminology Criteria for Adverse Events and Radiation Therapy Oncology Group/Subjective, Objective, Management, Analytic scales) and patient-reported quality of life (using the Expanded Prostate Inventory Composite questionnaire) when all patients had at least 6 months of follow-up. RESULTS: We randomized 80 participants. Two patients withdrew from radiation therapy. We ran analysis on results for 78 patients. The 2 arms were balanced in key patient and disease characteristics, except for a statistically worse baseline urinary function in the UHF arm (International Prostate Symptom Score >7: 68% vs 36%, P = .004). There were no statistically significant differences between the 2 arms in grade 3 or grade 2 toxic effects: grade ≥3 MHF 8%, UHF 2% (P = .235); grade ≥2 MHF 36%, UHF 24% (P = .235). There were also no significant differences in percentages of patients with a "minimal important change" of quality of life in the Incontinence (MHF 36%, UHF 33%; P = .746), Irritative/Obstructive (MHF 56%, UHF 74%; P = .074), or Bowel domains (MHF 58%, UHF 52%; P = .508) on the Expanded Prostate Inventory Composite questionnaire. CONCLUSIONS: UHF radiation therapy for prostate cancer is well tolerated, and there were no significant differences in toxic effects and quality of life changes between UHF and MHF up to 6 months after treatment in the current trial.

Real-time interactive planning for radiotherapy of head and neck cancer with volumetric modulated arc therapy.

BACKGROUND AND PURPOSE: Planning complex radiotherapy treatments can be inefficient, with large variation in plan quality. In this study we evaluated plan quality and planning efficiency using real-time interactive planning (RTIP) for head and neck (HN) volumetric modulated arc therapy (VMAT). MATERIALS AND METHODS: RTIP allows manipulation of dose volume histograms (DVHs) in real-time to assess achievable planning target volume (PTV) coverage and organ at risk (OAR) sparing. For 20 HN patients previously treated with VMAT, RTIP was used to minimize OAR dose while maintaining PTV coverage. RTIP DVHs were used to guide VMAT optimization. Dosimetric differences between RTIP-assisted plans and original clinical plans were assessed. Five blinded radiation oncologists indicated their preference for each PTV, OAR and overall plan. To assess efficiency, ten patients were planned de novo by experienced and novice planners and a RTIP user. RESULTS: The average planning time with RTIP was <20 min, and most plans required only one optimization. All 20 RTIP plans were preferred by a majority of oncologists due to improvements in OAR sparing. The average maximum dose to the spinal cord was reduced by 10.5 Gy (from 49.5 to 39.0 Gy), and the average mean doses for the oral cavity, laryngopharynx, contralateral parotid and submandibular glands were reduced by 3.5 Gy (39.1-35.7 Gy), 6.8 Gy (42.5-35.7 Gy), 1.7 Gy (17.0-15.3 Gy) and 3.3 Gy (22.9-19.5 Gy), respectively. CONCLUSIONS: Incorporating RTIP into clinical workflows may increase both planning efficiency and OAR sparing.

Patterns of Relapse in Squamous Cell Carcinoma of the Tonsil - Unilateral vs. Bilateral Radiation in the HPV-Era.

OBJECTIVES:  In the pre-human papillomavirus (HPV) era, unilateral radiation therapy (URT) for tonsil cancer was associated with low contralateral failure rates and had less toxicity than bilateral radiation therapy (BRT). This study explores the validity of URT in HPV-positive tonsil cancers. METHODS:  Tonsil squamous cell carcinomas (SCC) treated (typically with 70 Gy radiation and Cisplatin-based chemotherapy) between 2001 and 2007 were reviewed. Retrospective p16 immunohistochemistry staining was undertaken. Baseline, treatment, and response data were collected. RESULTS:  Of 182 patients, 78% were p16-positive, were younger (predominantly male), mostly former or non-smokers, and had a more advanced nodal stage. With a median follow-up of 68 months, contralateral recurrence (CLR) rates were low (3.5% p16-positive versus 2.5% p16-negative, p=0.63). Overall survival (OS) was 74% for p16-positive versus 54% for p16-negative subjects (p=0.01), but all other outcomes were similar. Analysis amongst only p16-positive subjects revealed URT was delivered to 37%, with CLR rates of 7.5% versus 1.1% for those treated with BRT, p=0.05. Of the four p16-positive subjects treated with URT who developed contralateral recurrences, three were managed with neck dissection (two disease-free and one died of lung metastases) and one received palliative radiation to the neck and distant metastatic site. All disease control and survival outcomes were similar between those treated with URT versus BRT. CONCLUSION:  While CLRs remain rare overall, there appears to be a slightly increased rate among HPV-positive subjects treated with URT. However, overall outcomes do not appear to be impacted, suggesting that URT remains a reasonable approach in HPV-positive subjects.

Follow-up patterns of cancer survivors: a survey of Canadian radiation oncologists.

PURPOSE: With continual advancements in cancer care, improved outcomes, and increasing survivors, survivorship has become an important area of research. This project seeks to determine the current status of follow-up care in oncology. METHODS: An electronic survey was sent to the Canadian Association of Radiation Oncology members. Based on brief clinical scenarios pertaining to various survivor populations, questions were posed to determine routine follow-up practices. RESULTS: One hundred eleven radiation oncologists (RO) responded (44% response rate); 29% were female, 43% were in practice <10 years, and most of Canada was represented. Most worked in centers with >10 oncologists (69%) and saw >200 new consults per year (78%). Only 10% reported not following their patients routinely, mainly in those with breast cancer. Most would follow their central nervous system, gastrointestinal, head and neck, gynecologic, and genitourinary patients. Lack of resources and a belief that follow-up by family physicians (FPs) is equally effective were the top reasons for not following. Treatment toxicity and possibility of further treatment were the most common reasons for routine follow-up. The majority (55%) would follow patients for <5 years, with 36% for 5-10 years, and a minority (9%) for longer than 10 years; 54% would not change the frequency of follow-up, but 39% would decrease and only 7% would increase follow-up. Some felt transferring more care to other health professionals would require additional training and more guidelines. Survivorship care plans are underutilized. CONCLUSIONS: Transfer of follow-up care to FPs is desired and feasible. This would allow for more comprehensive medical care and improve access to care for newly diagnosed patients. The development and usage of survivorship care plans would improve this care. IMPLICATIONS FOR CANCER SURVIVORS: Survivors may be increasingly followed by family physicians. Better coordination between oncologists and family physicians, including the use of survivorship care plans, may facilitate this transition.

Secondary sarcoma of bone post-prostate brachytherapy: A case report.

Malignancies associated with brachytherapy for prostate cancer are largely unreported in the literature. We report a case of post-brachytherapy osteogenic sarcoma in the pelvis 6 years after permanent (125)I implant for intermediate-risk prostate cancer. The patient was treated with neoadjuvant chemotherapy, limb-sparing surgical resection and postoperative radiation therapy for unexpected positive margins.

Toxicity and outcomes in combined modality treatment of head and neck squamous cell carcinoma: cisplatin versus cetuximab.

AIMS: The standard of care for locally advanced head and neck squamous cell carcinoma (HNSCC) is radiation therapy (RT) with concurrent cisplatin (CIS). Patients with renal or cardiac dysfunction, hearing loss or poor performance status (PS) may receive RT and cetuximab (CET) at our institution. This study compares treatment toxicities and outcomes. METHODS AND MATERIALS: All patients treated with curative intent RT and concurrent CIS (100 mg/m 2 Day 1, 22, 43) or CET (400 mg/m 2 Day -7, 250 mg/m 2 weekly during RT) between August 2007 and July 2010 were reviewed and toxicity and outcomes analyzed. RESULTS: Among 349 subjects (262 RT-CIS, 87 RT-CET) characteristics were similar except in age, head and neck subsite and RT fractionation. RT-CIS required more dose reductions, delays, and unplanned admissions and received less intended systemic therapy (ST). Weight loss and gastrostomy-tube use were similar. RT-CIS caused more nausea/vomiting, while RT-CET was associated with more dermatitis and acneiform rash. With mean follow-up of 20 months and 16 months, RT-CIS subjects experienced improved 1-year locoregional control (LRC) (90% vs. 72%, P < 0.01), disease-free survival (DFS) (83% vs. 67%, P < 0.01) and overall survival (OS) (90% vs. 80%, P = 0.04). On multivariate analysis type of ST was associated with LRC and DFS, but not OS. CONCLUSIONS: In patients with locally advanced HNSCC, CIS and CET were associated with different toxicity profiles. RT-CIS was associated with improved LRC and DFS, but similar OS compared to RT-CET.