Acute neurologic toxicity of palliative radiotherapy for brain metastases in patients receiving immune checkpoint blockade.

BACKGROUND: The interaction between immune checkpoint blockade (ICB) and radiation (RT) for brain metastases has not been well understood. Given that acute neurotoxicity from this combination is not well characterized, we reviewed patients receiving ICB and RT for brain metastases. METHODS: Patients treated with ICB and cranial RT from 2010 through 2017 were reviewed. ICB and RT must have been administered within 30 days of each other. Treatment parameters, performance status, symptoms prior to treatment, and toxicity were extracted from the electronic medical record. Survival was calculated from the end of RT to last follow-up or death. RESULTS: Seventy-eight patients were included. Median follow-up was 177 days (range, 12-1603). Median age was 64 years old (range, 29-98) and 47 (63%) were male. The main tumor types were melanoma (n = 47) and nonsmall-cell lung cancer (n = 19). Fifty-seven patients were treated with stereotactic radiosurgery (SRS) and 21 with whole-brain radiotherapy (WBRT). Most patients received single-agent ICB, though 4 patients received nivolumab and ipilimumab. Forty-one (53%) patients reported no neurologic toxicity. Grade 2 or greater neurologic toxicities were reported in 12 (21%) and 8 (38%) patients in the SRS and WBRT groups, respectively. WBRT was associated with a greater risk of any neurotoxicity, though there was no correlation between ICB agent and toxicity. Sequencing of ICB and RT (ie, <30 days vs <7) did not influence rates of toxicity. CONCLUSIONS: ICB during SRS or WBRT does not appear to worsen acute neurotoxicity compared to historical controls of RT alone.

Evaluating the Impact of Secure Mobile Messaging on Communication and Cancer Care Team Satisfaction in a Large Radiation Oncology Clinic.

PURPOSE: Communication is crucial in any clinical environment for efficient delivery of care and ensuring patient safety. A 2016 National Database of Nursing Quality Indicators questionnaire indicated poor physician-nurse satisfaction with communication in our department. We addressed gaps in our communication procedures by implementing a communication policy with a secure mobile messaging platform, and we surveyed care team members to evaluate the effectiveness of the implementation. METHODS: We designed a policy around best communication practices and implemented a secure mobile messaging platform, Cureatr, which enables closed-loop, two-way communication that is compliant with the Health Insurance Portability and Accountability Act. Pre- and postimplementation surveys evaluated self-reported impression of efficiency, timeliness, effectiveness, and overall quality of communication, which were scored on a 5-point Likert scale. The number of messages sent was evaluated as a measure of uptake in use, and patient navigation data were queried to measure changes in clinic workflow. RESULTS: After implementation of Cureatr and a communication policy, survey responses demonstrated a clear improvement in staff satisfaction with the efficiency, timeliness, effectiveness, and overall quality of communication. The number of messages sent reflected a progressive increase in use of Cureatr; however, a consistent improvement in clinical workflow as measured by a decrease in patient in-room time was not appreciated. CONCLUSION: Implementing a secure messaging application with a communication policy improved cancer care team satisfaction with communication on all levels. Additional work is needed to evaluate the impact of secure messaging on clinical workflows, patient satisfaction, and staff well-being.

A Single-institution Comparison of Cetuximab, Carboplatin, and Paclitaxel Induction Chemotherapy Followed by Chemoradiation (CRT) Versus CRT for Locally Advanced Squamous Cell Carcinoma of the Head and Neck (LA-SCCHN).

OBJECTIVES: Comparisons of induction chemotherapy (IC) against upfront chemoradiation (CRT) for locally advanced head and neck cancer (LA-HNSCC) have demonstrated no differences except greater toxicity with IC. Effective induction regimens that are less toxic are therefore warranted. To inform future efforts with IC, we present our institutional experience comparing a less toxic IC regimen to CRT. METHODS: We included patients with LA-HNSCC treated with organ-preservation CRT (+/-induction) between 2008 and 2011. Patients were of age above 18 years, ECOG performance status 0-1, and had minimum 6 months follow-up. IC consisted of 8 weekly cycles of cetuximab, carboplatin, and paclitaxel followed by CRT. The CRT regimen was platinum based, with cetuximab reserved for patients contraindicated to receive platinum. RESULTS: Of 118 patients, 24 (20%) received IC and 94 (80%) received CRT. Median follow-up was 17 (IC) and 19 (CRT) months (P=0.05). There were no differences in toxicity between the groups. IC patients were more likely male, with more advanced tumor and nodal stage. Even when controlling for these factors, IC was still associated with worse locoregional control (HR=3.6, P=0.02), distant metastasis-free survival (HR=5.3, P=0.02), and overall survival (HR=5.1, P<0.01). CONCLUSIONS: IC patients had greater disease burden than those receiving CRT. IC was well tolerated, but with significant rates of locoregional and systemic failures. Given the retrospective nature of the study, our findings are not meant to be definitive or conclusive, but rather suggestive in directing future efforts with IC. For now, we favor CRT as the standard option for treatment of inoperable LA-HNSCC.

Acute toxicity profile of patients with low-grade gliomas and meningiomas receiving proton therapy.

OBJECTIVES: Proton therapy is an emerging treatment modality. We studied its acute side effects on patients with low-grade gliomas and meningiomas. MATERIALS AND METHODS: Twenty-three patients diagnosed with low-grade gliomas or meningiomas enrolled in an Institutional Review Board-approved prospective proton treatment protocol (NCT01024907) were treated and followed between April 2010 and August 2011. Patients received 54 Gy (relative biological effectiveness) in 1.8 Gy (relative biological effectiveness) per fraction and were assessed at the time of consult, weekly during treatment, and at 1, 3, 6, and 9 months posttreatment. At each clinic visit, nursing completed a "Symptom Assessment/Grading" table. Symptoms were graded based on National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. RESULTS: Fatigue: At on-treatment visit (OTV) week 6, 13 patients had grade 1 and 6 patients had grade 2 fatigue. At 1-month follow-up, 3 patients had grade 1 and 1 patient had grade 2 fatigue. At each timepoint, 1 patient had grade 3 fatigue. Nausea: At OTV week 3, 5 patients experienced grade 1 nausea. At OTV week 6, 3 patients experienced grade 1 nausea. Headache: At OTV week 3, 10 patients had grade 1 headaches. At OTV week 6, 4 patients experienced grade 1 headaches and 1 patient by follow-up month 1. One to 2 patients experienced grade 2 headaches at each timepoint. At OTV week 3, 1 patient experienced a grade 3 headache. CONCLUSIONS: Our results suggest that proton therapy for patients with low-grade gliomas and meningiomas has a favorable acute toxicity profile-most patients experienced mild fatigue, headache, and insomnia that largely resolved by 1-month posttreatment.