Analysis of the Pediatric Radiotherapy Landscape in Mexico and a Subsequent Educational e-Contouring Intervention.

PURPOSE: Mexico and Central America have the highest childhood cancer incidence in the West. Pediatric-specific oncology knowledge contributes to the disparity. We sought to (1) determine the self-identified treatment patterns and needs of Mexican pediatric radiation oncologists and (2) pilot a workshop to improve contouring accuracy. MATERIALS AND METHODS: Partnering with local experts and the Sociedad Mexicana de Radioterapeutas (SOMERA), a 35-question survey was designed to ascertain pediatric radiotherapy capacity and distributed through the SOMERA listserv. The most challenging malignancies were selected for workshop. Participants received precontouring and postcontouring homework to assess improvement per the Dice metric. The Wilcoxon sign-rank test was used for comparative statistics. RESULTS: Ninety-four radiation oncologists attempted and 79 completed the survey. Forty-four (76%) felt comfortable treating a pediatric patient, and 36 (62%) were familiar with national protocols for pediatric treatment. Most had access to nutrition, rehabilitation, endocrinology, and anesthesia; 14% had access to fertility services and 27% to neurocognitive support; 11% noted no support, and only one respondent had child-life support. The postsurvey contouring workshop was conducted for high-grade glioma, medulloblastoma, and Hodgkin lymphoma. Significant improvements were seen in all target volumes. CONCLUSION: We present the first national survey of Mexico's pediatric radiotherapy capacity and Latin American e-contouring educational intervention with preworkshop and postworkshop Dice metrics, noting statistically significant improvement in all target volumes. Participation improved compared with prior experience through SOMERA partnership and Continuing Medical Education incentivization.

Mexican radiationdermatitis management consensus.

Background: Radiotherapy (RT) is an essential element in cancer treatment: 50-70% of cancer patients receive RT at some time of the course of their disease. Of these, almost 95% experience some grade of radiation dermatitis (RD). RD can affect patient's quality of life during and after treatment. Consequently, the management of RD is important. There are few randomized controlled clinical trials on interventions used to prevent and treat RD and no standardized consensus on RD management. A panel of opinion leaders of the Mexican Society of Radiotherapy (SOMERA) took part in a study of oncologic practice in Mexico. The following clinical guide is referenced both by the national practice reality and international evidence. Materials and methods: This RD management guide is based on input provided by 25 Mexican radiation oncologists, whose criteria were gathered using the Delphi Method and article review. Results: Twenty-one questions about experience in RD treatment were voted. More than 80% of the panel agreed with: the use of dermocosmetics/medical device in prevention and in treatment of RD grades 1-2. As for grade 3, they recommend individualizing each case and dermatologist evaluation. Topical steroids should be used when there is skin itching or pain. Consider the use of natural soaking elements. Skin care must be continued to avoid or reduce severity of late radiation skin lesions. Conclusion: This consensus was developed as a supportive educational tool that can be adapted to individual clinical needs, useful for professionals involved in the treatment of RT patients.

Cross-Sectional International Survey to Determine the Educational Interests of Spanish-Speaking Latin American Radiation Oncologists.

PURPOSE: With the existing oncology disparities in Latin America, physician expertise has been cited as a possible contributor to inferior oncologic outcomes in some cancers. As two-dimensional radiotherapy rapidly evolved to intensity-modulated radiation therapy in Latin America, adequate contouring education is an actionable target to improving physician knowledge and clinical outcomes. Yet, topics of interest to Latin American radiation oncologists are underreported. We assessed Latin American interest in a virtual platform for case discussion and identified the educational topics of most interest to them. MATERIALS AND METHODS: A Spanish-language online survey was designed by a team of Latin American educators. The questions assessed professional nationality, desire for an online educational platform for case presentation, career length, and topics of interest. Educational topics included head and neck (H&N), CNS, GI, lung, gynecologic, breast, and pediatric cancers, lymphoma, sarcoma, stereotactic body radiotherapy (SBRT), brachytherapy, and medical physics. RESULTS: One hundred thirty-three surveys were included for analysis. Overall, 127 respondents (98%) affirmed interest in participating in a virtual platform for case discussion and treatment advances. The most popular educational themes were H&N cancers (24%), SBRT (14%), and CNS cancers (13%). Of countries with > 10 respondents, the most popular educational topic remained H&N cancers for Argentina, Chile, and Mexico, but the most popular topic among Peruvian respondents was CNS cancer (27%). CONCLUSION: With international collaboration and a large sample size, we present the first survey results describing Latin American radiation oncology educational interests. Participants were overwhelmingly interested in a virtual platform, and most were specifically interested in H&N cancer education. These results can be used for focused didactic preparation in Latin America. Future efforts should expand on improving representation and outreach among Central American radiation oncologists.

Spillovers of health education at school on parents' physical activity.

This paper exploits state health education (HED) reforms as quasi-natural experiments to estimate the causal impact of HED received by children on their parents' physical activity. We use data from the Panel Study of Income Dynamics for the period 1999-2005 merged with data on state HED reforms from the National Association of State Boards of Education Health Policy Database and the 2000 and 2006 School Health Policies and Programs Study. To identify the spillover effects of HED requirements on parents' behavior, we use several methodologies (triple differences, changes in changes, and difference in differences) in which we allow for different types of treatments. We find a positive effect of HED reforms at the elementary school on the probability of parents doing light physical activity. Introducing major changes in HED increases the probability of fathers engaging in physical activity by between 6.3 and 13.7 percentage points, whereas on average, this probability for mothers does not seem to be affected. We analyze several heterogeneous impacts of the HED reforms to unveil the mechanisms behind these spillovers. We find evidence consistent with hypotheses such as gender specialization of parents in childcare activities or information sharing between children and parents.

¹8F-FDG PET/CT-based treatment response evaluation in locally advanced rectal cancer: a prospective validation of long-term outcomes.

PURPOSE: To prospectively evaluate the usefulness of (18)F-FDG PET/CT) imaging for predicting histopathological response and long-term clinical outcomes in locally advanced rectal cancer (LARC). METHODS: This prospective study included 38 patients with a confirmed diagnosis of LARC (cT3-4 or cN+) who underwent (18)F-FDG PET/CT before and after neoadjuvant therapy (NAT). Total mesorectal excision was scheduled 6 weeks after NAT and was followed by an expert histopathological analysis of the surgical specimen. Baseline variables and previously identified maximum FDG standardized uptake value (SUVmax) cut-off values before NAT (SUVmaxPRE ≥6) and after NAT (SUVmaxPOST ≥2), and the absolute and percentage reductions from baseline SUVmax (∆SUVmax <4 and ∆SUVmax% <65 %, respectively) were applied to differentiate patients showing a metabolic tumour response from nonresponders. These features were correlated with tumour regression grade (TRG), disease-free survival (DFS) and overall survival (OS). RESULTS: Significantly higher 5-year DFS and OS were seen in 19 responders (TRG 3 or 4) than in 19 nonresponders (TRG 0-2; 94.4 vs. 48.8 %, p = 0.001; 94.7 vs. 63.2 %, p = 0.02, respectively). In multivariate analysis the only PET/CT SUVmax-based parameter significantly correlated with the likelihood of recurrence and survival was ∆SUV% <65 % (HR = 5.95, p = 0.02, for DFS; HR = 5.26, p = 0.04, for OS) CONCLUSION: This prospective study proved that (18)F-FDG PET/CT is a valuable imaging tool for assessing rectal cancer TRG and long-term prognosis, and could potentially serve as an intermediate endpoint in treatment optimization research and rectal cancer patient care.

Aggressive treatment of primary tumor in patients with non-small-cell lung cancer and exclusively brain metastases.

Between 30% and 50% of patients with non-small-cell lung cancer (NSCLC) will develop cerebral metastases in the course of their illness. As improvements are made in the local brain treatment, the question arises on how to manage patients with NSCLC who have solely stable brain metastatic disease and if treatment should be considered for the primary lung lesion. The present article will review published series of patients with NSCLC and with brain metastases treated with aggressive thoracic management, with either lung tumor resection or thoracic radiation with or without chemotherapy as definitive treatment. We will also assess which prognostic factors may be useful in the identification of the subset of patients who could benefit from this more aggressive approach. For patients treated with surgical resection for the primary lung tumor, median survival ranged from 19 to 27 months, and the 1-, 2-, and 5-year survival reached 56%-69%, 28%-54%, and 11%-24%, respectively. Patients treated with aggressive radiotherapy with or without chemotherapy, achieved a median survival of 15.5-31.8 months, with a 1-year survival of 50%-71%, and a 2-year survival of 16%-60%. Well-selected patients with NSCLC and with exclusively oligometastatic cerebral disease represent a subgroup of patients with stage IV NSCLC that might achieve long-term survival after treatment directed to the brain and lung tumor lesions. Patients with N0 or N1 disease may be selected for surgical thoracic treatment, whereas those with N2 or N3 disease may benefit from combined chemoradiotherapy in the absence of progression after induction chemotherapy.

The effect of Medicaid eligibility on coverage, utilization, and children's health.

I estimate the causal impact of Medicaid eligibility on take up, private health insurance coverage, healthcare utilization, and children's health by using a regression discontinuity design. In contrast to a standard regression discontinuity design, identification exploits multiple thresholds that arise from variation across states in income eligibility rules. Using data from the Panel Study of Income Dynamics and its Child Development Study supplement, I find that Medicaid eligibility increases take up by 10-13 percentage points on average, rising to 24-29 percentage points at lower income eligibility thresholds. There are significant crowding out effects of the same magnitude as those on take up rates. Medicaid eligibility increases the use of preventive health care by 11-14 percentage points but only at low income thresholds. Finally, I find that Medicaid eligibility has no significant effects on health outcomes in the short and medium run.

(18)F-FDG PET bio-metabolic monitoring of neoadjuvant therapy effects in rectal cancer: focus on nodal disease characteristics.

OBJECTIVE: To evaluate efficacy of (18)F-FDG PET(CT) in the staging and re staging of patients with locally advanced rectal cancer, its potential role in predicting pathological response to neoadjuvant therapy. PATIENTS AND METHODS: Patients with confirmed diagnosis of rectal cancer (T2-4 or N+) were prospectively studied with (18)F-FDG PET before and after neoadjuvant therapy. Surgery was programmed 4-6 weeks after treatment followed by an expert histological analysis of the surgical specimen. Response to neoadjuvant treatment was assessed using two specific variables: difference in SUV (difSUV) pre/post-neoadjuvant treatment and response index (RI). RESULTS: A total of 64 patients were enrolled for pathological and bio-metabolic response assessment. Compared to cN0, cN+ patients had a higher SUV(1) mean value (6.5 vs. 7.6, p=0.04) and ypN+ patients had higher SUV(2) mean values (2.4 vs 3.5, p=0.06). difSUV values of ≥4 was the most efficient diagnostic parameter (sensitivity=45.8%, specificity=86.2%, positive predictive value (PPV)=73.3%, negative predictive value(NPV)=65.7%). With an RI of 66.6%, the sensitivity was 38.5%, specificity=81.5%, PPV=66.6%, and NPV=57.8%. Patients who experienced disease progression had an RI≤66% and a difSUV≤4. CONCLUSION: (18)F-FDG PET has proven to be an accurate diagnostic technique for assessing rectal cancer response to neoadjuvant therapy. The results in terms of sensitivity, specificity, PPV and NPV were similar, if not superior, to those reported with other diagnostic imaging techniques.

Preoperative chemoradiation with oral tegafur within a multidisciplinary therapeutic approach in patients with T3-4 rectal cancer.

PURPOSE: The aim of this study was to evaluate the activity in terms of downstaging histologic patterns of residual tumor and clinical tolerance of a neoadjuvant chemoradiation program with oral tegafur for rectal cancer. METHODS AND MATERIALS: From May 1998 to May 2001, 62 consecutive patients with cT(3-4) or cN(+) rectal cancer, or both, were treated with 45-50 Gy (1.8 Gy/day; 25 fractions) and oral tegafur 1200 mg/day. Surgery was performed 6 weeks after the completion of chemoradiation. All patients received a boost with intraoperative electron beam radiotherapy (IOERT) over the presacral space. RESULTS: Grade 3-4 hematologic toxicity consisted on Grade 3 anemia in 1 patient. Nonhematologic toxicity was mild. Fifteen patients (23%) had Grade 3 dermatitis, 16 (25%) had Grade 3, and 2 (3%) had Grade 4 proctitis. The median dose of radiotherapy was 50.4 Gy. Surgery consisted on anterior resection in 38 patients (61%) and abdominoperineal amputation in 24 (39%). Five complete pathologic responses were observed (8%), and 29 patients (47%) had a minimal microscopic residual tumor (mic category). The total downstaging rate was 68%. With a median follow-up of 46 months, the pelvic control rate was 95%, disease-free survival 74.1%, and overall survival 76.5%. CONCLUSIONS: Neoadjuvant chemoradiation with oral tegafur is feasible, well tolerated, and active, with the additional advantage of offering the convenience of oral chemotherapy.