Implementation and Efficacy of a Large-Scale Radiation Oncology Case-Based Peer-Review Quality Program across a Multinational Cancer Network.

PURPOSE: With expansion of academic cancer center networks across geographically-dispersed sites, ensuring high-quality delivery of care across all network affiliates is essential. We report on the characteristics and efficacy of a radiation oncology peer-review quality assurance (QA) system implemented across a large-scale multinational cancer network. METHODS AND MATERIALS: Since 2014, weekly case-based peer-review QA meetings have been standard for network radiation oncologists with radiation oncology faculty at a major academic center. This radiotherapy (RT) QA program involves pre-treatment peer-review of cases by disease site, with disease-site subspecialized main campus faculty members. This virtual QA platform involves direct review of the proposed RT plan as well as supporting data, including relevant pathology and imaging studies for each patient. Network RT plans were scored as being concordant or nonconcordant based on national guidelines, institutional recommendations, and/or expert judgment when considering individual patient-specific factors for a given case. Data from January 1, 2014, through December 31, 2019, were aggregated for analysis. RESULTS: Between 2014 and 2019, across 8 network centers, a total of 16,601 RT plans underwent peer-review. The network-based peer-review case volume increased over the study period, from 958 cases in 2014 to 4,487 in 2019. A combined global nonconcordance rate of 4.5% was noted, with the highest nonconcordance rates among head-and-neck cases (11.0%). For centers that joined the network during the study period, we observed a significant decrease in the nonconcordance rate over time (3.1% average annual decrease in nonconcordance, P = 0.01); among centers that joined the network prior to the study period, nonconcordance rates remained stable over time. CONCLUSIONS: Through a standardized QA platform, network-based multinational peer-review of RT plans can be achieved. Improved concordance rates among newly added network affiliates over time are noted, suggesting a positive impact of network membership on the quality of delivered cancer care.

Contemporary prostate cancer treatment choices in multidisciplinary clinics referenced to national trends.

BACKGROUND: The purpose of this study was to assess treatment choices among men with prostate cancer who presented at The University of Texas MD Anderson Cancer Center multidisciplinary (MultiD) clinic compared with nationwide trends. METHODS: In total, 4451 men with prostate cancer who presented at the MultiD clinic from 2004 to 2016 were analyzed. To assess nationwide trends, the authors analyzed 392,710 men with prostate cancer who were diagnosed between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. The primary endpoint was treatment choice as a function of pretreatment demographics. RESULTS: Univariate analyses revealed similar treatment trends in the MultiD and SEER cohorts. The use of procedural forms of definitive therapy decreased with age, including brachytherapy and prostatectomy (all P < .05). Later year of diagnosis/clinic visit was associated with decreased use of definitive treatments, whereas higher risk grouping was associated with increased use (all P < .001). Patients with low-risk disease treated at the MultiD clinic were more likely to receive nondefinitive therapy than patients in SEER, whereas the opposite trend was observed for patients with high-risk disease, with a substantial portion of high-risk patients in SEER not receiving definitive therapy. In the MultiD clinic, African American men with intermediate-risk and high-risk disease were more likely to receive definitive therapy than white men, but for SEER the opposite was true. CONCLUSIONS: Presentation at a MultiD clinic facilitates the appropriate disposition of patients with low-risk disease to nondefinitive strategies of patients with high-risk disease to definitive treatment, and it may obviate the influence of race.

Oncology Nurse Navigation: Development and Implementation of a Program at a Comprehensive Cancer Center
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BACKGROUND: Oncology nurse navigation programs enhance coordination of care and patient satisfaction. 
. OBJECTIVES: The objective was to evaluate the effect of oncology nurse navigation on access to care, patient and provider satisfaction, and clinical trial enrollment of patients with hematologic or gynecologic malignancies.
. METHODS: A descriptive cohort study with a historic control was undertaken. Data were collected from electronic health records and patient and provider surveys in two disease-specific groups.
. FINDINGS: A significant decrease in the mean days from first provider visit to first therapy was observed in the hematology population. In both groups, time from contact to first visit and from first visit to initiation of treatment decreased. Mean satisfaction survey scores for both groups were high regarding relationships with the navigator and care received. Providers were highly satisfied with the program, and the navigation program did not increase clinical trials enrollment.

The relevance of molecular biomarkers in cervical cancer patients treated with radiotherapy.

BACKGROUND: Radiotherapy (RT) plays an integral role in the combined-modality management of cervical cancer. Various molecular mechanisms have been implicated in the adaptive cellular response to RT. Identification of these molecular processes may permit the prediction of treatment outcome and enhanced radiation-induced cancer cell killing through tailoring of the management approach, and/or the employment of selective inhibitors of these pathways. METHODS: PubMed was searched for studies presenting biomarkers of cervical cancer radioresistance validated in patient studies or in laboratory experimentation. RESULTS: Several biomarkers of cervical cancer radioresistance are validated by patient survival or recurrence data. These biomarkers fall into categories of biological function including hypoxia, cell proliferation, cell-cell adhesion, and evasion of apoptosis. Additional radioresistance biomarkers have been identified in exploratory experiments. CONCLUSIONS: Biomarkers of radioresistance in cervical cancer may allow molecular profiling of individual tumors, leading to tailored therapies and better prognostication and prediction of outcomes.

Diagnosis and surgical delays in African American and white women with early-stage breast cancer.

BACKGROUND: Delays in diagnosis and treatment for breast cancer may contribute to excess deaths among African Americans. We examined racial differences in delays in diagnosis and surgical treatment for early-stage breast cancer and evaluated race-specific predictors associated with delay. METHODS: A retrospective cohort study was conducted among 634 African American and white women diagnosed with invasive breast cancer between 2005 and 2010 in New Jersey. Detailed medical-chart abstraction and patient interviews were undertaken. Time intervals were calculated from symptom recognition to diagnosis (diagnosis delay) and from diagnosis to first operation (surgical delay). Binomial regression models were used to examine racial differences in delay and factors associated with ≥2 months delay in the overall population and stratified by race. Reasons responsible for diagnosis delay were also examined by race. RESULTS: Compared to white women, African American women experienced significantly higher risk of ≥2 months delay in diagnosis and surgical treatment (adjusted relative risks=1.44 (1.12-1.86) and 3.08 (1.88-5.04), respectively). For the African Americans, predictors of diagnosis delay included mode of detection, insurance, and tumor size; for whites, mode of detection and tumor grade. Surgical delay was associated with operation type and education among African Americans but with operation type and tumor size for whites. Patient-related factors were commonly noted as reasons for diagnosis delay. CONCLUSIONS: These findings emphasize the need to raise further awareness, especially among African American patients and their providers, of the importance of prompt evaluation and treatment of breast abnormalities. Research on effective ways to accomplish this is needed.

Three-dimensional dosimetric considerations from different point A definitions in cervical cancer low-dose-rate brachytherapy.

PURPOSE: To investigate the dosimetric difference due to the different point A definitions in cervical cancer low-dose-rate (LDR) intracavitary brachytherapy. MATERIAL AND METHODS: Twenty CT-based LDR brachytherapy plans of 11 cervical patients were retrospectively reviewed. Two plans with point As following the modified Manchester system which defines point A being 2 cm superior to the cervical os along the tandem and 2 cm lateral (Aos), and the American Brachytherapy Society (ABS) guideline definition in which the point A is 2 cm superior to the vaginal fornices instead of os (Aovoid) were generated. Using the same source strength, two plans prescribed the same dose to Aos and Aovoid. Dosimetric differences between plans including point A dose rate, treatment volume encompassed by the prescription isodose line (TV), and dose rate of 2 cc of the rectum and bladder to the prescription dose were measured. RESULTS: On average Aovoid was 8.9 mm superior to Aos along the tandem direction with a standard deviation of 5.4 mm. With the same source strength and arrangement, Aos dose rate was 19% higher than Aovoid dose rate. The average TV(Aovoid) was 118.0 cc, which was 30% more than the average TV(Aos) of 93.0 cc. D2cc/D(Aprescribe) increased from 51% to 60% for rectum, and increased from 89% and 106% for bladder, if the prescription point changed from Aos to Aovoid. CONCLUSIONS: Different point A definitions lead to significant dose differences. Careful consideration should be given when changing practice from one point A definition to another, to ensure dosimetric and clinical equivalency from the previous clinical experiences.

Utilization of breast conserving therapy in stages 0, I, and II breast cancer patients in New Jersey: an American College of Surgeons National Cancer Data Base (NCDB) analysis.

BACKGROUND: The purpose of the study was to determine the use of breast conservation surgery (BCS) followed by whole breast irradiation [BCS+radiation therapy (RT)] in stages 0, I, and II breast cancer patients treated in New Jersey using the National Cancer Database. MATERIALS AND METHODS: A retrospective analysis was conducted using the data from 13 hospitals in New Jersey certified by the American College of Surgeons Commission on Cancer and members of the Cancer Institute of New Jersey's Network affiliates. Subjects with a first primary malignancy of the breast (stages 0, I, and II) treated from 2000 to 2006 were included in the analysis. RESULTS: A total of 11,146 patients with stage 0 (n=2843), stage I (n=4757), and stage II (n=3546) were treated for their breast cancer. Of stage 0, I, and II patients, 72% (n=2053), 73% (n=3482), and 53% (n=1865) received BCS, respectively. Of these patients, 40% (n=826), 67.6% (n=2353), and 63% (n=1177) received adjuvant RT after BCS for their stages 0, I, and II, respectively. Use of BCS+RT was equivalent across racial groups and all ages, except patients above 70 years of age (61% <40 y, 57% 40 to 49 y, 60% 50 to 59 y, 65% 60 to 69 y, and 51% >70 y). CONCLUSIONS: These data report an underutilization of RT after BCS in patients with stage 0 breast cancer treated across 13 hospitals in New Jersey. The Commission on Cancer's Rapid Quality Reporting System may be one method of identifying groups of patients not receiving care according to evidence-based guidelines.

A novel paradigm in the treatment of oligometastatic non-small cell lung cancer.

BACKGROUND: Stage IV non-small cell lung cancer (NSCLC) is thought to uniformly carry a poor prognosis with a median survival of less than 1 year and 5-year survival of less than 5%. In patients with a low volume (i.e. single site) of distant disease, the prognosis is slightly more favorable than that of more advanced (i.e. multiple sites of metastases) disease. For those with limited metastases, we developed a paradigm of adding concurrent chemotherapy and radiotherapy to the primary tumor once the tumor demonstrated chemotherapy sensitivity. METHODS: Charts of patients from 1999-2006 with non-small cell lung cancer were reviewed to find those with a single extra-thoracic site of disease treated with combined modality therapy. We found nine patients of 640 who met these criteria. Initial treatment consisted of induction chemotherapy, except for brain metastases which were managed first (n=1). If patients experienced a response to chemotherapy without new metastases, the extra-thoracic site was treated for total control with curative dose chemoradiotherapy to the primary site. Survival, time to progression, and sites of progression were assessed. RESULTS: Median survival was 28 months (95% CI 18-50 mo) with median time to progression of 15 months (95% CI 8-24 mo). All except one patient progressed in the CNS, either with brain metastases (n=7) or leptomeningeal disease (n=1). CONCLUSIONS: Such an approach offers the potential for enhanced quality and quantity of survival by incorporating aggressive RT for select patients without disease progression after induction chemotherapy. Patients tended to fail in the CNS, suggesting the importance of continued surveillance of the neuraxis or possibly prophylactic cranial irradiation. Future plans will correlate outcomes with molecular markers.

A novel method of island blocking in whole abdominal radiotherapy using a modified electronic tissue compensation technique.

Traditionally, large fields requiring island blocking used external beam radiation therapy (EBRT) with Cerrobend blocks to limit dose to the critical structures. It is laborious to construct blocks and use them on a daily basis. We present a novel technique for island blocking using a modified electronic tissue compensation (MECOMP) technique. Five patients treated at our institution were selected for this study. The study compared two planning techniques: a novel MECOMP and a conventional EBRT technique. Conventional fields were defined using anterior-posterior and posterior-anterior (PA) fields. The kidneys were contoured and an aperture cut-out block was fitted to the OAR with a 1-cm margin (OAR(CTV)) and placed in the PA field. A dynamic multileaf collimation (DMLC) plan with ECOMP was developed using identical beam and blocking strategy; this tissue compensation-based fluence map was modified to deliver a "zero" dose to the CTV(OAR) from the PA field. There were no significant differences in the mean, maximum, and minimum doses to the right or left kidney between the two methods. The mean, maximum, and minimum doses to the peritoneal cavity were also not significantly different. The number of monitor units (MUs) required was increased using the MECOMP (273 vs. 1152, p < 0.01). The MECOMP is effectively able to deliver DMLC-based radiotherapy, even with island blocks present. This novel use of MECOMP for whole abdominal radiotherapy should substantially reduce the labor, daily treatment time, and treatment-related errors through the elimination of cerrobend blocks.

Relevant patient and tumor considerations for early prostate cancer treatment.

Prostate cancer remains the most commonly diagnosed noncutaneous malignancy in American men. Currently, there are 3 standard treatment options available to men with early prostate cancer: expectant management, radiation therapy, and radical prostatectomy. Although a number of studies have evaluated survival after treatment for early prostate cancer, the optimal choice of therapy for any given patient remains a difficult decision and requires the consideration of a variety of patient and tumor factors. The final selection of therapy for early prostate cancer should be based on an informed discussion between the physician and patient. To accomplish this goal, patients must be made familiar with the pertinent factors that affect survival. We review the factors most relevant for patients to understand as they consider their treatment options for early prostate cancer and summarize the data for physicians who counsel them.

Causes for the undertreatment of elderly breast cancer patients: tailoring treatments to individual patients.

BACKGROUND: Ageism has been suggested as a cause for the undertreatment of elderly breast cancer patients. The purpose of this study was to determine the rate and causes of elderly patients not receiving standard therapy. STUDY DESIGN: A random sample of 500 patients was reviewed for age, cancer stage, surgical, radiation, cytotoxic or hormonal chemotherapy, number and type of comorbidities, type of therapeutic deficiencies, and their causes. RESULTS: The average age was 59.9+/-13.6 years. Of the patients less than 65 years old, 6.0% did not receive standard treatment, compared with 22.2% of patients 65 years or older. Treatment omitted in the less than 65-year-old group: 16.7%, no tumor extirpation; 38.9%, no axillary dissection; 33.3%, no radiation therapy; and 33.3% no chemotherapy. Treatment omitted in the 65-year and older group: 11.4%, no tumor extirpation; 39.1%, no axillary dissection; 47.7%, no radiation therapy; and 18.2%, no chemotherapy. Causes in the less than 65-year-old group were: prohibitive associated medical conditions, 27.8%; favorable primary tumor pathology, 16.7%; and patient treatment refusal, 55.6%. Causes in the 65-year and older group were: prohibitive associated medical conditions, 40.9%; favorable tumor pathology, 13.6%; patient treatment refusal, 31.8%; and unexplainable, 13.6%. The median number of concomitant medical conditions in patients receiving standard therapy was one compared with three in the undertreated patients from prohibitive associated medical conditions or unexplained causes. CONCLUSION: Population-based studies of breast cancer treatment do not adequately assess the complex decision making associated with breast cancer in the elderly. Patients do not receive standard care for specific reasons.