Cost of upper tract imaging obtained during hematuria evaluation: Analysis of a national claims database.

INTRODUCTION: To investigate the actual cost of hematuria evaluation using nationally representative claims data, given that the workup for hematuria burdens the healthcare system with significant associated costs. We hypothesized that evaluation with contrast-enhanced computed tomography (CT) confers more cost to hematuria evaluation than renal ultrasound (US). METHODS: Using a national, privately insured database (MarketScan), we identified all individuals with an incident diagnosis of hematuria. We included patients who underwent cystoscopy and upper tract imaging within 3 months of diagnosis. We tabulated the costs of the imaging study as well as the total healthcare cost per patient. A multivariable model was developed to evaluate patient factors associated with total healthcare costs. RESULTS: We identified 318,680 patients with hematuria who underwent evaluation. Median costs associated with upper tract imaging were $362 overall, $504 for CT with contrast, $163 for US, $680 for magnetic resonance imaging (MRI), $283 for CT without contrast, and $294 for retrograde pyelogram. Median cystoscopy cost was $283. Total healthcare costs per patient were highest when utilizing MRI and CT imaging. When adjusted for comorbidities, the use of any imaging other than ultrasound was associated with higher costs. CONCLUSIONS: In this nationally representative analysis, hematuria evaluation confers a significant cost burden, while the primary factor associated with higher costs of screening was imaging type. Based upon reduced cost of US-based strategies, further investigation should delineate its cost-effectiveness in the diagnosis of urological disease.

The Kelowna template for combined intracavitary and interstitial brachytherapy for gynecologic malignancies: Design, application, treatment planning, dosimetric and treatment outcomes.

PURPOSE: We report the feasibility, experience, and early outcomes of the combined intracavitary and interstitial dedicated applicator using the Kelowna GYN template (Varian, Palo Alto, CA). METHODS AND MATERIALS: The Kelowna GYN template is CT compatible and used for the treatment of gynecologic cancers. In cases with patients that have an intact uterus, a modified applicator system using the Kelowna GYN template and a 3D printed adapter piece allows for compatibility with an intrautaerine tandem. RESULTS: We reviewed the treatment course of 23 patients comprising of 86 fractions of HDR treatment. Median D90 for cervical tumors (n = 7) was 82.4 Gy (range 77.7-92.6); for postoperative cervical tumors (n = 2) was 73.9 Gy (range 72.0-5.8); for vaginal tumors (n = 4) was 85.8 Gy (range 79.8-88.1); for recurrent endometrial (n = 10) was 86.9 Gy (range 74.8-103.2). Median EQD2 D2cc for bladder was 72.4 Gy (range 47.7-99.4), for rectum was 61.2 Gy (range 52.4-80.6), and for sigmoid colon of 50.5 Gy (44.3-66.9). At a median follow-up of 12 months, 2 patients had a local recurrence. Two patients had distant recurrence: one with carcinomatosis at 6 months, and one with pulmonary metastases at 3 months. No patients had late grade three toxicities. CONCLUSIONS: Our single institutional experience supports the use of the Kelowna template as a robust system as a combined IC-IS applicator resulting in versatile and reproducible implants for a variety of gynecologic malignancies.

Gynecologic interstitial brachytherapy curriculum using a low-cost phantom with ultrasound workshop and a treatment planning workshop is effective.

PURPOSE/OBJECTIVE(S): Standardized simulation training geared towards interstitial brachytherapy (IS BT) for gynecologic malignancies is lacking in radiation oncology resident education. We developed and implemented a curriculum for IS BT training with (1) lecture on equipment, workflow, and guidelines, (2) hands-on ultrasound-guided IS BT workshop, and (3) treatment planning workshop. METHODS AND MATERIAL: The cost in materials of each phantom was approximately $66. After a lecture, two alternating workshops were performed. The first session consisted of a hands-on ultrasound-guided IS BT workshop with one resident imaging the phantom with a transabdominal ultrasound probe and the other resident implanting the phantom with needles. A second session consisted of a hands-on treatment planning workshop using BrachyVision and an l-Q spreadsheet with the following objectives: coverage goal, meeting D2cc constraints, and minimizing V200. The primary outcome was improvement in knowledge assessed with Likert-style questions and objective knowledge-based questions (KBQs). RESULTS: Four of the seven medical residents that participated in this curriculum had prior IS BT experience. Residents reported significantly improved knowledge regarding gynecologic IS BT equipment and procedure, evaluating gynecologic anatomy using ultrasound, CT simulation, contouring, and plan review (overall median pre-session subjective score 2 (1) -(3) versus post-session score 4 (3) -(4, p < 0.01). Residents demonstrated improvement in answering KBQs correctly from 44% correct at baseline to 88% after completion of the curriculum (p < 0.01). All residents "Agree" and "Strongly Agree" the session was an effective learning experience. CONCLUSIONS: Residents participating in phantom training with an ultrasound curriculum and a treatment planning session is effective for improving knowledge and skills in IS BT for radiation oncology residents.

A Contemporary Update on the Role of Stereotactic Body Radiation Therapy (SBRT) for Liver Metastases in the Evolving Landscape of Oligometastatic Disease Management.

Metastases to the liver are common, and stereotactic body radiation therapy (SBRT) is a recognized tool for ablation of liver metastases. Colorectal cancers commonly metastasize to the liver, and long-term survival is possible after metastasectomy. However, many patients are not candidates for surgical resection, which opened the door to early studies investigating noninvasive techniques such as liver SBRT. Multiple prospective trials have demonstrated excellent local control with this approach coupled with an excellent safety record. The oligometastatic disease state is now appreciated across many histologies, and treatment of liver metastases as a component of oligometastatic disease management has emerged as a rational and relevant strategy. To this end, recent randomized studies in oligometastatic non-small-cell lung cancer demonstrated improved progression-free survival with consolidative local therapy, and this approach is the topic of ongoing cooperative group studies inclusive of patients with an array of primary histologies. Further, there is a push to explore the role of radiation as a means to enhance the efficacy of immune enabling drugs. Recent prospective data evaluating the safety and response of SBRT with anti-CTLA-4 therapy for patients with lung or liver metastasis demonstrated clinical benefit (out of field immune-related partial response or immune-related stable disease ≥6 months) in about a quarter of enrolled patients. Interestingly, SBRT to liver metastases was found to elicit a greater systemic immune response than SBRT to lung metastases. Classic management paradigms for metastatic disease are rapidly being supplanted by approaches that are improving outcomes for patients previously offered best supportive care or palliation alone. In this article, we will review the established and emerging potential indications for liver SBRT in this new era of oncologic care.

Physician Bias in Prophylactic Cranial Irradiation Decision Making-An Opportunity for a Patient Decision Aid.

INTRODUCTION: Guidelines have recommended prophylactic cranial irradiation (PCI) for patients with limited-stage small-cell lung cancer with at least a partial response after thoracic chemoradiation. However, the survival advantage has been small and was observed in an era before magnetic resonance imaging and surveillance. Neurotoxicity also remains a concern, especially in older adults. Thus, patients have a complex value-laden decision to make. We sought to better understand the role physicians play in patient decision making and introduce a patient decision aid (PDA) to potentially facilitate these discussions. MATERIALS AND METHODS: An e-mail survey was sent to International Association for the Study of Lung Cancer members querying their personal perspectives and professional recommendations regarding PCI for limited-stage small-cell lung cancer. RESULTS: We received 295 responses. Most were from the United States (35%) and Europe (35%) and were radiation (45%) or medical (43%) oncologists. Of those responding, 88% and 50% reported they would recommend PCI to a 50- and 70-year-old patient, respectively. Also, 79% reported that they would wish to receive PCI if faced with this decision. The physicians who would have chosen PCI if faced with the decision were 27.6 and 12.9 times more likely to recommend PCI to a 50- and 70-year-old patient, respectively, than were physicians who would not undergo PCI themselves. Most of the respondents had positive responses to the proposed PDA. CONCLUSION: Physician bias appears to play a role in PCI counseling, and most physicians reported that the provided PDA was better than their present method for discussing PCI and would help patients make such value-laden choices.

Brachytherapy should not be omitted when treating locally advanced neuroendocrine cervical cancer with definitive chemoradiation therapy.

PURPOSE: Neuroendocrine cervical cancer is a rare malignancy with a poor prognosis, yet there is a paucity of data to guide treatment decisions when managing patients with this diagnosis. Specifically, there are little data to aid practitioners in deciding if there is added value to brachytherapy given the additional time, cost, discomfort, and toxicity to patients. METHODS AND MATERIALS: We used the National Cancer Data Base to identify women with locally advanced neuroendocrine cervical cancer treated with definitive chemoradiotherapy to determine if the addition of brachytherapy improves outcomes in this disease. We also assessed outcomes based on chemotherapy timing in this cohort. RESULTS: We identified 100 patients with locally advanced nonmetastatic neuroendocrine cervical cancer that were treated with definitive chemoradiotherapy between 2004 and 2012. There was a substantial improvement in overall survival when brachytherapy was administered in addition to external beam radiotherapy. In multivariate analysis, the addition of brachytherapy, compared with external beam radiotherapy alone, was associated with an improved median survival of 48.6 vs. 21.6 months (hazard ratio (HR), 0.475; 95% CI, 0.255-0.883; p = 0.019). We observed no difference in overall survival for patients treated with neoadjuvant chemotherapy compared with the group who received chemotherapy started concurrently with radiation (HR, 0.851; 95% CI, 0.483-1.500; p = 0.578). CONCLUSIONS: Brachytherapy should be considered an essential component of definitive chemoradiotherapy for the treatment of neuroendocrine cervical cancer. Chemotherapy timing, however, does not impact outcome.