Proton beam therapy in paediatric cancer: Anticipating the opening of the Australian Bragg Centre for Proton Therapy and Research.

Proton Beam Therapy (PBT) has the potential to improve paediatric cancer care by reducing radiation exposure and thus long-term toxicities. Ethical concerns and debates surrounding the treatment, such as eligibility and accessibility, are ongoing in Australia. The Australian Bragg Centre for Proton Therapy and Research (ABCPTR) (named after Sir William Henry Bragg who described the Bragg peak in his laboratory at the University of Adelaide in 1903) aims to increase access to PBT in Australasia and offer a patient-centred care approach. Research is underway to assess PBT's safety and cost-effectiveness, using tools including Normal Tissue Complication Probability (NTCP) models. Collaborative efforts are focused on developing tailored survivorship clinics to enhance patient follow-up and quality of life. With the anticipated opening of the ABCPTR, Australia is preparing to take a significant step in radiation oncology, offering new research opportunities and creating a publicly funded treatment centre. The initiative aims to balance treatment efficacy with patient care, setting the stage for a future in which radiation therapy will reduce long-term side effects compared to the current standard of care. The implementation of PBT in Australia represents a complex and promising approach to paediatric oncology. This article provides an overview of the current landscape, highlighting the potential benefits and challenges of a treatment that could redefine the quality of survivorship and contribute to global research and best clinical practice.

Radiation Therapy and Indigenous Peoples in Canada and Australia: Building Paths Toward Reconciliation in Cancer Care Delivery.

Indigenous peoples represent approximately 5% of the world's population and reside in over 90 countries worldwide. They embody a rich diversity of cultures, traditions, languages and relationships with the land that are shared through many generations and that are distinct from those of the settler societies within which they now live. Many Indigenous peoples have a shared experience of discrimination, trauma, and violation of rights, rooted in complex sociopolitical relationships with settler societies that are still ongoing. This results in continuing social injustices and pronounced disparities in health for many Indigenous peoples around the globe. Indigenous peoples exhibit a significantly higher cancer incidence, mortality, and poorer survival compared to non-Indigenous peoples. Cancer services, including radiotherapy, have not been designed to support the specific values and needs of Indigenous populations, resulting in poorer access to cancer services for Indigenous peoples globally across the entire cancer care spectrum. Specific to radiotherapy, available evidence demonstrates disparities in radiotherapy uptake between Indigenous and non-Indigenous patients. Radiotherapy centres are also located disparately further away from Indigenous communities. Studies are limited by a lack of Indigenous-specific data to help inform effective radiotherapy delivery. Recent Indigenous-led partnerships and initiatives have helped to address existing gaps in cancer care, and radiation oncologists play an important role in supporting such efforts. In this article, we present an overview of access to radiotherapy for Indigenous peoples in Canada and Australia, with a focus on strengthening cancer care delivery through education, partnerships, and research.

Efficacy of topical Calendula officinalis on prevalence of radiation-induced dermatitis: A randomised controlled trial.

OBJECTIVES: A randomised controlled trial was undertaken to compare the efficacy of topical Calendula officinalis (Calendula) versus standard of care (Sorbolene: 10% glycerine in cetomacragol cream) in reducing the prevalence of radiation-induced dermatitis in women undergoing breast cancer radiotherapy. METHODS: A total of 271 women were screened and 82 were randomised. The primary outcome was prevalence of acute radiation-induced dermatitis (RTOG grade 2+) assessed at multiple skin sites. A chi-squared test was conducted for the primary outcome with a worst-case scenario imputation. RESULTS: The recruitment target (n = 178) was not achieved. A total of n = 81 participants were analysed (n = 40 Calendula; n = 41 Sorbolene). There was no detectable difference in prevalence of radiation-induced dermatitis grade 2+ between the Calendula (53%) and Sorbolene (62%) groups (primary analysis OR = 0.87, 95% CI: [0.36, 2.09], P = 0.92; covariate adjusted complete case analysis OR 0.40, 95% CI: [0.13, 1.20], P = 0.10). CONCLUSION: This randomised controlled trial showed no difference between Calendula and standard of care (Sorbolene) for the prevention of radiation-induced dermatitis. However, the study was underpowered (limited recruitment) for the primary comparison.

Survey of clinician opinions on the role of proton beam therapy in Australia and New Zealand.

INTRODUCTION: We surveyed the Australian and New Zealand (ANZ) radiation oncology community to assess their perceptions, understanding and experience of the current role of proton beam therapy (PBT) and the existing referral process to access PBT overseas, ahead of the development of the first PBT centre in Australia. METHODS: The survey was conducted between September and October 2019 using a 17-question instrument, which was distributed by email to all 632 radiation oncology fellows and trainees listed in the Royal Australian and New Zealand College of Radiologists database. RESULTS: One hundred and one respondents completed the survey, with an overall response rate of 16%. Most respondents were based in Australia (93%), with the majority working in public centres only (59%); 51% were > 10 years post fellowship and 17% were trainees. Most respondents (76%) reported moderate or high levels of confidence in the role of PBT. Only 28% had previously referred a patient for PBT overseas, with the most common referral indication being chordoma. Of those who had not previously referred a patient, 48% were not convinced about the rationale of PBT over current therapies available locally, 33% were not aware of the referral process, and 24% had concerns about the timeliness of a decision for government-funded PBT abroad. CONCLUSION: This survey has demonstrated that, although there is reasonable confidence in the role of PBT among ANZ radiation oncologists, there are a number of important aspects of PBT awareness, education and access that need to be developed prior to commencement of PBT in Australia.

Particle therapy toxicity outcomes: A systematic review.

Owing to its physical properties, particle therapy (PT), including proton beam therapy (PBT) and carbon ion therapy (CIT), can enhance the therapeutic ratio in radiation therapy. The major factor driving PT implementation is the reduction in exit and integral dose compared to photon plans, which is expected to translate to reduced toxicity and improved quality of life. This study extends the findings from a recent systematic review by the current authors which concentrated on tumour outcomes for PT, to now examine toxicity as a separate focus. Together, these reviews provide a comprehensive collation of the evidence relating to PT outcomes in clinical practice. Three major databases were searched by two independent researchers, and evidence quality was classified according to the National Health and Medical Research Council evidence hierarchy. One hundred and seventy-nine studies were included. Most demonstrated acceptable and favourable toxicity results. Comparative evidence reported reduced morbidities and improvement in quality of life in head and neck, paediatrics, sarcomas, adult central nervous system, gastrointestinal, ocular and prostate cancers compared to photon radiotherapy. This suggestion for reduced morbidity must be counterbalanced by the overall low quality of evidence. A concerted effort in the design of appropriate comparative clinical trials is needed which takes into account integration of PT's pace of technological advancements, including evolving delivery techniques, image guidance availability and sophistication of planning algorithms.

Particle therapy tumour outcomes: An updated systematic review.

Particle therapy (PT) offers the potential for reduced normal tissue damage as well as escalation of target dose, thereby enhancing the therapeutic ratio in radiation therapy. Reflecting the building momentum of PT use worldwide, construction has recently commenced for The Australian Bragg Centre for Proton Therapy and Research in Adelaide - the first PT centre in Australia. This systematic review aims to update the clinical evidence base for PT, both proton beam and carbon ion therapy. The purpose is to inform clinical decision-making for referral of patients to PT centres in Australia as they become operational and overseas in the interim. Three major databases were searched by two independent researchers, and evidence quality was classified according to the National Health and Medical Research Council evidence hierarchy. One hundred and thirty-six studies were included, two-thirds related to proton beam therapy alone. PT at the very least provides equivalent tumour outcomes compared to photon controls with the possibility of improved control in the case of carbon ion therapy. There is suggestion of reduced morbidities in a range of tumour sites, supporting the predictions from dosimetric modelling and the wide international acceptance of PT for specific indications based on this. Though promising, this needs to be counterbalanced by the overall low quality of evidence found, with 90% of studies of level IV (case series) evidence. Prospective comparative clinical trials, supplemented by database-derived outcome information, preferably conducted within international and national networks, are strongly recommended as PT is introduced into Australasia.

Comparative proton versus photon treatment planning for the Medicare Medical Treatment Overseas Program: The Royal Adelaide Hospital experience.

INTRODUCTION: Australia's first proton beam therapy (PBT) service, The Australian Bragg Centre for Proton Therapy and Research, is scheduled to open in the near future providing PBT for patients closer to home. Patients currently access Commonwealth funding for PBT via the Medicare Medical Treatment Overseas Program (MTOP). Proton versus photon treatment planning is a pre-requisite for the MTOP application. The Royal Adelaide Hospital (RAH) Department of Radiation Oncology has been providing this since 2016. We aim to provide a descriptive overview of our proton versus photon treatment planning process, presenting a summary of the comparative planning results and the treatment pathways selected for the patients referred. METHODS: All patients referred to the RAH for comparative planning between January 2016 and December 2018 were included in the analysis. Comparative plans were generated for each case using Pinnacle or Eclipse treatment planning systems. The planning techniques used and plan quality metrics were reported. RESULTS: Forty three patients were referred for comparative planning. The age range was 1-63 years, with the majority (72%) being paediatric patients (age ≤18 years). Of the 19 cases that have been submitted to MTOP, 16 have been accepted and 3 denied. Two of the accepted cases chose not to travel abroad for PBT. The other 14 cases have received PBT overseas. CONCLUSIONS: The RAH has provided an important service to demonstrate the dosimetric difference between PBT and photon therapy for Australian patients, an important step in supporting the funding of patients for treatment overseas.

Cost-effectiveness of proton therapy in treating base of skull chordoma.

While proton beam therapy (PBT) can offer increased sparing of healthy tissue, it is associated with large capital costs and as such, has limited availability. Furthermore, it has not been well established whether PBT has significant clinical advantages over conventional volumetric modulated arc therapy (VMAT) for all tumour types. PBT can potentially offer improved clinical outcomes for base of skull chordoma (BOSCh) patients compared with photon (X-ray) therapy, however the cost-effectiveness of these treatments is unclear. In this study, the cost-effectiveness of PBT in the treatment of BOSCh patients is assessed, based on an analysis of comparative radiotherapy treatment plans using a radiobiological Markov model. Seven BOSCh patients had treatment plans for the delivery of intensity modulated proton therapy and VMAT retrospectively analysed. The patient outcome (in terms of tumour local control and normal tissue complications) after receiving each treatment was estimated with a radiobiological Markov model. In addition, the model estimated the cost of both the primary treatment and treating any resultant adverse events. The incremental cost-effectiveness ratio (ICER) was obtained for each patient. PBT was found to be cost-effective for 5 patients and cost-saving for 2. The mean ICER was AUD$1,990 per quality adjusted life year gained. Variation of model parameters resulted in the proton treatments remaining cost-effective for these patients. Based on this cohort, PBT is a cost-effective treatment for patients with BOSCh. This supports the inclusion of PBT for BOSCh in the Medicare Services Advisory Committee 1455 application.

Change management for radiation therapists - transitioning to the new Royal Adelaide Hospital.

One of the largest change operations to take place in South Australia was the moving of the Royal Adelaide Hospital (RAH) to its new site in 2017. Change can influence workplace effectiveness and staff satisfaction and morale. Understanding the stages of change, staff experience and carefully managing the process is important. This paper aims to describe the successful move of the radiation therapy department at the RAH to its new site, focusing on the staff experience and management strategies to ensure the success of the move. A four-stage model of change was used to guide understand, manage and reflect upon the transition of the RAH radiation therapy department to a new site. Key change events and management strategies are described and aligned with the four stages of change. The move to the new site was a great success with a transition period working across two sites enabling a slower ramp up of activity at the new site supporting staff and patients in adjusting to the new environment. The four-stage model of change assisted in the smooth implementation of a transition plan for radiation oncology. At the RAH, innovation and development are encouraged, along with management having a comprehensive understanding of organisational change enabling the radiation oncology department to successfully navigate rapid change.

Measuring (and narrowing) the gap: The experience with attendance of Indigenous cancer patients for Radiation Therapy in the Northern Territory.

INTRODUCTION: Barriers exist for both Indigenous and remote patients attending cancer care facilities. We sought to measure clinical attendance of all patients referred for consideration of radiation therapy (RT) at the single radiation therapy centre in the Northern Territory (NT), with particular attention to a comparison of Indigenous and non-Indigenous patients, and to analyse methods introduced to address the attendance of patients. METHODS: Patients referred for radiation therapy over a 5 year period from the commencement of the Alan Walker Cancer Care Centre (AWCCC), NT, were analysed for attendance, and for possible improvement over time. RESULTS: Multivariate analysis of non-attendance prior to RT (pre-RT) showed significance for Indigenous status (P < 0.001), and female gender (P < 0.001), and during RT showed significance for Indigenous status (P < 0.001) and curative intent RT (P = 0.012). Attendance during RT over the 5 years showed significant improvement over time for Indigenous patients from 70.6% to 81.6% (P = 0.038). There was no significant improvement with pre-RT attendance for either the Indigenous or non-Indigenous cohort. CONCLUSION: Indigenous patients experienced a lower level of attendance during RT, but this has significantly improved over the first 5 years of operation at AWCCC, as recognition and management of contributing factors has improved.

Postoperative Concurrent Chemoradiotherapy Versus Postoperative Radiotherapy in High-Risk Cutaneous Squamous Cell Carcinoma of the Head and Neck: The Randomized Phase III TROG 05.01 Trial.

Purpose To report the results of the Trans Tasman Radiation Oncology Group randomized phase III trial designed to determine whether the addition of concurrent chemotherapy to postoperative radiotherapy (CRT) improved locoregional control in patients with high-risk cutaneous squamous cell carcinoma of the head and neck. Patients and Methods The primary objective was to determine whether there was a difference in freedom from locoregional relapse (FFLRR) between 60 or 66 Gy (6 to 6.5 weeks) with or without weekly carboplatin (area under the curve 2) after resection of gross disease. Secondary efficacy objectives were to compare disease-free survival and overall survival. Results Three hundred twenty-one patients were randomly assigned, with 310 patients commencing allocated treatment (radiotherapy [RT] alone, n = 157; CRT, n = 153). Two hundred thirty-eight patients (77%) had high-risk nodal disease, 59 (19%) had high-risk primary or in-transit disease, and 13 (4%) had both. Median follow-up was 60 months. Median RT dose was 60 Gy, with 84% of patients randomly assigned to CRT completing six cycles of carboplatin. The 2- and 5-year FFLRR rates were 88% (95% CI, 83% to 93%) and 83% (95% CI, 77% to 90%), respectively, for RT and 89% (95% CI, 84% to 94%) and 87% (95% CI, 81% to 93%; hazard ratio, 0.84; 95% CI, 0.46 to 1.55; P = .58), respectively, for CRT. There were no significant differences in disease-free or overall survival. Locoregional failure was the most common site of first treatment failure, with isolated distant metastases as the first site of failure seen in 7% of both arms. Treatment was well tolerated in both arms, with no observed enhancement of RT toxicity with carboplatin. Grade 3 or 4 late toxicities were infrequent. Conclusion Although surgery and postoperative RT provided excellent FFLRR, there was no observed benefit with the addition of weekly carboplatin.

Palliative chemoradiotherapy versus radiotherapy alone for dysphagia in advanced oesophageal cancer: a multicentre randomised controlled trial (TROG 03.01).

BACKGROUND: A short course of radiotherapy is commonly prescribed for palliative relief of malignant dysphagia in patients with incurable oesophageal cancer. We compared chemoradiotherapy with radiotherapy alone for dysphagia relief in the palliative setting. METHODS: This multicentre randomised controlled trial included patients with advanced or metastatic oesophageal cancer who were randomly assigned (1:1) through a computer-generated adaptive biased coin design to either palliative chemoradiotherapy or radiotherapy alone for treatment of malignant dysphagia at 22 hospitals in Australia, Canada, New Zealand, and the UK. Eligible patients had biopsy-proven oesophageal cancer that was unsuitable for curative treatment, symptomatic dysphagia, Eastern Cooperative Oncology Group performance status 0-2, and adequate haematological and renal function. Patients were stratified by hospital, dysphagia score (Mellow scale 1-4), and presence of metastases. The radiotherapy dose was 35 Gy in 15 fractions over 3 weeks for patients in Australia and New Zealand and 30 Gy in ten fractions over 2 weeks for patients in Canada and the UK. Chemotherapy consisted of one cycle of intravenous cisplatin (either 80 mg/m2 on day 1 or 20 mg/m2 per day on days 1-4 of radiotherapy at clinician's discretion) and intravenous fluorouracil 800 mg/m2 per day on days 1-4 of radiotherapy in week 1. Patients were assessed weekly during treatment. The primary endpoint was dysphagia relief (defined as ≥1 point reduction on the Mellow scale at 9 weeks and maintained 4 weeks later), and key secondary endpoints were dysphagia progression-free survival (defined as a worsening of at least 1 point on the Mellow scale from baseline or best response) and overall survival. These endpoints were analysed in the intention-to-treat population. This study is registered at ClinicalTrials.gov, number NCT00193882. This trial is closed. FINDINGS: Between July 7, 2003, and March 21, 2012, 111 patients were randomly assigned to chemoradiotherapy and 109 patients to radiotherapy. One patient in the chemoradiotherapy group was omitted from analysis because of ineligibility. 50 (45%, 95% CI 36-55) patients in the chemoradiotherapy group and 38 (35%, 26-44) in the radiotherapy group obtained dysphagia relief (difference 10·6%, 95% CI -2 to 23; p=0·13). Median dysphagia progression-free survival was 4·1 months (95% CI 3·5-4·8) versus 3·4 months (3·1-4·3) in the chemoradiotherapy and radiotherapy groups, respectively (p=0·58), and median overall survival was 6·9 months (95% CI 5·1-8·3) versus 6·7 months (4·9-8·0), respectively (p=0·88). Of the 211 patients who commenced radiotherapy, grade 3-4 acute toxicity occurred in 38 (36%) patients in the chemoradiotherapy group and in 17 (16%) patients in the radiotherapy group (p=0·0017). Anaemia, thrombocytopenia, neutropenia, oesophagitis, diarrhoea, nausea and vomiting, and mucositis were significantly worse in patients who had chemoradiotherapy than in patients who had radiotherapy. INTERPRETATION: Palliative chemoradiotherapy showed a modest, but not statistically significant, increase in dysphagia relief compared with radiotherapy alone, with minimal improvement in dysphagia progression-free survival and overall survival with chemoradiotherapy but at a cost of increased toxicity. A short course of radiotherapy alone should be considered a safe and well tolerated treatment for malignant dysphagia in the palliative setting. FUNDING: National Health and Medical Research Council, Canadian Cancer Society Research Institute, Canadian Cancer Trials Group, Trans Tasman Radiation Oncology Group, and Cancer Australia.

Phase I study evaluating the safety and efficacy of oral panobinostat in combination with radiotherapy or chemoradiotherapy in patients with inoperable stage III non-small-cell lung cancer.

Panobinostat is a radiosensitizing agent and targets the epigenetics of malignancy. This phase I study evaluated the safety and efficacy of combining oral panobinostat with radiotherapy (RT) or chemoradiotherapy (CRT) in patients with inoperable stage III non-small-cell lung cancer. This study had a parallel dose-escalating design combining oral panobinostat twice a week (dose escalations 20, 30, 45 mg) with either palliative RT (group A) or radical CRT (group B) using a standard chemotherapy protocol of cisplatin and etoposide. In group A (RT), nine recruited patients received treatment with oral panobinostat (doses 20, 30, 45 mg) with RT. Two serious adverse events, rapid atrial fibrillation and tracheo-oesophageal fistula, were not attributable to study treatment. The most common grade 3/4 toxicities were thrombocytopenia and lymphopenia, which resolved promptly after cessation of panobinostat. The disease control rate was 66%, the progression-free survival was 3 months and the median overall survival was 9 months. In group B (CRT), panobinostat dose was not escalated beyond 20 mg because of infection-related complications. Serious adverse events included opportunistic infection associated with treatment-related lymphopenia and febrile neutropenia without a source. One patient had cerebral infarct that was not attributed to study treatment. All patients achieved a partial response to treatment. At 33 months of follow-up, all patients were still alive. Panobinostat can be combined with palliative-dose RT at doses up to 45 mg twice a week with tolerable toxicity. Dose-limiting toxicities prevented the dose escalation of the panobinostat with CRT.

Post-traumatic stress disorder and post-traumatic growth in breast cancer patients--a systematic review.

Breast cancer (BC) is potentially a traumatic stressor which may be associated with negative outcomes, such as post-traumatic stress disorder (PTSD) or positive changes, such as post-traumatic growth (PTG). This study aims to identify the core issues of BC related PTSD, PTG and psychological distress by interrogating the literature in BC survivors. We have also highlighted issues related to the assessment, diagnosis and clinical management of PTSD and PTG. The authors systematically reviewed studies published from 1985 to 2014 pertaining to PTSD, psychological distress and PTG in BC survivors with particular attention paid to incidence rates and causative factors. Multiple studies intimated that women with BC have evidence of PTSD at the initial stages of diagnosis, whereas PTG develops once patients undergo treatment. Early diagnosis and treatment of PTSD/PTG is paramount from literature review but the previously mentioned relationship between PTSD and PTG in BC patients could not be verified. It is evident from the literature that a small percentage of BC patients experience PTSD, while the majority experience PTG after BC diagnosis and treatment. Future research should include prospective studies focusing on high-risk patients, causative factors and the development of psychological interventions.

External evaluation of the Radiation Therapy Oncology Group brachial plexus contouring protocol: several issues identified.

INTRODUCTION: The aims of the study were to evaluate interobserver variability in contouring the brachial plexus (BP) using the Radiation Therapy Oncology Group (RTOG)-approved protocol and to analyse BP dosimetries. METHODS: Seven outliners independently contoured the BPs of 15 consecutive patients. Interobserver variability was reviewed qualitatively (visually by using planning axial computed-tomography images and anteroposterior digitally reconstructed radiographs) and quantitatively (by volumetric and statistical analyses). Dose-volume histograms of BPs were calculated and compared. RESULTS: We found significant interobserver variability among outliners in both qualitative and quantitative analyses. These were most pronounced for the T1 nerve roots on visual inspection and for the BP volume on statistical analysis. The BP volumes were smaller than those described in the RTOG atlas paper, with a mean volume of 20.8 cc (range 11-40.7 cc) compared with 33 ± 4 cc (25.1-39.4 cc). The average values of mean dose, maximum dose, V60Gy, V66Gy and V70Gy for patients treated with conventional radiotherapy and IMRT were 42.2 Gy versus 44.8 Gy, 64.5 Gy versus 68.5 Gy, 6.1% versus 7.6%, 2.9% versus 2.4% and 0.6% versus 0.3%, respectively. CONCLUSION: This is the first independent external evaluation of the published protocol. We have identified several issues, including significant interobserver variation. Although radiation oncologists should contour BPs to avoid dose dumping, especially when using IMRT, the RTOG atlas should be used with caution. Because BPs are largely radiologically occult on CT, we propose the term brachial-plexus regions (BPRs) to represent regions where BPs are likely to be present. Consequently, BPRs should in principle be contoured generously.

Phase 3 trial of domiciliary humidification to mitigate acute mucosal toxicity during radiation therapy for head-and-neck cancer: first report of Trans Tasman Radiation Oncology Group (TROG) 07.03 RadioHUM study.

PURPOSE: To assess the impact of domicile-based humidification on symptom burden during radiation therapy (RT) for head-and-neck (H&N) cancer. METHODS AND MATERIALS: From June 2007 through June 2011, 210 patients with H&N cancer receiving RT were randomized to either a control arm or to receive humidification using the Fisher & Paykel Healthcare MR880 humidifier. Humidification commenced on day 1 of RT and continued until Common Terminology Criteria for Adverse Events (CTCAE), version 3.0, clinical mucositis (CMuc) grade ≤1 occurred. Forty-three patients (42%) met a defined benchmark for humidification compliance and contributed to per protocol (PP) analysis. Acute toxicities, hospitalizations, and feeding tube events were recorded prospectively. The McMaster University Head and Neck Radiotherapy Questionnaire (HNRQ) was used for patient-reported outcomes. The primary endpoint was area under the curve (AUC) for CMuc grade ≥2. RESULTS: There were no significant differences in AUC for CMuc ≥2 between the 2 arms. Humidification patients had significantly fewer days in hospital (P=.017). In compliant PP patients, the AUC for CTCAE functional mucositis score (FMuc) ≥2 was significantly reduced (P=.009), and the proportion who never required a feeding tube was significantly greater (P=.04). HNRQ PP analysis estimates also in the direction favoring humidification with less symptom severity, although differences at most time points did not reach significance. CONCLUSIONS: TROG 07.03 has provided efficacy signals consistent with a role for humidification in reducing symptom burden from mucositis, but the influence of humidification compliance on the results moderates recommendations regarding its practical utility.

Radiation treatment compliance in the Indigenous population: the pilot Northern Territory experience and future directions.

INTRODUCTION: There is a perception that Indigenous patients are less likely to attend radiotherapy treatment. This study sought to determine if a difference in radiotherapy treatment compliance rates exists between Indigenous and non-Indigenous patients. Secondly, we aimed to ascertain which patient, disease and treatment factors affect compliance in Indigenous patients. METHODS: All patients treated with radiotherapy at the Alan Walker Cancer Care Centre between March and October 2010 were analysed. Data regarding compliance rates (defined as those who chose and completed the recommended course of treatment), patient, disease and treatment factors were collected, and chi-squared and Fisher's exact tests were applied. RESULTS: A total of 41 courses were delivered to Indigenous patients and 224 courses delivered to non-Indigenous patients in this period. There was no difference in compliance between Indigenous and non-Indigenous patients (83% vs. 81%, P = 0.75). Of the factors assessed, it was found that there was an association between toxicity grade and compliance (P = 0.048). CONCLUSIONS: From this cohort, we cannot support the perception that Indigenous patients have overall poorer compliance with recommended radiation treatment courses. In this study, the only factor which correlated significantly with compliance was toxicity grade. It is felt that a number of factors, which negatively impact on compliance, can potentially be counteracted by a culturally sensitive model of care.

The complex relationship between lung tumor volume and survival in patients with non-small cell lung cancer treated by definitive radiotherapy: a prospective, observational prognostic factor study of the Trans-Tasman Radiation Oncology Group (TROG 99.05).

BACKGROUND AND PURPOSE: To investigate the hypothesis that primary tumor volume is prognostic independent of T and N stages in patients with non-small cell lung cancer (NSCLC) treated by definitive radiotherapy. MATERIALS AND METHODS: Multicenter prospective observational study. Patient eligibility: pathologically proven stage I-III non-small cell lung cancer planned for definitive radiotherapy (minimum 50 Gy in 20 fractions) using CT-based contouring. Volumes of the primary tumor and enlarged nodes were measured according to a standardized protocol. Survival was adjusted for the effect of T and N stage. RESULTS: There were 509 eligible patients. Five-year survival rates for tumor volume grouped by quartiles were, for increasing tumor volume, 22%, 14%, 15% and 21%. Larger primary tumor volume was associated with shorter survival (HR=1.060 (per doubling); 95% CI 1.01-1.12; P=0.029). However, after adjusting for the effects of T and N stage, there was no evidence for an association (HR=1.029, 95% CI, 0.96-1.10, P=0.39). There was evidence, however, that larger primary tumor volume was associated with an increased risk of dying, independently of T and N stage, in the first 18 months but not beyond. CONCLUSIONS: In patients treated by non-surgical means we were unable to show that lung tumor volume, overall, provides additional prognostic information beyond the T and N stage (TNM, 6th edition). There is evidence, however, that larger primary tumor volume adversely affects outcome only within the first 18 months. Larger tumor size alone should not by itself exclude patients from curative (chemo)radiotherapy.