A Prospective Study Assessing the Efficacy and Toxicity of Stereotactic Body Radiation Therapy for Oligometastatic Bone Metastases.

Purpose: Stereotactic body radiation therapy (SBRT) is a promising treatment for oligometastatic disease in bone because of its delivery of high dose to target tissue and minimal dose to surrounding tissue. The purpose of this study is to assess the efficacy and toxicity of this treatment in patients with previously unirradiated oligometastatic bony disease. Methods and Materials: In this prospective phase II trial, patients with oligometastatic bone disease, defined as ≤3 active sites of disease, were treated with SBRT at Brigham and Women's Hospital/Dana Farber Cancer Center and Beth Israel Deaconess Medical Center between December 2016 and May 2019. SBRT dose and fractionation regimen were not protocol mandated. Local progression-free survival, progression-free survival, prostatic specific antigen progression, and overall survival were reported. Treatment-related toxicity was also reported. Results: A total of 98 patients and 126 lesions arising from various tumor histologies were included in this study. The median age of patients enrolled was 72.8 years (80.6% male, 19.4% female). Median follow-up was 26.7 months. The most common histology was prostate cancer (68.4%, 67/98). The most common dose prescriptions were 27/30 Gy in 3 fractions (27.0%, 34/126), 30 Gy in 5 fractions (16.7%, 21/126), or 30/35 Gy in 5 fractions (16.7%, 21/126). Multiple doses per treatment regimen reflect dose painting employing the lower dose to the clinical target volume and higher dose to the gross tumor volume. Four patients (4.1%, 4/98) experienced local progression at 1 site for each patient (3.2%, 4/126). Among the entire cohort, 2-year local progression-free survival (including death without local progression) was 84.8%, 2-year progression-free survival (including deaths as well as local, distant, and prostatic specific antigen progression) was 47.5%, and 2-year overall survival was 87.3%. Twenty-six patients (26.5%, 26/98) developed treatment-related toxicities. Conclusions: Our study supports existing literature in showing that SBRT is effective and tolerable in patients with oligometastatic bone disease. Larger phase III trials are necessary and reasonable to determine long-term efficacy and toxicities.

Survival in Patients With Spinal Metastatic Disease Treated Nonoperatively With Radiotherapy: Are the SORG-ML Algorithms Relevant?

SUMMARY OF BACKGROUND DATA: The SORG-ML algorithms for survival in spinal metastatic disease were developed in patients who underwent surgery and were externally validated for patients managed operatively. OBJECTIVE: To externally validate the SORG-ML algorithms for survival in spinal metastatic disease in patients managed nonoperatively with radiation. STUDY DESIGN: Retrospective cohort. METHODS: The performance of the SORG-ML algorithms was assessed by discrimination [receiver operating curves and area under the receiver operating curve (AUC)], calibration (calibration plots), decision curve analysis, and overall performance (Brier score). The primary outcomes were 90-day and 1-year mortality. RESULTS: Overall, 2074 adult patients underwent radiation for spinal metastatic disease and 29% (n=521) and 59% (n=917) had 90-day and 1-year mortality, respectively. On complete case analysis (n=415), the AUC was 0.76 (95% CI: 0.71-0.80) and 0.78 (95% CI: 0.73-0.83) for 90-day and 1-year mortality with fair calibration and positive net benefit confirmed by the decision curve analysis. With multiple imputation (n=2074), the AUC was 0.85 (95% CI: 0.83-0.87) and 0.87 (95% CI: 0.85-0.89) for 90-day and 1-year mortality with fair calibration and positive net benefit confirmed by the decision curve analysis. CONCLUSION: The SORG-ML algorithms for survival in spinal metastatic disease generalize well to patients managed nonoperatively with radiation.

Clinical Outcomes Among Patients Treated With Stereotactic Body Radiation Therapy to Femur Metastases for Oligometastatic Disease Control or Reirradiation: Results From a Large Single-Institution Experience.

Purpose: There are limited data regarding outcomes after stereotactic body radiation therapy (SBRT) for femur metastases, which was an exclusion criteria for the Stereotactic Ablative Radiotherapy for the Comprehensive Treatment of Oligometastatic Cancers (SABR-COMET) trial. We aimed to characterize clinical outcomes from a large single institution experience. Methods and Materials: Forty-eight patients with 53 lesions were consecutively treated with femur SBRT from May 2017 to June 2022. The Kaplan-Meier method and Cox proportional hazard models were used to characterize time-to-event endpoints and associations between baseline factors and clinical outcomes, respectively. Local control and locoregional control were defined as the absence of tumor progression within the radiation treatment field or within the treated femur, respectively. Results: Most patients had Eastern Cooperative Oncology Group performance status 0 to 1 (90%), prostate (52%) or breast/lung (17%) cancer, and 1 to 3 lesions (100%), including 29 proximal and 5 distal. Fifty-seven percent of the lesions were treated with concurrent systemic therapy. Median planning target volume was 49.1 cc (range, 6.6-387 cc). Planning target volume V100 (%) was 99% (range, 90-100). Fractionation included 18 to 20 Gy/1F, 27 to 30 Gy/3F, and 28.5-40 Gy/5F. Forty-two percent had Mirels score ≥7 and most (94%) did not have extraosseous extension. Acute toxicities included grade 1 fatigue (15%), pain flare (7.5%), nausea (3.8%), and decreased blood counts (1.9%). Late toxicities included fracture (1.9%) at 1.5 years and osteonecrosis (4%) from dose of 40 Gy in 5F and 30 Gy in 5F (after prior 30 Gy/10F). One patient (2%) required fixation postradiation for progressive pain. With median follow-up 19.4 months, 1- and 2-year rates of local control were 94% and 89%, locoregional control was 83% and 67%, progression-free survival were 56% and 25%, and overall survival were 91% and 73%. Fifty percent of local regional recurrence events occurred within 5 cm of gross tumor volume. Conclusions: Femur SBRT for oligometastatic disease control in well-selected patients was associated with good outcomes with minimal rates of acute and late toxicity. Patterns of local regional recurrence warrant consideration of larger elective volume coverage. Additional prospective study is needed.

Decoding biological age from face photographs using deep learning.

Because humans age at different rates, a person's physical appearance may yield insights into their biological age and physiological health more reliably than their chronological age. In medicine, however, appearance is incorporated into medical judgments in a subjective and non-standardized fashion. In this study, we developed and validated FaceAge, a deep learning system to estimate biological age from easily obtainable and low-cost face photographs. FaceAge was trained on data from 58,851 healthy individuals, and clinical utility was evaluated on data from 6,196 patients with cancer diagnoses from two institutions in the United States and The Netherlands. To assess the prognostic relevance of FaceAge estimation, we performed Kaplan Meier survival analysis. To test a relevant clinical application of FaceAge, we assessed the performance of FaceAge in end-of-life patients with metastatic cancer who received palliative treatment by incorporating FaceAge into clinical prediction models. We found that, on average, cancer patients look older than their chronological age, and looking older is correlated with worse overall survival. FaceAge demonstrated significant independent prognostic performance in a range of cancer types and stages. We found that FaceAge can improve physicians' survival predictions in incurable patients receiving palliative treatments, highlighting the clinical utility of the algorithm to support end-of-life decision-making. FaceAge was also significantly associated with molecular mechanisms of senescence through gene analysis, while age was not. These findings may extend to diseases beyond cancer, motivating using deep learning algorithms to translate a patient's visual appearance into objective, quantitative, and clinically useful measures.

Advance care planning and hospital outcomes in solid tumour oncology inpatients.

OBJECTIVES: To assess the association between advance care planning (ACP) and outcomes of in-hospital mortality, 30-day hospital readmission and 30-day emergency department (ED) visits among patients with cancer. METHODS: This observational cohort analysis included patients with solid tumour malignancies receiving oncology care and admitted at Yale New Haven Hospital between 1 January 2018 and 31 December 2021. RESULTS: Among 19 422 patients, 1283 (6.6%) had a documented ACP note. Compared with patients without an ACP, patients with an ACP tended to be older, have longer LOS, be admitted to an oncology inpatient team, subsequently admitted to intensive care unit and have a lower Rothman Index. Multivariable logistic regression identified ACP as independently associated with decreased 30-day readmission (OR=0.70 (95% CI: 0.60 to 0.82)) and 30-day ED visit (OR=0.79 (95% CI: 0.68 to 0.91)), adjusting for in-hospital mortality and patient characteristics. CONCLUSION: ACP documentation is associated with decreased readmissions and ED visits, independent of hospice utilisation.

Is Oligometastatic Cancer Curable? A Survey of Oncologist Perspectives, Decision Making, and Communication.

Purpose: Oligometastatic disease (OMD) refers to a limited state of metastatic cancer, which potentially derives benefit from local treatments. Given the relative novelty of this paradigm, oncologist perspectives on OMD are not well established. We thus explored oncologist views on curability of and treatment recommendations for patients with OMD. Methods and Materials: We developed a survey focused on oncologist views of 3 subtypes of OMD: synchronous, oligorecurrent, and oligoprogressive. Eligible participants included medical and radiation oncologists at 2 large cancer centers invited to participate between May and June 2022. Participants were presented with 3 hypothetical patient scenarios and asked about treatment recommendations, rationale, and demographic information. Results: Of 44 respondents, over half (61.4%) agreed that synchronous OMD is curable. A smaller proportion (46.2% and 13.5%) agreed for oligorecurrence and oligoprogression, respectively. When asked whether they use the word "cure" or "curative" in discussing prognosis, 31.8% and 33.3% agreed for synchronous and oligorecurrent OMD, respectively, while 78.4% disagreed for oligoprogression. Views on curability did not significantly affect treatment recommendations. More medical oncologists recommended systemic treatment only compared with radiation oncologists for the synchronous OMD (50.0% vs 5.3%; P < .01) and oligoprogression cases (43.8% vs 10.5%; P = .02), not the oligorecurrent case. There were no significant differences in confidence in treatment recommendations by specialty. Conclusions: In this exploratory study, we found notable divergence in oncologists' views about curability of OMD as well as variability in treatment recommendations, suggesting need for more robust research on outcomes of patients with OMD.

Spiritual needs in Denmark: a population-based cross-sectional survey linked to Danish national registers.

Background: Spiritual aspects of the human condition may give rise to spiritual pain and suffering, especially in the face of illness or difficult life situations. A growing volume of research documents the effects of religiosity, spirituality, meaning, and purpose on health. In supposedly secular societies, however, spiritual matters are rarely addressed in healthcare. This is the first large scale study to examine spiritual needs in Danish culture, and the largest study on spiritual needs to date. Methods: A population-based sample of 104,137 adult (≥18 yrs) Danes were surveyed cross-sectionally (the EXICODE study) and responses were linked to data from Danish national registers. The primary outcome was spiritual needs in four dimensions: religious, existential, generativity, and inner peace. Logistic regression models were fitted to examine the relationship between participant characteristics and spiritual needs. Findings: A total of 26,678 participants responded to the survey (25.6%). Of included participants 19,507 (81.9%) reported at least one strong or very strong spiritual need in the past month. The Danes scored highest on inner peace needs, followed by generativity, then existential, and lastly, religious needs. Affiliating as religious or spiritual, regularly meditating or praying, or reporting low health, low life satisfaction, or low well-being increased the odds of having spiritual needs. Interpretation: This study demonstrated that spiritual needs are common among Danes. These findings have important implications for public health policies and clinical care. Care for the spiritual dimension of health is warranted as part of holistic, person-centered care in what we term 'post-secular' societies. Future research should inform how spiritual needs might be addressed in healthy and diseased populations in Denmark and other European countries and the clinical effectiveness of such interventions. Funding: The paper was supported by the Danish Cancer Society (R247-A14755), The Jascha Foundation (ID 3610), The Danish Lung Foundation, AgeCare, and the University of Southern Denmark.

Spinal Cord Delineation Based on Computed Tomography Myelogram Versus T2 Magnetic Resonance Imaging in Spinal Stereotactic Body Radiation Therapy.

Purpose: Spinal cord delineation is critical to the delivery of stereotactic body radiation therapy (SBRT). Although underestimating the spinal cord can lead to irreversible myelopathy, overestimating the spinal cord may compromise the planning target volume coverage. We compare spinal cord contours based on computed tomography (CT) simulation with a myelogram to spinal cord contours based on fused axial T2 magnetic resonance imaging (MRI). Methods and Materials: Eight patients with 9 spinal metastases treated with spinal SBRT were contoured by 8 radiation oncologists, neurosurgeons, and physicists, with spinal cord definition based on (1) fused axial T2 MRI and (2) CT-myelogram simulation images, yielding 72 sets of spinal cord contours. The spinal cord volume was contoured at the target vertebral body volume based on both images. The mixed-effect model assessed comparisons of T2 MRI- to myelogram-defined spinal cord in centroid deviations (deviations in the center point of the cord) through the vertebral body target volume, spinal cord volumes, and maximum doses (0.035 cc point) to the spinal cord applying the patient's SBRT treatment plan, in addition to in-between and within-subject variabilities. Results: The estimate for the fixed effect from the mixed model showed that the mean difference between 72 CT volumes and 72 MRI volumes was 0.06 cc and was not statistically significant (95% confidence interval, -0.034, 0.153; P = .1832). The mixed model showed that the mean dose at 0.035 cc for CT-defined spinal cord contours was 1.24 Gy lower than that of MRI-defined spinal cord contours and was statistically significant (95% confidence interval, -2.292, -0.180; P = .0271). Also, the mixed model indicated no statistical significance for deviations in any of the axes between MRI-defined spinal cord contours and CT-defined spinal cord contours. Conclusions: CT myelogram may not be required when MRI imaging is feasible, although uncertainty at the cord-to-treatment volume interface may result in overcontouring and hence higher estimated cord dose-maximums with axial T2 MRI-based cord definition.

Spirituality and spiritual distress in neurologic illness.

Neurologic illnesses present multiple challenges to patients and their families from the time of initial diagnosis and throughout their illness trajectory, including challenges related to accepting the diagnosis and its various impacts and anxiety about future living with their illness. Often patients and their families rely on their spirituality to cope with and to maintain meaning and dignity in the midst of disease. As a result, spiritual care provision is a critical component of holistic medical care to patients with neurologic illness. Spiritual care provision follows a generalist-specialist model, which requires all healthcare professionals involved in the care of patients facing serious illness to play a role in recognizing and addressing spiritual needs. This model is characterized by generalist spiritual care providers (e.g., nurses, physicians, social workers) who perform spiritual screenings through history taking. Chaplains function as specialist spiritual care providers and can address spiritual care more deeply. In addition, several developed psychotherapeutic approaches may be useful for patients with neurologic disease, and chaplains are especially trained to offer supportive spiritual care to patients with neurologic illnesses and their families and to work together with physicians and other members of the healthcare team as part of a holistic approach to care.

Prognostic Understanding and Goals of Palliative Radiotherapy: A Qualitative Study.

CONTEXT: There is a paucity of data describing patients' expectations of goals of palliative radiotherapy (RT) and overall prognosis. OBJECTIVES: To explore patients' perceptions of and preferences for communication surrounding goals of palliative RT and cancer prognosis. METHODS: We conducted a qualitative study utilizing semi-structured interviews with seventeen patients with either bone or lung metastases receiving their first course of palliative RT at a comprehensive cancer center. All patient interviews were recorded, transcribed verbatim, and thematically analyzed. RESULTS: Themes of goals of palliative RT centered on either restoration, such as through improving quality of life or minimizing pain, or on a desire to combat cancer by eliminating tumor. While most patients perceived that palliative RT would palliate symptoms but not cure their cancer, some patients believed that the goal of palliative RT was to cure. Themes that emerged surrounding patients' understanding of prognosis and what lies ahead included uncertainty and apprehension about the future, a focus on additional treatment, and confronting mortality. Most patients preferred to receive information about goals of treatment and prognosis from their doctors, including radiation oncologists, rather than other members of the medical team. Patients also expressed a desire for written patient education materials on palliative RT. CONCLUSION: Unclear perceptions of goals of treatment and prognosis may motivate some patients to pursue unnecessarily aggressive cancer treatments. Patients desire prognostic information from their doctors, including radiation oncologists, who are important contributors to goals of care discussions and may improve patient understanding and well-being by using restorative rather than combat-oriented language.

Less Time Is Less Motion: Analysis of Practical Efficiencies Gained With a Modified Workflow Integrating Planar kV Midimaging With CBCT for Spine Stereotactic Body Radiation Therapy.

Purpose: Our purpose was to optimize an image guided radiation therapy (IGRT) workflow to achieve practical setup accuracy in spine stereotactic body radiation therapy (SBRT). We assessed the time-saving efficiencies gained from incorporating planar kV midimaging as a surrogate for cone beam computed tomography (CBCT) for intrafraction motion monitoring. Methods and Materials: We selected 5 thoracic spine SBRT patients treated in 5 fractions and analyzed patient shifts captured by a modified IGRT workflow using planar kV midimaging integrated with CBCT to maintain a tolerance of 1 mm and 1°. We determined the frequency at which kV midimaging captured intrafraction motion as validated on repeat CBCT and assessed the potential time and dosimetric advantages of our modified IGRT workflow. Results: Patient motion, detected as out-of-tolerance shifts on planar kV midimaging, occurred during 6 of 25 fractions (24%) and were validated on repeat CBCT 100% of the time. Observed intrafraction absolute shifts (mean ± standard deviation) for the 25 fractions were 0.39 ± 0.21, 0.56 ± 0.22, and 0.45 ± 0.21 mm for lateral-longitude-vertical translations and 0.38 ± 0.12°, 0.32 ± 0.09°, and 0.47 ± 0.14° for pitch-roll-yaw rotation, which if uncorrected, could have significantly affected target coverage and increased spinal cord dose. The average times for pretreatment imaging, midtreatment verification, and total treatment time were 8.94, 2.81, and 16.21 minutes. Our modified IGRT workflow reduced the total number of CBCTs required from 120 to 35 (70%) and imaging dose from 126.2 to 43.4 cGy (65.6%) while maintaining high fidelity for our patient population. Conclusions: Accurate patient positioning was effectively achieved with use of multiple 2-dimensional-3-dimensional kV images and an average of 1 verification CBCT scan per fraction. Integration of planar kV midimaging can effectively reduce treatment time associated with spine SBRT delivery and minimize the potential dosimetric effect of intrafraction motion on target coverage and spinal cord dose.

Patient and Treatment Factors Associated With Improved Local Control and Survival in Oligometastatic Bone Disease: Results From a Large Single-Institution Experience Using Stereotactic Body Radiation Therapy.

PURPOSE: Limited data exist to guide optimal patient selection and treatment of bone metastases with curative intent despite the increasing application of stereotactic body radiation therapy (SBRT) for oligometastatic (OM) disease control and reirradiation (Re-RT). METHODS AND MATERIALS: Clinical characteristics for 434 patients consecutively treated with bone SBRT at a single institution from March 2011 to June 2020 were analyzed by OM, spine, and nonspine bone using Cox regression to determine association with local control (LC), progression-free survival (PFS), and overall survival (OS), and the Kaplan-Meier method to estimate PFS and OS. RESULTS: Most patients had prostate (39%) or breast/lung (21%) cancer and 1 to 3 lesions (96%), with 651 lesions (spine 63%) treated for Re-RT (12%) or OMD (88%), including synchronous (10%), metachronous (28%), repeat (27%), or induced (23%) states as defined by The European Society for Radiotherapy and Oncology and European Organisation for Research and Treatment of Cancer criteria. Biologically effective dose (BED10) ≥50 (hazard ratio, 0.68; 95% confidence interval, 0.48-0.96; P < .03) predicted improved LC among OM lesions and planning target volume (PTV) ≥150 cc (hazard ratio, 1.94; 95% confidence interval, 1.02-3.70; P < .04) predicted worse LC for nonspine bone. Prostate histology, performance status (PS) 0 to 1, and metastasis-free interval ≥2 year predicted improved PFS and OS (P < .05). Metachronous, synchronous, or repeat OM had higher PFS and OS (P ≤ .001) than induced OM. With median follow-up 25.7 months, 1- and 2-year PFS was 63% and 47% for OM and 36% and 25% for Re-RT; 1- and 2-year OS was 87% and 73% for OM and 58% and 43% for Re-RT. Acute toxicities included grade 1 to 2 pain flare (9%) and fatigue (14%). Late toxicities included fracture (1%) for OM and myelopathy (2.5%) or nerve pain (1.2%) for Re-RT. CONCLUSIONS: BED10 ≥50 for OM and PTV <150 cc for nonspine bone lesions was associated with improved LC. Prostate histology, PS 0 to 1, metastasis-free interval ≥2 years, and metachronous, synchronous, or repeat presentations per The European Society for Radiotherapy and Oncology and European Organisation for Research and Treatment of Cancer criteria predicted improved PFS and OS among OM patients treated with bone SBRT.

Longitudinal symptoms and temporal trends in palliative care, palliative radiotherapy, and anti-cancer treatment near end of life among patients with metastatic cancer.

BACKGROUND: Early specialty palliative care (PC) integration improves oncologic outcomes. We aimed to examine longitudinal relationships between specialty PC and palliative radiotherapy (RT), temporal distribution of symptoms, and predictors of earlier specialty PC. METHODS: We retrospectively reviewed 135 patients with metastatic cancer who received palliative RT at our institution (7/2017-2/2018) and who had died by final study follow-up (6/2021). Descriptive statistics summarized frequencies of clinical visits and symptoms over relative survival time (quartiles 1-3: first 75% of life remaining from metastatic diagnosis to death versus quartile 4: last 25% of life remaining from metastatic diagnosis to death). Logistic regression analyses revealed predictors of receiving earlier (quartiles 1-3) versus later (quartile 4) specialty PC. RESULTS: There were 16.3%, 10.4%, 26.7%, and 46.7% of palliative RT consultations, compared to 4.7%, 7.6%, 14.0%, and 73.7% of specialty PC visits, that occurred in quartiles 1, 2, 3, and 4, respectively. On multivariable analysis, pain significantly predicted for receiving earlier specialty PC [odds ratios (OR) =15.34; 95% confidence interval (CI): 2.16-324.23; P=0.020], while patients with ≥2 prior chemotherapy regimens were less likely to have received earlier specialty PC (OR =0.16; 95% CI: 0.04-0.58; P=0.009). The most common reasons for first specialty PC visit were addressing pain (61.0%) and goals of care (19.5%). Overall, 73.3% (99/135) of patients were referred to hospice and 9.6% (13/135) received either palliative RT, chemotherapy, or surgery within 30 days of death. CONCLUSIONS: Nearly 47% of palliative RT visits compared with 74% of specialty PC visits occurred in the last quarter of life from metastatic diagnosis to death. Multidisciplinary efforts are needed to manage longitudinal symptoms and offer goal-concordant care.

Spirituality in Serious Illness and Health.

Importance: Despite growing evidence, the role of spirituality in serious illness and health has not been systematically assessed. Objective: To review evidence concerning spirituality in serious illness and health and to identify implications for patient care and health outcomes. Evidence Review: Searches of PubMed, PsycINFO, and Web of Science identified articles with evidence addressing spirituality in serious illness or health, published January 2000 to April 2022. Independent reviewers screened, summarized, and graded articles that met eligibility criteria. Eligible serious illness studies included 100 or more participants; were prospective cohort studies, cross-sectional descriptive studies, meta-analyses, or randomized clinical trials; and included validated spirituality measures. Eligible health outcome studies prospectively examined associations with spirituality as cohort studies, case-control studies, or meta-analyses with samples of at least 1000 or were randomized trials with samples of at least 100 and used validated spirituality measures. Applying Cochrane criteria, studies were graded as having low, moderate, serious, or critical risk of bias, and studies with serious and critical risk of bias were excluded. Multidisciplinary Delphi panels consisting of clinicians, public health personnel, researchers, health systems leaders, and medical ethicists qualitatively synthesized and assessed the evidence and offered implications for health care. Evidence-synthesis statements and implications were derived from panelists' qualitative input; panelists rated the former on a 9-point scale (from "inconclusive" to "strongest evidence") and ranked the latter by order of priority. Findings: Of 8946 articles identified, 371 articles met inclusion criteria for serious illness; of these, 76.9% had low to moderate risk of bias. The Delphi panel review yielded 8 evidence statements supported by evidence categorized as strong and proposed 3 top-ranked implications of this evidence for serious illness: (1) incorporate spiritual care into care for patients with serious illness; (2) incorporate spiritual care education into training of interdisciplinary teams caring for persons with serious illness; and (3) include specialty practitioners of spiritual care in care of patients with serious illness. Of 6485 health outcomes articles, 215 met inclusion criteria; of these, 66.0% had low to moderate risk of bias. The Delphi panel review yielded 8 evidence statements supported by evidence categorized as strong and proposed 3 top-ranked implications of this evidence for health outcomes: (1) incorporate patient-centered and evidence-based approaches regarding associations of spiritual community with improved patient and population health outcomes; (2) increase awareness among health professionals of evidence for protective health associations of spiritual community; and (3) recognize spirituality as a social factor associated with health in research, community assessments, and program implementation. Conclusions and Relevance: This systematic review, analysis, and process, based on highest-quality evidence available and expert consensus, provided suggested implications for addressing spirituality in serious illness and health outcomes as part of person-centered, value-sensitive care.

Retrospective Review of Outcomes After Radiation Therapy for Oligoprogressive Disease on Immune Checkpoint Blockade.

PURPOSE: We retrospectively evaluated outcomes after radiation therapy for patients with oligoprogression on immune checkpoint inhibitors (ICI). METHODS AND MATERIALS: We identified patients irradiated to ≤5 progressive lesions while receiving ICI between 2010 and 2020. We excluded patients whose systemic therapy was switched after radiation but before progression. We evaluated predictors of local control (LC), progression-free survival (PFS) and overall survival (OS). RESULTS: We screened 1423 patients and identified 120 who were eligible; the most common histologies were lung cancer (n = 59) and melanoma (n = 36). The median number of oligoprogressive lesions was 1. For the median LC of irradiated oligoprogressive lesions, PFS and OS were not reached at 6.41 (4.67-7.66) and 29.80 (22.54-43.33) months, respectively. Tumor histology, radiated site, or radiation modality were not associated with LC, PFS, or OS. Local response to radiation (P < .0001) and radiation of newly developed lesions (P = .02) were associated with LC. Predictors of PFS on univariate and multivariate analyses were best response to radiation (P = .006) and high programmed death ligand 1 tumor proportion score (P = .02). On multivariate analyses, OS was associated with cumulative oligoprogressive lesion volumes (P = .02) and duration of ICI before oligoprogression (P = .03). CONCLUSIONS: Promising outcomes were observed among patients irradiated for oligoprogression on ICI, especially those with a favorable local response, high tumor programmed death ligand 1 expression, and those receiving ICI for longer periods before oligoprogression. These data can help identify patients well suited for radiation therapy versus those who should switch systemic treatment.

Evaluating the Role of Stereotactic Body Radiation Therapy With Respect to Androgen Receptor Signaling Inhibitors for Oligometastatic Prostate Cancer.

PURPOSE: Outcomes of stereotactic body radiation therapy (SBRT) with respect to androgen receptor signaling inhibitors (ARSI) have not been characterized for oligometastatic prostate cancer. We sought to characterize prostate specific antigen (PSA) response and progression-free survival (PFS) after SBRT among men who have progressed on ARSI therapy in the oligometastatic castration-resistant setting. METHODS AND MATERIALS: A single-institution retrospective analysis was performed for men with ARSI-resistant, oligometastatic, castrate-resistant prostate cancer (omCRPC). Intervention consisted of SBRT. PSA reduction greater than 50% and median PFS (PSA or radiographic progression) as determined by routine care comprised outcome measurements. Cox regression analysis was used to determine factors influencing PFS. RESULTS: Thirty-five men with ARSI-resistant omCRPC and 65 lesions treated with SBRT were followed for a median of 17.2 months. In 63% of men PSA reduction greater than 50% was achieved. Median PFS was 9.0 months. Incomplete ablation (defined as the presence of untreated lesions after SBRT or receipt of prior palliative radiation therapy doses) was associated with worse PFS (hazard ratio 4.21 [1.74-10.19]; P < .01). For a subgroup of 22 men with complete ablation of metastatic sites with SBRT, the median PFS was 13.1 months. One-year overall survival was 93.1% (95% confidence interval, 84.4-100). CONCLUSIONS: SBRT may augment the efficacy of ARSI in omCRPC, provided that all lesions receive ablative radiation doses. Future prospective study of SBRT for men receiving ARSI is warranted.

A Natural History of Patients Treated Operatively and Nonoperatively for Spinal Metastases Over 2 Years Following Treatment: Survival and Functional Outcomes.

STUDY DESIGN: Prospective observational study. OBJECTIVE: We present the natural history, including survival and function, among participants in the prospective observational study of spinal metastases treatment investigation. SUMMARY OF BACKGROUND DATA: Surgical treatment has been touted as a means to preserve functional independence, quality of life, and survival. Nearly all prior investigations have been limited by retrospective design and relatively short-periods of post-treatment surveillance. METHODS: This natural history study was conducted using the records of patients who were enrolled in the prospective observational study of spinal metastases treatment study (2017-2019). Eligible participants were 18 or older and presenting for treatment of spinal metastatic disease. Patients were followed at predetermined intervals (1, 3, 6, 12, and 24-mo) following treatment. We conducted cox proportional hazard regression analysis adjusting for confounders including age, biologic sex, number of comorbidities, type of metastatic lesion, neurologic symptoms at presentation, number of metastases involving the vertebral body, vertebral body collapse, New England Spinal Metastasis Score (NESMS) at presentation, and treatment strategy. RESULTS: We included 202 patients. Twenty-three percent of the population had died by 3 months following treatment initiation, 51% by 1 year, and 70% at 2 years. There was no significant difference in survival between patients treated operatively and nonoperatively (P = 0.16). No significant difference in HRQL between groups was appreciated beyond 3 months following treatment initiation. NESMS at presentation (scores of 0 [HR 5.61; 95% CI 2.83, 11.13] and 1 [HR 3.00; 95% CI 1.60, 5.63]) was significantly associated with mortality. CONCLUSION: We found that patients treated operatively and nonoperatively for spinal metastases benefitted from treatment in terms of HRQL. Two-year mortality for the cohort as a whole was 70%. When prognosticating survival, the NESMS appears to be an effective utility, particularly among patients with scores of 0 or 1.Level of Evidence: 2.

Medical Outcomes of Oncology Inpatients With and Without Chaplain Spiritual Care Visit: The Yale New Haven Hospital Experience.

PURPOSE: Although there exists some literature on the psychosocial elements of health between patients with and without spiritual care, less information is available on hospital health outcomes. Hence, we aimed to describe and compare health care utilization and outcomes among medical oncology patients who received and did not receive spiritual care consultation during inpatient admission. METHODS: We conducted a retrospective chart review of medical oncology patients admitted to Yale New Haven Hospital between January 1, 2018, and December 31, 2020, to compare hospital outcomes between patients with and without spiritual care. RESULTS: Thirty-one thousand six hundred twenty-three patients were included, of whom 11,053 (35%) received a chaplain spiritual care visit and had a spiritual care note. Patients who received spiritual care were older and sicker. Readmission rates within 30 days were greater in the spiritual care group (OR = 1.07; P = .018). In addition, patients receiving spiritual care were at greater odds of increased length of stay (ß = 4.92; P < .0001), intensive care unit admission (OR = 2.98; P < .0001), hospital death (OR = 1.46; P < .0001), and emergency department visit within 30 days of discharge (OR = 1.17; P < .0001). CONCLUSION: Patients who were older and sicker had greater spiritual care utilization than their younger and healthier counterparts. Spiritual care assessment of existential distress, complex grief, and faith-based support may be positively associated not only with patient care and quality of life but also with health care utilization and outcomes.

Prospective comparison of the accuracy of the New England Spinal Metastasis Score (NESMS) to legacy scoring systems in prognosticating outcomes following treatment of spinal metastases.

BACKGROUND CONTEXT: We developed the New England Spinal Metastasis Score (NESMS) as a simple, informative, scoring scheme that could be applied to both operative and non-operative patients. The performance of the NESMS to other legacy scoring systems has not previously been compared using appropriately powered, prospectively collected, longitudinal data. PURPOSE: To compare the predictive capacity of the NESMS to the Tokuhashi, Tomita and Spinal Instability Neoplastic Score (SINS) in a prospective cohort, where all scores were assigned at the time of baseline enrollment. PATIENT SAMPLE: We enrolled 202 patients with spinal metastases who met inclusion criteria between 2017-2019. OUTCOME MEASURES: One-year survival (primary); 3-month mortality and ambulatory function at 3- and 6-months were considered secondarily. METHODS: All prognostic scores were assigned based on enrollment data, which was also assigned as time-zero. Patients were followed until death or survival at 365 days after enrollment. Survival was assessed using Kaplan-Meier curves and score performance was determined via logistic regression testing and observed to expected plots. The discriminative capacity (c-statistic) of the scoring measures were compared via the z-score. RESULTS: When comparing the discriminative capacity of the predictive scores, the NESMS had the highest c-statistic (0.79), followed by the Tomita (0.69), the Tokuhashi (0.67) and the SINS (0.54). The discriminative capacity of the NESMS was significantly greater (p-value range: 0.02 to <0.001) than any of the other predictive tools. The NESMS was also able to inform independent ambulatory function at 3- and 6-months, a function that was only uniformly replicated by the Tokuhashi score. CONCLUSIONS: The results of this prospective validation study indicate that the NESMS was able to differentiate survival to a significantly higher degree than the Tokuhashi, Tomita and SINS. We believe that these findings endorse the utilization of the NESMS as a prognostic tool capable of informing care for patients with spinal metastases.