Referral practices to dermatologists for the treatment of radiation dermatitis in the USA: a call for a multidisciplinary approach.

PURPOSE: Acute radiation dermatitis (RD) is a disfiguring and painful rash that occurs in up to 95% of patients receiving radiation therapy (RT) for cancer. Treatment for RD varies among practitioners with no evidence-based gold standard for management. While a multi-disciplinary approach has been utilized to manage other cancer-related toxicities, RD is most often managed by the treating radiation oncologist. METHODS: This study evaluated the referral practices of radiation oncologists to dermatologists for management of RD utilizing a survey of radiation oncologists across the USA. The goal was to identify the referral practices of radiation oncologists for RD and any barriers to a multidisciplinary approach. RESULTS: Of the 705 respondents, 15% reported ever referring patients to dermatology. Private practitioners referred significantly less than providers in academic or oncology centers (p < 0.01). Practitioners in urban settings were more likely to refer (p < 0.01), and radiation oncologists in the Southeastern USA were less likely to refer (p < 0.01). CONCLUSIONS: Lack of timely access to dermatologists in various geographic areas in addition to radiation oncologists' preference to treat RD are barriers to multidisciplinary management of RD. Inclusion of dermatologists and wound care specialists in cancer treatment teams could improve patient care and stimulate needed research into strategies for treatment and prevention of RD.

Practice patterns for the prophylaxis and treatment of acute radiation dermatitis in the United States.

PURPOSE: Due to the inconclusive evidence for available treatment options, management of radiation dermatitis (RD) varies among practitioners. This study defines and reviews the current treatment patterns for RD in the USA, providing guidance for practicing physicians as well as directions for future research. METHODS: An online survey of 21 questions was emailed to all 5626 members of the 2013 American Society for Radiation Oncology (ASTRO) directory, which included radiation oncologists, residents, fellows, physician assistants, nurse practitioners, registered nurses and other care providers. The questions were designed to evaluate demographics of responders, their training and comfort in the management RD, and their patterns of care regarding prophylaxis and treatment of RD. Data was analyzed using simple summary and descriptive statistics. RESULTS: Out of the 5626 emails sent, we were left with 709 physician respondents for our analysis, or a response rate of 12.9%. Although 84.7% of physicians felt that RD had a moderate or large impact on patients' quality of life during cancer treatment, only 30.1% received special training or specific instructional courses in treating RD during their medical training in residency or fellowship. Eighty-nine percent of surveyed physicians rely on observational and/or anecdotal findings to guide treatment decisions, and 51.4% reported using evidence-based treatments. CONCLUSION: The results of our study show that there is great variability in the topical agents and dressings used in practice by radiation oncologists to prevent and treat RD. This information may be useful to other practitioners to develop their own personal recommendations and can guide further research into strategies to prevent and treat radiation dermatitis.

The impact of hormonal therapy on sexual quality of life in men receiving intensity modulated radiation therapy for prostate cancer.

PURPOSE: Sexual function is an important concern in men receiving intensity modulated radiation therapy (IMRT) for prostate cancer. Our aim was to study the impact of IMRT and androgen deprivation therapy (ADT) on sexual function over time and to report the effectiveness of sexual medications or aids. METHODS AND MATERIALS: A total of 179 men, median age 69, received definitive IMRT for prostate cancer and completed 2 surveys (Expanded Prostate Cancer Index Composite-26 and a sexual medicines/devices survey) for at least 2 time points. Surveys were prospectively collected at baseline (before all therapy), and 2, 6, 12, 18, and 24 months after IMRT. Median dose was 76 Gy to the prostate. ADT was administered to 59% of patients (median duration 5 months, initiated 2 months before IMRT). Global scores were generated for the Expanded Prostate Cancer Index Composite-26 questions. Longitudinal analysis was performed by constructing a generalized estimation equations model, and clinical variables were tested for association with global scores. RESULTS: Overall, there was a significant decline in global sexual score through 2 years. Men receiving ADT had a lower sexual score at 2 and 6 months, but this difference disappeared at 24 months. Analysis of individual sexual symptoms showed no significant difference at 24 months except that men on ADT were less likely to be sexually active (P = .02); this difference was not observed for men receiving short-term ADT only. Longitudinal analysis revealed that duration of ADT was the only factor associated with global sexual score. Phosphodiesterase inhibitors were attempted by roughly half of all men, with 66% experiencing benefit, whereas other aids were attempted by roughly 5% of men. CONCLUSIONS: Although ADT adversely affected short-term sexual function, there was no significant difference in global score and most sexual symptoms by 24 months. These data are useful for anticipatory guidance regarding expectations after IMRT.

Late toxicity and quality of life after definitive treatment of prostate cancer: redefining optimal rectal sparing constraints for intensity-modulated radiation therapy.

The objective of this study was to assess late toxicity and quality of life (QOL) for patients receiving definitive intensity-modulated radiotherapy (IMRT) and image-guided radiation therapy (IGRT) with regard to normal tissue sparing objectives. Three hundred and seventy-two consecutive men treated with definitive IMRT for prostate adenocarcinoma. Toxicity was graded by CTC v3.0 genitourinary (GU) and gastrointestinal (GI) toxicity at each follow-up visit. Patient-reported QOL (EPIC-26) was prospectively collected for a subset of men. Dosimetric data for bladder and rectum were compared to toxicity and QOL global domain scores, specifically analyzing outcomes for men who met ideal rectal constraints (V70 <10%, V65 <20%, V40 <40%). The median age and prescription dose was 69 years and 76 Gy, respectively. Median follow-up was 47 months. At 4 years, freedom from Grade 2 (FFG2) GI toxicity was 92% and FFG2 GU toxicity was 76%. On univariate analysis, current smoking, larger bladder volume, and higher RT dose were associated with decreased FFG2 GU toxicity, while use of anticoagulation, increasing age, and not meeting ideal rectal constraints were associated with decreased FFG2 GI toxicity (all P ≤ 0.05). Bowel QOL remained stable over the 2-year follow-up period and was higher for patients who met ideal rectal constraints (P = 0.05). IMRT with IGRT is associated with low rates of severe toxicity and a high GI and GU QOL. The use of strict rectal constraints can further improve GI QOL and reduce GI toxicity.

Positron emission tomography for predicting pathologic response after neoadjuvant chemoradiotherapy for locally advanced rectal cancer.

PURPOSE: To investigate whether before and after chemoradiotherapy (CRT) positron emission tomography (PET) predict for pathologic response after preoperative CRT in patients with locally advanced rectal adenocarcinoma. METHODS: Thirty-five patients who underwent pre-CRT and post-CRT PET scans before surgery were included. All patients were staged with endoscopic ultrasound or high resolution CT. CRT was given with 50.4 Gy at 1.8 Gy per fraction and concurrent 5-fluorouracil-based chemotherapy. Surgery occurred at a median of 46 days (range, 27 to 112 d) after completing CRT. The maximum standardized uptake value (SUV(max)) and the metabolic tumor volume (MTV) using various minimum SUV thresholds (2, 2.5, 3) on the PET scans (MTV(2.0), MTV(2.5), MTV(3.0)) were determined. Post-CRT PET scans were done 3 to 5 weeks after completion of CRT. Pathologic response was assessed using the tumor regression grade (TRG) scale. Patients with complete or near-complete response (TRG=0 to 1) were considered pathologic responders. The pre-CRT and post-CRT PET scan SUV(max) and MTV values were correlated with TRG. The ΔSUV(max) and ΔMTV were correlated with TRG. RESULTS: No correlation was seen with SUV(max) (P=0.99), MTV(2.0) (P=0.73), MTV(2.5) (P=0.73), or MTV(3.0) (P=0.31) on the pre-CRT PET between pathologic responders versus nonresponders. No correlation was noted between SUV(max) (P=0.49), MTV(2.0) (P=0.73), MTV(2.5) (P=0.49), or MTV(3.0) (P=0.31) on the post-CRT PET scan and pathologic response. Finally, the ΔSUV(max) (P=0.32), ΔMTV(2.0) (P=0.99), ΔMTV(2.5) (P=0.31), ΔMTV(3.0) (P=0.31) did not correlate with pathologic response. CONCLUSIONS: Changes seen on PET have limited value in predicting for pathologic response of rectal cancer after preoperative neoadjuvant therapy.

Pediatric intracranial ependymoma: the roles of surgery, radiation and chemotherapy.

Management of pediatric intracranial ependymomas poses a major challenge, and optimal treatment remains controversial. We sought to investigate the roles of surgery, radiation, and chemotherapy in a historical cohort. Thirty-nine children, age 21 or younger, with non-metastatic intracranial ependymomas were treated from 1972 to 2008. Median age was 8 years (range 0.2-19.1). Twenty-one patients (54%) underwent GTRs, and 18 (45%) underwent STRs. Twenty-six patients (67%) received upfront adjuvant RT (67%), and 14 (44%) received adjuvant chemotherapy. Twenty-four patients had disease recurrence and 12 died. Only one patient recurred after 5 years. Median PFS was 2.7 years and median OS was 20 years. Fifteen year PFS and OS were 30 and 67%. Adjuvant RT was associated with improved PFS (P = 0.045), and remained significant after adjusting for EOR (P = 0.04). Greater EOR trended towards prolonged survival, but did not reach statistical significance (P = 0.156). Of the patients that underwent GTR, the median PFS was 38 months for those treated with adjuvant RT versus 30 months for those that were not treated with RT. Of the patients that had STR, the median PFS for those treated with RT was 26.3 months versus 6.9 months for those were not treated with RT. In conclusion, for localized intracranial pediatric ependymomas, adjuvant RT is associated with improved PFS, even after adjusting for EOR. Our findings suggest the benefit of RT even in the presence of GTR. Future prospective studies with larger sample number are needed to validate our findings.

Hearing preservation after stereotactic radiosurgery for vestibular schwannoma: a systematic review.

Radiosurgery has evolved into an effective alternative to microsurgical resection in the treatment of patients with vestibular schwannoma. We performed a systematic analysis of the literature in English on the radiosurgical treatment of vestibular schwannoma patients. A total of 254 published studies reported assessable and quantifiable outcome data of patients undergoing radiosurgery for vestibular schwannomas. American Association of Otolaryngology-Head and Neck Surgery (AAO-HNS) class A or B and Gardner-Robertson (GR) classification I or II were defined as having preserved hearing. A total of 5825 patients (74 articles) met our inclusion criteria. Practitioners who delivered an average dose of 12.5 Gy as the marginal dose reported having a higher hearing preservation rate (12.5 Gy=59% vs. >12.5 Gy=53%, p=0.0285). Age of the patient was not a significant prognostic factor for hearing preservation rates (<65 years=58% vs. >65 years=62%; p=0.4317). The average overall follow-up was 41.2 months. Our data suggest that an overall hearing preservation rate of about 57% can be expected after radiosurgical treatment, and patients treated with 12.5 Gy were more likely to have preserved hearing.

Superior outcomes in children compared with adults after microsurgical resection of brain arteriovenous malformations.

OBJECT: Young age is considered an important factor in determining outcomes after microsurgical resection of arteriovenous malformations (AVMs), but better results in children have not been adequately explained. A consecutive series of pediatric and adult patients was reviewed to determine whether differences in outcomes between these two groups were due to differences in AVM anatomy, rupture rates, neurological condition at presentation, treatment techniques, or other causes. METHODS: As assessed using the modified Rankin Scale (mRS), patient characteristics, clinical presentation, AVM anatomy, treatment techniques, and outcomes were compared between age groups. Thirty-two pediatric and 192 adult patients underwent microsurgical AVM resection during a 6.4-year period; complete resection was achieved in 97% of the children and 98% of adults. Superior outcomes were observed in children, who had better final mRS scores (p = 0.003) and more favorable changes in these scores (the condition of 94% of children improved or remained unchanged, compared with 70% of adults; p = 0.001). The change in the mean mRS scores was 1.31 for children and 0.14 for adults (p = 0.001). There were no significant clinical, anatomical, or therapeutic differences between children and adults. CONCLUSIONS: This analysis confirms the observation that children fare better than adults after microsurgical AVM resection. This discrepancy cannot be explained by differences in AVM anatomy, lesion rupture rates, presenting neurological condition, or treatment techniques, leading the authors to infer that neural plasticity may augment surgical tolerance and recovery in children. These findings bolster the choice of aggressive microsurgical management of AVMs and recalibration of surgical risk assessment in children.