Improving identification of candidates for lung cancer screening in a high risk population.

BACKGROUND: Low dose computerized tomography (LDCT) has been shown to reduce lung cancer specific mortality by 20 %. Despite U.S. Preventive Services Task Force (USPSTF) endorsement, screening of appropriate patients in the U.S. remains low, at 1.9 %. The goal of this study was to assess the number and type of patients that would qualify for lung cancer screening based upon recommendations by various guidelines. METHODS: We prospectively collected a patient reported questionnaire, including smoking history, family history, exposure history, and demographics, from April-October 2017 from new consults in the Department of Radiation Oncology and Otolaryngology (ORL). Patients smoking status and patient factors were collected and reported. Patients qualifying for screening by USPSTF, the National Comprehensive Cancer Network (NCCN), and Tammemagi scoring criteria were identified. Multivariate analysis assessed the factors associated with positive criteria for screening and the sensitivity of each criterion was calculated. RESULTS: There were 546 new consults during the study period and 528 successfully completed the questionnaire. A total of 104/528 (20 %) patients who completed questionnaires qualified for screening based on any guideline. After exclusion of active lung cancer (n = 19), poor prognosis (n = 24), and CT as part of surveillance (n = 16), 45 (8.5 %) patients would require LDCT. Of the entire population, 10 %, 11 % and 18 % of patients qualified based on USPSTF, NCCN, and Tammemagi, which was reduced to 4.9 %, 5.3 %, and 7.8 %, respectively after exclusions. Patients with head and neck cancer (40 %), skin cancer (27 %), and prostate cancer (11 %) accounted for the majority of patients eligible for screening after exclusions. The sensitivity of the USPSTF, NCCN, and Tammemagi criteria in patients with a diagnosis of lung cancer (n = 26) was 38.5 % (CI95 20.2 %-59.4 %), 46.2 % (CI95 26.6 %-66.6 %), and 61.5 % (CI95 40.6 %-79.8 %), respectively. CONCLUSIONS: We successfully identified 9 % of an oncology population at consultation who could benefit from lung cancer screening in survivorship. Distribution of a written or electronic questionnaire at consultation is a simple, low cost, effective method of identifying patients who would benefit from LDCT.

Idiopathic mast cell activation syndrome and radiation therapy: a case study, literature review, and discussion of mast cell disorders and radiotherapy.

BACKGROUND: Mast Cell Activation Syndrome (MCAS) is classified as an idiopathic mast cell disorder where inconsistent or unknown triggers release inflammatory mediators and cause a constellation of symptoms. Studies demonstrate mast cells increase histamine, tryptase, and inflammatory cytokine expression following ionizing radiation. Additionally, there are cases of cutaneous mastocytosis developing within the initial radiation field suggesting mast cells play a role in local tissue reactions. Literature is sparse on radiation induced toxicity in patients with mast cell disorders. CASE PRESENTATION: A 62 year old female patient with a history of MCAS received breast conservation therapy for invasive lobular carcinoma of the left breast initially AJCC 7th Stage IIB, pT3 pN0 M0. The patient underwent external beam radiotherapy (EBRT) and received 4500 cGy to the left whole breast, followed by a 1000 cGy boost to the lumpectomy cavity. She developed grade 1 radiation dermatitis. Two years later she progressed distantly and received stereotactic body radiation therapy to a lumbar vertebrae lesion to a dose of 2400 cGy in a single fraction. She developed no in-field dermatologic or systemic flare in her MCAS symptoms during radiation therapy. CONCLUSIONS: To our knowledge there are no reported cases in the literature of patients diagnosed with MCAS or other idiopathic mast cell disorders undergoing radiation therapy. Idiopathic mast cell disorders such as MCAS and primary mast cell disorders alike should not be considered a contraindication to treatment with EBRT. This patient population appears to tolerate treatment without systemic flares in symptoms.

Google Search Trends in Oncology and the Impact of Celebrity Cancer Awareness.

Introduction There is widespread public interest when celebrities are diagnosed with cancer. We sought to assess how this interest impacts awareness of prevalent cancers. Methods We reviewed common cancer-related search terms using Google Trends (Google LLC, Mountain View, CA) between the years 2004 and 2017 and retrospectively correlated these findings with media or celebrity-related events. The Google Trends application was used to obtain the "search volume index" (SVI), defined as the number of searches for a specific term standardized to the total number of searches over that time period. Data were presented in a graphical format. Isolated peaks of greater than 25% from the baseline SVI were identified. Using the date of the peaks, a further search was performed to determine if any event in the media triggered the peak. Results "Lung Cancer," "Pancreas Cancer," "Endometrial Cancer," "Cervical Cancer," "Brain Cancer," and "Glioblastoma" each had the highest peak correspond with a celebrity-related event covered in the media. These search terms displayed several additional isolated peaks, the majority of which could all be correlated with a significant media event (%). The search term "Breast Cancer" consistently had a peaked interest during October (breast cancer awareness month). Breast cancer events relating to public figures had little to no relative impact on search volume during this period. None of the other cancer search terms displayed the same cyclical pattern during their respective awareness months. Colon, rectal, and prostate cancer demonstrated stable search volumes over time, without an isolated peak. Conclusion Internet search activity among English speakers of most general cancer terms exhibit peaks coinciding with events that occur to celebrity figures or advances in medicines that are substantially covered in the media. In all cases but "breast cancer," these events lend to higher search activity as compared to campaigns and awareness months. Our study suggests that media coverage of public figures with cancer may trigger substantial Internet interest in non-breast cancers, more so than traditional efforts to raise awareness.

Identifying the Most Costly Patients in Radiation Oncology and Predicting the Top Spenders.

PURPOSE: Quality payment programs aim to adjust payments on the basis of quality and cost; however, few quality metrics exist in radiation oncology. This study evaluates and predicts the top spenders (TS) after radiation therapy (RT). MATERIALS AND METHODS: Patient characteristics, cancer details, treatments, toxicity, and survival data were collected for patients treated with RT at Mayo Clinic from 2007 to 2016. Standardized costs were obtained and adjusted for inflation. TSs were identified as those with greater than 93rd percentile costs (≥ $120,812). Prediction models were developed to predict TSs using training and validation sets using information available at consultation, after RT, and at last follow-up. RESULTS: A total of 15,131 patients were included and 1,065 TSs identified. Mean cost overall was $55,290 (median, $39,996) for all patients. Prediction models 1, 2, and 3 had concordance statistics of 0.83 to 0.83, 0.85 to 0.85, and 0.87 to 0.88, respectively in training and validation, indicating excellent prediction of TSs. Factors that were most predictive of TSs included stage N/A and stage 4 (v stage 0; odds ratio [OR], 18.23 and 8.44, respectively; P < .001); hematologic, upper GI, skin and lung cancers (v breast; OR, 11.45, 7.69, 3.81, and 2.43, respectively; P < .01); immunotherapy, surgery, and chemotherapy use (OR, 4.36, 2.51, and 1.61, respectively; P < .01); hospitalizations within 90 days of RT (OR, 2.26; P < .01); or death during the episode (OR, 1.56; P < .01). CONCLUSION: This is the first study of its kind to predict with high accuracy the highest spenders in radiation oncology. These patients may benefit from pre-emptive management to mitigate costs, or may require exclusion or adjustment from quality payment programs.

Cost of Acute and Follow-Up Care in Patients With Pre-Existing Psychiatric Diagnoses Undergoing Radiation Therapy.

PURPOSE: The impact of psychiatric comorbidities on the cost of cancer care in radiation oncology practices is not well studied. We assessed the acute and 24-month follow-up costs for patients with and without pre-existing psychiatric comorbidities undergoing radiation therapy. METHODS AND MATERIALS: Patients with cancer undergoing radiation therapy at our institution from 2009 to 2014 were denoted as having pre-existing psychiatric conditions (Psych group) if they had associated billing codes for any of the 422 International Classification of Diseases, 9th revision psychiatric conditions during the 12 months before their cancer diagnosis. The Elixhauser comorbidity index was calculated, excluding psychiatric categories. Medicare reimbursement was assigned to professional services, and Medicare departmental cost-to-charge ratios were applied to service line hospital charges and adjusted for inflation to create 2017 standardized costs. Acute (0-6 month) and follow-up (6-24 month) costs were subcategorized into clinic, emergency department, hospital inpatient, and outpatient costs. RESULTS: Among 1275 patients, 126 (9.9%) had at least 1 pre-existing psychiatric diagnosis. On univariate analysis, both acute and long-term costs were higher in the Psych group. The largest significant differences in costs were follow-up hospital inpatient costs ($5861 higher; 95% confidence interval [CI], $687-$11,035; P = .002), follow-up hospital outpatient costs ($2086 higher; 95% CI, -$142 to $4,314; P = .040), and follow-up emergency department costs ($396 higher; 95% CI, $149-$643; P < .001). Age, race, sex, and treatment modalities were comparable, but the Psych group patients had more median comorbidities (2 vs 1) and had more respiratory cancer diagnoses than the nonpsychiatric group (31% vs 17%). On multivariate analysis adjusted for age, sex, cancer diagnosis, and comorbidities, global follow-up costs remained 150% higher in the Psych group (P < .001). Acute costs were similar after adjustment (P = .63). CONCLUSIONS: Psychiatric comorbidities independently predict elevated healthcare costs in patients treated for cancer. Radiation oncology payment models should consider adjustments to account for psychiatric comorbidities because addressing these may mitigate cost differential.

The pervasive crisis of diminishing radiation therapy access for vulnerable populations in the United States-Part 4: Appalachian patients.

PURPOSE: Compared with the rest of the United States, the population of Appalachia has lower education levels, higher rates of poverty, and limited access to health care. The presence of disparities in radiation therapy (RT) access for Appalachian patients with cancer has rarely been examined. METHODS AND MATERIALS: The National Cancer Institute initiatives toward addressing disparities in treatment access for rural populations were examined. An extensive literature search was undertaken for studies investigating RT access disparities in Appalachian patients, beginning with the most common cancers in these patients (lung, colorectal, and cervical). RESULTS: Although the literature investigating RT access disparities in Appalachia is relatively sparse, studies examining lung, colorectal, cervical, prostate, head and neck, breast, and esophageal cancer, as well as lymphoma, indicate an unfortunate commonality in barriers to optimal RT access for Appalachian patients with cancer. These barriers are predominantly socioeconomic in nature (low income and lack of private insurance) but are exacerbated by paucities in both the number and quality of radiation centers that are accessible to this patient population. CONCLUSIONS: Regardless of organ system, there are significant barriers for Appalachian patients with cancer to receive RT. Such diminished access is alarming and warrants resources devoted to addressing these disparities, which often go overlooked because of the assumption that the overall wealth of the United States is tangibly applicable to all of its citizens. Without intelligently targeted investments of time and finances in this arena, there is great risk of exacerbating rather than alleviating the already heavy burden facing Appalachian patients with cancer.

Primary histiocytic sarcoma of the central nervous system: a case report with platelet derived growth factor receptor mutation and PD-L1/PD-L2 expression and literature review.

BACKGROUND: Histiocytic sarcoma (HS) is an aggressive malignant neoplasm. HS in the central nervous system is exceptionally rare and associated with a poor prognosis. This report documents a case of primary HS of the central nervous system with treatment including surgery, radiotherapy, and chemotherapy. CASE PRESENTATION: Our patient was a 47 year old female presenting with progressive ataxia, headaches, imbalance, nausea, vomiting, and diplopia. MRI showed a heterogeneously enhancing lesion approximately 2.9 × 3.0 × 2.3 cm centered upon the cerebellar vermis with mild surrounding vasogenic edema and abnormal enhancement of multiple cranial nerves. The patient underwent surgical debulking, which revealed histiocytic sarcoma with grossly purulent drainage. Staging revealed diffuse leptomeningeal involvement, primarily involving the brain and lower thoracic and lumbar spine. She underwent adjuvant radiotherapy to the brain and lower spine and was started on high dose methotrexate. However, she experienced progressive disease in the cervical and thoracic spine as well as pulmonary involvement. Genomic sequencing of her tumor showed a mutation in the platelet-derived growth factor receptor A (p.V0681) which could be targeted with Dasatinib. However, she did not tolerate Dasatinib and she succumbed to progressive disseminated disease eight months from original diagnosis. Our pathologic evaluation also revealed expression of PD-L1 and PD-L2 by tumor cells raising the potential therapeutic role for immune checkpoint inhibition. CONCLUSIONS: This case provides an example of effective CNS control with resection and moderate doses of radiation therapy. A review of the literature confirms aggressive multidisciplinary treatment is the most effective treatment against this disease. In addition, genomic sequencing may play an important role in determining new therapeutic options. However, CNS histiocytic sarcoma remains an aggressive disease with a propensity for early widespread dissemination and few long term survivors.

Central neurocytoma: Clinical characteristics, patterns of care, and survival.

PURPOSE: To investigate clinical characteristics and patterns of care among patients with central neurocytomas in a large cohort of patients. METHODS: The National Cancer Database (NCDB) was queried to identify patients with biopsy confirmed neurocytoma from 2004 to 2015. Patterns of care were described and univariable and multivariable models were performed to investigate the impact of prognostic factors on overall survival. RESULTS: Among 223,404 patients with brain tumors in the NCDB, 868 patients were diagnosed with biopsy-proven neurocytoma and analyzed (0.4% or approximately 75 patients annually). Median age at diagnosis was 31 years and median tumor size was 4-5 cm. Diagnosis was similar between male (49.5%) and female (50.5%). Regarding location, 622 (72%) tumors were intraventricular, 168 (19%) were extra-ventricular, and 78 (9%) overlapping or unspecified. Five-year overall survival among all patients was 89%. On multivariable analysis tumor location, extent of resection, and use of radiation, were not predictive for improved survival (each p > 0.05); however, patient age (p < 0.001), WHO grade (p < 0.001), and medical comorbidity scores (p = 0.002) were independently associated with overall survival. CONCLUSION: Patients with central neurocytoma often present as young adults with sizable tumor burden and are well managed with surgery alone. Considering their favorable survival, efforts to improve tumor control should be carefully weighed against the long-term risks associated with adjuvant therapy like radiation.

Implementation of patient pagers in radiation oncology waiting rooms for patient privacy and satisfaction.

OBJECTIVE: In order to improve privacy, quality, and coordination of care, a patient pager system was introduced to notify patients of daily treatment in the Department of Radiation Oncology. One hundred patients undergoing daily radiation therapy prospectively participated in a six-question survey addressing the paging service, privacy prior to pager use, and demographics. Twelve radiation therapists also participated in a survey addressing privacy and workflow. RESULTS: Survey results from all patient participants revealed that convenience, privacy, ease of use, desire for use for consults and return visits were highly rated as very good to excellent. The top three categories were "ease of use," "convenience" and "privacy." Nineteen patients had the experience of our waiting room prior to introduction of the patient pagers and highly rated "privacy," "efficiency," and "satisfaction." Twelve radiation therapists participated and rated workflow related categories fair to good. Only patient privacy was rated as very good to excellent. Thus, patients and staff highly rated the paging system for privacy protection and satisfaction. However, it did not change overall workflow. Our study shows clinics should prioritize privacy in the waiting room to address the emotional needs of patients and improve satisfaction.

Treatment of a glioblastoma multiforme dural metastasis with stereotactic radiosurgery: A case report and select review of the literature.

Glioblastoma multiforme (GBM) is a primary brain neoplasm accounting for approximately 75% of all high grade gliomas. It is diffusely infiltrative and exhibits rapid proliferation with a poor overall prognosis. Maximum surgical resection and postoperative radiotherapy, accompanied by concurrent and adjuvant temozolomide chemotherapy, remain the standard of care without major therapeutic advances over the past 10 years. Herein, we present the case of a 64-year-old Caucasian male with a GBM who subsequently developed a left frontal dural metastasis, subsequently treated with stereotactic radiosurgery (20 Gy in 1 fraction). With six month follow-up, the patient showed near complete resolution of his dural metastases and no overall change in neurological symptoms or side effects following radiosurgery. Due to the paucity of clinical literature regarding dural metastases from GBM, its optimal treatment remains unknown. While the role of SRS has yet to be defined in this setting, here we provide evidence suggesting its overall efficacy in the treatment of select dural GBM metastases.

ASTRO's Advances in Radiation Oncology: Success to date and future plans.

ASTRO's Advances in Radiation Oncology was launched as a new, peer-reviewed scientific journal in December 2015. More than 200 manuscripts have been submitted and 97 accepted for publication as of May 2017. As Advances enters its second year of publication, we have chosen to highlight subjects that will transform the way we practice radiation oncology in special issues or ongoing series: immunotherapy, biomedical analytics, and social media. A teaching case report contest for North American radiation oncology residents will be launched at American Society of Radiation Oncology 2017 to encourage participation in scientific publication by trainees early in their careers. Recognizing our social mission, Advances will also begin a series of articles devoted to highlighting the growing disparities in access to radiation oncology services in vulnerable populations in North America. We wish to encourage the American Society of Radiation Oncology membership to continue its support of the journal through high-quality manuscript submission, participation in the peer review process, and highlighting important manuscripts through sharing on social media.

Reducing unnecessary testing: an intervention to improve resident ordering practices.

PURPOSE OF THE STUDY: To reduce the number of unnecessary laboratory tests ordered through a measurement of effects of education and cost awareness on laboratory ordering behaviour by internal medicine residents for common tests, including complete blood cell count (CBC) and renal profile (RP), and to evaluate effects of cost awareness on hospitalisation, 30-day readmission rate and mortality rate. STUDY DESIGN: 567 patients admitted during February, March and April 2014 were reviewed as the control group. Total CBC, CBC with differential and RP tests were counted, along with readmission and mortality rates. Interventions were education and visual cost reminders. The same tests were reassessed for 629 patients treated during 12 months after intervention in 2015. RESULTS: Data showed a significant increase in CBCs ordered after the intervention (mean number per hospitalisation changed from 1.7 to 2.3 (p<0.001)), a decrease in CBCs with differential (mean number changed from 1.7 to 1.2 (p<0.001)) and no change in RPs ordered (mean number, 3.7 both before and after intervention (p=0.23)). No change was found in mortality rate, but the decrease in the readmission rate was significant (p=0.008). CONCLUSIONS: Education in the form of cost reminders did not significantly reduce the overall ordering of the most common daily laboratory testing in our academic teaching service. We believe further research is needed to fully evaluate the effectiveness of other education forms on the redundant ordering of tests in the hospital setting.

Post-Transplant Lymphoproliferative Disorder Presenting as CD20-Negative Plasmablastic Lymphoma in the Lung.

Post-transplant lymphoproliferative disorders (PTLD) are a serious complication of transplantation with a high mortality. Most PTLD present within the first year of transplantation and are associated with Epstein-Barr virus (EBV) infection. Plasmablastic lymphoma (PBL) is a rare but aggressive disease originally described in patients with HIV, presenting most commonly in the jaw and oral mucosa. To our knowledge, this is the first case of PBL presenting as PTLD of the lung in a HIV and EBV negative patient. Given the increasing number of transplants performed, we would like to share this uncommon presentation of PTLD as PBL.

Langerhan's Cell Sarcoma: Two Case Reports.

Langerhan's cell sarcoma (LCS) is a rare neoplasm with a poor prognosis. To our knowledge, only sixty-six cases have been published. We discuss two patients who presented very differently with LCS, as well as a recently published review of all sixty-six cases. Our first case had a complicated history of metastatic, high-grade myxofibrosarcomas and presented with a single skin lesion of LCS which was treated with resection to a positive margin and adjuvant radiotherapy. The LCS recurred locoregionally and was again resected. The patient is alive two years after initial diagnosis. The second case presented with bone marrow and splenic involvement, leukocytosis, and thrombocytopenia. This patient had an excellent response to etoposide, prednisone, oncovorin, cyclophosphamide, and adriamycin, with normalization of the complete blood count, negative bone marrow biopsy at follow up, and splenectomy without viable neoplasm. This patient is alive without signs of disease at 16 months after initial diagnosis.