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1.
Br J Radiol ; 93(1107): 20190378, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31430188

RESUMO

Radiation therapy is an essential component of treatment for locally advanced non-small cell lung cancer (NSCLC) but can be technically challenging because of the proximity of lung tumors to nearby critical organs or structures. The most effective strategy for reducing radiation-induced toxicity is to reduce unnecessary exposure of normal tissues by using advanced technology; examples from photon (X-ray) therapy have included three-dimensional conformal radiation therapy versus its predecessor, two-dimensional radiation therapy, and intensity-modulated photon radiation therapy versus its predecessor, three-dimensional conformal therapy. Using particle-beam therapy rather than photons offers the potential for further advantages because of the unique depth-dose characteristics of the particles, which can be exploited to allow still higher dose escalation to tumors with greater sparing of normal tissues, with the ultimate goal of improving local tumor control and survival while preserving quality of life by reducing treatment-related toxicity. However, the costs associated with particle therapy with protons are considerably higher than the current state of the art in photon technology, and evidence of clinical benefit from protons is increasingly being demanded to justify the higher financial burden on the healthcare system. Some such evidence is available from preclinical studies, from retrospective, single-institution clinical series, from analyses of national databases, and from single-arm prospective studies in addition to several ongoing randomized comparative trials. This review summarizes the rationale for and challenges of using proton therapy to treat thoracic cancers, reviews the current clinical experience, and suggests topics for future research.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/radioterapia , Neoplasias Pulmonares/radioterapia , Órgãos em Risco/efeitos da radiação , Terapia com Prótons/métodos , Lesões por Radiação/prevenção & controle , Radioterapia de Intensidade Modulada/métodos , Carcinoma Pulmonar de Células não Pequenas/patologia , Previsões , Humanos , Neoplasias Pulmonares/patologia , Tratamentos com Preservação do Órgão/métodos , Estudos Prospectivos , Terapia com Prótons/economia , Terapia com Prótons/tendências , Qualidade de Vida , Radioterapia Conformacional/métodos , Radioterapia de Intensidade Modulada/economia , Radioterapia de Intensidade Modulada/tendências , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Resultado do Tratamento
2.
Semin Oncol ; 46(3): 193-201, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31395286

RESUMO

The contemporary approach to the management of a cancer patient requires an "ab initio" involvement of different medical domains in order to correctly design an individual patient's pathway toward cure. With new therapeutic tools in every medical field developing faster than ever before the patient care outcomes can be achieved if all surgical, drug, and radiation options are considered in the design of the appropriate therapeutic strategy for a given patient. Radiation therapy (RT) is a clinical discipline in which experts from different fields continuously interact in order to manage the multistep process of the radiation treatment. RT is found to be an appropriate intervention for diverse indications in about 50% of cancer patients during the course of their disease. Technologies are essential in dealing with the complexity of RT treatments and for driving the increasingly sophisticated RT approaches becoming available for the treatment of Cancer. High conformal techniques, namely intensity modulated or volumetric modulated arc techniques, ablative techniques (Stereotactic Radiotherapy and Stereotactic Radiosurgery), particle therapy (proton or carbon ion therapy) allow for success in treating irregularly shaped or critically located targets and for the sharpness of the dose fall-off outside the target. The advanced on-board imaging, including real-time position management systems, makes possible image-guided radiation treatment that results in substantial margin reduction and, in select cases, implementation of an adaptive approach. The therapeutic gains of modern RT are also due in part to the enhanced anticancer activity obtained by coadministering RT with chemotherapy, targeted molecules, and currently immune checkpoints inhibitors. These main clinically relevant steps forward in Radiation Oncology represent a change of gear in the field that may have a profound impact on the management of cancer patients.


Assuntos
Neoplasias/radioterapia , Radioterapia (Especialidade)/tendências , Radioterapia Guiada por Imagem/tendências , Radioterapia de Intensidade Modulada/tendências , Radioterapia com Íons Pesados , Humanos , Radiocirurgia
3.
Int J Radiat Oncol Biol Phys ; 105(3): 581-590, 2019 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-31319091

RESUMO

PURPOSE: Previous studies demonstrated that the radiation therapy, image technology, and the application of chemotherapy have developed in the last 2 decades. This study explored the survival trends and treatment failure patterns of patients with nonmetastatic nasopharyngeal carcinoma (NPC) treated with radiation therapy. Furthermore, we evaluated the survival benefit brought by the development of radiation therapy, image technology, and chemotherapy based on a large cohort from 1990 to 2012. METHODS AND MATERIALS: Data from 20,305 patients with nonmetastatic NPC treated between 1990 and 2012 were analyzed. Patients were divided into 4 calendar periods (1990-1996, 1997-2002, 2003-2007, and 2008-2012). Overall survival (OS) was the primary endpoint. RESULTS: Magnetic resonance imaging has replaced computed tomography as the most important imaging technique since 2003. Conventional 2-dimensional radiation therapy, which was the main radiation therapy technique in our institution before 2008, was replaced by intensity modulated radiation therapy later. An increasing number of patients have undergone chemotherapy since 2003. The 5-year OS across the 4 calendar periods increased at each TNM stage with progression-free survival (PFS) and locoregional relapse-free survival (LRFS) showing a similar trend, whereas distant metastasis-free survival showed small differences. Multivariate analyses showed that the application of intensity modulated radiation therapy and magnetic resonance imaging were independent protective factors in OS, PFS, LRFS, and distant metastasis-free survival. Chemotherapy benefited patients in OS, PFS, and LRFS. The main pattern of treatment failure shifted from recurrence to distant metastasis. CONCLUSIONS: The development of radiation therapy, image technology, and chemotherapy increased survival rates among patients with NPC because of excellent locoregional control. Distant failure has become the greatest challenge for NPC treatment.


Assuntos
Carcinoma Nasofaríngeo/mortalidade , Carcinoma Nasofaríngeo/radioterapia , Neoplasias Nasofaríngeas/mortalidade , Neoplasias Nasofaríngeas/radioterapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Criança , Estudos de Coortes , DNA Viral/sangue , Feminino , Humanos , Imagem por Ressonância Magnética/mortalidade , Imagem por Ressonância Magnética/tendências , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Carcinoma Nasofaríngeo/diagnóstico por imagem , Carcinoma Nasofaríngeo/tratamento farmacológico , Neoplasias Nasofaríngeas/diagnóstico por imagem , Neoplasias Nasofaríngeas/tratamento farmacológico , Recidiva Local de Neoplasia/mortalidade , Papillomaviridae/genética , Prognóstico , Intervalo Livre de Progressão , Radioterapia/métodos , Radioterapia/mortalidade , Radioterapia/tendências , Radioterapia de Intensidade Modulada/mortalidade , Radioterapia de Intensidade Modulada/tendências , Taxa de Sobrevida , Fatores de Tempo , Tomografia Computadorizada por Raios X/tendências , Falha de Tratamento , Adulto Jovem
4.
Am J Clin Oncol ; 42(6): 519-526, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31136369

RESUMO

BACKGROUND: Anal canal squamous cell carcinoma (SCC) is managed definitively with chemoradiation, reserving surgery for salvage. The dosage of radiation has varied from 30 Gy to in excess of 60 Gy. RTOG 0529 established intensity modulated radiation therapy (IMRT) as standard of care for anal canal SCC with doses of 50.4 to 54 Gy. We sought to use the National Cancer Database to examine trends in dose selection and radiation technique over time. METHODS: We queried the National Cancer Database from 2004 to 2015 for cases of anal cancer stage groups 1 to 3, treated with definitive doses of radiation with chemotherapy. Dose escalation was defined as >54 Gy. Univariable and multivariable analyses were performed to identify factors predictive of dose, IMRT, and overall survival. Propensity-adjusted Cox proportional hazard ratios for survival were used to account for indication bias. RESULTS: We identified 7792 patients meeting the eligibility criteria, with 4269 treated to doses of 45 to 54 Gy and 3163 treated to doses >54 Gy. Patients who were older, had government or private insurance, IMRT treatment, treatment at an academic center, or more recent years were less likely to get dose escalation. The use of dose escalation decreased over time, from 50% in 2005 to 30% in 2015. IMRT use increased over time from 2% to 63%. On multivariable analysis with propensity score included it was found that increased age, higher comorbidity score, lower income, shorter distance to facility, and male sex were predictive of decreased overall survival. In addition, escalated dose was associated with a lower survival (hazard ratio: 1.10, 95% confidence interval: 1.01-1.20, P=0.03). CONCLUSIONS: The results of this analysis show a steady increase in the use of IMRT, with corresponding decrease in dose escalation. These findings correlate with the results of RTOG 0529 establishing IMRT as standard of care for anal SCC, using doses of 50.4 to 54 Gy.


Assuntos
Neoplasias do Ânus/radioterapia , Carcinoma de Células Escamosas/radioterapia , Radioterapia de Intensidade Modulada/tendências , Neoplasias do Ânus/patologia , Carcinoma de Células Escamosas/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Dosagem Radioterapêutica , Radioterapia de Intensidade Modulada/métodos , Estudos Retrospectivos , Taxa de Sobrevida
5.
Br J Cancer ; 120(8): 779-790, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30911090

RESUMO

Imaging has an essential role in the planning and delivery of radiotherapy. Recent advances in imaging have led to the development of advanced radiotherapy techniques-including image-guided radiotherapy, intensity-modulated radiotherapy, stereotactic body radiotherapy and proton beam therapy. The optimal use of imaging might enable higher doses of radiation to be delivered to the tumour, while sparing normal surrounding tissues. In this article, we review how the integration of existing and novel forms of computed tomography, magnetic resonance imaging and positron emission tomography have transformed tumour delineation in the radiotherapy planning process, and how these advances have the potential to allow a more individualised approach to the cancer therapy. Recent data suggest that imaging biomarkers that assess underlying tumour heterogeneity can identify areas within a tumour that are at higher risk of radio-resistance, and therefore potentially allow for biologically focussed dose escalation. The rapidly evolving concept of adaptive radiotherapy, including artificial intelligence, requires imaging during treatment to be used to modify radiotherapy on a daily basis. These advances have the potential to improve clinical outcomes and reduce radiation-related long-term toxicities. We outline how recent technological advances in both imaging and radiotherapy delivery can be combined to shape the future of precision radiation oncology.


Assuntos
Neoplasias/diagnóstico por imagem , Neoplasias/radioterapia , Radioterapia (Especialidade)/tendências , Humanos , Imagem por Ressonância Magnética/métodos , Neoplasias/patologia , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons/métodos , Terapia com Prótons/tendências , Radiocirurgia/tendências , Planejamento da Radioterapia Assistida por Computador/métodos , Radioterapia Guiada por Imagem/tendências , Radioterapia de Intensidade Modulada/tendências
7.
Oral Oncol ; 86: 19-24, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30409300

RESUMO

Patients with head and neck cancer who are treated with radiotherapy often have significant weight loss or tumor regression during treatment. Adaptive radiotherapy refers to acquiring new imaging during treatment and changing the parameters of the radiation plan based on the new imaging findings. There is accumulating evidence that adaptive radiotherapy can reduce toxicity and improve tumor control, though it is not yet known which patients benefit most. For patients with profound tumor regression, there is also uncertainty about how much to shrink the region receiving high radiation dose. Another form of adaptive radiotherapy uses advanced imaging such as positron emission tomography to visualize changes in tumor biology during treatment. Tumor regions that are thought to be more radioresistant can then be treated to a higher radiation dose, and vice-versa. Studies employing this strategy to boost radiation dose have shown a high rate of late toxicity, specifically the development of persistent mucosal ulcers. Therefore, this sort of adaptive radiotherapy is currently confined to the research setting.


Assuntos
Carcinoma Nasofaríngeo/radioterapia , Neoplasias Nasofaríngeas/radioterapia , Radioterapia Guiada por Imagem/métodos , Radioterapia de Intensidade Modulada/métodos , Carcinoma de Células Escamosas de Cabeça e Pescoço/radioterapia , Ensaios Clínicos como Assunto , Fracionamento da Dose de Radiação , Relação Dose-Resposta à Radiação , Humanos , Carcinoma Nasofaríngeo/diagnóstico por imagem , Carcinoma Nasofaríngeo/patologia , Neoplasias Nasofaríngeas/diagnóstico por imagem , Neoplasias Nasofaríngeas/patologia , Tomografia por Emissão de Pósitrons , Lesões por Radiação/etiologia , Lesões por Radiação/prevenção & controle , Tolerância a Radiação , Dosagem Radioterapêutica , Planejamento da Radioterapia Assistida por Computador/métodos , Planejamento da Radioterapia Assistida por Computador/tendências , Radioterapia Guiada por Imagem/efeitos adversos , Radioterapia Guiada por Imagem/tendências , Radioterapia de Intensidade Modulada/efeitos adversos , Radioterapia de Intensidade Modulada/tendências , Carcinoma de Células Escamosas de Cabeça e Pescoço/diagnóstico por imagem , Carcinoma de Células Escamosas de Cabeça e Pescoço/patologia , Resultado do Tratamento , Carga Tumoral/efeitos da radiação
8.
Technol Cancer Res Treat ; 17: 1533033818802304, 2018 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30343661

RESUMO

Stereotactic body radiation therapy and stereotactic radiosurgery have become important treatment options for the treatment of spinal malignancies. A better understanding of dose tolerances with more conformal technology have allowed administration of higher and more ablative doses. In this review, the framework for approaching a patient with spinal metastases and primary tumors will be discussed as well as details on the delivery of this treatment.


Assuntos
Radiocirurgia , Neoplasias da Coluna Vertebral/radioterapia , Neoplasias da Coluna Vertebral/cirurgia , Humanos , Metástase Neoplásica , Radioterapia de Intensidade Modulada/tendências , Neoplasias da Coluna Vertebral/patologia , Coluna Vertebral/patologia , Coluna Vertebral/efeitos da radiação , Coluna Vertebral/cirurgia
9.
J Korean Med Sci ; 33(9): e67, 2018 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-29441739

RESUMO

BACKGROUND: This study aimed to assess the recent changes of radiation therapy (RT) modalities in Korea. In particular, we focused on intensity-modulated radiation therapy (IMRT) utilization as the main index, presenting the application status of advanced RT. METHODS: We collected information from the Korean Health and Insurance Review and Assessment Service data based on the National Health Insurance Service claims and reimbursements records by using treatment codes from 2010 to 2016. We classified locating region of each institution as capital vs. non-capital areas and metropolitan vs. non-metropolitan areas to assess the regional difference in IMRT utilization in Korea. RESULTS: IMRT use has been steadily increased in Korea, with an annual increase estimate (AIE) of 37.9% from 2011 to 2016 (P < 0.001) resulting in IMRT being the second most common RT modality following three-dimensional conformal radiotherapy. In general, an increasing trend of IMRT utilization was observed, regardless of the region. The rate of AIE in the capital areas or metropolitan areas was higher than that in non-capital areas or non-metropolitan areas (40.7% vs. 31.9%; P < 0.001 and 39.7% vs. 29.4%; P < 0.001, respectively). DISCUSSION: The result of our survey showed that IMRT has become one of the most common RT modalities. IMRT is becoming popular in both metropolitan and non-metropolitan areas, while metropolitan area has faster AIE possibly due to concentration of medical resources and movement of advanced patients.


Assuntos
Radioterapia de Intensidade Modulada/tendências , Braquiterapia/tendências , Bases de Dados Factuais , Humanos , Programas Nacionais de Saúde , Radiocirurgia/tendências , Radioterapia Conformacional/tendências , República da Coreia , Inquéritos e Questionários
10.
Int J Radiat Oncol Biol Phys ; 99(2): 304-316, 2017 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-28871980

RESUMO

Considering the clinical potential of protons attributable to their physical characteristics, interest in proton therapy has increased greatly in this century, as has the number of proton therapy installations. Until recently, passively scattered proton therapy was used almost entirely. Notably, the overall clinical results to date have not shown a convincing benefit of protons over photons. A rapid transition is now occurring with the implementation of the most advanced form of proton therapy, intensity modulated proton therapy (IMPT). IMPT is superior to passively scattered proton therapy and intensity modulated radiation therapy (IMRT) dosimetrically. However, numerous limitations exist in the present IMPT methods. In particular, compared with IMRT, IMPT is highly vulnerable to various uncertainties. In this overview we identify three major areas of current limitations of IMPT: treatment planning, treatment delivery, and motion management, and discuss current and future efforts for improvement. For treatment planning, we need to reduce uncertainties in proton range and in computed dose distributions, improve robust planning and optimization, enhance adaptive treatment planning and delivery, and consider how to exploit the variability in the relative biological effectiveness of protons for clinical benefit. The quality of proton therapy also depends on the characteristics of the IMPT delivery systems and image guidance. Efforts are needed to optimize the beamlet spot size for both improved dose conformality and faster delivery. For the latter, faster energy switching time and increased dose rate are also needed. Real-time in-room volumetric imaging for guiding IMPT is in its early stages with cone beam computed tomography (CT) and CT-on-rails, and continued improvements are anticipated. In addition, imaging of the proton beams themselves, using, for instance, prompt γ emissions, is being developed to determine the proton range and to reduce range uncertainty. With the realization of the advances described above, we posit that IMPT, thus empowered, will lead to substantially improved clinical results.


Assuntos
Movimento , Terapia com Prótons/métodos , Planejamento da Radioterapia Assistida por Computador , Radioterapia de Intensidade Modulada/métodos , Tecnologia Radiológica , Física Sanitária , Humanos , Transferência Linear de Energia , Neoplasias/diagnóstico por imagem , Neoplasias/radioterapia , Terapia com Prótons/normas , Terapia com Prótons/tendências , Qualidade da Assistência à Saúde , Dosagem Radioterapêutica , Planejamento da Radioterapia Assistida por Computador/normas , Radioterapia Guiada por Imagem , Radioterapia de Intensidade Modulada/normas , Radioterapia de Intensidade Modulada/tendências , Eficiência Biológica Relativa , Respiração , Incerteza
11.
Int J Radiat Oncol Biol Phys ; 99(5): 1154-1161, 2017 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-28927756

RESUMO

PURPOSE: Limited data exist regarding the range of heart doses received in routine practice with radiation therapy (RT) for breast cancer in the United States today and the potential effect of the continual assessment of the cardiac dose on practice patterns. METHODS AND MATERIALS: From 2012 to 2015, 4688 patients with breast cancer treated with whole breast RT at 20 sites participating in a state-wide consortium were enrolled into a registry. The importance of limiting the cardiac dose has been emphasized in the consortium since 2012, and the mean heart dose (MHD) has been reported by each institution since 2014. The effects on the MHD were estimated for both conventional and accelerated fractionation using regression models, with technique (intensity modulated RT [IMRT] vs 3-dimensional conformal RT), deep inspiration breath hold use, patient position (supine vs prone), nodal RT (if delivered), and boost (yes vs no) as covariates. RESULTS: For left-sided breast cancer treated with conventional fractionation, the median MHD in 2012 was 2.19 Gy versus 1.65 Gy in 2015 (P<.001). The factors that significantly increased the MHD for conventional fractionation were increased separation relative to 22 cm (1.5%/1 cm), supraclavicular or infraclavicular nodal RT (17.1%), internal mammary nodal RT (40.7%), use of a boost (20.9%), treatment year before 2015 (7.7%), and use of IMRT (20.8%). For left-sided BC treated with accelerated fractionation, the median MHD in 2012 was 1.70 Gy versus 1.22 Gy in 2015 (P<.001). The factors that significantly increased the MHD for accelerated fractionation were separation (1.7%/1 cm), use of a boost (20.0%), year before 2015 (8.5%), and use of IMRT (19.2%). The factors for both conventional fractionation and accelerated fractionation that significantly reduced the MHD were the use of deep inspiration breath hold and prone positioning. CONCLUSIONS: The MHD for left-sided breast cancer decreased during a recent 4-year period, coincident with an increased focus on cardiac sparing in the radiation oncology community in general and a state-wide consortium specifically. These data suggest a positive effect of systematically monitoring the heart dose delivered.


Assuntos
Coração/efeitos da radiação , Lesões por Radiação/prevenção & controle , Radioterapia (Especialidade)/tendências , Radioterapia Conformacional/métodos , Neoplasias Unilaterais da Mama/radioterapia , Suspensão da Respiração , Fracionamento da Dose de Radiação , Feminino , Humanos , Órgãos em Risco/efeitos da radiação , Posicionamento do Paciente/métodos , Dosagem Radioterapêutica , Radioterapia Adjuvante/efeitos adversos , Radioterapia Adjuvante/métodos , Radioterapia Adjuvante/tendências , Radioterapia Conformacional/efeitos adversos , Radioterapia Conformacional/tendências , Radioterapia de Intensidade Modulada/efeitos adversos , Radioterapia de Intensidade Modulada/métodos , Radioterapia de Intensidade Modulada/tendências , Análise de Regressão , Fatores de Tempo , Estados Unidos
12.
Surg Oncol Clin N Am ; 26(3): 467-475, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28576183

RESUMO

The treatment of anal cancer has evolved remarkably in the past 30 years. Definitive chemoradiotherapy is the standard of care, allowing organ preservation and maintenance of continence for most patients. This article reviews recent advances in radiotherapy planning and delivery that have resulted in improvements in treatment-related toxicity. Most notably, the advent and wide adoption of intensity-modulated radiotherapy provides a superior toxicity profile compared with older techniques, while maintaining similar oncologic outcomes. Current areas of active research include optimizing and individualizing treatment intensity and possible integration of biologic agents and immunotherapies in the treatment of anal cancer.


Assuntos
Canal Anal/efeitos da radiação , Neoplasias do Ânus/radioterapia , Radioterapia de Intensidade Modulada/efeitos adversos , Radioterapia de Intensidade Modulada/métodos , Canal Anal/patologia , Neoplasias do Ânus/patologia , Neoplasias do Ânus/cirurgia , Neoplasias do Ânus/terapia , Carcinoma de Células Escamosas , Quimiorradioterapia , Humanos , Planejamento da Radioterapia Assistida por Computador , Radioterapia de Intensidade Modulada/tendências , Resultado do Tratamento
13.
J Am Coll Radiol ; 14(8): 1027-1033.e2, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28408078

RESUMO

Despite enthusiasm for advanced radiation technologies, understanding of their adoption in recent years is limited. The aim of this study was to elucidate utilization trends of conventional radiation, intensity-modulated radiotherapy (IMRT), brachytherapy, proton radiotherapy, stereotactic body radiotherapy (SBRT), and stereotactic radiosurgery (SRS) using a large convenience sample of irradiated patients with cancer identified from private insurance claims in the United States. The unit of analysis was a claim corresponding to a fraction of delivered radiotherapy from 2008 to 2014. Each claim was assigned a disease site on the basis of the diagnosis code and a radiation technology on the basis of the procedure code. In 2014, conventional radiation and IMRT constituted 56% and 39% of all radiation treatment claims, respectively, while brachytherapy constituted 2%, proton radiotherapy 1%, SBRT 1%, and SRS <1%. Compared with the first quarter of 2008, the proportional contribution of conventional radiation and brachytherapy to all radiation claims each decreased by 16% in the fourth quarter of 2014. In contrast, proportional contribution increased by 32% for IMRT, 83% for proton radiotherapy, 124% for SRS, and 309% for SBRT. Prostate cancer constituted 60% of all proton claims in 2008 but declined to 37% by 2014. SBRT was used to treat a variety of disease sites, most commonly primary lung (25%), prostate (12%), secondary bone (9%), and secondary lung (9%), in 2014. In this claims-based analysis of younger patients with private insurance, conventional radiation and IMRT were the most commonly used technologies from 2008 to 2014, while SBRT showed the most robust growth over the study period.


Assuntos
Radioterapia/estatística & dados numéricos , Radioterapia/tendências , Braquiterapia/estatística & dados numéricos , Braquiterapia/tendências , Humanos , Formulário de Reclamação de Seguro/estatística & dados numéricos , Formulário de Reclamação de Seguro/tendências , Seguro Saúde/estatística & dados numéricos , Masculino , Setor Privado/estatística & dados numéricos , Terapia com Prótons/estatística & dados numéricos , Terapia com Prótons/tendências , Radiocirurgia/estatística & dados numéricos , Radiocirurgia/tendências , Radioterapia/métodos , Radioterapia de Intensidade Modulada/estatística & dados numéricos , Radioterapia de Intensidade Modulada/tendências , Estados Unidos
14.
Int J Radiat Oncol Biol Phys ; 98(1): 177-185, 2017 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-28258896

RESUMO

PURPOSE: We examined the impact of intensity modulated radiation therapy (IMRT) on hospitalization rates in the Surveillance, Epidemiology, and End Results (SEER)-Medicare population with anal squamous cell carcinoma (SCC). METHODS AND MATERIALS: We performed a retrospective cohort study using the SEER-Medicare database. We identified patients with nonmetastatic anal SCC diagnosed between 2001 and 2011 and treated with chemoradiation therapy. We assessed the relation between IMRT and first hospitalization by use of a multivariate competing-risk model, as well as instrumental variable analysis, using provider IMRT affinity as our instrument. RESULTS: Of the 1165 patients included in our study, 458 (39%) received IMRT. IMRT use increased over time and was associated more with regional and provider characteristics than with patient characteristics. The 3- and 6-month cumulative incidences of first hospitalization were 41.9% (95% confidence interval [CI], 37.3%-46.4%) and 47.6% (95% CI, 43.0%-52.2%), respectively, for the IMRT cohort and 46.7% (95% CI, 43.0%-50.4%) and 52.1% (95% CI, 48.4%-55.7%), respectively, for the non-IMRT cohort. IMRT was associated with a decreased hazard of first hospitalization compared with 3-dimensional radiation techniques (hazard ratio, 0.70; 95% CI, 0.58-0.84; P=.0002). Instrumental variable analysis suggested an even greater reduction in hospitalizations with IMRT after controlling for unmeasured confounders. There was a trend toward improved overall survival with IMRT, with an adjusted hazard ratio of 0.77 (95% CI, 0.59-1.00; P=.05). CONCLUSIONS: The use of IMRT is associated with reduced hospitalizations in elderly patients with anal SCC. Further work is warranted to understand the long-term health and cost impact of IMRT, particularly for patient subgroups most at risk of toxicity and hospitalization.


Assuntos
Neoplasias do Ânus/radioterapia , Carcinoma de Células Escamosas/radioterapia , Hospitalização/estatística & dados numéricos , Medicare/estatística & dados numéricos , Radioterapia de Intensidade Modulada/estatística & dados numéricos , Programa de SEER/estatística & dados numéricos , Idoso , Neoplasias do Ânus/mortalidade , Neoplasias do Ânus/patologia , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Intervalos de Confiança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Modelos de Riscos Proporcionais , Radioterapia de Intensidade Modulada/mortalidade , Radioterapia de Intensidade Modulada/tendências , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos
15.
Prostate ; 77(6): 559-572, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28093791

RESUMO

BACKGROUND: The role of local therapy, in the form of radiation therapy (RT) or radical prostatectomy(RP), and its association on outcomes is not well established in patients with metastatic prostate cancer. METHODS: Using the National Cancer Database (NCDB), we evaluated patterns of care and outcomes among patients diagnosed with metastatic prostate cancer from 2004 to 2013 treated with local therapy (RP, intensity-modulated radiation therapy [IMRT], or 2D/3D-conformal radiation therapy [CRT]). The association between local therapy, co-variates, and outcomes was assessed in a multivariable Cox proportional hazards model and Propensity score (PS) matching was performed to balance confounding factors. Survival was estimated using the Kaplan-Meier method. RESULTS: Among the 1,208,180 patients in the NCDB with prostate cancer, 6,051 patients met the inclusion criteria. No local therapy was used in 5,224 patients, while 622 (10.3%), 52 (0.9%), 153 (2.5%) patients received RP, IMRT, and 2D/3D-CRT, respectively. Use of local therapy was associated with younger age (≤70), lower co-morbidity score, lower T-stage, Gleason score <8, node-negative status, private, and Medicare insurance, higher income quartile, and treatment at comprehensive or academic/research programs (P < 0.05). Five-year overall survival for patients receiving local therapy was 45.7% versus 17.1% for those not receiving local therapy (P < 0.01). In multivariate analysis, RP (HR = 0.51; 95%CI, 0.45-0.59, P < 0.01) and IMRT (HR = 0.47; 95%CI, 0.31-0.72, P < 0.01) were independently associated with superior overall survival. After PS-matching, the use of local therapy (RP or IMRT) remained significantly associated with overall survival (HR = 0.35; 95%CI, 0.30-0.41, P < 0.01). CONCLUSIONS: The use of RP and IMRT, to treat the primary disease, was associated with improvements in overall survival for patients with metastatic prostate cancer. We have identified patient-specific variations in the use of local therapy that may be tested in subsequent prospective clinical trials to improve patient outcomes in this setting. Prostate 77: 559-572, 2017. © 2017 Wiley Periodicals, Inc.


Assuntos
Prostatectomia/tendências , Neoplasias da Próstata/radioterapia , Neoplasias da Próstata/cirurgia , Radioterapia de Intensidade Modulada/tendências , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Bases de Dados Factuais/tendências , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Prostatectomia/mortalidade , Neoplasias da Próstata/mortalidade , Radioterapia de Intensidade Modulada/mortalidade , Sistema de Registros , Estudos Retrospectivos , Taxa de Sobrevida/tendências
17.
Gynecol Oncol ; 144(1): 130-135, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27887805

RESUMO

OBJECTIVE: To analyze the patterns of care regarding intensity modulated radiation therapy (IMRT) usage in the postoperative management of uterine cancer. METHODS: The National Cancer Database was queried to identify women with endometrial adenocarcinoma who underwent hysterectomy followed by external beam radiation between 2004-2012. Descriptive statistics were used to analyze IMRT usage with comparison via the Chi Square test. Overall survival was also compared between IMRT and three dimensional conformal radiation therapy. Multivariable logistic regression and multivariable Cox Regression were used to identify covariables that impact IMRT usage and improved survival respectively. RESULTS: 7839 women were included in this study. IMRT utilization increased from 1.9% in 2004 to 32.4% in 2012 (p<0.001). The adjusted odds ratio (OR) for IMRT in 2012 compared with 2004 was 24.90, 95% CI 15.24-40.67 (p<0.001). Aside from year, other predictors of IMRT usage on multivariate analysis were positive nodes, higher dose, private insurance and higher income. Black race was associated with lower IMRT usage compared to Whites with an OR of 0.60, 95% CI 0.44-0.81 (p=0.001). IMRT was not associated with significantly increased survival (HR 0.86, 95% CI 0.73-1.01, p=0.06). Black race and positive nodes were associated with decreased survival within the group studied whereas private insurance and higher income were associated with improved survival. CONCLUSIONS: In this hospital-based registry, IMRT has significantly increased in utilization for postoperative radiation in uterine cancer between 2004-2012 although not resulting in significantly improved survival. Socioeconomic and racial disparities exist in the allocation of IMRT usage.


Assuntos
Adenocarcinoma/radioterapia , Neoplasias do Endométrio/radioterapia , Radioterapia de Intensidade Modulada/estatística & dados numéricos , Adenocarcinoma/secundário , Adenocarcinoma/cirurgia , Afro-Americanos/estatística & dados numéricos , Idoso , Bases de Dados Factuais , Neoplasias do Endométrio/patologia , Neoplasias do Endométrio/cirurgia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Humanos , Histerectomia , Renda , Seguro Saúde , Metástase Linfática , Pessoa de Meia-Idade , Período Pós-Operatório , Dosagem Radioterapêutica , Radioterapia Adjuvante/estatística & dados numéricos , Radioterapia de Intensidade Modulada/tendências , Taxa de Sobrevida , Estados Unidos
18.
Int J Radiat Oncol Biol Phys ; 97(3): 450-461, 2017 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-28011046

RESUMO

PURPOSE: Leaders in the oncology community are sounding a clarion call to promote "value" in cancer care decisions. Value in cancer care considers the clinical effectiveness, along with the costs, when selecting a treatment. To discuss possible solutions to the current obstacles to achieving value in the use of advanced technologies in oncology, the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine held a workshop, "Appropriate Use of Advanced Technologies for Radiation Therapy and Surgery in Oncology" in July 2015. The present report summarizes the discussions related to radiation oncology. METHODS AND MATERIALS: The workshop convened stakeholders, including oncologists, researchers, payers, policymakers, and patients. Speakers presented on key themes, including the rationale for a value discussion on advanced technology use in radiation oncology, the generation of scientific evidence for value of advanced radiation technologies, the effect of both scientific evidence and "marketplace" (or economic) factors on the adoption of technologies, and newer approaches to improving value in the practice of radiation oncology. The presentations were followed by a panel discussion with dialogue among the stakeholders. RESULTS: Challenges to generating evidence for the value of advanced technologies include obtaining contemporary, prospective, randomized, and representative comparative effectiveness data. Proposed solutions include the use of prospective registry data; integrating radiation oncology treatment, outcomes, and quality benchmark data; and encouraging insurance coverage with evidence development. Challenges to improving value in practice include the slow adoption of higher value and the de-adoption of lower value treatments. The proposed solutions focused on engaging stakeholders in iterative, collaborative, and evidence-based efforts to define value and promote change in radiation oncology practice. Recent examples of ongoing or successful responses to the discussed challenges were provided. CONCLUSIONS: Discussions of "value" have increased as a priority in the radiation oncology community. Practitioners in the radiation oncology community can play a critical role in promoting a value-oriented framework to approach radiation oncology treatment.


Assuntos
Neoplasias/radioterapia , Radioterapia (Especialidade)/normas , Custos e Análise de Custo , Tomada de Decisões , Difusão de Inovações , Humanos , Avaliação de Programas e Projetos de Saúde , Terapia com Prótons/economia , Terapia com Prótons/estatística & dados numéricos , Terapia com Prótons/tendências , Radioterapia (Especialidade)/economia , Radioterapia (Especialidade)/instrumentação , Radioterapia/economia , Radioterapia/instrumentação , Radioterapia/normas , Radioterapia de Intensidade Modulada/economia , Radioterapia de Intensidade Modulada/estatística & dados numéricos , Radioterapia de Intensidade Modulada/tendências , Pesquisadores , Tecnologia Radiológica/economia , Tecnologia Radiológica/normas , Estados Unidos
20.
Clin Oncol (R Coll Radiol) ; 28(8): e28-34, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-26880064

RESUMO

AIMS: Between 2012 and 2014 the number of patients treated in the UK with intensity-modulated radiotherapy (IMRT) techniques increased significantly. One reason for this was the radiotherapy innovation fund for the centres in England. Before the announcement of the fund, a survey of radiotherapy centres was carried out in 2012 which collected data on IMRT uptake, obstacles to implementation, equipment used, delivery techniques and verification methods. A repeat survey was carried out in 2014 to identify key changes to IMRT quality assurance and verification practices. MATERIALS AND METHODS: An online questionnaire was sent out to all 65 UK radiotherapy centres in the summer of 2012 and again in the summer of 2014. Questions covered background and equipment, machine tolerance and quality assurance, machine-based verification, software-based verification and future plans. RESULTS: There have been significant changes in the delivery techniques used for IMRT, with more than twice as many centres reporting the use of volumetric-modulated arc therapy techniques in 2014 compared with 2012. This has been combined with an increase in Monte Carlo-based algorithms in treatment planning systems. In 2012 all centres reported the need to carry out machine-based measurements for IMRT plan verification, dropping to 93% in 2014. Nineteen per cent of centres now report making only one measurement per month for prostate plans and 8% of breast plans never have physical measurements. Most centres use detector arrays for quality assurance measurement (86% in 2012 and 91% in 2014), but a significant number still use film and/or ionisation chambers (51% and 41%). In the analysis of these measurements there has been an increase in the use of tighter criteria. There has been a significant increase in the use of software for verification from 63% in 2012 to 95% in 2014. All centres reported that they needed further resources in order to efficiently achieve the quality assurance required for the number of patients planned to be treated in their centre. CONCLUSIONS: The increased numbers of patients being treated with IMRT has meant that there have been significant changes in the way that quality assurance is carried out. These have been mainly in the reduction of measurements and the increase in software-based verification. However, quality assurance is still a significant burden and still has an effect on the numbers of patients who can be treated with IMRT.


Assuntos
Planejamento da Radioterapia Assistida por Computador/métodos , Planejamento da Radioterapia Assistida por Computador/normas , Radioterapia de Intensidade Modulada/métodos , Radioterapia de Intensidade Modulada/normas , Inglaterra , Humanos , Método de Monte Carlo , Dosagem Radioterapêutica , Planejamento da Radioterapia Assistida por Computador/tendências , Radioterapia de Intensidade Modulada/tendências
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