Design and implementation of automated notification systems and an electronic whiteboard for radiation therapy planning monitoring.

PURPOSE: Radiotherapy (RT) treatment and treatment planning is a complex process prepared and delivered by a multidisciplinary team of specialists. Efficient communication and notification systems among different team members are therefore essential to ensure the safe, timely delivery of treatments to patients. METHOD: To address this issue, we developed and implemented automated notification systems and an electronic whiteboard to track every CT simulation, contouring task, the new-start schedule, and physician's appointments and tasks, and notify team members of overdue and missing tasks and appointments. The electronic whiteboard was developed to have a straightforward view of current patients' planning workflow and to help different team members coordinate with each other. The systems were implemented and have been used at our center to monitor the progress of treatment-planning tasks for over 2 years. RESULTS: The last-minute plans were relatively reduced by about 40% in 2023 compared to 2021 and 2022 with a p-value < 0.05. The overdue contouring tasks of more than 1 day decreased from 46.8% in 2019 and 33.6% in 2020 to 20%-26.4% in 2021-2023 with a p-value < 0.05 after the implementation of the notification system. The rate of plans with 1-3 day planning time decreased by 20.31%, 39.32%, and 24.08% with a p-value < 0.05 and the rate of plans with 1-3 day planning time due to the contouring task overdue more than 1 day decreased by 49.49%, 56.89%, and 46.52% with a p-value < 0.05 after the implementation. The rate of outstanding appointments that are overdue by more than 7 days decreased by more than 5% with a p-value < 0.05 following the implementation of the system. CONCLUSIONS: Our experience shows that this system requires minimal human intervention, improves the treatment planning workflow and process by reducing errors and delays in the treatment planning process, positively impacts on-time treatment plan completion, and reduces the need for compressed or rushed treatment planning timelines.

Proton therapy for high-risk prostate cancer: Results from the Proton Collaborative Group PCG 001-09 prospective registry trial.

BACKGROUND: Data for proton therapy in high-risk prostate cancer (HRPC) are limited. Using the Proton Collaborative Group prospective registry, we evaluated outcomes for HRPC patients treated with proton therapy. METHODS: A totsl of 605 men with localized HRPC treated with proton therapy from 8/2009 to 3/2019 at nine institutions were selected. Outcomes examined included freedom from progression (FFP), metastasis free survival (MFS), overall survival (OS), and toxicity. Multivariable cox/binomial regression models were used to assess predictors of FFP and toxicity. RESULTS: Median age was 71 years. Gleason grade groups 4 (49.4%) and 5 (31.7%) were most common, as were clinical stage T1c (46.1%) and cT2 (41.3%). The median pretreatment prostate specific antigen (PSA) was 9.18 and median International Prostate Symptom Score (IPSS) was 6. Androgen deprivation therapy was given in 63.6%. Median dose was 79.2 GyE in 44 fractions. Pelvic lymph nodes were treated in 58.2% of cases. Pencil beam scanning was used in 54.5%, uniform scanning in 38.8%, and a rectal spacer in 14.2%. At a median followup of 22 months, the 3- and 5-year FFP were 90.7% and 81.4%, respectively. Five-year MFS and OS were 92.8% and 95.9%, respectively. Independent correlates of FFP included Gleason ≥8, PSA > 10, and cT2 (all p < 0.05). No grade 4 or 5 adverse events were reported. There were 23 (5%) grade 2 and 0 grade 3 gastrointestinal events. Prevalence of late grade 3, late grade 2, acute grade 3, and acute grade 2 genitourinary toxicity was 1.7%, 5.8%, 0%, and 21.8%, respectively. Prevalence of grade 2 and 3 erectile dysfunction at 2 years was 48.4% and 8.4%, respectively. CONCLUSIONS: In the largest series published to date, our results suggest early outcomes using proton therapy for HRPC are encouraging for both safety and efficacy. Further evaluation is needed to determine if an advantage exists to use protons over other radiation techniques in this population.

Reducing PTV margins for prostate SBRT with motion compensation and gating techniques.

The purpose of this study is to investigate the dosimetric accuracy of prostate SBRT when motion is considered. To account for target movement, motion compensation and gating techniques were investigated with PTV margins reduced to 2 mm. To allow for dosimetric measurements a Delta4 phantom, Gafchromic film, and Hexamotion motion platform were utilized. Four motion files were utilized that represent a range of motions. Analysis of measured prostate motions for fifteen patients was performed to ensure detected motions were similar to those previously reported and motion files utilized were suitable. Five patient plans were utilized to allow for the effects of MLC and target motion interplay to be investigated. For both motion compensation and gating techniques, plans were delivered to the stationary phantom and for each of four motion types with/without compensation/gating enabled. Using a 3%, 2 mm and 80% threshold gamma criteria, film measurements had an average pass rate of 80.5% for uncorrected deliveries versus 96.0% for motion compensated deliveries. For gated techniques average pass rates increased from 89.9% for uncorrected to 94.8% with gating enabled. Measurements with the Delta4 arrays were analyzed with a 3%, 2 mm and 10% threshold dose. An average pass rate of 83.8% was measured for uncorrected motions versus 94.8% with motion compensation. For the gated technique an average pass rate of 87.2% was found for uncorrected motions versus 96.9% with gating enabled. These results show that very high gamma pass rates are achievable when motion compensation or gating techniques are applied. When target motion is not accounted for shifts up to 5 mm in planned versus delivered isodose distributions were found. However, when motion compensation, or gated techniques were applied, much smaller differences between planned and delivered isodose distributions were found. With these techniques dose delivery accuracy is greatly improved, allowing for PTV margins to be reduced.

Volumetric changes of the parotid gland during IMRT based on mid-treatment imaging: implications for parotid stem cell sparing strategies in head and neck cancer.

BACKGROUND: To evaluate the change in parotid glands at mid-treatment during IMRT and the association between radiation dose to the parotid gland stem cell (PGSC) region and patient-reported xerostomia for patients with head and neck cancer (HNC). MATERIAL AND METHODS: Patients who were treated from 2006-2012 at our institution with patient-reported xerostomia outcomes available at least 9 months following RT were included. PG and PGSC regions were delineated and the dose was estimated from the treatment plan dose distribution, using contours from pre- and mid-treatment CT scans. The association between radiation dose and volumetric changes was assessed using linear regression. Univariable logistic regression, logistic dose-response curves, and receiver operating characteristics (ROC) were used to examine the relationship between radiation dose and patient-reported xerostomia. RESULTS: Sixty-three patients were included, most treated with 70 Gy in 33 fractions; 34 patients had mid-treatment CT scans. Both contralateral and ipsilateral PGs had considerable volume reduction from baseline to mid-treatment (25% and 27%, respectively, both p < .001), significantly associated with mean PG dose (-0.44%/Gy, p = .008 and -0.54%/Gy, p < .001, respectively). There was a > 5 Gy difference in mean PG and PGSC dose for 8/34 patients at mid-treatment, with 6/8 (75%) reporting severe xerostomia. Xerostomia prediction based on whole PG or PGSC region dose showed similar performance (ROC AUC 0.754 and 0.749, respectively). The corresponding dose-response models also predicted similar risk of patient-reported xerostomia with mean dose to the contralateral PG (32.5%) or PGSC region (31.4%) at the 20 Gy QUANTEC-recommended sparing level. CONCLUSIONS: The radiation dose to the PGSC region did not show stronger association with patient-reported xerostomia compared to that of whole PG, possibly due to considerable anatomical changes identified at mid-treatment. This shift in the size and position of the PG warrants adaptive planning strategies to evaluate the true benefit of parotid stem cell sparing.

Organ-at-risk dose prediction using a machine learning algorithm: Clinical validation and treatment planning benefit for lung SBRT.

OBJECTIVE: To quantify the clinical performance of a machine learning (ML) algorithm for organ-at-risk (OAR) dose prediction for lung stereotactic body radiation therapy (SBRT) and estimate the treatment planning benefit from having upfront access to these dose predictions. METHODS: ML models were trained using multi-center data consisting of 209 patients previously treated with lung SBRT. Two prescription levels were investigated, 50 Gy in five fractions and 54 Gy in three fractions. Models were generated using a gradient-boosted regression tree algorithm using grid searching with fivefold cross-validation. Twenty patients not included in the training set were used to test OAR dose prediction performance, ten for each prescription. We also performed blinded re-planning based on OAR dose predictions but without access to clinically delivered plans. Differences between predicted and delivered doses were assessed by root-mean square deviation (RMSD), and statistical differences between predicted, delivered, and re-planned doses were evaluated with one-way analysis of variance (ANOVA) tests. RESULTS: ANOVA tests showed no significant differences between predicted, delivered, and replanned OAR doses (all p ≥ 0.36). The RMSD was 2.9, 3.9, 4.3, and 1.7Gy for max dose to the spinal cord, great vessels, heart, and trachea, respectively, for 50 Gy in five fractions. Average improvements of 1.0, 1.4, and 2.0 Gy were seen for spinal cord, esophagus, and trachea max doses in blinded replans compared to clinically delivered plans with 54 Gy in three fractions, and 1.8, 0.7, and 1.5 Gy, respectively, for the esophagus, heart and bronchus max doses with 50 Gy in five fractions. Target coverage was similar with an average PTV V100% of 94.7% for delivered plans compared to 97.3% for blinded re-plans for 50 Gy in five fractions, and respectively 98.4% versus 99.2% for 54 Gy in three fractions. CONCLUSION: This study validated ML-based OAR dose prediction for lung SBRT, showing potential for improved OAR dose sparing and more consistent plan quality using dose predictions for patient-specific planning guidance.

Impact of Nonadherence to NCCN Adjuvant Radiotherapy Initiation Guidelines in Head and Neck Squamous Cell Carcinoma in an Underserved Urban Population.

BACKGROUND: Nonadherence to NCCN Guidelines during time from surgery to postoperative radiotherapy (S-PORT) can alter survival outcomes in head and neck squamous cell carcinomna (HNSCC). There is a need to validate this impact in an underserved urban population and to understand risk factors and reasons for delay. We sought to investigate the impact of delayed PORT with outcomes of overall survival (OS) in HNSCC, to analyze predictive factors of delayed PORT, and to identify reasons for delay. METHODS: We conducted a retrospective cohort study in an urban, community-based academic center. A total of 184 patients with primary HNSCC were identified through the Montefiore Medical Center cancer registry who had been treated between March 1, 2005, and March 8, 2017, and met the inclusion and exclusion criteria. The primary exposure was S-PORT. OS, recurrence, and risk factors and reasons for treatment delay were the main outcomes and measures. RESULTS: Among 184 patients with HNSCC treated with PORT, the median S-PORT was 48.5 days (interquartile range, 41-67 days). The S-PORT threshold that optimally differentiated worse OS outcomes was >50 days (46.7% of our cohort; n=86). Independent of other relevant factors, patients with HNSCC and S-PORT >50 days had worse OS (hazard ratio, 2.30; 95% CI, 1.34-3.95) and greater recurrence (odds ratio, 3.51; 95% CI, 1.31-9.39). Predictors of delayed S-PORT included being underweight or obese, prolonged postoperative length of stay, and age >70 years. The most frequent reasons for PORT delay were complications related to surgery (22.09%), unrelated medical comorbidities (18.60%), and nonadherence/missed appointments (6.98%). CONCLUSIONS: Delayed PORT beyond 50 days after surgery was associated with decreased OS and greater recurrence. Identification of predictive factors and reasons for treatment delay helps to target at-risk patients and facilitates interventions in underserved populations.

Prolongation of radiotherapy duration is associated with inferior overall survival in patients with pediatric medulloblastoma and central nervous system primitive neuroectodermal tumors.

BACKGROUND: The importance of radiotherapy (RT) duration in medulloblastoma in the modern era of chemotherapy has not been well elucidated. The aim of this study was to determine the impact of RT treatment duration on overall survival (OS) in pediatric medulloblastoma and cenral nervous system neuroectodermal tumors (PNETs). METHODS: The National Cancer Database (NCDB) was queried to identify patients with newly diagnosed medulloblastoma and CNS PNETs diagnosed between 2004 and 2014. Patients were excluded if they had extraneural metastasis, did not receive standard craniospinal irradiation dose, had a nonstandard total dose outside of 54 or 55.8 Gy, did not receive adjuvant chemotherapy, or if the RT duration was outside of the expected range of 37 to 80 days. The Kaplan-Meier estimator was used to estimate the association between RT duration (≤45 days or >45 days) and OS. Multivariate Cox regression was used to assess other confounders of OS. RESULTS: Six-hundred twenty-five patients met inclusion criteria, of which 181 were assigned to the "RT long" (>45 days) cohort (29.0%) and 444 (71.0%) to the "RT short" group (≤45 days). The five-year OS for the "RT short" compared with "RT long" cohort was 82.2% versus 70.9%, respectively (log-rank, P < 0.0037). For average risk patients, the five-year OS was 84.6% versus 86.4% for "RT short" and "RT long," respectively (log-rank, P = 0.40). However, for high-risk patients, five-year OS was 77.7% versus 51.0% (log-rank, P < 0.0001) in the "RT short" and "RT long" cohorts. CONCLUSION: For patients with high-risk medulloblastoma and CNS PNETs, RT duration >45 days was associated with inferior OS.

Recommendations of megavoltage computed tomography settings for the implementation of adaptive radiotherapy on helical tomotherapy units.

Megavoltage computed tomography (MVCT) image quality metrics were evaluated on an Accuray Radixact unit to recommend scan settings for the implementation of a consistent adaptive radiotherapy program. Megavoltage computed tomography image quality was evaluated and compared to a kilovoltage CT (kVCT) simulator using a commercial cone beam computed tomography image quality phantom. Megavoltage computed tomographies were acquired on the Accuray Radixact using fine, normal, and coarse pitches, with all available reconstruction slice thicknesses, each of which were reconstructed using standard and iterative reconstruction (IR). Image quality metrics (IQM) were evaluated using DoseLab: automatically and manually calculated spatial resolution, subject contrast, and contrast-to-noise ratio (CNR). Scanning time was 15.6 s/cm for fine, 8.1 s/cm for normal, and 5.6 s/cm for coarse pitch. Automatically evaluated spatial resolutions ranged from 0.39, 0.41, to 0.42 lp/mm for standard reconstruction and from 0.24, 0.21, to 0.18 lp/mm for soft-tissue IR, respectively, with general IR yielding values in between these. Spatial resolution for kVCT was measured to be at least 0.42 lp/mm. Contrast was consistent across MVCT settings with 8.1 ± 0.2%, while kVCT contrast was 10.27 ± 0.05%. CNR was calculated to be 3.3 ± 0.4 for standard reconstruction, 7.4 ± 0.4 for general IR, and 12.0 ± 1.9 for soft-tissue IR. It was found that increasing reconstruction slice thickness for a given pitch does not improve IQMs. Based on the consistency of contrast metrics across pitch values and the only slightly reduced spatial resolution using normal compared to fine pitch, we recommend the use of normal pitch with 2 mm slice thickness to maximize image quality for ART while limiting scanning time. Only for sites for which improved CNR is required and reduced spatial resolution is acceptable, soft-tissue IR is recommended.

Cisplatin and radiation therapy in HIV-positive women with locally advanced cervical cancer in sub-Saharan Africa: A phase II study of the AIDS malignancy consortium.

PURPOSE: To determine the feasibility, safety, and tolerability of concomitant chemoradiotherapy administered at standard doses in HIV-infected women with locally-advanced cervical cancer (LACC) receiving antiretroviral therapy (ART). PATIENTS AND METHODS: Eligible participants had HIV infection and untreated, histologically-confirmed, invasive carcinoma of the uterine cervix, FIGO stages IB2, IIA (if tumor >4 cm), IIB, IIIA, IIIB, or IVA and met standard eligibility criteria. Subjects were prescribed 41.4-45 Gy external beam radiation therapy followed by high dose rate brachytherapy concomitant with up to six weekly doses of cisplatin 40 mg/m2 and were followed for 12 months. RESULTS: Sixty-four women were screened at two sites in sub-Saharan Africa, of whom 40 eligible participants were enrolled, for a screening ratio of 1.60. Of the 38 eligible participants who initiated study treatment, 31 (82%) completed treatment. By the 12-month follow-up visit, 7 women had died of disease and 29 of 31 (94%) returned for follow-up. One-year progression-free survival was 76.3% (95% CI, 59.4-86.9%), and did not significantly differ according to stage at entry (p = 0.581). Participant-reported adherence to ART was high; by 12 months, 93% of participants had an undetectable viral load. The most common grade 3 or 4 adverse event was decreased lymphocyte count that affected all treated participants. Non-hematologic serious adverse events were similar to those observed in women with LACC without HIV infection. CONCLUSIONS: The majority of HIV-infected women with LACC can complete concomitant chemoradiotherapy with the same cisplatin dose used in HIV-uninfected women with comparable tolerability and high ART adherence while on treatment.

Human papillomavirus, radiation dose and survival of patients with anal cancer.

Purpose: To determine if anal cancer patients with HPV positive disease have different overall survival (OS) compared to those with HPV negative disease, and to elucidate differences in the association between radiation dose and OS.Patients and methods: We utilized the National Cancer Database (NCDB) registry to identify a cohort of non-metastatic anal cancer patients treated with curative intent between 2008 and 2014. Propensity score matching was used to account for potential selection bias between patients with HPV positive and negative disease. Multivariable Cox regression was used to determine the association between HPV status and OS. Kaplan-Meier methods were used to compare actuarial survival estimates.Results: We identified 5927 patients with tumor HPV status for this analysis, 3523 (59.4%) had HPV positive disease and 2404 (40.6%) had HPV negative disease. Propensity-matched analysis demonstrated that patients with HPV positive locally advanced (T3-4 or node positive) anal cancer had better OS (HR = 0.81 (95%CI: 0.68-0.96), p=.018). For patients with early stage disease (T1-2 and node negative) there was no difference in OS (HR = 1.11 (95%CI: 0.86-1.43), p=.43). In the unmatched cohort, we found a significant improvement in OS with increasing radiation dose only for patients with locally advanced, HPV negative disease (p<.001). In those patients, significant improvement in OS compared to the group receiving 30-45 Gy was seen for increasing doses up to 55-60 Gy, but not beyond 60 Gy.Conclusion: We found HPV to be a significant prognostic marker in anal tumors, especially for locally advanced disease. We further found that higher radiation dose up to 55-60 Gy was associated with better OS, but only for patients with locally advanced, HPV negative disease.

Pretreatment financial toxicity predicts progression-free survival following concurrent chemoradiotherapy for locally advanced non-small-cell lung cancer.

Aim: Financial toxicity (FT) describes patients' burden from out-of-pocket medical treatment costs. We studied associations between patient-reported pretreatment FT, socioeconomic status and clinical outcomes for locally advanced non-small-cell lung cancer (LA-NSCLC) patients. Methods: Patients received chemoradiotherapy for locally advanced non-small-cell lung cancer and completed the European Organization for the Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) quality of life assessment before treatment. One question asks whether patients experience 'financial difficulties'. We tested FT and socioeconomic status (SES) as predictors of progression-free survival (PFS) and overall survival (OS). Results: A total of 43 patients were included. Median follow-up for surviving patients was 15 months. A total of 19 patients (44%) experienced disease progression and 17 patients (40%) died. Increasing FT was associated with shorter PFS (p = 0.011). FT did not predict overall survival (p = 0.67). Conclusion: Higher pretreatment FT is associated with shorter PFS.

NRG oncology RTOG 9006: a phase III randomized trial of hyperfractionated radiotherapy (RT) and BCNU versus standard RT and BCNU for malignant glioma patients.

From 1990 to 1994, patients with newly diagnosed malignant gliomas were enrolled and randomized between hyperfractionated radiation (HFX) of 72.0 Gy in 60 fractions given twice daily and 60.0 Gy in 30 fractions given once daily. All patients received 80 mg/m2 of 1,3 bis(2 chloroethyl)-1 nitrosourea on days 1-3 q8 weeks for 1 year. Patients were stratified by age, KPS, and histology. The primary endpoint was overall survival (OS), with secondary endpoints including progression-free survival (PFS) and toxicity. Out of the 712 patients accrued, 694 (97.5%) were analyzable cases (350 HFX, 344 standard arm). There was no significant difference between the arms on overall acute or late treatment-related toxicity. No statistically significant effect for HFX, as compared to standard therapy, was found on either OS, with a median survival time (MST) of 11.3 versus 13.1 months (p = 0.20) or PFS, with a median PFS time of 5.7 versus 6.9 months (p = 0.18). The treatment effect on OS remained insignificant based on the multivariate analysis (hazard ratio 1.16; p = 0.0682). When OS was analyzed by histology subgroup there was also no significant difference between the two arms for patients with glioblastoma multiforme (MST: 10.3 vs. 11.2 months; p = 0.34), anaplastic astrocytoma (MST: 69.8 vs. 50.0 months; p = 0.91) or anaplastic oligodendroglioma (MST: 92.1 vs. 66.5 months; p = 0.33). Though this trial provided many invaluable secondary analyses, there was no trend or indication of a benefit to HFX radiation to 72.0 Gy in any subset of malignant glioma patients.

The impact of dietary regimen compliance on outcomes for HNSCC patients treated with radiation therapy.

OBJECTIVE: To analyze nutritional factors and compliance with dietary recommendations for associations with overall survival (OS) and progression-free survival (PFS) in patients receiving definitive RT for laryngeal and oropharyngeal cancers. MATERIALS/METHODS: We identified 352 patients with non-metastatic laryngeal (146) and oropharyngeal (206) cancer treated with definitive RT between 2004 and 2013. Disease and patient characteristics, treatment information, sarcopenia based on muscle areas at L3 level on CT, compliance with the nutritional program, and clinical outcomes data were tabulated. Descriptive statistics, Kaplan-Meier survival analysis, and log rank tests were performed, and Cox regression models were used to examine predictors of OS and PFS. RESULTS: The median follow-up for the entire cohort was 22.86 months. The actuarial rates for OS were 91, 86, and 73% at years 1, 2, and 5, respectively. Of patients with abdominal CT prior to starting RT, 70.9% (112/158) were sarcopenic with a median muscle mass index of 48.2 (range 30.4-70.9) for males and 35.9 (range 24.6-53.2) for females. The majority (85.8%) of patients met with a dietitian during their course of RT and 62.6% of these patients were compliant with the nutritional program. Compliance with the nutritional program resulted in 27% (HR 0.73, 95% CI 0.43-1.26) protection from death (did not reach significance) and 31% (HR 0.69, 95% CI 0.50-0.94) significant protection from disease progression. Higher pretreatment BMI was associated with a lower risk of death (HR 0.94, 95% CI 0.90-0.99) and disease progression (HR 0.96, 95% CI 0.93-0.99). CONCLUSION: Laryngeal and oropharyngeal cancer patients treated with definitive RT who are compliant with regular dietetic counseling and contact appear to have improved outcomes. TRIAL REGISTRATION: Not applicable.

Management algorithm for HIV-associated parotid lymphoepithelial cysts.

We report an evidence-based management algorithm for benign lymphoepithelial cysts (BLEC) of the parotid glands in HIV patients based on long-term outcomes after radiation therapy. From 1987 to 2013, 72 HIV-positive patients with BLEC of the parotid glands treated at our institutions were identified and their medical records were reviewed and analyzed. The primary endpoint of our study was to determine a dose response in HIV patients with BLEC. In group A (≤18 Gy), which received a median dose of 10 Gy (8-18), overall response (OvR), complete response (CR), partial response (PR), and local failure (LF) was experienced by 7, 7, 0, and 93 %, respectively. In group B (≥22.5 Gy), which received a median dose of 24 Gy (22.5-30), OvR, CR, PR, and LF was experienced by 88, 65, 23, and 12 %. Logistic regression revealed that higher dose (≥22.5 Gy) predicted for cosmetic control (p = 0.0003). Multiple regression analysis revealed higher dose predicted for cosmetic control (p = 0.0001) after adjusting for confounding variables (age, gender, race, HAART use, BLEC duration, and fractionation size). No patients in either group experienced RTOG grade ≥3 toxicities. A radiation dose of 24 Gy delivered in 12-16 fractions of 1.5-2 Gy per fraction provides long-term cosmetic control in HIV-positive patients with BLEC of the parotid glands.

Combined P16 and human papillomavirus testing predicts head and neck cancer survival.

While its prognostic significance remains unclear, p16(INK4a) protein expression is increasingly being used as a surrogate marker for oncogenic human papillomavirus (HPV) infection in head and neck squamous cell carcinomas (HNSCC). To evaluate the prognostic utility of p16 expression in HNSCC, we prospectively collected 163 primary tumor specimens from histologically confirmed HNSCC patients who were followed for up to 9.4 years. Formalin fixed tumor specimens were tested for p16 protein expression by immunohistochemistry (IHC). HPV type-16 DNA and RNA was detected by MY09/11-PCR and E6/E7 RT-PCR on matched frozen tissue, respectively. P16 protein expression was detected more often in oropharyngeal tumors (53%) as compared with laryngeal (24%), hypopharyngeal (8%) or oral cavity tumors (4%; p<0.0001). With respect to prognosis, p16-positive oropharyngeal tumors exhibited significantly better overall survival than p16-negative tumors (log-rank test p=0.04), whereas no survival benefit was observed for nonoropharyngeal tumors. However, when both p16 and HPV DNA test results were considered, concordantly positive nonoropharyngeal tumors had significantly better disease-specific survival than concordantly negative nonoropharyngeal tumors after controlling for sex, nodal stage, tumor size, tumor subsite, primary tumor site number, smoking and drinking [adjusted hazard ratio (HR)=0.04, 0.01-0.54]. Compared with concordantly negative nonoropharyngeal HNSCC, p16(+)/HPV16(-) nonoropharyngeal HNSCC (n=13, 7%) demonstrated no significant improvement in disease-specific survival when HPV16 was detected by RNA (adjusted HR=0.83, 0.22-3.17). Our findings show that p16 IHC alone has potential as a prognostic test for oropharyngeal cancer survival, but combined p16/HPV testing is necessary to identify HPV-associated nonoropharyngeal HNSCC with better prognosis.

Machine Learning-Based Prediction of Hospitalization During Chemoradiotherapy With Daily Step Counts.

Importance: Toxic effects of concurrent chemoradiotherapy (CRT) can cause treatment interruptions and hospitalizations, reducing treatment efficacy and increasing health care costs. Physical activity monitoring may enable early identification of patients at high risk for hospitalization who may benefit from proactive intervention. Objective: To develop and validate machine learning (ML) approaches based on daily step counts collected by wearable devices on prospective trials to predict hospitalizations during CRT. Design, Setting, and Participants: This study included patients with a variety of cancers enrolled from June 2015 to August 2018 on 3 prospective, single-institution trials of activity monitoring using wearable devices during CRT. Patients were followed up during and 1 month following CRT. Training and validation cohorts were generated temporally, stratifying for cancer diagnosis (70:30). Random forest, neural network, and elastic net-regularized logistic regression (EN) were trained to predict short-term hospitalization risk based on a combination of clinical characteristics and the preceding 2 weeks of activity data. To predict outcomes of activity data, models based only on activity-monitoring features and only on clinical features were trained and evaluated. Data analysis was completed from January 2022 to March 2023. Main Outcomes and Measures: Model performance was evaluated in terms of the receiver operating characteristic area under curve (ROC AUC) in the stratified temporal validation cohort. Results: Step counts from 214 patients (median [range] age, 61 [53-68] years; 113 [52.8%] male) were included. EN based on step counts and clinical features had high predictive ability (ROC AUC, 0.83; 95% CI, 0.66-0.92), outperforming random forest (ROC AUC, 0.76; 95% CI, 0.56-0.87; P = .02) and neural network (ROC AUC, 0.80; 95% CI, 0.71-0.88; P = .36). In an ablation study, the EN model based on only step counts demonstrated greater predictive ability than the EN model with step counts and clinical features (ROC AUC, 0.85; 95% CI, 0.70-0.93; P = .09). Both models outperformed the EN model trained on only clinical features (ROC AUC, 0.53; 95% CI, 0.31-0.66; P < .001). Conclusions and Relevance: This study developed and validated a ML model based on activity-monitoring data collected during prospective clinical trials. Patient-generated health data have the potential to advance predictive ability of ML approaches. The resulting model from this study will be evaluated in an upcoming multi-institutional, cooperative group randomized trial.

Evaluation of multiple-vendor AI autocontouring solutions.

BACKGROUND: Multiple artificial intelligence (AI)-based autocontouring solutions have become available, each promising high accuracy and time savings compared with manual contouring. Before implementing AI-driven autocontouring into clinical practice, three commercially available CT-based solutions were evaluated. MATERIALS AND METHODS: The following solutions were evaluated in this work: MIM-ProtégéAI+ (MIM), Radformation-AutoContour (RAD), and Siemens-DirectORGANS (SIE). Sixteen organs were identified that could be contoured by all solutions. For each organ, ten patients that had manually generated contours approved by the treating physician (AP) were identified, totaling forty-seven different patients. CT scans in the supine position were acquired using a Siemens-SOMATOMgo 64-slice helical scanner and used to generate autocontours. Physician scoring of contour accuracy was performed by at least three physicians using a five-point Likert scale. Dice similarity coefficient (DSC), Hausdorff distance (HD) and mean distance to agreement (MDA) were calculated comparing AI contours to "ground truth" AP contours. RESULTS: The average physician score ranged from 1.00, indicating that all physicians reviewed the contour as clinically acceptable with no modifications necessary, to 3.70, indicating changes are required and that the time taken to modify the structures would likely take as long or longer than manually generating the contour. When averaged across all sixteen structures, the AP contours had a physician score of 2.02, MIM 2.07, RAD 1.96 and SIE 1.99. DSC ranged from 0.37 to 0.98, with 41/48 (85.4%) contours having an average DSC ≥ 0.7. Average HD ranged from 2.9 to 43.3 mm. Average MDA ranged from 0.6 to 26.1 mm. CONCLUSIONS: The results of our comparison demonstrate that each vendor's AI contouring solution exhibited capabilities similar to those of manual contouring. There were a small number of cases where unusual anatomy led to poor scores with one or more of the solutions. The consistency and comparable performance of all three vendors' solutions suggest that radiation oncology centers can confidently choose any of the evaluated solutions based on individual preferences, resource availability, and compatibility with their existing clinical workflows. Although AI-based contouring may result in high-quality contours for the majority of patients, a minority of patients require manual contouring and more in-depth physician review.

Application of platelet-rich fibrin and freeze-dried bone allograft following apicoectomy: A comparative assessment of radiographic healing.

Background: Apicoectomy conceptualizes surgically maintaining a tooth with an endodontic lesion that cannot be resolved by conventional endodontic (re-) treatment. To achieve this, continuous improvement in surgical techniques, materials and instruments is being done to enhance the outcome of periapical endodontic surgeries. The purpose of this study was to compare, radiographically, the healing kinetics of platelet-rich fibrin (PRF) and mineralized freeze-dried bone allograft (FDBA) in patients undergoing apicoectomy. Materials and Methods: Nineteen patients (aged 18-40 years) were included in the study and randomly assigned to groups A or B, where they received PRF or FDBA, respectively. Following apicoectomy, PRF gel and FDBA graft were prepared and placed in the osseous defect followed by placement of PRF membrane for graft stabilization and flap closure. Radiographic follow-up was done at the 1st, 3rd, 6th and 12th months for evaluation of healing using Molven's criteria. Statistical analysis was done with Pearson's and McNemar's Chi-square tests. Results: A highly significant difference (P = 0.002) in radiographic healing was observed at 6 months. Complete healing was observed in 50% of cases in Group A whereas in Group B, none of the cases presented with complete radiographic healing. However, at the end of 12 months, complete radiographic healing was observed in both groups. Conclusion: Our data suggest that PRF accelerates bone healing as compared to FDBA and is both time and cost-efficient.

Racial inequity and other social disparities in the diagnosis and management of bladder cancer.

BACKGROUND: We investigate the impact of gender, race, and socioeconomic status on the diagnosis and management of bladder cancer in the United States. METHODS: We utilized the National Cancer Database to stratify cases of urothelial cell carcinoma of the bladder as early (Tis, Ta, T1), muscle invasive (T2-T3, N0), locally advanced (T4, N1-3), and metastatic. Multivariate binomial and multinomial logistic regression analyses identified demographic characteristics associated with stage at diagnosis and receipt of cancer-directed therapies. Odds ratios (OR) are reported with 95% confidence intervals. RESULTS: After exclusions, we identified 331,714 early, 72,154 muscle invasive, 15,579 locally advanced, and 15,161 metastatic cases from 2004-2016. Relative to diagnosis at early stage, the strongest independent predictors of diagnosis at muscle invasive, locally advanced, and metastatic disease included Black race (OR = 1.19 [1.15-1.23], OR = 1.49 [1.40-1.59], OR = 1.66 [1.56-1.76], respectively), female gender (OR = 1.21 [1.18-1.21], OR = 1.16 [1.12-1.20], and OR = 1.34 [1.29-1.38], respectively), and uninsured status (OR = 1.22 [1.15-1.29], OR = 2.09 [1.94-2.25], OR = 2.57 [2.39-2.75], respectively). Additional demographic factors associated with delayed diagnosis included older age, treatment at an academic center, Medicaid insurance and patients from lower income/less educated/more rural areas (all p < 0.01). Treatment at a non-academic center, older age, women, Hispanic and Black patients, lower income and rural areas were all less likely to receive cancer-directed therapies in early stage disease (all p < 0.01). Women, older patients, and Black patients remained less likely to receive treatment in muscle invasive, locally advanced, and metastatic disease (all p < 0.01). CONCLUSION: Black race was the strongest independent predictor of delayed diagnosis and substandard treatment of bladder cancer.