Survival of African American and non-Hispanic white men with prostate cancer in an equal-access health care system.

BACKGROUND: African American (AA) men in the general US population are more than twice as likely to die of prostate cancer (PC) compared with non-Hispanic white (NHW) men. The authors hypothesized that receiving care through the Veterans Affairs (VA) health system, an equal-access medical system, would attenuate this disparity. METHODS: A longitudinal, centralized database of >20 million veterans was used to assemble a cohort of 60,035 men (18,201 AA men [30.3%] and 41,834 NHW men [69.7%]) who were diagnosed with PC between 2000 and 2015. RESULTS: AA men were more likely to live in regions with a lower median income ($40,871 for AA men vs $48,125 for NHW men; P < .001) and lower high school graduation rates (83% for AA men vs 88% for NHW men; P < .001). At the time of diagnosis, AA men were younger (median age, 63.0 years vs 66.0 years; P < .001) and had a higher prostate-specific antigen level (median, 6.7 ng/mL vs 6.2 ng/mL; P < .001), but were less likely to have Gleason score 8 to 10 disease (18.8% among AA men vs 19.7% among NHW men; P < .001), a clinical T classification ≥3 (2.2% vs 2.9%; P < .001), or distant metastatic disease (2.7% vs 3.1%; P = 0.01). The 10-year PC-specific mortality rate was slightly lower for AA men (4.4% vs 5.1%; P = .005), which was confirmed in multivariable competing-risk analysis (subdistribution hazard ratio, 0.85; 95% CI, 0.78-0.93; P < .001). CONCLUSIONS: AA men diagnosed with PC in the VA health system do not appear to present with more advanced disease or experience worse outcomes compared with NHW men, in contrast to national trends, suggesting that access to care is an important determinant of racial equity.

Palliative Radiotherapy Versus Esophageal Stent Placement in the Management of Patients With Metastatic Esophageal Cancer.

BACKGROUND: Patients with advanced esophageal cancer often experience pain and dysphagia, yet the optimal palliative management remains unclear. This retrospective study evaluated outcomes and adverse effects of palliative radiotherapy (RT) compared with esophageal stenting among a cohort of U.S. veterans with metastatic esophageal cancer. PATIENTS AND METHODS: We identified 1,957 veterans in the United States with metastatic esophageal cancer who received palliative RT to the esophagus or esophageal stenting, and assessed the risks of severe adverse effects, including esophageal fistula formation, perforation, obstruction, hemorrhage, and esophagitis. We determined palliative efficacy by evaluating pain and dysphagia scores before and after intervention. Multivariable analyses were used to control for potential confounding factors. RESULTS: In our cohort, 1,593 patients underwent RT and 364 underwent esophageal stenting. The cumulative incidence of any severe adverse effect at 6 months was higher among patients who received stents compared with those who received RT (21.7% vs 12.4%; P<.0010). In multivariable analysis, patients who received stents had an increased risk of any severe adverse effect, including fistula, perforation, and hemorrhage (all P<.0500). Multivariable analysis also showed that, compared with stenting, RT was associated with more rapid and durable pain relief (P<.0010) with no difference in relief of dysphagia over time when accounting for pretreatment dysphagia scores (P=.1029). CONCLUSIONS: Compared with esophageal stenting, RT was associated with a decreased risk of adverse effects, greater pain relief, and equivalent relief of moderate to severe dysphagia over time. Unmeasured patient- or tumor-related factors could have influenced the choice of intervention, thereby impacting our study outcomes. To our knowledge, this is the largest study to date analyzing the comparative risks and benefits of palliative RT and esophageal stenting among patients with metastatic esophageal cancer.

Clinical Impact of Local Progression in Pancreatic Cancer.

Background: The high prevalence of distant metastatic disease among patients with pancreatic cancer often draws attention away from the local pancreatic tumor. This study aimed to define the complications and hospitalizations from local versus distant disease progression among a retrospective cohort of patients with pancreatic cancer. Methods: Records of 298 cases of pancreatic cancer treated at a single institution from 2004 through 2015 were retrospectively reviewed, and cancer-related symptoms and complications requiring hospitalization were recorded. Hospitalizations related to pancreatic cancer were attributed to either local or distant progression. Cumulative incidence analyses were used to estimate the incidence of hospitalization, and multivariable Fine-Gray regression models were used to identify factors predictive of hospitalizations. Results: The 1-year cumulative incidences of hospitalization due to local versus distant disease progression were 31% and 24%, respectively. Among 509 recorded hospitalizations, leading local etiologies included cholangitis (10%), biliary obstruction (7%), local procedure complication (7%), and gastrointestinal bleeding (7%). On multivariable analysis, significant predictors of hospitalization from local progression included unresectable disease (subdistribution hazard ratio [SDHR], 2.42; P<.01), black race (SDHR, 3.34; P<.01), younger age (SDHR, 1.02 per year; P=.01), tumor in the pancreatic head (SDHR, 2.19; P<.01), and larger tumor size (SDHR, 1.13 per centimeter; P=.02). Most patients who died in the hospital from pancreatic cancer (56%) were admitted for complications of local disease progression. Conclusions: Patients with pancreatic cancer experience significant complications of local tumor progression. Although distant metastatic progression represents a hallmark of pancreatic cancer, future research should also focus on improving local therapies.

Retrospective Review of Follow-up Strategies for Patients Receiving Palliative Radiotherapy.

CONTEXT: There is no current standard-of-care follow-up strategy for patients who receive palliative radiotherapy (PRT) for bone metastases. Within our institution there is currently a heterogenous practice in which some providers schedule routine follow up 1-3 months after initial PRT while others do follow up only as needed (PRN). OBJECTIVES: Our study aims to compare rates of retreatment based on follow-up strategies (planned vs. PRN), explore factors that potentially affect retreatment, and evaluate whether provider follow-up strategy correlates with measurable differences in quality of care. METHODS: In a retrospective chart review, PRT courses for bone metastases at our single institution were divided by follow-up strategies (planned vs. PRN). Demographic, clinical, and PRT data were collected and analyzed via descriptive statistics. The relationship between planned follow-up appointment and subsequent retreatment was studied. RESULTS: More patients received retreatment within one year of initial PRT in the planned follow-up group than in the PRN follow-up group (40.4% vs. 14.4%, p<0.001). Retreatment was achieved sooner in the planned follow-up group than in the PRN follow-up group (137 days vs. 156 days). When accounting for other variables, having a planned follow-up appointment remains the most important factor in establishing retreatment (OR = 3.32, 2.11-5.29, p<0.001). CONCLUSION: Having a planned follow-up appointment after the initial course of PRT improves identification of patients who would benefit from additional treatment, thus improving patient experience and quality of care.

Successful Noninvasive 12-Lead ECG Mapping-Guided Radiotherapy of Inaccessible Ventricular Tachycardia Substrate Due to Mechanical Valves.

In patients presenting with refractory ventricular tachycardia (VT) and aortic and mitral mechanical prosthetic valves, traditional catheter ablation is challenging. We describe a case in which a novel noninvasive computational electrocardiogram mapping algorithm localized VT sources originating from substrate near the mechanical valves, in which stereotactic ablative radiotherapy eliminated VT in 1.5-year follow-up. (Level of Difficulty: Advanced.).

Society for Palliative Radiation Oncology: Report from the Ninth Annual Meeting (2022).

The Society for Palliative Radiation Oncology (SPRO) is an international group of clinicians whose primary aim is to advance the field of palliative radiation oncology by promoting evidence-based palliative radiation therapy and excellence in primary palliative care through research, education, collaboration, and patient advocacy. SPRO held its 9th Annual Meeting on October 23, 2022 in association with the American Society for Radiation Oncology (ASTRO) 64th Annual Meeting. Accomplishments and goals from the previous year were discussed and newly appointed officers were announced. Dr. Dirk Rades from the University of Lubeck in Germany gave the keynote address, reviewing critical trials and evidence for the use of stereotactic body radiotherapy (SBRT) in the palliative and oligometastatic settings. Recipients of the Lifetime Service Award and the Rising Star Award were announced and presented. This Meeting Report summarizes the proceedings of SPRO's 9th Annual Meeting.

Split course palliative radiotherapy for advanced lung cancer with 3D planning based analysis of outcome: a retrospective review.

BACKGROUND: Durable palliation of advanced lung cancer is a common objective for radiation oncologists. However, there is no consensus on how to deliver the radiation course. Herein we report our experience of using split course radiotherapy and our assessment of outcomes based on planning from three-dimensional (3D) simulation before each treatment course. METHODS: All lung cancer patients from 2006-2020 were identified. Of these, 52 patients received a split course treatment of 50-60 Gy in 18-25 fractions intended to provide durable palliation for disease not amenable to curative therapy. Treatment involved 3D planning with repeat computed tomography (CT) simulation prior to the second course. Survival and symptomatic response were analyzed via chart review. We categorized rapid responders versus non-rapid responders from the initial radiation course based on ≥30% gross tumor volume (GTV) reduction at the second CT simulation. We evaluated the impact of response on overall survival and palliative response. RESULTS: Among our cohort treated with split course palliative radiotherapy, 33 (63%) had a rapid response to initial treatment. There was no difference in survival between groups [hazard ratio (HR) =1.30, P=0.47]. There was no significant difference in palliative response rates between rapid and non-rapid responders. On multivariable analysis, only female sex (HR =0.26, P<0.01) and receipt of systemic therapy following radiotherapy (HR =0.19, P<0.01) were associated with improved survival. CONCLUSIONS: There is currently significant practice pattern variability for palliative lung radiotherapy. Split course palliative radiation of 50-60 Gy in 18-25 fractions represents an option to consider for patients with advanced lung cancer who do not undergo definitive therapy and may benefit from a higher dose regimen. Our retrospective review suggests that rapid tumor response in a split course model does not predict survival or symptomatic response. Prospective studies are needed to further define which lung cancer patients may benefit from higher dose regimens.

Hypofractionated radiation therapy as palliative management for symptomatic and local control of advanced thoracic malignancies.

BACKGROUND: Radiation therapy plays an important role for symptom palliation for intrathoracic malignancies ineligible for curative-intent therapy. Limited data exists regarding the role of stereotactic body radiation therapy (SBRT) versus conformal radiation in intrathoracic tumors for palliation. We report the efficacy of hypofractionated RT (or palliative SBRT) in the symptom management and durable control of lung and non-lung intrathoracic tumors. METHODS: We performed a retrospective review of ninety-two thoracic lesions across 76 patients who completed palliative SBRT with doses ranging 25-50 Gy in 5-10 fractions between 2009 and 2019. Symptoms (cough, chest pain, hemoptysis, shortness of breath) were assessed at consult and 1-6 months follow-up. Local control was evaluated using follow-up CT imaging via RECIST criteria. Descriptive statistics were used to evaluate symptom palliation and Kaplan-Meier method to analyze local control. RESULTS: Of primary lung (Cohort P) lesions, 40% showed stable symptoms, 30% never developed symptoms, and 19% showed symptom relief. CT imaging 1-6 months post-SBRT showed 91% with partial response (PR) or stable disease (SD) in Cohort P and 87% with PR or SD in metastatic (Cohort M) lesions. In patients with initial PR/SD, local control until death was achieved in 71% of Cohort P and 84% of Cohort M. Of our symptomatic patients (Cohort S), 98% showed no symptom progression post-radiotherapy. All patients with hemoptysis at presentation achieved hemostasis post-radiotherapy. CONCLUSIONS: Palliative SBRT has the advantage of higher biologic dose without protracted course for patients with limited prognosis. Patients showed significant symptom palliation and long-term local control. Palliative SBRT represents a reasonable treatment modality for incurable thoracic malignancies.

Cost Savings Associated With Palliative Care Among Older Adults With Advanced Cancer.

BACKGROUND: There is inconsistent evidence that palliative care intervention decreases total healthcare expenditure at end-of-life for oncology patients. This inconsistent evidence may result from small sample sizes at single institution studies and disparate characterization of costs across studies. Comprehensive studies in population-based datasets are needed to fully understand the impact of palliative care on total healthcare costs. This study analyzed the impact of palliative care on total healthcare costs in a nationally representative sample of advanced cancer patients. METHODS: We conducted a matched cohort study among Medicare patients with metastatic lung, colorectal, breast and prostate cancers. We matched patients who received a palliative care consultation to similar patients who did not receive a palliative care consultation on factors related to both the receipt of palliative care and end of life costs. We compared direct costs between matched patients to determine the per-patient economic impact of a palliative care consultation. RESULTS: Patients who received a palliative care consultation experienced an average per patient cost of $5,834 compared to $7,784 for usual care patients (25% decrease; p < 0.0001). Palliative care consultation within 7 days of death decreased healthcare costs by $451, while palliative care consultation more than 4 weeks from death decreased costs by $4,643. CONCLUSION: This study demonstrates that palliative care has the capacity to substantially reduce healthcare expenditure among advanced cancer patients. Earlier palliative care consultation results in greater cost reductions than consultation in the last week of life.

Radiation Recall Pneumonitis After Treatment With Checkpoint Blockade Immunotherapy: A Case Series and Review of Literature.

BACKGROUND: Radiation recall pneumonitis (RRP) is a poorly understood clinical syndrome in which patients develop radiation pneumonitis triggered by a systemic agent, often years after the completion of radiation therapy. Immune checkpoint blockade agents have only recently been posited as a trigger for RRP. Here, we present three cases of immunotherapy-induced RRP. CASE PRESENTATION: Our first patient was diagnosed with primary lung adenocarcinoma, and 4.5 years after completing radiation therapy developed symptomatic RRP immediately following a second dose of nivolumab-containing immunotherapy regimen. Our second patient was diagnosed with primary bladder cancer metastatic to the mediastinum, which was treated twice with radiation therapy. He developed RRP in the days following his second course of ipilimumab-pembrolizumab which was months after his second course of radiation that he received. Our final patient was diagnosed with metastatic small cell lung cancer and received local consolidative radiation therapy in addition to whole-brain radiation. He developed RRP on the 11th day after concluding his 4th cycle of nivolumab-ipilimumab, approximately 7 months after having had completed chest radiation therapy. CONCLUSIONS: Immunotherapy-induced RRP is a rare diagnosis which can present more focally than traditional immunotherapy pneumonitis and which must be clinically differentiated from other local processes such as pneumonia. Further research should explore the mechanisms underlying these radiation recall reactions as many patients receive radiation and immunotherapy during the course of their cancer treatment.

Computational ECG mapping and respiratory gating to optimize stereotactic ablative radiotherapy workflow for refractory ventricular tachycardia.

BACKGROUND: Stereotactic ablative radiotherapy (SAbR) is an emerging therapy for refractory ventricular tachycardia (VT). However, the current workflow is complicated, and the precision and safety in patients with significant cardiorespiratory motion and VT targets near the stomach may be suboptimal. OBJECTIVE: We hypothesized that automated 12-lead electrocardiogram (ECG) mapping and respiratory-gated therapy may improve the ease and precision of SAbR planning and facilitate safe radiation delivery in patients with refractory VT. METHODS: Consecutive patients with refractory VT were studied at 2 hospitals. VT exit sites were localized using a 3-D computational ECG algorithm noninvasively and compared to available prior invasive mapping. Radiotherapy (25 Gy) was delivered at end-expiration when cardiac respiratory motion was ≥0.6 cm or targets were ≤2 cm from the stomach. RESULTS: In 6 patients (ejection fraction 29% ± 13%), 4.2 ± 2.3 VT morphologies per patient were mapped. Overall, 7 out of 7 computational ECG mappings (100%) colocalized to the identical cardiac segment when prior invasive electrophysiology study was available. Respiratory gating was associated with smaller planning target volumes compared to nongated volumes (71 ± 7 vs 153 ± 35 cc, P < .01). In 2 patients with inferior wall VT targets close to the stomach (6 mm proximity) or significant respiratory motion (22 mm excursion), no GI complications were observed at 9- and 12-month follow-up. Implantable cardioverter-defibrillator shocks decreased from 23 ± 12 shocks/patient to 0.67 ± 1.0 (P < .001) post-SAbR at 6.0 ± 4.9 months follow-up. CONCLUSIONS: A workflow including computational ECG mapping and protocol-guided respiratory gating is feasible, is safe, and may improve the ease of SAbR planning. Studies to validate this workflow in larger populations are required.

American Brachytherapy Society working group report on the patterns of care and a literature review of reirradiation for gynecologic cancers.

PURPOSE: Recurrences of previously irradiated gynecological malignancies are uncommon. Standardized management of these cases is not well established. We aim to provide an in-depth literature review and present current practice patterns among an international group of experienced practitioners in the reirradiation setting of gynecologic cancers. METHODS AND MATERIALS: An extensive literature search was performed and 35 articles were selected based on preset criteria. A 20-question online survey of 10 experts regarding their retreatment practices was also conducted. RESULTS: The reviewed publications include a diverse group of patients, multiple treatment techniques, a range of total doses, local control, overall survival, and toxicity outcomes. Overall, local control ranged from 44% to 88% over 1-5 years with OS in the range of 39.5-82% at 2-5 years. Late G3-4 toxicity varied very broadly from 0% to 42.9%, with most papers reporting serious toxicities greater than 15%. The most common reirradiation technique utilized was brachytherapy. Some low-dose-rate data suggest improved outcomes with doses >50 Gy. The high-dose-rate data are more varied with some studies suggesting improved local control with doses >40 Gy. In general, a longer time interval between the first and second course of radiation as well as recurrences <2-4 cm tend to have improved outcomes. CONCLUSIONS: Reirradiation with brachytherapy results in relatively reasonable local control and toxicities for women with recurrent gynecologic cancers. The appropriate dose for each case needs to be individualized given the heterogeneity of cases. Multidisciplinary management is critical to develop individualized plans and to clearly communicate potential side effects and expected treatment outcomes. TAKE HOME MESSAGE: Reirradiation with brachytherapy is an acceptable effective organ preserving approach for recurrent gynecologic cancers with a reasonable local control and toxicity profile. Each case requires multidisciplinary management to develop an individualized approach. Monitoring for potential long-term toxicities is essential.

Effect of Palliative Care on Aggressiveness of End-of-Life Care Among Patients With Advanced Cancer.

PURPOSE: Palliative care's role in oncology has expanded, but its effect on aggressiveness of care at the end of life has not been characterized at the population level. METHODS: This matched retrospective cohort study examined the effect of an encounter with palliative care on health-care use at the end of life among 6,580 Medicare beneficiaries with advanced prostate, breast, lung, or colorectal cancer. We compared health-care use before and after palliative care consultation to a matched nonpalliative care cohort. RESULTS: The palliative care cohort had higher rates of health-care use in the 30 days before palliative care consultation compared with the nonpalliative cohort, with higher rates of hospitalization (risk ratio [RR], 3.33; 95% CI, 2.87 to 3.85), invasive procedures (RR, 1.75; 95% CI, 1.62 to 1.88), and chemotherapy administration (RR, 1.61; 95% CI, 1.45 to 1.78). The opposite pattern emerged in the interval from palliative care consultation through death, where the palliative care cohort had lower rates of hospitalization (RR, 0.53; 95% CI, 0.44-0.65), invasive procedures (RR, 0.52; 95% CI, 0.45 to 0.59), and chemotherapy administration (RR, 0.46; 95% CI, 0.39 to 0.53). Patients with earlier palliative care consultation in their disease course had larger absolute reductions in health-care use compared with those with palliative care consultation closer to the end of life. CONCLUSION: This population-based study found that palliative care substantially decreased health-care use among Medicare beneficiaries with advanced cancer. Given the increasing number of elderly patients with advanced cancer, this study emphasizes the importance of early integration of palliative care alongside standard oncologic care.

Cancer Cachexia: Beyond Weight Loss.

Cancer cachexia is a multifactorial syndrome characterized by skeletal muscle loss leading to progressive functional impairment. Despite the ubiquity of cachexia in clinical practice, prevention, early identification, and intervention remain challenging. The impact of cancer cachexia on quality of life, treatment-related toxicity, physical function, and mortality are well established; however, establishing a clinically meaningful definition has proven challenging because of the focus on weight loss alone. Attempts to more comprehensively define cachexia through body composition, physical functioning, and molecular biomarkers, while promising, are yet to be routinely incorporated into clinical practice. Pharmacologic agents that have not been approved by the US Food and Drug Administration but that are currently used in cancer cachexia (ie, megestrol, dronabinol) may improve weight but not outcomes of interest such as muscle mass, physical activity, or mortality. Their routine use is limited by adverse effects. For the practicing oncologist, early identification and management of cachexia is critical. Oncologists must recognize cachexia beyond weight loss alone, focusing instead on body composition and physical functioning. In fact, becoming emaciated is a late sign of cachexia that characterizes its refractory stage. Given that cachexia is a multifactorial syndrome, it requires early identification and polymodal intervention, including optimal cancer therapy, symptom management, nutrition, exercise, and psychosocial support. Consequently, oncologists have a role in ensuring that these resources are available to their patients. In addition, in light of the promising investigational agents, it remains imperative to refer patients with cachexia to clinical trials so that available options can be expanded to effectively treat this pervasive problem.

Lack of documentation of evidence-based prognostication in cancer patients by inpatient palliative care consultants.

BACKGROUND: Prognostication plays a key role in palliative care (PC). It is critical for advance care planning, determining hospice eligibility, and communication. In contrast to subjective clinical prognostication, evidence-based prognostication (EBP) uses existing validated data to quantify prognosis; however, the extent to which PC providers use EBP is limited. OBJECTIVE: The objective was to analyze documentation of EBP by PC providers in the absence of an inpatient consultation note template at a single academic medical center. METHODS: We retrospectively evaluated prognostic documentation of inpatient PC consultations on oncology patients at a single academic hospital. Ratings of Eastern Cooperative Oncology Group (ECOG) Scale, Karnofsky Performance Scale (KPS), Palliative Performance Scale, and/or activities of daily living (ADLs) were considered documentation of functional status. PC-specific documentation of EBP included the Palliative Prognostic Index and/or Palliative Prognostic Score. RESULTS: There were 412 inpatient PC consultations for oncology patients (2012-2013). Reasons for consultation included goals of care (n=108), symptom management (n=181), or both (n=123). In the absence of a note template, functional status was documented in 6% (n=24) of consultation notes, while no consultation notes contained EBP documentation of the Palliative Prognostic Index and Palliative Prognostic Score. CONCLUSION: This retrospective analysis conducted at a single academic medical center suggests poor documentation by PC providers of EBP in the absence of a consultation note template. Research and educational opportunities exist to evaluate barriers to EBP utilization and documentation by PC providers.