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Dose prescription and reporting in stereotactic body radiotherapy: A multi-institutional study

Das, Indra J; Yadav, Poonam; Andersen, Aaron D; Chen, Zhe Jay; Huang, Long; Langer, Mark P; Lee, Choonik; Li, Lin; Popple, Richard A; Rice, Roger K; Schiff, Peter B; Zhu, Timothy C; Abazeed, Mohamed E
BACKGROUND AND PURPOSE/OBJECTIVE:Radiation dose prescriptions are foundational for optimizing treatment efficacy and limiting treatment-related toxicity. We sought to assess the lack of standardization of SBRT dose prescriptions across institutions. MATERIALS & METHODS/METHODS:were used to assess dosimetric variability. RESULTS: ≥ 110 % was found in nearly half of the institutions. There was significant dosimetric variation across institutions. CONCLUSIONS:The SBRT prescriptions in the literature or in treatment guidelines currently lack nuance and hence there is significant variation in dose prescriptions across academic institutions. These findings add greater importance to the identification of dose parameters associated with improved clinical outcome comparisons as we move towards more hypofractionated treatments. There is a need for standardized reporting to help institutions in adapting treatment protocols based on the outcome of clinical trials. Dosimetric parameters are subsequently needed for uniformity and thereby standardizing planning guidelines to maximize efficacy, mitigate toxicity, and reduce treatment disparities are urgently needed.
PMID: 36822361
ISSN: 1879-0887
CID: 5448272

PO40 Presentation Time: 4:45 PM: Definitive Management of Cervical Cancer Patients at an Urban Institution During the COVID-19 Pandemic - Brachytherapy Treatment During the Surge [Meeting Abstract]

Lymberis, S C; Lee, S S; Boyd, L; Hacker, K E; Salame, G; Pothuri, B; Schiff, P B
Purpose: Locally advanced cervical cancer was defined by an international consensus panel as a high priority malignancy during the COVID-19 pandemic, recommending prompt initiation of definitive treatment and completion of treatment (PMID 32563593). The objective of this study was to study the clinical outcomes of patients (pts) with cervical cancer treated with definitive chemoradiation (CRT) and brachytherapy (BT) at our institution in 2019 (pre-COVID) and in 2020 (peri-COVID).
Material(s) and Method(s): This was a retrospective cohort study of pts with FIGO Stage IB2-IVA cervical cancer at our institutions from 1/1/2019 to 12/31/2020. Pts received CRT followed by intracavitary brachytherapy (IC) with two operative insertions one week apart, or interstitial (IS) BT with one operative insertion. BT treatment was planned using image-guided CT or MR delineation. Pre-COVID was defined by initiation of CRT in 1/2019-12/2019, and peri-COVID was defined by initiation in 1/2020-10/2020. Process changes peri-COVID included limited on-site staff (e.g., minimal OR staff, no trainees, remote physics team), universal implementation of COVID-19 testing prior to surgery, and CT instead of MR-delineation based treatment. Outcomes of interest were time to treatment initiation and completion and differences in treatment planning modality or dosimetry. Fisher's exact and Mann Whitney U tests were used with significance p<0.05.
Result(s): Thirty-one pts were included, with 18 patients undergoing treatment pre-COVID and 13 peri-COVID. The median age at diagnosis pre-COVID was 57.7 (range 23-77) and for peri-COVID, 45.5 (range 28-62, p=0.06). There were no differences in non-English speaking pts (44% vs 59%, p=0.71) or uninsured pts (11% vs 33%, p=0.184) between the two cohorts. Median time to initiation of treatment from biopsy diagnosis was 52 days (range 13-209) in 2019 and for peri-COVID, 55.5 (range 20-173, p=0.71). During COVID, four pts had delayed initiation to treatment >100 days: two related to fertility, and one due to fear of COVID-19. For this pt, tumor size progressed from 2.3 cm to 4.2 cm maximal dimension. One pt treated in 2020 tested positive following treatment and did not require hospital admission. All pts except one completed CRT with RT: 25 pts pelvic RT (45 Gy), 3 pelvic and para-aortic RT (45 Gy with 57.5 Gy concomitant boost to nodes), 8 pts pelvic RT (45Gy) with sequential parametrial boost (50.4-59.4 Gy) using IMRT with no dose differences between pre and peri-COVID (Table 1). No pts required treatment breaks and the median overall treatment time was 50 days (range 31-85) in 2019 vs 50 days (range 43-63) in 2020 (p=0.710).
Conclusion(s): Despite the significant burden of the COVID-19 pandemic on our health care system, all cervical cancer pts receiving CRT met standard of care including CRT and BT within the recommended time frame with no significant differences in dosimetric treatment parameters pre- and peri-COVID. Delays in treatment initiation of treatment initiation were seen in 30% of pts in the peri-COVID period, suggesting that patients may have had increased barriers to access care. More follow-up is needed to determine how the Covid pandemic impacted cervical cancer outcome measures.
Copyright
EMBASE:2021567637
ISSN: 1873-1449
CID: 5510352

Stereotactic Body Radiation Therapy for the Treatment of Locally Recurrent and Oligoprogressive Non-Small Cell Lung Cancer: A Single Institution Experience

Katz, Leah M; Ng, Victor; Wu, S Peter; Yan, Sherry; Grew, David; Shin, Samuel; Colangelo, Nicholas W; McCarthy, Allison; Pass, Harvey I; Chachoua, Abraham; Schiff, Peter B
Objectives/UNASSIGNED:To investigate the efficacy and safety of lung stereotactic body radiation therapy (SBRT) for non-small cell lung cancer (NSCLC) including oligorecurrent and oligoprogressive disease. Methods/UNASSIGNED:Single-institution retrospective analysis of 60 NSCLC patients with 62 discrete lesions treated with SBRT between 2008 and 2017. Patients were stratified into three groups, including early stage, locally recurrent, and oligoprogressive disease. Group 1 included early stage local disease with no prior local therapy. Group 2 included locally recurrent disease after local treatment of a primary lesion, and group 3 included regional or well-controlled distant metastatic disease receiving SBRT for a treatment naive lung lesion (oligoprogressive disease). Patient/tumor characteristics and adverse effects were recorded. Local failure free survival (LFFS), progression free survival (PFS), and overall survival (OS) were estimated using the Kaplan Meier method. Results/UNASSIGNED:At median follow-up of 34 months, 67% of the study population remained alive. The estimated 3-year LFFS for group 1, group 2, and group 3 patients was 95% (95% CI: 86%-100%), 82%(62% - 100%), and 83% (58-100%), respectively. The estimated 3-year PFS was 59% (42-83%), 40% (21%-78%), and 33% (12%-95%), and the estimated 3-year OS was 58% (41-82%), 60% (37-96%), and 58% (31-100%)), respectively for each group. When adjusted for age and size of lesion, no significant difference in OS, LFFS, and PFS emerged between groups (p > 0.05). No patients experienced grade 3 to 5 toxicity. Eighteen patients (29%) experienced grade 1 to 2 toxicity. The most common toxicities reported were cough and fatigue. Conclusions/UNASSIGNED:Our data demonstrates control rates in group 1 patients comparable to historical controls. Our study also reveals comparable clinical results for SBRT in the treatment of NSCLC by demonstrating similar rates of LFFS and OS in group 2 and group 3 patients with locally recurrent and treatment naïve lung lesion with well-controlled distant metastatic disease.
PMCID:9170989
PMID: 35686111
ISSN: 2234-943x
CID: 5283292

A Sexual and Gender Minority Inclusive Tool to Identify and Reduce Psychological Distress Related to Vaginal Brachytherapy Treatment

Domogauer, J D; Ganey-Aquino, S; Cabrera, A; Pietrzyk-Busta, B; Huppert, N E; Schiff, P B; Lymberis, S C
PURPOSE/OBJECTIVE(S): Evidence has shown treatments for gynecologic cancers can pose a significant impact to quality of life (QoL) and psychosocial functioning for cancer patients and cancer survivors, with very limited understanding of the impact of such treatments on the lesbian, gay, bisexual, transgender and queer/questioning community, also referred to as sexual and gender minorities (SGM), a diverse and medically underserved population. Specifically, intracavitary vaginal brachytherapy (ICVBT) for endometrial cancers can cause a negative impact on QoL and can even result in PTSD after treatment. Thus, better understanding a patient's unique identity and chosen sexual preferences, as well as assessing underlying anxiety, psychosocial issues, and/or prior non-consensual sexual encounter(s) can potentially alleviate distress during and after this sensitive treatment. Here, we present an innovative, SGM-inclusive assessment tool to identify potential risk factors for physical and/or psychosocial distress that may occur in patients undergoing ICVBT. MATERIALS/METHODS: We combined two previously published, validated tools to assess for urinary, bowel, and sexual symptoms in patients undergoing ICVBT. Next, as part of the ongoing LGBTQ initiative at our academic comprehensive cancer center, our department's LGBTQ Task Force, which is composed of volunteer patients, physicians, nurses, physicists, dosimetrists, and support staff reviewed the questionnaire and provided critical feedback for inclusivity. We subsequently had the questionnaire reviewed for health literacy by our Patient Education Liaisons.
RESULT(S): The task force recommended inclusion of sexual orientation and gender identity (SOGI) demographic questions to the survey, and adjustment of previous questions for improved inclusivity of SGM-identifying patients, especially those who identify as transgender, gender non-binary, and/or who choose to not engage in penetrative vaginal intercourse. Additionally, it was recommended to include a question that screens for a history of non-consensual sexual encounters to reduce triggering past trauma. The task force felt these items were important for the practitioner to discuss with their patient prior to the procedure, with the goal to reduce acute anxiety and possibly prevent acute and long-term negative physical and/or emotional outcomes.
CONCLUSION(S): Our ICVBT survey tool is designed to screen for "at-risk" patients, and provide a pathway for open dialogue between patients and physicians to potentially reduce undue harm during this important, yet sensitive treatment. To the best of our knowledge, this is the first such ICVBT survey tool to assess for a history of sexual trauma, and include SOGI and gender-inclusive questions. This adaptation has allowed our team to approach patients in a sensitive manner inclusive of their identity and prior experiences. Preliminary data is being collected and will be presented at the conference.
Copyright
EMBASE:636626298
ISSN: 1879-355x
CID: 5077792

Development of a Big Data Radiation Oncology Dashboard

Yuan, Y; Winner, M; Chandras, R; Barbee, D; Xiao, J; Barton, S M; Schiff, P B; Sulman, E P
PURPOSE/OBJECTIVE(S): Healthcare data often exist in silos and in unstructured formats that limit interoperability and require tedious manual extraction. Our institution has adopted a flexible and scalable big data platform built on Hadoop that integrates data from Epic/Clarity as well as Aria and allows users to leverage modern data science tools to facilitate access. We hypothesize that a data analytics and visualization dashboard can be built using open-source tools that will (1) allow non-technical users to explore de-identified clinical data within our institutional big data platform and (2) connect with repositories of molecular data to demonstrate potential methods of integrating clinical and basic science data. MATERIALS/METHODS: De-identified patient-level radiation oncology data from the institutional big data platform (Hadoop) were extracted with the python packages pyodbc and pandas. For the purposes of this dashboard, radiation oncology specific clinical data elements were queried including the date of first radiation treatment, treatment location, treatment modality (SBRT, external beam, SRS, TBI, LDR/HDR brachytherapy), ICD10 codes, anatomic treatment site, number of fractions, treatment prescription, and dose per fraction. A python client connection with the publicly accessible instance of cBioPortal for Cancer Genomics was established using the Bravado library. Data transformation and cleaning was performed in python using panda's data frames. A web-based dashboard to facilitate user-defined visualizations was implemented using the Dash python library and interactive visualizations of subsets of extracted data were generated in real-time using the plotly plotting library.
RESULT(S): We developed a web-based dashboard that gives users without extensive programming expertise the ability to explore de-identified clinical data extracted from Hadoop. As proof of principle, the dashboard was used to visualize the clinical impact of the COVID-19 pandemic on radiation oncology patient volumes, revealing a significant decline in new radiation treatments in April and May of 2020 (-54% and -36% compared to 2019) during the initial COVID-19 surge. Furthermore, the dashboard allows users to interact with the cBioPortal for Cancer Genomics repository, which currently houses clinical and molecular data from 301 publicly available studies spanning 869 different cancer types. This interface with cBioPortal illustrates the potential for future integration of clinically meaningful sequencing results with clinical outcomes data.
CONCLUSION(S): We built an interactive web-based dashboard to enable general users' easy access to de-identified clinical data stored within the institutional big data platform. Additional data sources, including external molecular data can be connected to the dashboard allowing for future integration.
Copyright
EMBASE:636625718
ISSN: 1879-355x
CID: 5081992

Retrospective Cohort Study of Oligometastatic and Oligoprogressive Malignancy Treated With Stereotactic Body Radiation Therapy (SBRT) With Intent to Delay New Systemic Therapy

Barton, S M; Yan, S X; Goyal, R; Schiff, P B; Barbee, D; Cooper, B
PURPOSE/OBJECTIVE(S): Use of local therapy such as stereotactic body radiation therapy (SBRT) to treat oligometastatic malignancy is a well-established paradigm, but whether benefit extends to the oligoprogressive setting remains unclear. We present our institutional series of patients with oligometastatic or oligoprogressive malignancy treated with SBRT. MATERIALS/METHODS: We performed a retrospective study of patients with oligometastatic and oligoprogressive malignancy treated with SBRT between 2014 and 2019. Oligometastatic patients were defined as those with five or fewer metastatic lesions in total. Oligoprogressive patients were defined as those with more than five and up to twenty metastatic lesions in total, of which five or fewer metastases were progressing on current systemic therapy. Patients lacking complete treatment records or follow-up imaging were excluded. The study was approved by the NYU Institutional Review Board.
RESULT(S): A total of 114 patients were treated with 123 courses of SBRT, of which 96 treated oligometastasis and 27 treated oligoprogression. Primary sites of disease included lung (38%), prostate (20%), and GI (12%), as well as gynecologic, abdominal, and cutaneous malignancies. Median follow-up was 21 months. No grade 3 or higher radiation-related adverse events were reported. Patients with oligometastatic malignancy had longer 2-year overall survival (79% vs 59%; P=0.003), local control (73% vs 55%; P=0.01), and progression-free survival (26% vs 8%; P < 0.001), but similar freedom from new systemic therapy (36% vs 31%; P=0.8). This result held true in subgroup analysis regardless of lung vs non-lung primary site, and regardless of the presence or absence of a targetable mutation.
CONCLUSION(S): In this hypothesis-generating retrospective cohort study, patients with oligoprogressive malignancy treated with SBRT have similar freedom from new systemic therapy to patients with oligometastatic malignancy, strengthening the rationale for treating oligoprogressive malignancy with SBRT.
Copyright
EMBASE:636624839
ISSN: 1879-355x
CID: 5082232

Modern Management of High-risk Soft Tissue Sarcoma With Neoadjuvant Chemoradiation: A Single-center Experience

Byun, David J; Katz, Leah M; Xiao, Julie; Rapp, Timothy B; Paoluzzi, Luca; Rosen, Gerald; Schiff, Peter B
OBJECTIVE:Neoadjuvant chemoradiation (NA-CRT), followed by resection of high-risk soft tissue sarcoma (STS), may offer good disease control and toxicity outcomes. We report on a single institution's modern NA-CRT experience. MATERIALS AND METHODS/METHODS:Delay to surgical resection, resection margin status, extent of necrosis, tumor cell viability, presence of hyalinization, positron emission tomography (PET)/computed tomography data, and treatment toxicities were collected. Using the Kaplan-Meier survival analysis, 5-year overall survival, disease-free survival, distant metastasis-free survival, and local control (LC) were estimated. Clinicopathologic features and PET/computed tomography avidity changes were assessed for their potential predictive impact using the log-rank test. RESULTS:From 2011 to 2018, 37 consecutive cases of localized high-risk STS were identified. Twenty-nine patients underwent ifosfamide-based NA-CRT to a median dose of 50 Gy before en bloc resection. At a median follow-up of 40.3 months, estimated 5-year overall survival was 86.1%, disease-free survival 70.2%, distant metastasis-free survival 75.2%, and LC 86.7%. Following NA-CRT, a median reduction of 54.7% was observed in tumor PET avidity; once resected, median tumor necrosis of 60.0% with no viable tumor cells was detected in 13.8% of the cases. Posttreatment resection margins were negative in all patients, with 27.6% having a margin of ≤1 mm. Delays of over 6 weeks following the end of radiation treatment to surgical resection occurred in 20.7% cases and was suggestive of inferior LC (92.8% vs. 68.6%, P=0.025). CONCLUSIONS:This single-institution series of NA-CRT demonstrates favorable disease control. Delay in surgical resection was associated with inferior LC, a finding that deserves further evaluation in a larger cohort. LEVEL OF EVIDENCE/METHODS:Level III-retrospective cohort study.
PMID: 33086232
ISSN: 1537-453x
CID: 4642332

Treating through the surge: institutional experience of definitive management of cervical cancer patients at an urban institution during the COVID-19 pandemic [Meeting Abstract]

Lee, Sarah; Boyd, Leslie; Hacker, Kari; Salame, Ghadir; Pothuri, Bhavana; Schiff, Peter B. Schiff; Lymberis, Stella
ISI:000687070800589
ISSN: 0090-8258
CID: 4990762

Factors associated with delay in treatment initiation of locally advanced cervical cancer [Meeting Abstract]

Lee, S S; Berger, A A; Ishaq, O; Curtin, J P; Salame, G M; Pothuri, B; Schiff, P B; Boyd, L R; Lymberis, S
Objective: We aimed to explore the disparities associated with the delay of initiating chemoradiation therapy (CRT) and brachytherapy (BT) beyond the recommended 8 weeks for patients with cervical cancer and the effect on outcomes.
Method(s): Patients with FIGO stage IB2-IVA cervical cancer treated at an academic medical center and an urban public hospital by the same team of gynecologic and radiation oncologists with definitive CRT and BT from July 2009 to September 2017 were included. Patients received CRT followed by BT (7 Gy x 4 fractions) delivered via 2 insertions 1 week apart with image-guided CT/MR delineation. Patients who initiated CRT within 8 weeks from diagnosis as recommended (rCRT) were compared across demographic and cancer outcomes to patients who received delayed CRT after 8 weeks (dCRT). Disease-free survival (DFS) and overall survival (OS) were analyzed using adjusted Cox regression analysis (P < 0.05).
Result(s): In our cohort of 97 patients, 72 (75.0%) had rCRT and 24 (25.0%) had dCRT. At a median follow-up of 31.5 months, overall local control was achieved in 94.8% of patients. Patients with dCRT were more likely to be African-American (37.5% vs 17.8%, P = 0.046) and be uninsured or on Medicaid (87.5% vs 61.6%, P = 0.023). There were no differences in stage and grade. Patients with dCRT were more likely to recur or progress (OR = 2.65, 95% CI 1.02-6.86). Of those who recurred, 35.0% of rCRT patients had locoregional recurrence versus 66.7% of dCRT patients (P = 0.144). When controlling for age, race, insurance, referring hospital, and stage, patients with dCRT had lower DFS than patients with rCRT (50.6 vs 63.2 months, aHR = 6.11, 95% CI 2.00-18.62). However, there were no differences in OS.
Conclusion(s): Patients receiving delayed CRT tended to have worse recurrence and DFS than those initiating CRT by 8 weeks from diagnosis. African-American and uninsured patients were more likely to experience a delay in care. Navigator and social work services may help improve access to treatments for these patients.
Copyright
EMBASE:2008347033
ISSN: 0090-8258
CID: 4638422

Intraoperative Ultrasound Guided Intracavitary Brachytherapy: Improving Toxicity and Precision of Tandem Applicator Placement in Cervical Cancer [Meeting Abstract]

Domogauer, J. D.; Duckworth, T.; Osterman, S.; Pothuri, B.; Boyd, L.; Salame, G.; Kehoe, S.; Schiff, P. B.; Lymberis, S. C.
ISI:000582521501533
ISSN: 0360-3016
CID: 4686282