Adam C. Olson

Training Global Oncologists: Addressing the Global Cancer Control Problem

The global incidence of cancer has increased by approximately 20% in the past decade, an increase mostly due to cases in low- and middle-income countries (LMICs) (1). By 2020, up to 70% of the 20 million annual new cancer cases are expected to occur in LMICs (2). The incidence of cancer in LMICs is increasing rapidly; however, many countries are not prepared to address this epidemic. Cancer survival rates in LMICs are often less than one-third of those in high-income countries (3). In addition to local capacity-building efforts, the involvement of the oncology community from high-income countries will be instrumental in changing the course of this impending global cancer crisis. There is a vital need to train global oncologists to work with colleagues in LMICs to develop sustainable capacity and infrastructure for clinical oncology care, research, and education. However, enumeration of specific goals and novel programs, and the path to implementing these programs, is not clear. Oncology programs in North America lack formal training or exposure to global oncology. Even without a formal curriculum, with the rise in global health (GH) oncology interest, several opportunities have developed for trainees committed to GH. We describe herein current opportunities and future directions for oncology trainees in the United States (US) who are interested in pursuing careers as global oncologists.

Radiation Oncology in India: Challenges and Opportunities ☆

Rising cancer incidence and mortality in India emphasize the need to address the increasing burden of this disease and the stark inequities in access to radiotherapy and other essential medical treatments. State-of-the-art technology is available within the private sector and a few hospitals in the public sector, but 75% of patients in the public sector in India do not have access to timely radiotherapy. This inequity in access to radiotherapy in the public sector is amplified in rural areas, where most of India׳s population lives. A long-term government commitment to machine purchase and human resource development in the public sector is needed to improve access. A number of innovative initiatives to improve cancer treatment and access have emerged that could support such an investment. These include local production of equipment, twinning programs between institutions in high- and low-income countries to exchange knowledge and expertise, and nongovernmental and state-sponsored schemes to sponsor and support patients in their cancer journey. Strengthening of cancer registries and regulatory bodies with authority to enforce minimum standards is also required to improve care. The more uniform and frequent availability of high-quality radiotherapy can improve cancer outcomes and may be regarded as a marker of a comprehensive and equitable system of health care delivery.

A Roadmap for a New Academic Pathway for Global Radiation Oncology

A Roadmap for a New Academic Pathway for Global Radiation Oncology Adam C. Olson, MD,* C. Norman Coleman, MD,y Stephen M. Hahn, MD, FASTRO,z Theodore L. DeWeese, MD,x Lawrence N. Shulman, MD,k Bruce A. Chabner, MD,{ Nelson Chao, MD, MBA, Yehoda M. Martei, MD,** Arno J. Mundt, MD, FASTRO,yy and Surbhi Grover, MDzz *Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina; yThe International Cancer Expert Corps, Chevy Chase, Maryland; zDivision of Radiation Oncology, M D Anderson Cancer Center, Houston, Texas; xDepartment of Radiation Oncology and Molecular Radiation Science, Johns Hopkins Medical Institute, Baltimore, Maryland; kAbramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; {Dana-Farber Cancer Institute, Boston, Massachusetts; Division of Hematologic Malignancies and Cellular Therapy, Bone Marrow Transplant and Global Cancer, Duke Cancer Institute, Durham, North Carolina; **Division of Hematology-Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; yyDepartment of Radiation Medicine and Applied Sciences, University of California, San Diego, San Diego, California; and zzDepartment of Radiation Oncology, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

Hippocampal dose from stereotactic radiosurgery for 4 to 10 brain metastases: Risk factors, feasibility of dose reduction via re-optimization, and patient outcomes

This study aimed to report hippocampal dose from single-fraction stereotactic radiosurgery (SRS) for 4 to 10 brain metastases and determine feasibility of hippocampal-sparing SRS. Patients with 4 to 10 brain metastases receiving single-isocenter, multi-target single-fraction SRS were identified. Hippocampi were contoured using the Radiation Therapy Oncology Group (RTOG) 0933 atlas. RTOG 0933 dose constraints were converted to a biologically effective dose using an alpha/beta of 2 (D100 421 cGy, Dmax 665 cGy). Number of metastases, total target volume, prescribed dose, and distance of nearest metastasis (dmin) were analyzed as risk factors for exceeding hippocampal constraints. If hippocampi exceeded constraints, the SRS plan was re-optimized. Key dosimetric parameters were compared between original and re-optimized plans. To determine if a single target can exceed constraints, all targets but the closest metastasis were removed from the plan, and dosimetry was compared. Forty plans were identified. Fifteen hippocampi (19%) exceeded constraints in 12 SRS plans. Hippocampal sparing was achieved in 10 of 12 replanned cases (83%). Risk factors associated with exceeding hippocampal constraints were decreasing dmin (24.0 vs 8.0 mm, p = 0.002; odds ratio [OR] 1.14, 95% confidence interval [CI] 1.04 to 1.26) and total target volume (5.46 cm3vs 1.98 cm3, p = 0.03; OR 1.14, 95% CI 1.00 to 1.32). There was no difference in exceeding constraints for 4 to 5 vs 6 to 10 metastases (27% vs 21%, p = 0.409) or prescribed dose (18 Gy, p = 0.58). For re-optimized plans, there were no significant differences in planning target volume (PTV) coverage (99.6% vs 99.0%, p = 0.17) or conformality index (1.47 vs 1.4, p = 0.78). Six (50%) plans exceeded constraints with a single target. A substantial minority of hippocampi receive high radiation dose from SRS for 4 to 10 brain metastases. Decreasing distance of the closest metastasis and total target volume are associated with exceeding hippocampal constraints. Re-optimizing these plans yielded hippocampal-sparing SRS plans with acceptable dosimetry. Prospective evaluation of the impact of hippocampal dose from SRS on neurocognition merits consideration.

Corrigendum: “Training Global Oncologists: Addressing the Global Cancer Control Problem”

[This corrects the article on p. 80 in vol. 5, PMID: 25905040.].

Estimating survival for renal cell carcinoma patients with brain metastases: an update of the Renal Graded Prognostic Assessment tool

Background Brain metastases are a common complication of renal cell carcinoma (RCC). Our group previously published the Renal Graded Prognostic Assessment (GPA) tool. In our prior RCC study (n = 286, 1985-2005), we found marked heterogeneity and variation in outcomes. In our recent update in a larger, more contemporary cohort, we identified additional significant prognostic factors. The purpose of this study is to update the original Renal-GPA based on the newly identified prognostic factors. Methods A multi-institutional retrospective institutional review board-approved database of 711 RCC patients with new brain metastases diagnosed from January 1, 2006 to December 31, 2015 was created. Clinical parameters and treatment were correlated with survival. A revised Renal GPA index was designed by weighting the most significant factors in proportion to their hazard ratios and assigning scores such that the patients with the best and worst prognoses would have a GPA of 4.0 and 0.0, respectively. Results The 4 most significant factors were Karnofsky performance status, number of brain metastases, extracranial metastases, and hemoglobin. The overall median survival was 12 months. Median survival for GPA groups 0-1.0, 1.5-2.0, 2.5-3, and 3.5-4.0 (% n = 25, 27, 30 and 17) was 4, 12, 17, and 35 months, respectively. Conclusion The updated Renal GPA is a user-friendly tool that will help clinicians and patients better understand prognosis, individualize clinical decision making and treatment selection, provide a means to compare retrospective literature, and provide more robust stratification of future clinical trials in this heterogeneous population. To simplify use of this tool in daily practice, a free online application is available at brainmetgpa.com.

Organ-Specific Toxicities Due to Radiation Therapy in Cancer Patients With or Without HIV Infection: A Systematic Review of the Literature

Background: To synthesize published literature on the association between human immunodeficiency virus (HIV) infection and radiation therapy (RT)-related toxicities. Methods: Two electronic databases, MEDLINE and Embase, were searched to identify studies published before November 2016 comparing RT-related toxicities between HIV-infected and HIV-uninfected patients receiving RT or chemoradiation therapy (CRT) for cancer. A qualitative synthesis of included articles and organ-specific toxicities was then performed. Results: Of the 21 studies included in this review, 15 reported on anal cancer treatment, three on cervical cancer, two on Kaposi sarcoma, and one on prostate cancer. Reports in the pre-antiretroviral therapy (ART) or early ART era tended to identify increased morbidity and mortality with HIV infection. However, modern series incorporating more concurrent chemotherapy, conformal RT techniques, and ART administration result in fewer studies reporting toxicity differences in patients treated for anal and cervical cancers. When statistically significant, HIV-infected patients had higher rates of gastrointestinal toxicity with anal cancer CRT (up to 50%) and higher rates of hematologic toxicity with cervical cancer CRT (up to 31%). Of the 17 studies reporting treatment outcomes, nine suggest HIV-infected patients may have reduced local control and/or survival rates. Conclusions: Overall, RT is likely similarly tolerated between HIV-infected and HIV-uninfected patients, especially with modern RT techniques. HIV-infected patients should continue to receive established standard of care RT and CRT dosing.

Outcomes and toxicity of stereotactic radiosurgery for melanoma brain metastases in patients receiving ipilimumab

Purpose Patients with melanoma treated with ipilimumab and radiosurgery (stereotactic radiosurgery [SRS]) were reviewed for efficacy/safety. Methods Patients who received ipilimumab and SRS for brain metastases were analyzed for control of SRS-treated metastasis and overall survival. Results We identified 27 patients, 26 were assessable for outcomes. Median time-to-treated metastasis progression was 6.3 months (95% CI: 3.1-12.2). Overall survival was 23.4 months (95% CI: 5.7-not estimable) for SRS prior to/during ipilimumab (n = 14), and 10.4 months (95% CI: 1.9-not estimable) for SRS after ipilimumab (n = 12). Overall, no unexpected toxicities were seen: 11% of patients experienced grade 3 CNS toxicity and 7% developed radionecrosis. Conclusion SRS for melanoma brain metastases with ipilimumab was well-tolerated. There may be improved survival for patients receiving SRS prior to/during ipilimumab.

Radiation Needs In Pediatric Oncology in the Lake Region Of Tanzania

Abstract 32Background:The majority of new pediatric cancer diagnoses are made in resource-poor countries where survival rates range from 5-25%, compared with 80% in high-resource countries. A key component of treatment includes radiation therapy, but access is extremely limited in East Africa. This study estimates the potential clinical benefit of radiation therapy for pediatric oncology patients at Bugando Medical Centre (BMC), a tertiary referral center in the lake zone of Tanzania, one of two cancer treatment centers in Tanzania.Methods:Study design is a retrospective review of recorded hospital admissions and clinic visits to the oncology department at BMC from January 2010-December 2014. The indication for radiation therapy was extrapolated from contemporary SIOP and COG protocols. The benefits of radiotherapy, both for curative and palliative intent, were estimated based on age, diagnosis and stage at presentation by two radiation oncologists.Results:A total of 221 pediatric patients were identified...