Alex K. Bryant

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

PURPOSE Palliative cares 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.

Trends in Radiation Therapy among Cancer Survivors in the United States, 2000–2030

Background: Although the number of cancer survivors has increased substantially over the past several decades, the composition of survivors treated with radiotherapy is not well defined. Radiotherapy carries unique long-term toxicity risks for cancer survivors. This study describes the current estimates and future projections of the epidemiology of 5-year cancer survivors who receive radiation therapy. Methods: We used cancer incidence and survival data from the Surveillance, Epidemiology, and End-Results (SEER) database linked to U.S. Census data to estimate the number of 5-year cancer survivors treated with radiation between 2000 and 2030. Future projections assumed continuing incidence and survival trends based on historical rates. Results: In 2016, there were an estimated 3.05 million cancer survivors treated with radiation, accounting for 29% of all cancer survivors. The number of radiation-treated cancer survivors is projected to reach 3.38 million by 2020 and 4.17 million by 2030. In 2016, breast (40%) and prostate cancer (23%) composed the majority of radiation-treated survivors, followed by head and neck cancer (5.8%), lymphoma (5.6%), uterine (3.9%), and rectal cancer (3.8%). The percentage of 70 years or older radiation-treated survivors steadily increased between 2000 and 2030. Conclusions: The next several years are projected to see a large increase in the number of cancer survivors treated with radiation. Impact: This group of cancer survivors has unique needs given the long-term risks of radiation, and increased research and awareness are required to optimize health of this growing population. Cancer Epidemiol Biomarkers Prev; 26(6); 963–70. ©2017 AACR.

An interactive contouring module improves engagement and interest in radiation oncology among preclinical medical students: Results of a randomized trial

PURPOSE Studies have shown significant gaps in knowledge of radiation therapy among medical students and primary care providers. The goal of this study was to evaluate the effect of an interactive contouring module on knowledge and interest in radiation oncology among preclinical medical students. METHODS AND MATERIALS Second-year medical students at the University of California, San Diego were randomized to participate in an interactive contouring exercise or watch a traditional didactic lecture on radiation oncology. Participants completed knowledge tests and surveys at baseline, immediately following the exercise, and 3 months later. Statistical analysis included Wilcoxon signed-rank test for pre- and posttest comparisons and Wilcoxon rank sum test for comparison between groups. RESULTS Forty-three medical students participated in the trial (21 in the didactic group; 22 in the contouring group). Students completing the contouring module demonstrated similar overall knowledge improvement compared with the traditional didactic group (+8.6% vs +6.6%, not significant) but endorsed greater engagement on a 5-point Likert-type scale (3.10 vs 3.76, P = .02). At 3-month follow-up, there was a nonsignificant trend toward improved overall knowledge in the contouring group (43% vs 51%, P = .10), with a significance difference in a subset of questions on knowledge of the process of radiation therapy as well as side effects (51% vs 75%, P = .002). Students in the contouring group demonstrated more interest in pursuing a clinical radiation oncology rotation (2.52 vs 3.27, P = .01). CONCLUSIONS Use of an interactive contouring module was an effective method to teach preclinical medical students about radiation oncology, with no significant difference in knowledge gained compared with a traditional didactic lecture; however, higher engagement among students completing the contouring module led to improved retention of knowledge of radiation side effects and greater interest in radiation oncology. These data suggest a potential benefit of integrating an interactive radiation oncology module into the preclinical medical school curriculum.

Intensity Modulated Radiation Therapy Versus Conventional Radiation for Anal Cancer in the Veterans Affairs System

PURPOSE Compared with conventional radiation therapy, intensity modulated radiation therapy (IMRT) may reduce acute toxicity from anal cancer treatment, potentially leading to improved long-term outcomes. We analyze the effect of IMRT on short- and long-term outcomes among a large sample of US veterans. METHODS AND MATERIALS From a national Veterans Affairs database, we identified 779 patients (n = 403 conventional radiation therapy, n = 376 IMRT) with locally advanced anal squamous cell carcinoma diagnosed between 2000 and 2015 and treated with concurrent chemoradiation therapy. Radiation treatment planning and dosimetric constraints were not standardized across patients. We analyzed the effect of IMRT on short-term outcomes (acute toxicity, treatment breaks, and incomplete chemotherapy) and long-term outcomes (survival and ostomy placement) in multivariable logistic regression, Fine-Gray, and frailty models, adjusting for potential confounders. RESULTS IMRT was associated with decreased radiation treatment breaks ≥5 days (odds ratio [OR] 0.58; 95% confidence interval [CI] 0.37-0.91; P = .02), increased rates of receiving 2 cycles of mitomycin C chemotherapy (OR 2.04; 95% CI 1.22-3.45; P = .007), increased rates of receiving 2 cycles of any chemotherapy (OR 3.45; 95% CI 1.82-6.25; P < .001), and decreased risk of ostomy related to tumor recurrence or progression (subdistribution hazard ratio 0.60; 95% CI 0.37-0.99; P = .045). IMRT was not associated with a decrease in grade 3 to 4 hematologic toxicity (P = .79), hospitalization for gastrointestinal toxicity (P = .59), or cancer-specific survival (P = 0.18). CONCLUSIONS Among a large sample of US veterans with anal cancer, IMRT was associated with higher rates of receiving 2 chemotherapy cycles, decreased radiation treatment breaks, and decreased rates of ostomy placement. IMRT appears to offer substantial benefits over conventional radiation therapy for patients undergoing concurrent chemoradiation therapy for anal cancer.

Prognostic Role of p16 in Nonoropharyngeal Head and Neck Cancer

Background Previous studies have reported conflicting information regarding the prognostic role of p16 in nonoropharyngeal head and neck squamous cell carcinoma (HNSCC). Methods Using the US Veterans Affairs database, we analyzed 1448 patients with locoregionally advanced HNSCC and known p16 status diagnosed between 2005 and 2015 and treated with surgery, radiotherapy, or chemoradiotherapy. Tumor p16 status was determined through manual review of pathology reports of primary tumor specimens. Oropharyngeal (n = 1061) or nonoropharyngeal (n = 387; hypopharyngeal, laryngeal, or oral cavity) tumor site was determined from tumor registry data and manually reviewed for accuracy. We used multivariable Cox regression to analyze the effect of p16 status on overall survival (OS), cancer-specific survival (CSS), and competing mortality (CM) for oropharyngeal or nonoropharyngeal tumor sites. All statistical tests were two-sided. Results In multivariable models adjusting for treatment, stage, age, comorbidity, and body mass index, patients with p16-positive tumors had improved OS, CSS, and CM compared with patients with p16-negative tumors in both oropharyngeal (OS: hazard ratio [HR] = 0.53, 95% confidence interval [CI] = 0.40 to 0.71, P < .001; CSS: HR = 0.50, 95% CI = 0.35 to 0.73, P < .001; CM: HR = 0.59, 95% CI = 0.38 to 0.93, P = .02) and nonoropharyngeal primary sites (OS: HR = 0.41, 95% CI = 0.25 to 0.69, P < .001; CSS: HR = 0.37, 95% CI = 0.18 to 0.77, P = .008; CM: HR = 0.46, 95% CI = 0.23 to 0.95, P = .04). The prognostic impact of p16 status did not statistically significantly differ by primary tumor site for OS, CSS, or CM (Pinteraction > .05). Conclusions Our findings support the hypothesis that p16 has a similar prognostic role in both nonoropharyngeal and oropharyngeal cancer. Consideration should be given to increased testing for p16 in laryngeal, hypopharyngeal, and oral cavity primaries.

Association of HIV Status With Outcomes of Anal Squamous Cell Carcinoma in the Era of Highly Active Antiretroviral Therapy

This study uses data from the Veterans Affairs database to examine the association of HIV status with outcomes in patients with anal cancer.

Association of Androgen Deprivation Therapy With Dementia in Men With Prostate Cancer Who Receive Definitive Radiation Therapy

Association of Androgen Deprivation Therapy With Dementia in Men With Prostate Cancer Who Receive Definitive Radiation Therapy There is conflicting evidence on the association of androgen deprivation therapy (ADT) and dementia.1-4 Two studies1,2 reported a strong statistically significant association between ADT and both dementia and Alzheimer disease in patients with prostate cancer (PC). However, these studies1,2 analyzed heterogeneous populations, including patients with localized and metastatic disease, treated with curative and palliative intent, and ADT use in the upfront or recurrent setting.1,2 Different treatment modalities and disease stages are associated with substantial selection bias that may predispose results to false associations.5 Furthermore, an association between ADT use and dementia in the recurrent or metastatic setting may be confounded by factors, such as chronic pain, or salvage treatments, such as chemotherapy. We hypothesized that there is no statistically significant association between ADT use and the development of dementia in men with PC who received definitive radiotherapy after controlling for multiple sources of selection bias.

Three-month posttreatment prostate-specific antigen level as a biomarker of treatment response in patients with intermediate-risk or high-risk prostate cancer treated with androgen deprivation therapy and radiotherapy: Prognostic Value of 3-Month Post-RT PSA

Prostate‐specific antigen (PSA) measurement after definitive radiotherapy (RT) and androgen deprivation therapy for localized prostate cancer has been proposed as an early prognostic biomarker. In the current study, the authors investigated the association between 3‐month post‐RT PSA level and biochemical progression‐free survival (bPFS), prostate cancer‐specific survival (PCSS), and overall survival (OS).