Bismarck Odei

Chemoradiation versus chemotherapy or radiation alone in stage III endometrial cancer: Patterns of care and impact on overall survival

PURPOSE We aimed to investigate the patterns-of-care and overall survival (OS) benefit of aCRT versus adjuvant monotherapy (aMT), defined as either chemotherapy or radiation alone, utilizing a large national registry of patients. PATIENTS AND METHODS Adult patients with stage III endometrial adenocarcinoma diagnosed from 2004 to 2013 were included. Logistic and Cox regression modeling was used to identify factors predictive of receipt of aCRT and OS, respectively. Survival analysis was performed with Kaplan Meier and log-rank analysis. Propensity score matching and sensitivity analysis was performed to address selection bias and presence of potential confounding variables. RESULTS A total of 21,027 patients were identified: 11,435 (54.4%) patients received aMT, while 9592 (45.6%) received aCRT. Utilization of aCRT increased over the study period (p<0.01). Factors predictive of receiving aCRT include private insurance (OR: 1.67, 95% CI: 1.30-2.14), Medicare (OR: 1.33, 95% CI: 1.01-1.75), FIGO stage IIIC disease (OR: 1.36, 95% CI: 1.19-1.54), lymphovascular space invasion (OR: 1.14, 95% CI: 1.03-1.27), and lymph node surgery performed (OR: 1.42, 95% CI: 1.15-1.74). Median survival in years for aCRT, RT, and CT was 10.3, 7.1, and 5.6, respectively (p<0.001). Compared to aMT, aCRT was associated with a decrease risk of death on multivariate analysis (HR: 0.62, 95% CI: 0.56-0.70). The benefit of aCRT over aMT persisted after propensity score matching. CONCLUSION The use of aCRT for stage III endometrial cancer is increasing. Multiple clinical and demographic factors were predictive of aCRT use. When compared to chemotherapy or radiation alone, aCRT is associated with an OS benefit.

Patterns of Care in Proton Radiation Therapy for Pediatric Central Nervous System Malignancies

PURPOSE Proton beam therapy (PBT) potentially allows for improved sparing of normal tissues, hopefully leading to decreased late side effects in children. Using a national registry, we sought to perform a patterns-of-care analysis for children receiving PBT for primary malignancies of the central nervous system (CNS). METHODS AND MATERIALS Using the National Cancer Data Base, we identified pediatric patients with primary CNS malignancies that were diagnosed between 2004 and 2012. We used a standard t test for comparison of means and χ2 testing to identify differences in demographic and clinical characteristics. Univariate and multivariate logistical regression was applied to identify predictors of PBT use. RESULTS We identified 4637 pediatric patients receiving radiation therapy from 2004 to 2012, including a subset of 267 patients treated with PBT. We found that PBT use increased with time from <1% in 2004 to 15% in 2012. In multivariate logistical regression, we found the following to be predictors of receipt of PBT: private insurance, the highest income bracket, younger age, living in a metropolitan area, and residing >200 miles from a radiation treatment facility (P<.05). CONCLUSIONS We noted the proportion of children receiving PBT to be significantly increasing over time from <1% to 15% from 2004 to 2012. We also observed important disparities in receipt of PBT based on socioeconomic status. Children from higher-income households and with private insurance were more likely to use this expensive technology. As we continue to demonstrate the potential benefits of PBT in children, efforts are needed to expand the accessibility of PBT for children of all socioeconomic backgrounds and regions of the country.

The Addition of Adjuvant Chemotherapy to Radiation in Early-Stage High-Risk Endometrial Cancer: Survival Outcomes and Patterns of Care.

Objective Early-stage high-risk endometrial cancer (HREC) treated with adjuvant radiotherapy (aRT) alone has been associated with an increased risk of distant relapse. The addition of chemotherapy to radiotherapy (aCRT) may benefit overall survival (OS). We investigated the patterns-of-care and OS benefit of aCRT in HREC by analyzing a large national registry. Methods Our query was limited to patients with the International Federation of Gynecology and Obstetrics stage IB and II HREC with either papillary serous, clear cell, or grade 3 adenocarcinoma, diagnosed between 2004 and 2012. Logistic and Cox regression analyses were utilized to identify predictors of aCRT use and OS, respectively. Survival analysis was performed with Kaplan Meier and log-rank methods. Propensity score matching was employed to decrease the potential influence of selection bias. Results A total of 11,746 patients were identified for analysis with 8206 (69.9%) receiving aCRT, and 3540 (30.1%) received aRT. Predictors of aCRT included International Federation of Gynecology and Obstetrics stage II (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.22–1.57), papillary serous (OR, 9.44; 95% CI, 8.22–10.85) or clear cell (OR, 3.21; 95% CI, 2.59–3.97) histology, lymph nodes removed (OR, 1.48; 95% CI, 1.31–1.69), and receipt of brachytherapy alone (OR, 1.55; 95% CI, 1.36–1.78). Estimated 5-year OS was 75.2% for patients receiving aRT only and 79.2% for those receiving aCRT (P < 0.001). When compared with aRT, aCRT was associated with improved OS on multivariate (hazard ratio, 0.78; 95% CI, 0.61–0.99) analysis. A univariate shared-frailty Cox regression after propensity score matching revealed persistence of the OS benefit with aCRT (hazard ratio, 0.74; 95% CI, 0.65–0.84). Conclusions The addition of adjuvant chemotherapy to radiation in HREC is associated with improved OS. Multiple demographic and clinical factors significantly influence the choice of adjuvant therapy in this setting.

The Role of Radiation in All Stages of Nodular Lymphocytic Predominant Hodgkin Lymphoma

Micro‐Abstract We assessed the role of radiotherapy in nodular lymphocytic Hodgkin lymphoma, particularly among patients with advanced stage disease, and B symptoms. We found that among patients with nodular lymphocytic Hodgkin lymphoma, radiotherapy had a potential role in advanced‐stage disease and those with B symptoms, suggesting further exploratory studies. Background: The goal of this study was to assess the survival differences seen in early‐stage and advanced‐stage nodular lymphocytic predominant Hodgkin lymphoma (NLPHL) based on treatment modality. Patients and Methods: The National Cancer Database was queried to identify patients diagnosed with NLPHL between 2004 and 2012. Overall survival (OS) was determined using univariate and multivariate Cox regression analysis. Kaplan‐Meier and log‐rank analysis were used to estimate differences in OS between treatment groups. Results: A total of 1968 patients were identified for analysis, consisting of stage I (40.4%), stage II (29.3%), stage III (22.3%), and stage IV (8.0%) disease. The median age of patients was 46 years. The following factors were predictive of radiotherapy (RT) omission in treatment: increasing age, black race, Medicare insurance, chemotherapy use, stage II to IV disease, and the presence of B‐symptoms. On survival analysis, RT was associated with prolonged OS in all stages of NLPHL (50.1 vs. 42.4 months; P < .01). The OS benefit of RT persisted on multivariate analysis (hazard ratio, 0.37; P < .01). On subset analysis, RT was associated with prolonged OS in early disease (49.8 vs. 45.5 months; P < .01), whereas a trend towards an OS benefit was observed in advanced‐stage (54.1 vs. 39.6 months; P = .06) NLPHL. Radiotherapy was also associated with prolonged OS among patients with B‐symptoms (49.0 vs. 42.6 months; P < .01). Conclusion: The use of RT in NLPHL is less likely among those with advanced‐stage disease and B‐symptoms. However, we found RT to be associated with prolonged OS in all stages of NLPHL, including those with B‐symptoms.

A 20-Year Analysis of Clinical Trials Involving Proton Beam Therapy

Purpose Clinical trials (CTs) in proton beam therapy (PBT) are important for determining its benefits relative to other treatments. An analysis of PBT trials is, thus, warranted to understand the current state of PBT CTs and the factors affecting current and future trials. Materials and Methods We queried the clinicaltrials.gov Website using the search terms: proton beam therapy, proton radiation, and protons. A total of 152 PBT CTs were identified. We used χ2 analysis and logistic regression to evaluate trial characteristics. Results Most CTs were recruiting (n = 79; 52.0%), phase II (n = 95; 62.5%), open label (n = 134; 88.2%), single-group assignment (n = 84; 55.3%), and with primary treatment endpoints of safety and efficacy (n = 94; 61.8%). The primary treatment sites included gastrointestinal (n = 32; 21.1%), central nervous system (n = 31; 20.4%), lung (n = 21; 13.8%), prostate (n = 19; 12.5%), sarcoma (n = 15; 9.9%), and others (n = 24; 15.8%). Comparison studies between radiation modalities involved PBT and intensity-modulated photon therapy (n = 11; 7.2%), PBT and general photon therapy (n = 8; 5.3%), and PBT and carbon-ion therapy (n = 7; 4.6%). The PBT CTs underwent substantial growth after 2008 but now appear to be in decline. Nongovernmental institutions, comprising university centers, hospital systems, and research groups, have funded the greatest number of CTs (n= 106; 69.7%). The National Institutes of Health (NIH) were more likely to fund CTs involving the central nervous system (P = 0.02). Trials involving NIH funding were more likely to result in successful trial completion (P = 0.02). Conclusion Among PBT CTs, most were phase II trials, with a very few being phase III CTs. Funding of PBT CTs originating from industry or the NIH is limited. Recently, there has been a declining trajectory of newly initiated PBT trials. It is not yet clear whether this represents a true trend or just a pause in CT implementation. Despite multiple impediments to PBT CTs, the particle therapy community continues to work toward evidence generation.