Christine E. Hill-Kayser

An Internet Tool for Creation of Cancer Survivorship Care Plans for Survivors and Health Care Providers: Design, Implementation, Use and User Satisfaction

Background Survivorship care plans have been recommended by the Institute of Medicine for all cancer survivors. We implemented an Internet-based tool for creation of individualized survivorship care plans. To our knowledge, this is the first tool of this type to be designed and made publicly accessible. Objective To investigate patterns of use and satisfaction with an Internet-based tool for creation of survivorship care plans. Methods OncoLife, an Internet-based program for creation of survivorship care plans, was designed by a team of dedicated oncology nurses and physicians at the University of Pennsylvania. The program was designed to provide individualized, comprehensive health care recommendations to users responding to queries regarding demographics, diagnosis, and cancer treatments. After being piloted to test populations, OncoLife was made publicly accessible via Oncolink, a cancer information website based at the University of Pennsylvania which averages 3.9 million page views and over 385,000 unique visits per month. Data entered by anonymous public users was maintained and analyzed. Results From May 2007 to November 2008, 3343 individuals utilized this tool. Most (63%) identified themselves as survivors, but also health care providers (25%) and friends/family of survivors (12%). Median age at diagnosis was 48 years (18 - 100+), and median current age 51 (19 - 100+). Most users were Caucasian (87%), female (71%), and college-educated (82%). Breast cancer was the most common diagnosis (46%), followed by hematologic (12%), gastrointestinal (11%), gynecologic (9%), and genitourinary (8%). Of all users, 84% had undergone surgery, 80% chemotherapy, and 60% radiotherapy. Half of users (53%) reported receiving follow-up care from only an oncologist, 13% only a primary care provider (PCP), and 32% both; 12% reported having received survivorship information previously. Over 90% of users, both survivors and health care providers, reported satisfaction levels of “good” to “excellent” using this tool. Conclusions Based on our experience with implementation of what is, to our knowledge, the first Web-based program for creation of survivorship care plans, survivors and health care providers appear both willing to use this type of tool and satisfied with the information provided. Most users have never before received survivorship information. Future iterations will focus on expanding accessibility and improving understanding of the needs of cancer survivors in the era of the Internet.

Acute toxicity of proton beam radiation for pediatric central nervous system malignancies

Proton beam therapy (PBT) for pediatric CNS malignancies may reduce late toxicity, but acute toxicity is not well defined. We examined acute toxicity for children with CNS malignancies treated with PBT.

Long-term clinical and cosmetic outcomes after breast conservation treatment for women with early-stage breast carcinoma according to the type of breast boost.

PURPOSE The present study was performed to compare outcomes after breast conservation treatment with iridium-192 implant boost vs. electron boost. METHODS AND MATERIALS From 1977 to 1983, 141 patients were treated with whole breast radiotherapy followed by iridium-192 boost after breast-conserving surgery. They were matched 1:1 to patients treated with electron boost. Outcome measures included survival, local recurrence, cosmesis, and complications. RESULTS Median follow-up was 16.7 and 12.6 years for the implant vs. electron groups (p < 0.001). Rates of local recurrence, freedom from distant metastases, and overall survival at 10/20 years did not differ between the groups, nor did patterns of first failure. Patients in the electron group were more likely to have excellent/good cosmesis than those in the implant group 1 year after radiotherapy (p = 0.014); this trend continued through 10 years but did not reach statistical significance at years 5/10. Complication rates were similar, although patients receiving electron boost seemed less likely to develop breast fibrosis than did those receiving implant boost (23/141 vs. 58/141, respectively, incidence rate ratio 0.7, p = 0.17). CONCLUSIONS Twenty-year data demonstrate no difference in rates of local recurrence, freedom from distant metastases, overall survival, or patterns of failure between groups treated with these two well-described radiotherapy boost techniques. Better cosmesis was observed in the electron group 1 year after radiotherapy, with a trend continuing for 10 years. The incidence of complications was similar between the groups, with a trend toward increased fibrosis in patients receiving implant boost.

Development and Clinical Implementation of a Universal Bolus to Maintain Spot Size During Delivery of Base of Skull Pencil Beam Scanning Proton Therapy

PURPOSE To report on a universal bolus (UB) designed to replace the range shifter (RS); the UB allows the treatment of shallow tumors while keeping the pencil beam scanning (PBS) spot size small. METHODS AND MATERIALS Ten patients with brain cancers treated from 2010 to 2011 were planned using the PBS technique with bolus and the RS. In-air spot sizes of the pencil beam were measured and compared for 4 conditions (open field, with RS, and with UB at 2- and 8-cm air gap) in isocentric geometry. The UB was applied in our clinic to treat brain tumors, and the plans with UB were compared with the plans with RS. RESULTS A UB of 5.5 cm water equivalent thickness was found to meet the needs of the majority of patients. By using the UB, the PBS spot sizes are similar with the open beam (P>.1). The heterogeneity index was found to be approximately 10% lower for the UB plans than for the RS plans. The coverage for plans with UB is more conformal than for plans with RS; the largest increase in sparing is usually for peripheral organs at risk. CONCLUSIONS The integrity of the physical properties of the PBS beam can be maintained using a UB that allows for highly conformal PBS treatment design, even in a simple geometry of the fixed beam line when noncoplanar beams are used.

Supine Craniospinal Irradiation Using a Proton Pencil Beam Scanning Technique Without Match Line Changes for Field Junctions

PURPOSE To propose and validate a craniospinal irradiation approach using a proton pencil beam scanning technique that overcomes the complexity of the planning associated with feathering match lines. METHODS AND MATERIALS Ten craniospinal irradiation patients had treatment planned with gradient dose optimization using the proton pencil beam scanning technique. The robustness of the plans was evaluated by shifting the isocenter of each treatment field by ±3 mm in the longitudinal direction and was compared with the original nonshifted plan with metrics of conformity number, homogeneity index, and maximal cord doses. An anthropomorphic phantom study using film measurements was carried out on a plan with 5-cm junction length. To mimic setup errors in the phantom study, fields were recalculated with isocenter shifts of 1, 3, 5, and 10 mm longitudinally, and compared with the original plans and measurements. RESULTS Uniform dose coverage to the entire target volumes was achieved using the gradient optimization approach with averaged junction lengths of 6.7 ± 0.5 cm. The average conformity number and homogeneity index equaled 0.78 ± 0.03 and 1.09 ± 0.01, respectively. Setup errors of 3 mm per field (6 mm in worst-case scenario) caused on average 4.6% lower conformity number 2.5% higher homogeneity index and maximal cord dose of 4216.1 ± 98.2 cGy. When the junction length was 5 cm or longer, setup errors of 6 mm resulted in up to 12% dosimetric deviation. Consistent results were reached between film measurements and planned dose profiles in the junction area. CONCLUSIONS Longitudinal setup errors directly reduce the dosimetric accuracy of the proton craniospinal irradiation treatment with matched proton pencil beam scanning fields. The reported technique creates a slow dose gradient in the junction area, which makes the treatment more robust to longitudinal setup errors compared to conventional feathering methods.

Proton versus photon radiation therapy for patients with high-risk neuroblastoma: The need for a customized approach

Proton therapy for treatment for high‐risk neuroblastoma may offer sparing of organs at risk (OAR) when compared to intensity‐modulated X‐ray therapy (IMXT).

High Level Use and Satisfaction with Internet‐Based Breast Cancer Survivorship Care Plans

To the Editor: Breast cancer survivors remain a prominent subset of the survivor population, and may be at risk for myriad late effects associated with breast cancer diagnosis and treatments. In 2005, the Institute of Medicine recommended that all survivors be provided with a survivorship care plan (SCP), or a document summarizing possible late effects of treatment, as well as recommended follow-up care, at the completion of cancer treatment (1). This recommendation has been supported by both the oncology and primary care provider (PCP) communities (2). In May, 2007, we launched the first Internet-based tool for creation of SCP, available at http://www.live strongcareplan.org and via OncoLink (http://www. oncolink.org), a cancer information website based at the University of Pennsylvania. The tool consists of queries regarding demographics, cancer diagnoses, and cancer treatments received, and provides users with comprehensive, individualized survivorship care plans. Details of the care plan format, design, and implementation have been previously described (3). Following piloting and initial launch of the tool, breast cancer survivors were observed to be prominent within the user population, and particular attention was given to data-driven improvement of care plans created for breast cancer survivors. Data collection procedures were approved by the Institutional Review Board. Between 5 ⁄ 07 and 10 ⁄ 09, 8717 care plans were created, 48% (n = 4,021) by or for breast cancer survivors. Mean age at diagnosis was 48.5 years (median 48, range, 18–85), and mean current age 51.6 years (median 52, range, 19–89). Mean time since diagnosis was 3 years (median 2 years, range <1 year–39). Breast cancer survivors using this tool were mostly Caucasian (89%, n = 3565) and well-educated, with 83% (n = 3,333) having attended at least some college. These findings are consistent with those of other groups who have demonstrated that women, particularly those who are younger, Caucasian, and highly educated, are likely to utilize the Internet to seek information about breast cancer (4–7). Certainly, increasing accessibility to under-served populations is a priority. To this end, we have created a Spanish version of the tool; in addition, within our own institution and at several others, nursing staff complete care plans for patients when they complete treatment. Finally, we are hopeful that our partnership with the Lance Armstrong Foundation will promote awareness of the care plan tool. Even amongst this apparently highly motivated survivor group, the presence of survivorship information from resources other than this tool appears scarce: breast cancer survivors reported having received previous dedicated survivorship information in only 12% of cases (n = 408); of 411 breast cancer survivors queried, 17% (n = 68) reported knowing of established survivorship programs at their own cancer centers (Fig. 1). Of 3,348 breast cancer survivors who were queried regarding current follow-up care, 47% reported receiving follow-up care only from an oncologist, 10% only a PCP, 39% both, and 3% neither. Recognized late effects of breast cancer and its treatments are broad in nature; some, such as recurrence and second cancer risk, are clearly of an oncologic nature. Others, such as cardiac dysfunction and osteopenia, fall within a gray zone. While the optimal approach

Proton pencil beam scanning for mediastinal lymphoma: treatment planning and robustness assessment

ABSTRACT Background: Modern radiotherapy (RT) for lymphoma is highly personalized. While advanced imaging is largely employed to define limited treatment volumes, the use of proton pencil beam scanning (PBS) for highly conformal lymphoma RT is still in its infancy. Here, we assess the dosimetric benefits and feasibility of PBS for mediastinal lymphoma (ML). Materials and methods: Ten patients were planned using PBS for involved-site RT. The initial plans were calculated on the average four-dimensional computed tomography (4D-CT). PBS plans were compared with 3D conformal radiotherapy (3D-CRT), intensity-modulated radiotherapy (IMRT), and proton double scattering (DS). In order to evaluate the feasibility of PBS and the plan robustness against inter- and intra-fractional uncertainties, the 4D dose was calculated on initial and verification CTs. The deviation of planned dose from delivered dose was measured. The same proton beamline was used for all patients, while another beamline with larger spots was employed for patients with large motion perpendicular to the beam. Results: PBS provided the lowest mean lung dose (MLD) and mean heart dose (MHD) for all patients in comparison with 3D-CRT, IMRT, and DS. For eight patients, internal target volume (ITV) D98% was degraded by <3%; and the MLD and MHD deviated by <10% of prescription over the course of treatment when the PBS field was painted twice in each session. For one patient with target motion perpendicular to the beam (>5 mm), the degradation of ITV D98% was 9%, which was effectively mitigated by employing large spots. One patient exhibited large dose degradation due to pericardial effusion, which required replanning across all modalities. Conclusions: This study demonstrates that PBS plans significantly reduce MLD and MHD relative to 3D-CRT, IMRT, and DS and identifies requirements for robust free-breathing ML PBS treatments, showing that PBS plan robustness can be maintained with repainting and/or large spots.

Computed tomography and positron emission tomography/ computed tomography surveillance after combined modality treatment of supradiaphragmatic Hodgkin lymphoma: a clinical and economic perspective

Abstract We studied the clinical benefits of radiological imaging, in the follow-up of patients after combined modality treatment for stage I/II classical supradiaphragmatic Hodgkin lymphoma (HL). Imaging data were collected for 78 adults treated during 1996–2008. Median follow-up was 4.6 years. Six of the nine relapses were detected clinically. On average, 31 imaging studies/patient were performed, with an estimated cost of

Breast cancer screening for childhood cancer survivors after craniospinal irradiation with protons versus x-rays: a dosimetric analysis and review of the literature.

12 608/patient. Chest computed tomography (CT) scans accounted for 25%, abdominopelvic CT scans 41% and positron emission tomography (PET) or PET/CT scans 22% of this expense. Only one patient recurred infradiaphragmatically. The estimated radiation dose from imaging was 399 mSv and 229 mSv per patient, in relapse and non-relapse groups, respectively. CT scans contributed over 80% of the imaging radiation exposure. The routine use of CT scans in the surveillance of patients with HL after curative treatment adds to healthcare costs and total body radiation exposure with a low yield. History and physical examination remain effective tools for the follow-up of patients.