Elizabeth Garay

Patterns of care of IMRT usage in postoperative management of uterine cancer

OBJECTIVE To analyze the patterns of care regarding intensity modulated radiation therapy (IMRT) usage in the postoperative management of uterine cancer. METHODS The National Cancer Database was queried to identify women with endometrial adenocarcinoma who underwent hysterectomy followed by external beam radiation between 2004-2012. Descriptive statistics were used to analyze IMRT usage with comparison via the Chi Square test. Overall survival was also compared between IMRT and three dimensional conformal radiation therapy. Multivariable logistic regression and multivariable Cox Regression were used to identify covariables that impact IMRT usage and improved survival respectively. RESULTS 7839 women were included in this study. IMRT utilization increased from 1.9% in 2004 to 32.4% in 2012 (p<0.001). The adjusted odds ratio (OR) for IMRT in 2012 compared with 2004 was 24.90, 95% CI 15.24-40.67 (p<0.001). Aside from year, other predictors of IMRT usage on multivariate analysis were positive nodes, higher dose, private insurance and higher income. Black race was associated with lower IMRT usage compared to Whites with an OR of 0.60, 95% CI 0.44-0.81 (p=0.001). IMRT was not associated with significantly increased survival (HR 0.86, 95% CI 0.73-1.01, p=0.06). Black race and positive nodes were associated with decreased survival within the group studied whereas private insurance and higher income were associated with improved survival. CONCLUSIONS In this hospital-based registry, IMRT has significantly increased in utilization for postoperative radiation in uterine cancer between 2004-2012 although not resulting in significantly improved survival. Socioeconomic and racial disparities exist in the allocation of IMRT usage.

Impact of Timing of Adjuvant Chemoradiation for Glioblastoma in a Large Hospital Database

BACKGROUND Although the standard of care for glioblastoma remains maximal safe resection followed by chemoradiation, conflicting reports have emerged regarding the importance of the time interval between these 2 treatments. OBJECTIVE To assess whether differences in the duration between surgery and initiation of chemoradiation for glioblastoma had an impact on overall survival (OS) in a large hospital-based database. METHODS The National Cancer Database was queried to identify patients diagnosed with glioblastoma between 2010 and 2012 treated with surgery followed by chemoradiation. Patients who received biopsy only were excluded. The time from surgery to initiation of radiation therapy was divided into 4 equal quartiles of ≤24, 25 to 30, 31 to 37, and >37 d. Patient characteristics were compared between groups using Pearson Chi Square and Fishers Exact test. OS was analyzed via the Kaplan-Meier method and compared via the log-rank test. Univariable and multivariable Cox regression were performed to assess for impact of covariables on OS. RESULTS A total of 11 652 patients were included in the analysis. Median duration from surgery to radiation was 30 d. On multivariable regression, black race, larger tumor, gross-total resection, methyguanine-methyl transferase (MGMT+), and treatment at an academic facility were associated with a duration >30 d. On multivariable analysis, there were no significant differences when comparing start within 24 d to 25 to 30 d (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.90-1.01, P = .13) or > 37 d (HR 0.97, 95% CI 0.91-1.03, P = .26), although a small OS improvement was seen if initiated within 31 to 37 d (HR 0.93, 95% CI 0.88-0.99, P = .02). CONCLUSION There was no clear association between duration from surgery to initiation of chemoradiation on OS.

Patterns of care and outcomes for glioblastoma in patients with poor performance status

PURPOSE/OBJECTIVES While treatment with tumor resection followed by chemoradiation is generally the accepted standard of care for glioblastoma (GBM), the treatment for patients with poor performance status remains uncertain. Therefore we sought to examine patterns of care and survival outcomes among patients with poor performance status utilizing a large hospital database. METHODS/MATERIALS We queried the National Cancer Database (NCDB) for patients with GBM and Karnofsky performance status (KPS) <60 between 2010 and 2013. Data was collected regarding surgery, radiation therapy and chemotherapy. Logistic regression was used to analyze predictors for utilization of chemoradiation. The Kaplan-Meier method was used to compare survival between those who received chemoradiation to radiation alone and Cox regression was performed to assess covariates associated with survival. RESULTS There were 488 patients included in the analysis of which 51.2% received chemoradiation and 46.1% underwent subtotal or gross total resection. None of the factors analyzed were significantly associated with increased likelihood of receiving chemoradiation over radiation alone. Survival data was available for 236 patients that received radiation therapy with and without combination chemotherapy. The median overall survival for those receiving radiation alone was 3.6 months and 8.7 months in those who received chemoradiation (p < 0.001). On multivariable Cox regression, increasing age (HR 1.80-2.10, p = 0.001) was associated with worse survival while subtotal/gross total resection (HR 0.60, p = 0.003) and chemoradiation (HR 0.57, CI 0.40-0.83, p = 0.003) were associated with improved survival. CONCLUSION Even patients with poor performance status had better survival outcomes when they received treatment with chemoradiation over radiation alone.

Bilateral diffuse grade 5 radiation pneumonitis after intensity modulated radiation therapy for localized lung cancer

We are reporting a case of fatal radiation pneumonitis that developed six months following chemoradiation for limited stage small cell lung cancer. The patient was a 67-year-old man with a past medical history of Hashimoto’s thyroiditis and remote suspicion for CREST, neither of which were active in the years leading up to treatment. He received 6600 cGy delivered in 200 cGy daily fractions via intensity modulated radiation therapy with concurrent cisplatin/etoposide followed by additional chemotherapy with dose-reduced cisplatin/etoposide and carboplatin/etoposide and then received prophylactic cranial irradiation. The subsequent months were notable for progressively worsening episodes of respiratory compromise despite administration of prolonged steroids and he ultimately expired. Imaging demonstrated bilateral interstitial and airspace opacities. Autopsy findings were consistent with pneumonitis secondary to chemoradiation as well as lymphangitic spread of small cell carcinoma. The process was diffuse bilaterally although his radiation was delivered focally to the right lung and mediastinum.