Kwang Choi

Survival outcomes with the use of surgery in limited-stage small cell lung cancer: should its role be re-evaluated?

Although chemotherapy and radiation therapy currently are recommended in limited‐stage small cell lung cancer (L‐SCLC), several small series have reported favorable survival outcomes in patients who underwent surgical resection. The authors of this report used a US population‐based database to determine survival outcomes of patients who underwent surgery.

Impact of postoperative radiation after esophagectomy for esophageal cancer.

Introduction: Though postoperative radiation for esophageal cancer is offered in selected cases, there is conflicting evidence as to whether it improves overall survival (OS). We performed a retrospective analysis using the Surveillance Epidemiology and End Results database to analyze the impact of adjuvant radiation in a large cohort of patients. Methods: From 1998 to 2005, patients diagnosed with stage T3-4N0M0 or T1-4N1M0 esophageal adenocarcinoma (AC) or squamous cell carcinoma (SCC) who were definitively treated with esophagectomy, with or without postoperative radiation, were selected. Kaplan-Meier and Cox regression analysis were used to compare OS and disease-specific survival (DSS). Results: A total of 1046 patients met the selection criteria: 683 (65.3%) received surgery alone and 363 (34.7%) received postoperative radiation. For American Joint Committee on Cancer stage III esophageal carcinoma (T3N1M0 or T4N0-1M0), there was significant improvement in median and 3-year OS (p < 0.001) and DSS (p < 0.001), respectively. This benefit was present for both SCC and AC. However, for American Joint Committee on Cancer stages IIA and IIB disease there was no significant differences in OS or DSS. Multivariate analysis revealed that postoperative radiation was the most significant predictor for improved OS (hazard ratio 0.70, 95% confidence interval 0.59–0.83, p < 0.001). Conclusions: This large population-based review supports the use of postoperative radiation for stage III SCC and AC of the esophagus. Given the retrospective nature of this study, until appropriately powered randomized trials confirm these results, caution should be used before broadly applying these findings in clinical practice.

Analysis of pathologic extent of disease for clinically localized prostate cancer after radical prostatectomy and subsequent use of adjuvant radiation in a national cohort.

The Surveillance, Epidemiology, and End Results database was analyzed to explore the pathologic extent of disease for clinically localized prostate cancer after radical prostatectomy as well as the use of adjuvant radiation in this population.

Impact of Adjuvant External-Beam Radiation Therapy in Early-Stage Uterine Papillary Serous and Clear Cell Carcinoma

PURPOSE Adjuvant radiation therapy (RT) in early-stage high- to intermediate-risk endometrioid adenocarcinoma is well established and has been shown to improve locoregional control. Its role in the management of early-stage clear cell carcinoma and uterine papillary serous carcinoma (UPSC) remains controversial. METHODS AND MATERIALS Using the Surveillance Epidemiology and End Results database, we identified women with American Joint Committee on Cancer Stage Sixth Edition. Stage IA-IIB clear cell carcinoma or UPSC who underwent hysterectomy with or without adjuvant RT between 1988 and 2003. We used Kaplan-Meier and Cox regression analysis to compare overall survival (OS) for all patients. RESULTS We identified 1,333 women of whom 451 had clear cell carcinoma and 882 had UPSC. Of those patients, 775 underwent surgery alone and 558 received adjuvant RT as well. For Stages I-IIB disease, the median OS with surgery alone was 106 months, vs. 151 months with adjuvant RT (p = 0.006). On subgroup analysis, we saw the benefit from adjuvant RT only in Stage IB-C patients. For Stage IB disease, patients undergoing surgery alone had a median OS of 117 months, vs. median survival not reached with the addition of RT (p = 0.006). For Stage IC disease, surgery alone had a median OS of 35 months vs. 120 months with RT (p = 0.001). Although the apparent benefit of RT diminished when measured via multivariate analysis, the impact of RT on survival did show a trend toward significance (hazard ration 0.808, confidence interval 95% 0.651-1.002, p = 0.052) CONCLUSION In FIGO Stage IB-C papillary serous and clear cell uterine carcinoma, adjuvant RT seems to play an important role in improving survival.

Complications of combined radical hysterectomy and pelvic radiation

Long-term gastrointestinal (GI) and urinary tract (UT) complications were evaluated in 48 women treated by radical hysterectomy (RH) and pelvic node dissection (PND) and in 25 women who received 5000-5400 rad of external pelvic radiation (RT) after RH-PND. No major complications developed in the surgery-only group, but the 5-year minor GI complication rate was 4% and the 5-year minor UT complication rate was 10%. In 9 patients receiving RT at 200 rad/day, one major GI complication (13%) and one major UT complication (14%) developed. In 16 patients receiving RT at 180 rad/day only minor GI complications (7%) and minor UT complications (13%) developed. The conclusion is that after RH-PND, adjunctive RT delivered at 180 rad/day through four ports results in acceptable, minimal complications.

Survival Following Sublobar Resection for Early-Stage Non-Small Cell Lung Cancer With or Without Adjuvant External Beam Radiation Therapy: A Population-Based Study

BACKGROUND Patients undergoing sublobar resection for early-stage non-small cell lung cancer may receive adjuvant radiation therapy in an effort to improve outcomes despite limited data regarding its efficacy. METHODS Using the Surveillance, Epidemiology, and End-Results (SEER) registry we identified patients diagnosed with stage I non-small cell lung cancer between 1988 and 2003 who were definitively treated with sublobar surgical resection with or without adjuvant external beam radiation therapy. Kaplan-Meier, Cox regression, and propensity-score-matched survival analyses were performed to evaluate the effect of adjuvant external beam radiation therapy on survival. RESULTS A total of 5,908 eligible cases were identified: 493 received external beam radiation therapy and 5,415 received no additional local-regional treatment. The use of external beam radiation therapy was associated with significantly worse median overall and disease-specific survival compared with no additional local-regional therapy: 31 and 45 months vs 51 and 98 months, respectively (P < .001). On multivariate analysis, the most significant predictor of death was the use of adjuvant radiation therapy (hazard ratio 1.505; 95% CI, 1.318-1.717; P < .001). The survival detriment associated with external beam radiation therapy remained after propensity-score-matched analysis. CONCLUSIONS The use of adjuvant external beam radiation therapy is associated with a significant decrease in overall and disease-specific survival for patients with T1-2N0M0 non-small cell lung cancer treated with sublobar resection. Although this finding may be related to covariables not reported in SEER, such as margin status, chemotherapy use, radiation dose, and portal, alternative radiation treatment strategies should be explored.

Utilization of adjuvant therapies and their impact on survival for women with stage IIIC endometrial adenocarcinoma

PURPOSE/OBJECTIVES Adjuvant treatment options following surgical staging for women with stage IIIC endometrial carcinoma include chemotherapy (CT) with or without radiation therapy (RT). We utilized the National Cancer Database (NCDB) to investigate utilization of adjuvant CT and RT for this group of patients and assess their impact on overall survival (OS). MATERIALS/METHODS The NCDB was queried for patients diagnosed with non-metastatic surgically staged uterine adenocarcinoma between 2004 and 2011 with at least one pathologically positive lymph node. Overall survival (OS) was analyzed using the Kaplan-Meier method. Comparison was made between patients receiving no additional therapy, RT alone, CT alone, or a combination of CT and RT (CMT). Multivariable cox regression analysis (MVA) was performed to evaluate the effect of covariates on OS. RESULTS A total of 6720 patients were included in this study. Of whom, 1409 received no adjuvant treatment, 1533 received CT only, 1265 received RT only, and 2522 received CMT. The 5-year OS for patients receiving no adjuvant therapy, RT alone, CT alone, and CMT were 54.9%, 63.9%, 64.4%, and 72.6%, respectively. On pairwise analysis, CMT was associated with improved survival compared to all other subgroups (p<0.001). On MVA, CMT (HR 0.58, 95% CI 0.52-0.66, p<0.001) was the strongest predictor for improved OS compared to RT alone (HR 0.79, 95% CI 0.69-0.89, p<0.001) or CT alone (HR 0.75, 95% CI 0.66-0.85, p<0.001). CONCLUSIONS Both adjuvant CT and adjuvant RT were associated with improved OS for women with stage IIIC endometrial adenocarcinoma, but CMT was associated with the largest improvement in OS.

Complications of combined surgery and radiation therapy for carcinoma of the endometrium

Long‐term gastrointestinal (GI) and urinary tract (UT) complications were evaluated in 133 women with carcinoma of the endometrium who were treated by both radiotherapy and hysterectomy. Major complications developed in 8% of patients who received external pelvic radiation but in none with intracavitary radiation. GI complications were more frequent and more severe in patients receiving external pelvic radiation than in those who received only intracavitary radiotherapy, irrespective of the sequence of treatment. UT complications were more frequent with prehysterectomy external radiotherapy (N = 39) than with posthysterectomy external radiotherapy (N = 21).

Stereotactic radiotherapy of the prostate: fractionation and utilization in the United States

Purpose To analyze the utilization and fractionation of extreme hypofractionation via stereotactic body radiotherapy (SBRT) in the treatment of prostate cancer. Materials and Methods Data was analyzed on men diagnosed with localized prostate cancer between 2004–2012 and treated with definitive-intent radiation therapy, as captured in the National Cancer Database. This database is a hospital-based registry that collects an estimated 70% of all diagnosed malignancies in the United States. Results There were 299,186 patients identified, of which 4,962 (1.7%) were identified as receiving SBRT as primary treatment. Of those men, 2,082 had low risk disease (42.0%), 2,201 had intermediate risk disease (44.4%), and 679 had high risk disease (13.7%). The relative utilization of SBRT increased from 0.1% in 2004 to 4.0% in 2012. Initially SBRT was more commonly used in academic programs, though as time progressed there was a shift to favor an increased absolute number of men treated in the community setting. Delivery of five separate treatments was the most commonly utilized fractionation pattern, with 4,635 patients (91.3%) receiving this number of treatments. The most common dosing pattern was 725 cGy × 5 fractions (49.6%) followed by 700 cGy × 5 fractions (21.3%). conclusions Extreme hypofractionation via SBRT is slowly increasing acceptance. Currently 700-725 cGy × 5 fractions appears to be the most commonly employed scheme. As further long-term data regarding the safety and efficacy emerges, the relative utilization of this modality is expected to continue to increase.

Patterns of adjuvant radiation usage and survival outcomes for stage I endometrial carcinoma in a large hospital-based cohort

OBJECTIVE Two randomized trials have demonstrated a local control advantage in the absence of a survival advantage for the addition of adjuvant radiation therapy (RT) to surgery in patients with stage I endometrial adenocarcinoma (EC). This study analyzed the National Cancer Data Base (NCDB) to evaluate the impact of adjuvant RT on overall survival (OS) for patients with stage I EC. METHODS Patients with EC who underwent total hysterectomy/bilateral salpingo-oophorectomy between 2004 and 2011 were queried. Only those with AJCC stage pT1N0M0 were included. Patients surviving <4months excluded. Adjuvant RT included external beam RT (EBRT), brachytherapy, or external RT+brachytherapy. OS was analyzed using the Kaplan-Meier method. Multivariate Cox regression analysis and propensity matched analysis were performed to assess the impact of covariates on OS. RESULTS There were 61,697 patients included. Most women (83.9%) did not receive adjuvant RT. Adjuvant RT usage increased with increasing stage/grade. Usage of brachytherapy alone decreased with increasing stage/grade (78.2% for IA/G1 to 36.1% for IB/G3) corresponding to an increase in the use of EBRT (21.8% for IA/G1 to 53.9% for IB/G3). On multivariable analysis, adjuvant EBRT (HR 0.83, 95%CI 0.74-0.93, p=0.002) and brachytherapy (HR 0.82, 95%CI 0.74-0.93, p=0.002) were each associated with improved survival for women with stage IB. In the propensity matched cohort, RT was associated with improved survival (0.85, 95% CI 0.78-0.92, p<0.001). CONCLUSION The use of adjuvant RT for women with stage I EC is highly dependent on stage/grade and is associated with improved survival for stage IB.