Pascal Lambert

Prospective swallowing outcomes after IMRT for oropharyngeal cancer: Dosimetric correlations in a population-based cohort

OBJECTIVES To identify dose constraints to preserve swallowing after head and neck (H&N) radiotherapy using prospectively collected functional outcomes. MATERIALS AND METHODS Stage III-IV oropharyngeal cancer patients were prospectively evaluated using the Royal Brisbane Hospital Outcome Measure for Swallowing and Performance Status Scale for H&N Cancer Patients at pre-treatment and 3, 6, 12, and 24months after intensity-modulated radiotherapy. Dosimetric parameters were correlated with swallowing function. RESULTS Ninety-six patients were evaluated with median follow-up of 14.1months (interquartile range 9.9-26.3). Six patients (8.3%) remained feeding tube (FT) dependent at 12months. At 2years, 32.6% tolerated a normal diet without restrictions. Mean doses of 55Gy to supraglottic larynx, 44Gy to glottic larynx, 48Gy to cricopharyngeus, and 44Gy to esophageal inlet were associated with >25% risk of FT dependence at 6months. CONCLUSION Higher mean doses to the larynx and pharyngo-esophageal junction were associated with longer duration of FT dependence and dietary restrictions.

Extended adjuvant temozolomide with cis-retinoic acid for adult glioblastoma

OBJECTIVE To determine the toxicity and effectiveness of 24 months of adjuvant temozolomide (tmz) with cis-retinoic acid (cra) for patients with glioblastoma. METHODS This retrospective population-based review considered the charts of all patients diagnosed with glioblastoma in Manitoba and referred to a provincial cancer centre during 2002-2008. Consecutive patients came from a population-based referral centre and provincial cancer registry. All patients were treated according to the local standard of care with surgical resection followed by concurrent radiotherapy and tmz 75 mg/m(2) daily, followed by tmz 150-200 mg/m(2) for days 1-5, repeated every 28 days for up to 24 cycles, and cra 50 mg/m(2) twice daily for days 1-21, repeated every 28 days. The main outcome measures were safety, tolerability, and effectiveness of long-term tmz and cra. RESULTS Of 247 patients diagnosed with glioblastoma in Manitoba during the study period, 116 started concurrent chemoradiotherapy, and 80 received adjuvant tmz. Of the patients who started concurrent chemoradiotherapy, 80 began adjuvant chemotherapy. Patients completed a median of 5.5 cycles of tmz and 3 cycles of cra. Grade 3 or 4 hematologic toxicity was noted in 16% of patients. Median overall survival was 15.1 months, and 26.7% of patients remained alive at 2 years. CONCLUSIONS Extended adjuvant tmz and cra is well tolerated. However, the population-based effectiveness of this regimen is similar to the clinical trial efficacy of 6 months of adjuvant tmz. Future studies in glioblastoma should incorporate duration of adjuvant chemotherapy into the study design.

The impact of fellowship training on pathological outcomes following radical prostatectomy: a population based analysis

BackgroundRadical prostatectomy (RP) is a common treatment for prostate cancer (PCa). Morbidity, mortality and pathological outcomes may be superior in academic institutions. One explanation may be the involvement of oncology fellowship trained urologists within academic institutions. The literature examining pathological outcomes often lacks individual surgeon data. The objective of this study was to compare pathological outcomes following RP between fellowship trained and non-fellowship trained urologists.MethodsPopulation-based, retrospective chart review of men diagnosed with PCa between 2003 and 2008, the majority treated with open approach RP (>99%). Pathological outcomes were compared between oncology fellowship trained academic (FTA), non-fellowship trained academic (NFTA) and non-academic (NA) urologists. Relationships with pathological outcomes were examined utilizing multivariable logistic regression.Results83.1% of eligible patients were included in our analysis resulting in 1075 patients. In multivariable analysis, surgeon group was an independent predictor of positive surgical margin (PSM) (p < 0.0001). NFTA and NA urologists were more likely to have PSM compared to FTA urologists (OR 2.50; 95% CI: 1.44 - 4.35 and OR 2.10; 95% CI: 1.53 - 2.88, respectively). However, the proportion of PSM between NFTA and NA urologists was not significant (p = 0.492). In addition, pathological stage (p = 0.0004), Gleason sum (p < 0.0001), and surgeon volume (p = 0.017) were associated with PSM. Limitations include retrospective design and lack of clinical and functional outcomes.ConclusionsUro-oncology fellowship trained surgeons had significantly lower rates of PSM than non-fellowship trained surgeons in this population based cohort. This study demonstrates the importance of surgeon-related variables on pathological outcomes and highlights the value of additional urologic oncology fellowship training.

Impact of Feeding Tubes on Prospective Functional Outcomes in Patients With Locally-Advanced Head-and-Neck Cancer Undergoing Radiation Therapy

PURPOSE The optimal timing of enteral feeding tube (FT) insertion during radiation therapy for head and neck cancer remains controversial. This study compares prospectively collected functional outcomes for prophylactic versus reactive insertion. METHODS AND MATERIALS Patients undergoing primary radiation therapy for stage III-IV head and neck cancer between 2004 and 2009 underwent functional outcome assessment at baseline and 3, 6, 12, 24, and 36 months posttreatment. Instruments included the Royal Brisbane Hospital Outcome Measure for Swallowing, Performance Status Scale for Head and Neck Cancer Patients, and modified Edmonton Symptom Assessment Scale. Multivariable regression analysis was conducted to determine the impact of FT use on functional outcomes. RESULTS A total of 178 patients were assessed with a median follow-up of 36.4 months. Use of an FT was prophylactic in 92 and reactive in 24; no tube was used in 62 patients. Compared with prophylactic placement, reactive FT use was not associated with worse function for Performance Status Scale for Head and Neck Cancer Patients Normalcy of Diet for soft foods (adjusted odds ratio [AOR] 1.16, P = .85) or Eating in Public (AOR 1.87, P = .31). Similarly, there were no differences in the Royal Brisbane Hospital Outcome Measure for Swallowing for modified diet (AOR 1.27, P = .7) or FT dependence (AOR 3.01, P = .2). CONCLUSIONS There were no significant differences in long-term swallowing function between patients who received a prophylactic versus reactive FT.

Patterns of referral for adjuvant radiotherapy after radical prostatectomy in men with prostate cancer: A population-based analysis.

140 Background: Randomized trials have shown improved biochemical disease free survival after adjuvant radiotherapy (ART) in patients with pT3 or margin positive disease after radical prostatectomy for prostate cancer. This study examines the rates of referral to a radiation oncologist for patients with high risk pathologic features after prostatectomy. Also, the impact of the presentation of these randomized trials will be examined. METHODS All men diagnosed in the province of Manitoba with prostate adenocarcinoma between 2003 and 2008 who underwent radical prostatectomy were identified through a central cancer registry database. Manual chart review was performed and detailed demographic and clinico-pathologic data were analyzed to determine their influence on referral to a radiation oncologist within 6 months of surgery. Analysis of referral rates before and after the presentation of 2 randomized trials were also examined. RESULTS A total of 1080 patient records of men undergoing prostatectomy for prostate cancer were reviewed. Of these, 546 (50.6%) men had at least one high risk pathologic feature. This includes pT2 margin positive disease in 298/546 (54.6%), pT3a in 154/546 (28.2%), and pT3b in 94/546 (17.2%). Multivariable logistic regression was performed adjusting for age, distance from cancer centre, Gleason score, T stage, perineural invasion, and margin status. Gleason score 8-10 (p<0.0001), higher pathologic T stage (p<0.0001), and farther distance (p=0.0028) were associated with referral for ART. Age and margin status were not significantly associated. Men with pT3a (odds ratio 3.35) and pT3b disease (odds ratio 5.32) were more likely to be referred than pT2 margin positive disease (p<0.0001). There were 78/546 (14.3%) patients with a high risk factor who were referred for ART within 6 months of surgery. The rates of referral were not significantly different before and after the presentation of randomized trials (p=0.60). CONCLUSIONS Men with higher pathologic stage (pT3) and grade (Gleason 8-10) are more likely to receive ART. However, referral for ART did not increase significantly after presentation of the randomized trials and remains underutilized.