Shane Lloyd

Determinants and patterns of survival in adenoid cystic carcinoma of the head and neck, including an analysis of adjuvant radiation therapy.

Objectives: The effect of adjuvant radiation therapy (RT) on survival in patients with adenoid cystic carcinoma (ACC) is much debated. Studies with large numbers of patients and long follow-up are lacking in the literature. Methods: We identified 2286 single-primary ACCs of the head and neck treated with surgery in the National Cancer Institutes surveillance, epidemiology, and end results database. The determinants of survival, including the effect of adjuvant RT, were analyzed with a Cox Proportional Hazards Model. Results: The overall 5-, 10-, 15-, 20-, and 25-year survival rates for patients receiving surgical resection were 77.3%, 59.6%, 44.9%, 35.0%, 25.5%, respectively. In the interval between 10 and 30 years after diagnosis, 111 patients died of ACC, and 137 died of all competing causes combined. Increasing stage caused a decrease in survival that was proportional over time. On multivariable analysis, distant metastasis, lymph node involvement, higher T classification, increasing age, and submandibular gland, or sinus/nasal cavity subsites were each independently associated with decreased overall and cause-specific survival. Adjuvant RT failed to improve overall or cause-specific survival. Conclusions: Cause-specific survival continues to decline up to 30 years after diagnosis in ACC of the head and neck. In the interval between 10 and 30 years after diagnosis, patients are nearly as likely to die of ACC as from all competing causes combined. Certain clinicopathological factors are associated with decreased survival. There is no evidence of increased survival in patients receiving adjuvant RT.

A Prognostic Index for Predicting Lymph Node Metastasis in Minor Salivary Gland Cancer

PURPOSE Large studies examining the clinical and pathological factors associated with nodal metastasis in minor salivary gland cancer are lacking in the literature. METHODS AND MATERIALS Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified 2,667 minor salivary gland cancers with known lymph node status from 1988 to 2004. Univariate and multivariate analyses were conducted to identify factors associated with the use of neck dissection, the use of external beam radiation therapy, and the presence of cervical lymph node metastases. RESULTS Four hundred twenty-six (16.0%) patients had neck nodal involvement. Factors associated with neck nodal involvement on univariate analysis included increasing age, male sex, increasing tumor size, high tumor grade, T3-T4 stage, adenocarcinoma or mucoepidermoid carcinomas, and pharyngeal site of primary malignancy. On multivariate analysis, four statistically significant factors were identified, including male sex, T3-T4 stage, pharyngeal site of primary malignancy, and high-grade adenocarcinoma or high-grade mucoepidermoid carcinomas. The proportions (and 95% confidence intervals) of patients with lymph node involvement for those with 0, 1, 2, 3, and 4 of these prognostic factors were 0.02 (0.01-0.03), 0.09 (0.07-0.11), 0.17 (0.14-0.21), 0.41 (0.33-0.49), and 0.70 (0.54-0.85), respectively. Grade was a significant predictor of metastasis for adenocarcinoma and mucoepidermoid carcinoma but not for adenoid cystic carcinoma. CONCLUSIONS A prognostic index using the four clinicopathological factors listed here can effectively differentiate patients into risk groups of nodal metastasis. The precision of this index is subject to the limitations of SEER data and should be validated in further clinical studies.

Current strategies in chemoradiation for esophageal cancer.

Chemoradiotherapy (CRT) has an important role in the treatment of esophageal cancer in both the inoperable and the pre-operative settings. Pre-operative chemoradiation therapy is generally given to 41.4-50.4 Gy with platinum or paclitaxel based chemotherapy. The most common definitive dose in the U.S. is 50-50.4 Gy. New advances in CRT for esophageal cancer have come from looking for ways to minimize toxicity and maximize efficacy. Recent investigations for minimizing toxicity have focused advanced radiation techniques such as IMRT and proton therapy, have sought to further define normal tissue tolerances, and have examined the use of tighter fields with less elective clinical target volume coverage. Efforts to maximize efficacy have included the use of early positron emission tomography (PET) response directed therapy, molecularly targeted therapies, and the use of tumor markers that predict response.

A prospective, multicenter study of complementary/alternative medicine (CAM) utilization during definitive radiation for breast cancer.

PURPOSE Although complementary and alternative medicine (CAM) utilization in breast cancer patients is reported to be high, there are few data on CAM practices in breast patients specifically during radiation. This prospective, multi-institutional study was conducted to define CAM utilization in breast cancer during definitive radiation. MATERIALS/METHODS A validated CAM instrument with a self-skin assessment was administered to 360 Stage 0-III breast cancer patients from 5 centers during the last week of radiation. All data were analyzed to detect significant differences between users/nonusers. RESULTS CAM usage was reported in 54% of the study cohort (n=194/360). Of CAM users, 71% reported activity-based CAM (eg, Reiki, meditation), 26% topical CAM, and 45% oral CAM. Only 16% received advice/counseling from naturopathic/homeopathic/medical professionals before initiating CAM. CAM use significantly correlated with higher education level (P<.001), inversely correlated with concomitant hormone/radiation therapy use (P=.010), with a trend toward greater use in younger patients (P=.066). On multivariate analysis, level of education (OR: 6.821, 95% CI: 2.307-20.168, P<.001) and hormones/radiation therapy (OR: 0.573, 95% CI: 0.347-0.949, P=.031) independently predicted for CAM use. Significantly lower skin toxicity scores were reported in CAM users vs nonusers, respectively (mild: 34% vs 25%, severe: 17% vs 29%, P=.017). CONCLUSION This is the first prospective study to assess CAM practices in breast patients during radiation, with definition of these practices as the first step for future investigation of CAM/radiation interactions. These results should alert radiation oncologists that a large percentage of breast cancer patients use CAM during radiation without disclosure or consideration for potential interactions, and should encourage increased awareness, communication, and documentation of CAM practices in patients undergoing radiation treatment for breast cancer.

A comparison of three treatment strategies for locally advanced and borderline resectable pancreatic cancer

BACKGROUND The optimal treatment strategy for locally advanced and borderline resectable pancreatic cancer is not known. We compared overall survival (OS), local control (LC), metastasis free survival (MFS), and percent of patients who were able to undergo successful surgical resection for three treatment strategies. METHODS We retrospectively reviewed 115 sequentially treated cases of locally advanced (T4) or borderline resectable (T3 but unresectable) pancreatic cancer. Patients were treated with either chemotherapy alone (C), concurrent chemoradiation therapy (CRT), or chemotherapy followed by chemoradiation therapy (CCRT). We compared survival between groups using Kaplan-Meier analysis and Cox-proportional hazards models. RESULTS Median follow-up was 18.7 months. Fifty-six (49%) patients had locally advanced disease. Of the patients who received chemotherapy up-front, 82/92 (89%) received gemcitabine-based chemotherapy. Of the patients receiving C alone, 11/65 (17%) were diagnosed with distant metastases or died before 3 months. The rate of successful surgical resection was 6/50 (12%) in patients treated with radiation therapy (CRT or CCRT). Median survival times for patients undergoing C, CRT, and CCRT were 13.9, 12.5, and 21.5 months respectively. Patients treated with CCRT experienced statistically significant improved OS and MFS compared to C alone (P=0.003 and P=0.012 respectively). There was no difference in LC between treatment groups. On multivariable analysis younger age (P=0.009), borderline resectable disease (P=0.035), successful surgery (P=0.002), and receiving chemotherapy followed by chemoradiation therapy (P=0.035) were all associated with improved OS. CONCLUSIONS Treatment with CCRT is associated with improved median OS and MFS compared with C alone. This strategy may select for patients who are less likely to develop early metastases and therefore have a better prognosis.

Treatment-related determinants of survival in early-stage (T1-2N0M0) oral cavity cancer: A population-based study

National guidelines support both surgical and radiotherapy (RT) as initial treatment options for early‐stage oral cavity squamous cell carcinoma (SCC). There remains limited data evaluating the survival outcomes of RT and the current practice patterns for these lesions.

Increasing use of nonsurgical therapy in advanced-stage oral cavity cancer: A population-based study

National guidelines support surgical‐based treatment and offer nonsurgical therapy as an alternative for advanced‐stage oral cavity squamous cell carcinoma (SCC). There are limited data evaluating current utilization of these therapies and their survival outcomes.

ACR Appropriateness Criteria® external beam radiation therapy treatment planning for clinically localized prostate cancer, part I of II

Expert Panel on Radiation Oncology-Prostate: Nicholas G. Zaorsky MD , Timothy N. Showalter MD MPH *, Gary A. Ezzell PhD , Paul L. Nguyen MD , Dean G. Assimos MD , Anthony V. D’Amico MD PhD , Alexander R. Gottschalk MD PhD , Gary S. Gustafson MD , Sameer R. Keole MD , Stanley L. Liauw MD , Shane Lloyd MD , Patrick W. McLaughlin MD , Benjamin Movsas MD , Bradley R. Prestidge MD MS , Al V. Taira MD , Neha Vapiwala MD , Brian J. Davis MD PhD q

Increased risk of death due to heart disease after radiotherapy for esophageal cancer

OBJECTIVE To evaluate the risk of heart disease related death (HDRD) following radiation therapy (RT) for esophageal cancer (EC). METHODS Using the Surveillance, Epidemiology, and End Results (SEER) database, two cohorts of patients with EC were created: (I) patients who received RT with their initial therapy; and (II) those who did not. Heart disease specific survival (HDSS) was analyzed using Kaplan-Meier methods. Cox proportional-hazards regression methods were used for univariate and multivariate analyses. RESULTS We identified 40,778 patients with EC. A total of 26,377 patients received RT and 14,401 did not. HDSS analysis revealed increased risk of HDRD in those receiving RT (P<0.05), with an absolute risk of HDRD of 2.8%, 5.3% and 9.4% at 5-, 10- and 20-year, respectively. Log rank test of HDSS revealed the risk of HDRD became significant at 8 months (P<0.05). The following were associated with HDRD: RT, age, race, stage at presentation, time period of diagnosis, and known comorbid condition keeping one from esophagectomy. On multivariate analysis, RT remained predictive of HDRD [hazard ratio (HR) 1.46, P<0.05]. When considering only candidates for definitive therapy, RT remained predictive of HDRD on univariate (HR 1.53, P<0.0001) and multivariate (HR 1.62, P<0.0001) analyses. CONCLUSIONS The use of RT leads to increased risk of HDRD that is detectable as early as eight months from diagnosis. More research is needed to define optimal dose volume parameters to prevent cardiac death. Consideration should be given to this risk in relation to prognosis and the expected benefits of RT.

Multiagent induction chemotherapy followed by chemoradiation is associated with improved survival in locally advanced pancreatic cancer

The role of chemoradiotherapy (CRT) in locally advanced pancreatic cancer (LAPC) is uncertain after multiple randomized clinical trials have yielded mixed results. The authors used the National Cancer Data Base (NCDB) to determine whether CRT yields a survival benefit compared with chemotherapy alone (CT).