EFFECT OF REOPENING ORDERS ON COVID-19 HOSPITALIZATIONS IN THE US.

Shelter in place (SIP) orders were instituted by states to alleviate the impact of the COVID-19 pandemic. However, states proceeded to reopen as SIPs were noted to be hurting the economy. We evaluated whether these reopenings affected COVID-19 hospitalizations. We collected public data on US state reopening orders and COVID-19 hospitalizations from March 8 to August 8, 2020. We utilized a doubling time metric to compare increase in hospitalizations in line with reopenings and proceeded to quantify the impact of reopening orders on cumulative hospitalizations. We found that some reopenings increased hospitalizations, and this varied by state. We also discovered that the most negatively impactful reopenings overall tended to be restaurants/bars (-92%) and houses of worship (-63.6%). Without data-backed guidance on reopening states, the healthcare burden from COVID-19 will likely persist. State governments should use data to understand the potential effects of these reopenings to guide future policies.

Definitive Treatment of Early-Stage Non-Small Cell Lung Cancer with Stereotactic Ablative Body Radiotherapy in a Community Cancer Center Setting.

INTRODUCTION: Stereotactic ablative body radiotherapy (SABR) provides a superior non-small cell lung cancer (NSCLC) treatment option when compared to conventional radiotherapy for patients deemed inoperable or refusing surgery. This study retrospectively analyzed the rates of tumor control and toxicity following SABR treatment (Cyberknife system) of primary early-stage NSCLC in a community setting. METHODS: One hundred patients were treated between 2007 and 2011. Patients with T3-4 or N1-3 disease, metastasis, recurrent local disease, or a non-lung primary were excluded from analysis. All patients had biopsy proven disease. Staging included CT or fluorodeoxyglucose-positron emission tomography scan. Median dose was 54 Gy (45-60); 18 Gy (10-20) per fraction. Median planned target volume expansion was 8 mm (2-10). Median BED was 151.2. Tumors were tracked via Synchrony, X-Sight Lung, or X-Sight Spine. Patients were evaluated for local control, overall survival (OS), and toxicity. All local failures were determined by evaluating post treatment PET/CT. RESULTS: With a median follow up of 27.5 months, the 1-, 2-, and 3-year local control rates were 100, 93.55, and 84.33%, respectively. Median survival was 2.29 years; actuarial 3-year survival was 37.20%. Grade-3 toxicity was observed in 2% of patients (pneumonia within 2 months of treatment, n = 1; chronic pneumonitis requiring hospital admission, n = 1). No patients demonstrated toxicity above Grade-3. Multivariate analysis did not show T-stage as an independent predictor of OS, though it did trend toward significance. CONCLUSION: In a community-center setting, definitive treatment of NSCLC with SABR for non-surgical candidates and those who choose to forego surgery result in excellent and comparable rates of local control and toxicity compared to published series from large academic centers.

Salvage Fractionated Stereotactic Radiotherapy with or without Chemotherapy and Immunotherapy for Recurrent Glioblastoma Multiforme: A Single Institution Experience.

BACKGROUND: The current standard of care for salvage treatment of glioblastoma multiforme (GBM) is gross total resection and adjuvant chemoradiation for operable patients. Limited evidence exists to suggest that any particular treatment modality improves survival for recurrent GBM, especially if inoperable. We report our experience with fractionated stereotactic radiotherapy (fSRT) with and without chemo/immunotherapy, identifying prognostic factors associated with prolonged survival. METHODS: From 2007 to 2014, 19 patients between 29 and 78 years old (median 55) with recurrent GBM following resection and chemoradiation for their initial tumor, received 18-35 Gy (median 25) in three to five fractions via CyberKnife fSRT. Clinical target volume (CTV) ranged from 0.9 to 152 cc. Sixteen patients received adjuvant systemic therapy with bevacizumab (BEV), temozolomide (TMZ), anti-epidermal growth factor receptor (125)I-mAb 425, or some combination thereof. RESULTS: The median overall survival (OS) from date of recurrence was 8 months (2.5-61) and 5.3 months (0.6-58) from the end of fSRT. The OS at 6 and 12 months was 47 and 32%, respectively. Three of 19 patients were alive at the time of this review at 20, 49, and 58 months from completion of fSRT. Hazard ratios for survival indicated that patients with a frontal lobe tumor, adjuvant treatment with either BEV or TMZ, time to first recurrence >16 months, CTV <36 cc, recursive partitioning analysis <5, and Eastern Cooperative Oncology Group performance status <2 were all associated with improved survival (P < 0.05). There was no evidence of radionecrosis for any patient. CONCLUSION: Radiation Therapy Oncology Group (RTOG) 1205 will establish the role of re-irradiation for recurrent GBM, however our study suggests that CyberKnife with chemotherapy can be safely delivered, and is most effective in patients with smaller frontal lobe tumors, good performance status, or long interval from diagnosis.

SBRT: An Opportunity to Improve Quality of Life for Oligometastatic Prostate Cancer.

OBJECTIVE: Oligometastatic prostate cancer is a limited metastatic disease state in which potential long-term control is still possible with the use of targeted therapies such as surgery or stereotactic body radiation therapy (SBRT). SBRT may as well potentially prolong the time before the initiation of androgen deprivation therapy (ADT) and docetaxel chemotherapy for oligometastatic prostate cancer. The goal of this study is to outline prognostic factors associated with improved outcome with SBRT for metastatic prostate cancer and to quantify the effect of prior systemic treatments such as ADT and docetaxel on survival after SBRT. METHODS: Twenty-four prostate cancer patients were treated with SBRT at the Philadelphia CyberKnife Center between August 2007 and April 2014. Retrospective data collection and analysis were performed for these patients on this Institutional Review Board approved study. Kaplan-Meier methodology was utilized to estimate and visually assess overall survival (OS) at the patient level, with comparisons accomplished using the log-rank test. Unadjusted hazard ratios were estimated using Cox proportional hazards regression modeling. RESULTS: An improved median survival was noted for patients with oligometastatic disease defined as ≤4 lesions with median survival of >3 years compared with 11 months for polymetastases (p = 0.02). The use of docetaxel at some time in follow-up either before or after SBRT was associated with decreased survival with median survival of 9 months vs. >3 years (p = 0.01). CONCLUSION: Prognosis was better for men with recurrent prostate cancer treated with SBRT if they had ≤4 metastases (oligometastases) or if docetaxel was not necessary for salvage treatment. The prolonged median OS for men with oligometastases in this population of heavily pretreated prostate cancer patients following SBRT may allow for improved quality of life because of a delay of more toxic salvage therapies.

Twelve-month prostate-specific antigen values and perineural invasion as strong independent prognostic variables of long-term biochemical outcome after prostate seed brachytherapy.

PURPOSE: To determine whether post-treatment prostate-specific antigen (ptPSA) values at 12 months and other clinical parameters predict long-term PSA relapse-free survival (PRFS) following prostate seed brachytherapy. METHODS AND MATERIALS: Records of 204 hormone-naïve patients with localized adenocarcinoma of the prostate treated at St. Mary's Regional Medical Center in Reno, NV, and at Carson Tahoe Regional Medical Center in Carson City, NV, between 1998 and 2003, using I-125 or Pd-103 seed brachytherapy, were retrospectively analyzed. Treatment planning was done using a preplanned, modified peripheral loading technique. A total of 185 of 204 patients had PSA records at 12 months after implant. Variables included were age, initial pretreatment PSA, Gleason score, T stage, National Comprehensive Cancer Network (NCCN) risk group (RG), perineural invasion (PNI), external beam boost, dose, and ptPSA levels at 12 months with cutpoints at ≤1, 1.01 to 2.00, 2.01 to 3.00, and >3.00 ng/ml. RESULTS: Median follow-up was 80 months, and median age was 69 years. The numbers of patients stratified by NCCN low, intermediate, and high RG were 110:65:10, respectively. Monotherapy and boost prescription doses were 145 Gy and 110 Gy for I-125, and 125 Gy and 100 Gy for Pd-103 seeds, respectively. The median dose (D90) was 95.4% of the prescribed dose. The 5-year PRFS at the 12-months ptPSA levels of ≤1, 1.01 to 2.00, 2.01 to 3.00, and >3.00 ng/ml were 98.5%, 85.7%, 61.5%, and 22.2%, respectively. The 10-year PRFS at the 12-months ptPSA levels of ≤1 and 1.01 to 2.00 ng/ml were 90.5% and 85.7%, respectively. In multivariate analysis, both ptPSA and PNI were significant independent predictors of PRFS. Hazard ratios (HR) for ptPSA levels at ≤1, 1.01 to 2.00, 2.01 to 3.00, and >3.00 ng/ml at 12 months were 1, 4.96, 27.57, and 65.10, respectively. PNI had an HR of 6.1 (p=0.009). CONCLUSIONS: Presence of PNI and ptPSA values at 12 months are strong prognostic variables for long-term PRFS after definitive prostate brachytherapy seed implantation.

Acute toxicity after cyberknife-delivered hypofractionated radiotherapy for treatment of prostate cancer.

OBJECTIVE: To evaluate acute toxicity outcomes of prostate cancer patients treated with CyberKnife-delivered hypofractionated radiotherapy. METHODS: This study was a retrospective chart review analysis of the first 50 patients treated with CyberKnife radiotherapy for prostate cancer. Most patients were affected with early to intermediate stage prostate cancer. Two patients had metastatic disease at presentation and were excluded. A total of 37 patients received irradiation at a dose of 35 to 37.5 Gy in 5 fractions of 7 to 7.5 Gy per fraction. Assuming an alpha/beta ratio of 1.5 Gy, this process delivered an equivalent dose of 85 to 96 Gy in 2 Gy fractions (EQD2). A subset of patients (n = 11) received standard linear accelerator-based pelvic radiation treatment either by intensity modulated radiation therapy or tomotherapy and received a boost via the CyberKnife at a dose of 17.6 to 25 Gy in 2 to 5 fractions (EQD2= 46.6-72 Gy). The acute toxicities were recorded using the Common Terminology Criteria for Adverse Events, version 3.0, throughout treatment and at patients' follow-up visits. RESULTS: The median patient age at presentation was 66 years (range, 46-80). The mean pretreatment prostate specific antigen and Gleason scores were 9.16 ng/mL and 7, respectively. Grade 2 acute genitourinary toxicity was reported by 10% of patients (n = 5). Only 3 patients reported grade 3 acute genitourinary toxicity. No gastrointestinal grade 2 or grade 3 toxicities were reported. CONCLUSIONS: CyberKnife-delivered hypofractionated radiotherapy for the treatment of prostate cancer has an acceptable acute toxicity profile.