Dosimetric and radiobiologic comparison of 3D conformal versus intensity modulated planning techniques for prostate bed radiotherapy.

Adjuvant radiotherapy for locally advanced prostate cancer improves biochemical and clinical disease-free survival. While comparisons in intact prostate cancer show a benefit for intensity modulated radiation therapy (IMRT) over 3D conformal planning, this has not been studied for post-prostatectomy radiotherapy (RT). This study compares normal tissue and target dosimetry and radiobiological modeling of IMRT vs. 3D conformal planning in the postoperative setting. 3D conformal plans were designed for 15 patients who had been treated with IMRT planning for salvage post-prostatectomy RT. The same computed tomography (CT) and target/normal structure contours, as well as prescription dose, was used for both IMRT and 3D plans. Normal tissue complication probabilities (NTCPs) were calculated based on the dose given to the bladder and rectum by both plans. Dose-volume histogram and NTCP data were compared by paired t-test. Bladder and rectal sparing were improved with IMRT planning compared to 3D conformal planning. The volume of the bladder receiving at least 75% (V75) and 50% (V50) of the dose was significantly reduced by 28% and 17%, respectively (p = 0.002 and 0.037). Rectal dose was similarly reduced, V75 by 33% and V50 by 17% (p = 0.001 and 0.004). While there was no difference in the volume of rectum receiving at least 65 Gy (V65), IMRT planning significant reduced the volume receiving 40 Gy or more (V40, p = 0.009). Bladder V40 and V65 were not significantly different between planning modalities. Despite these dosimetric differences, there was no significant difference in the NTCP for either bladder or rectal injury. IMRT planning reduces the volume of bladder and rectum receiving high doses during post-prostatectomy RT. Because of relatively low doses given to the bladder and rectum, there was no statistically significant improvement in NTCP between the 3D conformal and IMRT plans.

Synopsis of history of American Society for Therapeutic Radiology and Oncology 1958-2008.

PURPOSE: To provide a synopsis of the history of the association of radiation oncologists in the United States, currently known as the American Society for Therapeutic Radiology and Oncology (ASTRO), with the occasion of the 50th anniversary of the organization. METHODS AND MATERIALS: The history of ASTRO, from its beginning as the American Club of Therapeutic Radiologists, is the subject of a book that is to be released with the occasion of the 50th Annual Meeting of the Society in 2008. This book was prepared by members of ASTRO's History Committee and History Working Subcommittee. The source material for the book was the archives of the Society and recorded interviews, conducted by members of the subcommittee, of members of the Society and of the past and present Society staff. The book was also based on previously published material. This article used the source material used for the Society anniversary book. RESULTS: This synopsis of the history of the Society will provide a source of reference for anyone interested in the history of the Society from its foundation in 1958 to the present, 2008.

Predictors of severe gastrointestinal toxicity after external beam radiotherapy and interstitial brachytherapy for advanced or recurrent gynecologic malignancies.

PURPOSE: The aim of this retrospective review of patients with gynecologic malignancies treated with external beam radiotherapy (EBRT) and interstitial brachytherapy was to determine the rate of Grade > or =2 rectovaginal fistula and Grade > or =4 small bowel obstruction as defined by the National Cancer Institute Common Toxicity Criteria for Adverse Events, version 3.0. METHODS AND MATERIALS: Thirty-six patients with primary and recurrent gynecologic cancers were treated with EBRT and interstitial brachytherapy. Median doses to tumor, bladder, and rectum were 75 Gy, 61 Gy, and 61 Gy, respectively. A univariate analysis was performed to identify variables that correlated with toxicity. RESULTS: At median follow-up of 19 months, the 3-year risk of small bowel obstruction was 6%. Those patients with prior abdomino-pelvic surgery who received EBRT with antero-posterior fields had higher rates of obstruction than patients without prior abdomino-pelvic surgery or those who received EBRT with four fields (50% vs. 0%, p < 0.0001). The 3-year risk of rectovaginal fistula was 18% and was significantly higher in patients who received >76 Gy to the rectum compared with those who received < or =76 Gy (100% vs. 7%, p = 0.009). CONCLUSIONS: Patients treated with EBRT and interstitial brachytherapy after abdomino-pelvic surgery should receive EBRT with four fields and the cumulative rectal dose should be < or =76 Gy.

Impact of a multidisciplinary thoracic oncology clinic on the timeliness of care.

BACKGROUND: Multidisciplinary clinics have been recommended for the evaluation of patients with lung cancer. Evidence to support this recommendation, however, is limited. A single-center, retrospective review of lung cancer patients at a Veterans Affairs hospital was performed comparing timeliness of diagnostic and treatment decisions during the operation of a multidisciplinary thoracic oncology clinic (MTOC) with a period after it closed (non-MTOC), during which only a weekly multidisciplinary conference was held. METHODS: Patients were identified from a tumor registry. Manual chart reviews were performed on all patients. Outcome measures included time from initial presentation to diagnosis (TTD) and time from diagnosis to treatment initiation (TTT). RESULTS: Three hundred forty-five patients (244 in MTOC, 101 in non-MTOC) diagnosed with lung cancer between 1999 and 2003 were included in the study. Baseline characteristics were similar between the two groups. Median TTD was 48 days (95% confidence interval [CI]: 37-61) and 47 days (95% CI: 39-55) in the MTOC (n = 164) and non-MTOC cohorts (n = 89), respectively (p = 0.09). Median TTT was 22 days (95% CI: 20-27) and 23 days (95% CI: 20-34) in the MTOC (n = 165) and non-MTOC cohorts (n = 89), respectively (p = 0.71). There was no difference in overall survival. CONCLUSION: Retrospective comparison of sequential cohorts failed to reveal benefit in the timeliness of care measures during the time period of MTOC operation. Potential confounders include the absence of a surgeon in the MTOC setting, an ongoing weekly multidisciplinary conference in the non-MTOC cohort, and existing infrastructures based on previous MTOC experiences and past provider experience. Confirmation of these findings in other health care settings is warranted, preferably in a prospective fashion.

The association between oral health and general health and quality of life in older male cancer patients.

OBJECTIVES: To describe the long-term effects of oral health problems on quality of life (QoL), functional status, pain, and general health in older male cancer patients. DESIGN: Secondary analysis of a prospective observational study. SETTING: Community dwelling cancer patients served by a Department of Veterans Affairs hospital. PARTICIPANTS: One hundred fifty male cancer patients responded to the question "Do you have tooth or mouth problems making it hard to eat?" The relationship between patients answering "yes" and the following parameters was assessed: demographics, comorbid conditions, habits, activities of daily living, pain, anxiety, depression, social support, spirituality, QoL, and overall health ratings. MEASUREMENTS: Chi-square contingency tables for dichotomous variables, Cochran-Mantel-Haenszel for ordered categorical variables, and t tests for associations with continuous variables. RESULTS: The median age of respondents was 67. Those reporting tooth or mouth problems had had their cancer diagnosed on average 2.9 years before, and 83.3% were found clinically to be cancer free. Patients with these problems had significantly lower global (P=.003) and subscale scores on QoL analysis and higher levels of anxiety (P<.001) and depression (P=.01) than those without tooth or mouth problems; they also had significantly more pain (P<.001) and lower physical functioning (P<.001) and were more impaired in activities of daily living (P<.001). Those with tooth or mouth problems were more likely to describe their overall health as fair or poor (P=.01). Having cancer located in the head and neck region related significantly to having mouth or tooth problems (P=.005), but these problems were not associated with race, education, income, insurance coverage, age, comorbid conditions, alcohol consumption, tobacco or medication usage, type of cancer treatment, tumor stage at diagnosis or follow-up, perceived social support, or spirituality. CONCLUSION: Older male cancer patients with mouth or tooth problems making it hard to eat are more likely to have a lower QoL, poorer emotional health, lower levels of physical functioning, and greater pain than patients without these problems.

Carcinoma of the vulva: combined modality treatment.

One of the most significant developments in recent decades in the management of malignant diseases is the recognition that surgery, radiation, and chemotherapy have limited curative potential. Along with this recognition has come the realization that although some patients can be cured with one of these modalities alone, the judicious combination of these modalities can result in better outcome. Carcinoma of the vulva, a disease that presents challenges with its management because of its anatomic location, affinity for spread to the lymph nodes, and incidence in elderly patients, lends itself to the use of this multimodality approach. The specific purpose of this approach is to decrease the sequelae of radical surgery. In addition, patients that could not be considered candidates for any treatment, such as patients with unresectable nodes, can be offered therapy with potential of cure. The patients with moderately or very advanced disease should be considered for the combination of chemotherapy, radiation, and surgery. This combined therapy results in better outcome with lesser morbidity. The studies that have been carried out in recent years for patients with advanced carcinoma of the vulva have helped to establish treatment guidelines that can be followed with confidence until more information becomes available.

Gastrointestinal toxicity of transperineal interstitial prostate brachytherapy.

PURPOSE: To characterize the severity and time course of rectal toxicity following transperineal prostate brachytherapy using prospectively recorded data, and to determine factors associated with toxicity. METHODS AND MATERIALS: One hundred thirty-four patients with prostate cancer treated with transperineal brachytherapy from 1997 to 1999 had rectal toxicity data available for analysis. Patients with Gleason score (GS) > 6, prostate-specific antigen (PSA) > 6, or stage > T2a were treated initially with external beam radiation therapy followed by brachytherapy boost; patients with none of these features were treated with brachytherapy alone. Both iodine-125 and palladium-103 sources were used, and loaded according to a modified Quimby distribution. At each follow-up, toxicity was recorded according to a modified RTOG gastrointestinal scale. RESULTS: Thirty-nine percent of patients experienced gastrointestinal toxicity, mostly Grade 1. Median duration of symptoms was 6 months. Two patients experienced Grade 3 toxicity, both of whom had minimal symptoms until their 12-month follow-up. There was no Grade 4 or 5 toxicity. The addition of external beam radiation therapy (p = 0.003), higher clinical stage (p = 0.006), and Caucasian race (p = 0.01) were associated with increased incidence of toxicity. CONCLUSION: Most patients with rectal toxicity have very mild symptoms. There is a small risk of severe late toxicity. External beam radiation, higher stage, and race are associated with toxicity.

Comprehensive assessment of the elderly cancer patient: the feasibility of self-report methodology.

PURPOSE: Comprehensive geriatric assessment (CGA) has aided the medical community greatly in understanding the quality-of-life issues and functional needs of older patients. With its professional team assessment approach, however, CGA may be time consuming and costly. The goal of the present study was to assess the ability of cancer patients to complete a self-administered CGA and then to characterize cancer patients across multiple domains and age groups. PATIENTS AND METHODS: Two hundred sixty-six male outpatient oncology patients at the Durham Veterans Affairs Medical Center were asked to fill out a survey assessing 10 domains (demographics, comorbid conditions, activities of daily living, functional status, pain, financial well being, social support, emotional state, spiritual well-being, and quality of life). RESULTS: Seventy-six percent of the patients who received their surveys and kept their appointments returned the assessment tool. Older oncology patients had significantly less education (P <.0001), income (P =.05), frequent exercise (P =.01), and chance of being disease free (P =.003) than younger patients. Other findings in older patients were a higher rate of marriage (P =.02), more difficulty in taking medications (P =.05), and less cigarette (P =.03) and alcohol (P =.03) use. Members of all age cohorts reported a sense of social support, with younger patients deriving this more from family and friends than older patients, and older patients deriving social support more from membership in religious communities than younger patients. No differences were found across age groups for number and impact of comorbid illnesses, number of medications, basic and instrumental activities of daily living, pain, overall health rating, financial adequacy, anxiety, depression, and quality of life. CONCLUSION: CGA can be conducted in an outpatient cancer community using a self-report format. Despite the fact that this population varied demographically across age groups and is limited to veterans, this study demonstrated remarkable similarities between younger and older cancer patients in terms of functional status, health states, and quality of life.