Proton radiotherapy and treatment delay in head and neck squamous cell carcinoma.

OBJECTIVE: For patients with head and neck squamous cell carcinoma (HNSCC), delays in the initiation of radiotherapy (RT) have been closely associated with worse outcomes. We sought to investigate whether RT modality (proton vs. photon) is associated with differences in the time to initiation of RT. METHODS: The National Cancer Database was queried for patients diagnosed with nonmetastatic HNSCC between 2004 and 2015 who received either proton or photon RT as part of their initial treatment. Wilcoxon rank-sum and chi-square tests were used to compare continuous and categorical variables, respectively. Multivariable logistic regression was used to determine the association between use of proton RT and delayed RT initiation. RESULTS: A total of 175,088 patients with HNSCC receiving either photon or proton RT were identified. Patients receiving proton RT were more likely to be white, reside in higher income areas, and have private insurance. Proton RT was associated with delayed RT initiation compared to photon RT (median 59 days vs. 45, P < 0.001). Receipt of proton therapy was independently associated with RT initiation beyond 6 weeks after diagnosis (adjusted OR [aOR, definitive RT] = 1.69; 95% confidence interval [CI] 1.26-2.30) or surgery (aOR [adjuvant RT] = 4.08; 95% CI 2.64-6.62). In the context of adjuvant proton RT, increases in treatment delay were associated with worse overall survival (weeks, adjusted hazard ratio = 1.099, 95% CI 1.011-1.194). CONCLUSION: Use of proton therapy is associated with delayed RT in both the definitive and adjuvant settings for patients with HNSCC and could be associated with poorer outcomes. LEVEL OF EVIDENCE: 2b Laryngoscope, 122:0000-0000, 2019 Laryngoscope, 130:E598-E604, 2020.

Patient Perspectives on the Ethical Implementation of a Rapid Learning System for Oncology Care.

INTRODUCTION: A rapid learning system (RLS) of health care harnesses data generated from routine patient care to create a virtuous cycle of data collection and analysis for quality improvement and research. The success of such systems depends on understanding patient perspectives regarding the ethical issues that arise from the ongoing implementation of this transformative concept. METHODS: An interview guide was designed to evaluate patient perspectives to inform the ethical implementation of an oncology RLS. A purposively selected, diverse sample of 32 patients with cancer was recruited from two institutions to participate in semistructured, in-depth interviews for formal qualitative analysis. RESULTS: The extent to which respondents expressed discomfort with more permissive system features (less formal notification/consent, broader uses/users, inclusion of sensitive data) reflected their trust, which in turn seemed to vary by sociodemographic features. It was also influenced by their familiarity with technology and their attitudes and beliefs regarding privacy and the use of electronic medical records more generally. Distrust of insurers and the pharmaceutical industry led subjects to desire greater oversight and restriction of these potential users of the system. Subjects were most comfortable when doctors were the primary users, engaged patients directly in the notification and consent discussion, and oversaw the system. CONCLUSION: Those actively developing RLSs should recognize the critical importance of trust and the key role that doctors will need to play in order for such systems to be successful and to ensure that their implementation is ethically palatable to the patients whose data are being included.

Calcified brainstem cavernoma in a patient with hundreds of intracranial cavernomas.

INTRODUCTION: Unexpected identification of hundreds of lesions on intracranial imaging can be a disconcerting discovery, but familiarity with the possible etiologies of such a finding may help guide further evaluation. We present a case report and literature review of multiple intracranial cavernous hemangiomas. CASE REPORT: A 67-year-old non-Hispanic white man developed the sudden onset of painless right-sided hearing loss in August 2006. Magnetic resonance imaging (MRI) of the brain revealed a lesion in the left lateral pontomesencephalic junction with mixed T1-weighted and decreased T2-weighted signal without mass effect or contrast enhancement. There were numerous additional lesions with low T2 signal involving both the cerebellum and the bilateral cerebral hemispheres. In January 2008, further imaging studies, including gradient-echo MRI, were obtained to assess for additional interval changes in the appearance of the intracranial lesions. Results of the patient's current and previous studies were considered most consistent with a clinical and imaging diagnosis of multiple cavernous hemangiomas. CONCLUSION: For patients with numerous intracranial lesions, such as those found in cases of multiple cavernous hemangiomas, the use of susceptibility-weighted or gradient-echo MRI can be useful for arriving at an appropriate differential diagnosis and to help guide proper management.