Changing the Physical Activity Behavior of Adults With Fitness Trackers: A Systematic Review and Meta-Analysis.

OBJECTIVE: To examine whether a fitness tracker (FT) intervention changes physical activity (PA) behavior compared to a control condition or compared to an alternative intervention. DATA SOURCE: Searches between January 01, 2010, and January 01, 2019, were conducted in PubMed, CINAHL, Cochrane CENTRAL, EMBASE, and PsycINFO. INCLUSION/EXCLUSION CRITERIA: Randomized clinical trials of adults using an FT to change PA behavior were included. Nonclinical trials, studies that included the delivery of structured exercise, and/or studies that only used the FT to assess PA were excluded. DATA EXTRACTION: Extracted features included characteristics of the study population, intervention components, PA outcomes, and results. DATA SYNTHESIS: Papers were pooled in a statistical meta-analysis using a fixed effects model. Where statistical pooling was not possible, standardized mean difference (SMD) and 95% confidence intervals (CI) were calculated. Findings were presented in a narrative form and tables. RESULTS: Of 2076 articles found, 21 were included in the review. A small yet significant positive effect (SMD = 0.25, 95% CI = 0.17-0.32; P < .01; I2 = 56.9%; P = .03) was found in step count for interventions compared to control. A small yet significant negative effect (SMD = -0.11, 95% CI = -0.20 to -0.02; P = .02; I2 = 58.2%; P = 0.03) was found in moderate-to-vigorous PA for interventions compared to an alternative intervention. CONCLUSION: Trackers may enhance PA interventions, as a general positive effect is found in step count compared to a control. However, there is no evidence of a positive effect when interventions are compared to an alternative intervention. It is unknown whether results are due to other intervention components and/or clinical heterogeneity.

Clinical implementation of tangential field intensity modulated radiation therapy (IMRT) using sliding window technique and dosimetric comparison with 3D conformal therapy (3DCRT) in breast cancer.

The purpose of this study was to evaluate the clinical implementation of tangential field IMRT using sliding window technique and to compare dosimetric parameters with 3-dimensional conformal radiation therapy (3DCRT). Twenty breast cancer patients were randomly selected for comparison of intensity modulated radiation therapy (IMRT)-based treatment plan with 3DCRT. Inverse treatment was performed using the sliding window technique, employing the Eclipse Planning System (version 7.1.59, Varian, Palo Alto, CA). The dosimetric parameters compared were V(95) (the percentage of target volume getting > or =95% of prescribed dose), V(105), V(110), and dose homogeneity index, DHI (percentage of target volume getting between 95% and 110% of prescribed dose). The mean V(95), DHI, V(105), and V(110) for target volume for IMRT vs. 3D were 90.6% (standard deviation [SD]: 3.2) vs. 91% (SD: 3.0), 87.7 (SD: 6.0) vs. 82.6 (SD: 7.8), 27.3% (SD: 20.3) vs. 49.4% (SD: 14.3), and 2.8 (SD: 5.6) vs. 8.4% (SD: 7.4), respectively. DHI was increased by 6.3% with IMRT compared to 3DCRT (p < 0.05). The reductions of V(105) and V(110) for the IMRT compared to 3DCRT were 44.7% and 66.3%, respectively (p < 0.01). The mean dose and V(30) for heart with IMRT were 2.3 (SD: 1.1) and 1.05 (SD: 1.5) respectively, which was a reduction by 6.8% and 7.9%, respectively, in comparison with 3D. Similarly, the mean dose and V(20) for the ipsilateral lung and the percentage of volume of contralateral volume lung receiving > 5% of prescribed dose with IMRT were reduced by 9.9%, 2.2%, and 35%, respectively. The mean of total monitor units used for IMRT and 3DCRT was about the same (397 vs. 387). The tangential field IMRT for intact breast using sliding window technique was successfully implemented in the clinic. We have now treated more than 1000 breast cancer patients with this technique. The dosimetric data suggest improved dose homogeneity in the breast and reduction in the dose to lung and heart for IMRT treatments, which may be of clinical value in potentially contributing to improved cosmetic results and reduced late treatment-related toxicity.

Treatment techniques for 3D conformal radiation to breast and chest wall including the internal mammary chain.

Breast, chest wall, and regional nodal irradiation have been associated with an improved outcome in high-risk breast cancer patients. Complex treatment planning is often utilized to ensure complete coverage of the target volume while minimizing the dose to surrounding normal tissues. The 2 techniques evaluated in this report are the partially wide tangent fields (PWTFs) and the 4-field photon/electron combination (the modified "Kuske Technique"). These 2 techniques were evaluated in 10 consecutive breast cancer patients. All patients had computerized tomographic (CT) scans for 3D planning supine on a breast board. The breast was defined clinically by the physician and confirmed radiographically with radiopaque bebes. The resulting dose-volume histograms (DVHs) of normal and target tissues were then compared. The deep tangent field with blocks resulted in optimal coverage of the target and the upper internal mammary chain (IMC) while sparing of critical and nontarget tissues. The wide tangent technique required less treatment planning and delivery time. We compared the 2 techniques and their resultant DVHs and feasibility in a busy clinic.

Early clinical outcome with concurrent chemotherapy and extended-field, intensity-modulated radiotherapy for cervical cancer.

PURPOSE: To assess the early clinical outcomes with concurrent cisplatin and extended-field intensity-modulated radiotherapy (EF-IMRT) for carcinoma of the cervix. METHODS AND MATERIALS: Thirty-six patients with Stage IB2-IVA cervical cancer treated with EF-IMRT were evaluated. The pelvic lymph nodes were involved in 19 patients, and of these 19 patients, 10 also had para-aortic nodal disease. The treatment volume included the cervix, uterus, parametria, presacral space, upper vagina, and pelvic, common iliac, and para-aortic nodes to the superior border of L1. Patients were assessed for acute toxicities according to the National Cancer Institute Common Toxicity Criteria for Adverse Events, version 3.0. All late toxicities were scored with the Radiation Therapy Oncology Group late toxicity score. RESULTS: All patients completed the prescribed course of EF-IMRT. All but 2 patients received brachytherapy. Median length of treatment was 53 days. The median follow-up was 18 months. Acute Grade > or = 3 gastrointestinal, genitourinary, and myelotoxicity were seen in 1, 1, and 10 patients, respectively. Thirty-four patients had complete response to treatment. Of these 34 patients, 11 developed recurrences. The first site of recurrence was in-field in 2 patients (pelvis in 1, pelvis and para-aortic in 1) and distant in 9 patients. The 2-year actuarial locoregional control, disease-free survival, overall survival, and Grade > or = 3 toxicity rates for the entire cohort were 80%, 51%, 65%, and 10%, respectively. CONCLUSION: Extended-field IMRT with concurrent chemotherapy was tolerated well, with acceptable acute and early late toxicities. The locoregional control rate was good, with distant metastases being the predominant mode of failure. We are continuing to accrue a larger number of patients and longer follow-up data to further extend our initial observations with this approach.

Breast skin doses from brachytherapy using MammoSite HDR, intensity modulated radiation therapy, and tangential fields techniques.

Skin doses from brachytherapy using MammoSite HDR, Intensity Modulated Radiation Therapy (IMRT), and conventional tangential fields techniques were compared. For each treatment technique, skin doses were measured using paired thermoluminescent dosimeters placed on the patient's skin: (i) directly above the balloon catheter during MammoSite HDR brachytherapy treatments and (ii) 4 cm inside the treatment borders during the IMRT and conventional breast treatments. The mean dose measured was about 58% of the prescription dose for the patients treated using the MammoSite technique. On the other hand, for patients treated with IMRT and tangential fields, the mean dose was found to be about 69% and 71% of the corresponding prescription dose. This study suggests that in breast cancer radiation treatments the MammoSite HDR technique reduces skin doses compared to IMRT and tangential field techniques.

High-dose-rate interstitial brachytherapy for gynecologic malignancies.

PURPOSE: The study aimed to assess the outcome of locally advanced cervical and vaginal cancer treated with high-dose-rate interstitial brachytherapy (HDRB). METHODS AND MATERIALS: Between 1998 and 2004, 16 previously unirradiated patients with locally advanced cervical and vaginal cancer not suitable for intracavitary brachytherapy because of distorted anatomy or extensive vaginal disease were treated with HDRB in combination with external beam radiotherapy. All patients received whole pelvis external beam radiation therapy (EBRT) followed by interstitial implantation. The median whole pelvis external beam dose was 45 Gy (range, 39.6-50.4 Gy) with 11 patients receiving parametrial boost to a median dose of 9 Gy. Twelve (75%) of these patients received chemotherapy concurrent with external beam. All patients received a single HDRB procedure using a modified Syed-Neblett template. A CT scan was performed postimplant for needle placement verification and treatment planning purpose. Dose was prescribed to the tumor volume based on the radiographic and clinical examination. All patients received 18.75 Gy in five fractions delivered twice daily. The median followup was 25 months (6-69 months). RESULTS: Median cumulative biologic effective dose (EBRT+HDRB) to tumor volume was 78.9 Gy10 with the range of 72.5-85.2Gy10. Median cumulative biologic effective dose for the rectum and bladder were 99.4 Gy3 (range, 79.6-107.8 Gy3) and 96.4 Gy3 (range, 78.3-105.3 Gy3), respectively. Complete response was achieved in 13 (81%) patients with 3 patients having persistent disease. Five of these 13 patients developed recurrence at a median time of 14 months (distant in 4 and local and distant in 1). The 5-year actuarial local control and cause-specific survival were 75% and 64%, respectively. In subset analysis, 5-year actuarial local control was 63% for cervical cancer patients and 100% for vaginal cancer patients. No patient had acute Grade 3 or 4 morbidity. Grade 3 or 4 delayed morbidity resulting from treatment occurred in 1 patient with 5-year actuarial rate of 7%. Three patients had late Grade 2 rectal morbidity and 1 patient had Grade 2 small bowel morbidity. CONCLUSIONS: Our series suggests that single interstitial implantation procedure with five fractions of 3.75 Gy each to target volume is an effective and safe fractionation schedule. The integration of imaging modality helps in decreasing dose to the critical organs. Additional patients and followup are ongoing to determine the long-term efficacy of this approach.

Comparison of 2D vs. 3D dosimetry for Rotte 'Y' applicator high dose rate brachytherapy for medically inoperable endometrial cancer.

The purpose of our research is to compare CT-based volumetric calculations and International Commission on Radiation Units and Measurements (ICRU) reference-point estimates of radiation doses to the target volume, bladder, rectum, and sigmoid colon in patients with carcinoma of the endometrium treated with high dose rate intracavitary Rotte 'Y' applicator brachytherapy (HDRB). Eleven patients with cancer of the endometrium were treated with CT-compatible HDR intracavitary Rotte 'Y' applicators (Nucletron) and underwent post-implant pelvic CT scans with applicators in place. All patients were treated using orthogonal radiography-based planning. The dose was prescribed to uterine point (a point located 2 cm below the center of a line drawn between the tips of the two ends of the Rotte applicator extending laterally from the tandem by half the maximum uterine width), Point A, and 0.5 cm depth along the upper 3 cm vagina. CT-images were transferred to the PLATO treatment planning system version 14.2.6 and retrospectively planned for volumetric calculations. The clinical target volume (CTV) included the entire uterus, cervix, and upper 3 cm of vagina. The volumes of organs at risk (OAR) were digitized. Dwell positions were identified and registered in both the uterine tandem for each patient. For those receiving HDRB alone, the prescribed dose was 7 Gy x 5 fractions. Patients who were treated following external beam radiation therapy (EBRT) received 4 Gy x 5 fractions. The interfraction interval was 6-8 hours. The DVHs were computed for the CTV, bladder, rectum, and sigmoid colon. To compare doses of OARs, 1.0 cc, 2.0 cc, and 5.0 cc volumes receiving the highest dose were calculated from DVHs. 3D optimization was done to improve target coverage and decrease dose to critical organs and compared with the 2D orthogonal radiograph-based plan. The mean of percentage of prescribed dose +/- S.D to 1 cc, 2 cc, and 5 cc of the OARs of interest were as follows: Rectum 44 +/- 21%, 39 +/- 18%, and 33 +/- 15%; bladder 104 +/- 36%, 91 +/- 31%, and 73.9 +/- 24%; and sigmoid 124 +/- 35%, 109 +/- 30%, and 89 +/- 25%, respectively. The corresponding dose to ICRU 38 bladder and rectal points were 98 +/- 55% and 50.5 +/- 32%, respectively. The mean dose to uterine point and point A were 99 +/- 1.7% and 98 +/- 3%, respectively. The mean CTV volume was 160 +/- 89 cc with the percentage of volume getting 100% and 90% of the dose being 62 +/- 12% and 68 +/- 12% with 2D plan versus 57 +/- 8% and 67 +/- 8.9% with 3D plan. The dose to critical organs were reduced with 3D optimization for rectum, bladder, and sigmoid by 5.6% (p = 0.04), 20.6% (p = 0.02), and 26.8% (p = 0.005), respectively. Compared to the 3-D volume dose, the prescription points overestimated the dose to the target volume. The under-dosing was because of inability of two channel applicator to cover volumes in the region of the cervix and vagina. The dose to sigmoid colon was high and attention should be given to the sigmoid dose at the time of treatment planning. 3D planning helped in reducing the dose to the critical organs without compromising target coverage. Correlations with outcome are needed to better define the role of 3D dosimetry in treatment planning.

The potential nephrotoxic effects of intensity modulated radiotherapy delivered to the para-aortic area of women with gynecologic malignancies: preliminary results.

OBJECTIVE: To assess kidney function via creatinine clearance before and after radiotherapy in gynecologic cancer patients treated to the para-aortic (PA) area via Intensity Modulated Radiotherapy (IMRT). METHODS: Twenty-three patients underwent IMRT to the para-aortic area, were followed for at least 5 months, and had the necessary laboratory data to calculate creatinine clearance. Various patient-related factors and radiotherapy-treatment related factors were analyzed to determine their association with changes in CrCl. RESULTS: Median follow-up was 10.9 months (range, 5-19 months). Median patient age was 51.7 years (range, 22-78). The average initial CrCl was noted to be 109.23 mL/min (range, 38.64-188.38) before radiotherapy and decreased to 90.00 mL/min (29.31-175.61) after radiotherapy (P = 0.004). Although 17 patients had a decrease in their CrCl, 6 were found to have a slight elevation. Five factors were associated with a decrement in CrCl greater than the average decrease (17.6%): presence of hydronephrosis, age <50, no history of cisplatin treatment, a BED to gross adenopathy exceeding mean BED, and salvage treatment of PA node recurrence. Subgroup analysis revealed that the only statistically significant change within the group of patient and/or treatment-related factors was between patients who were <50-year-old and patients who were > or =50 years of age (P = 0.03). No patient exhibited clinical signs of radiation-induced nephropathy. CONCLUSION: With a median follow-up of 10.9 months, the estimated CrCl decreased by 17.6% after IMRT to the para-aortic area +/- cisplatin chemotherapy. The greatest decrease in CrCl occurred in patients who had a history of hydronephrosis. Subgroup analysis revealed that the decline in CrCl was significantly greater for patients younger than 50 years of age. Interestingly, a greater decline in CrCl was noted for those patients who did not have a history of cisplatin treatment. Our preliminary results indicate that IMRT +/- cisplatin chemotherapy to the para-aortic area of women is safe and is not associated with any clinical sequelae of renal toxicity despite a small decrement in CrCl in most, but not all patients.

Twice-daily high-dose-rate brachytherapy for medically inoperable uterine cancer.

PURPOSE: Medically inoperable patients with uterine cancer pose a therapeutic challenge. We developed a twice-daily schedule of high-dose-rate brachytherapy (HDRB) after a single insertion procedure that required a hospitalization of 3 days. METHODS AND MATERIALS: Favorable patients were offered brachytherapy alone, and all other patients received HDRB after pelvic external beam radiation therapy (EBRT). The prescribed dose was 7Gyx5 fractions and 4-5Gyx4-5 fractions for those treated after EBRT. HDRB was delivered with a b.i.d. schedule (4-6-h interval). RESULTS: Twenty-two patients (21 Stage I, 1 Stage IIB) were deemed medically inoperable. Sixteen patients received EBRT followed by HDRB, and six received HDRB alone. There were no procedural complications or significant acute toxicity. No thromboembolic events occurred within 30 days of the implant. CONCLUSIONS: This technique allows patients to be treated using a single procedure for insertion, with brief hospitalization for twice-daily HDRB.

Feasibility of concurrent cisplatin and extended field radiation therapy (EFRT) using intensity-modulated radiotherapy (IMRT) for carcinoma of the cervix.

OBJECTIVES: To assess the acute tolerance of delivering concurrent cisplatin and extended field radiotherapy (EFRT) using intensity-modulated radiotherapy technique (IMRT) for cancer of the cervix. METHODS: All patients receiving definitive treatment for cervical cancer were treated with EFRT using IMRT technique and concurrent cisplatin. The treatment volume included the cervix, uterus, parametria, presacral space, upper vagina, pelvic, common iliac, and paraaortic nodes to the top of L1. All regions received 45 Gy (25 fractions) with a simultaneous boost to involved nodes (55 Gy/25 fractions). Patients were assessed weekly for toxicity and response. RESULTS: Twenty-two consecutive patients underwent treatment. All patients completed the prescribed course of EFRT. Median treatment length was 39.5 days (range 36-53). Treatment breaks of 2 and 3 days were required for bone marrow toxicity in 2 patients. The final week of chemotherapy was held in 2 patients because of neutropenia. No patient suffered acute or subacute grade 3 or 4 GI or GU toxicity. CONCLUSION: In this clinical study, an IMRT technique was used to successfully deliver EFRT with concurrent chemosensitization for cervical cancer. The technique was associated with an acceptable acute toxicity without significant treatment protraction. This new role for IMRT merits further evaluation with larger patient numbers and longer follow-up.

Preoperative chemoradiation for locally advanced carcinoma of the vulva.

OBJECTIVE: A twice daily (BID) radiation treatment schedule (interval of 4-6 h) delivered concurrent with chemotherapy for advanced or critically located carcinoma of the vulva was modeled on the schema developed by the Gynecology Oncology Group (GOG). Inguinal nodes were included in the treatment fields even if clinically negative. This review analyzed the outcomes using this approach. METHODS: A retrospective review was conducted of the records of 18 patients with vulvar cancer. Patients were treated with a modified GOG schema using 5-fluorouracil (5FU) and cisplatin with BID radiation treatments during the first and last weeks of treatment and seven daily radiation treatments in between. The regional nodes and primary tumor were prescribed 44.6 Gy. Resection of the primary tumor bed and inguinal dissection was planned at 4-6 weeks post-treatment. Clinical and pathological responses as well as locoregional control and toxicity were assessed. RESULTS: All patients responded. There were 13/18 complete clinical responses (cCR), of whom 12 remained NED at 25 months. Of the five partial clinical response (cPR) patients, two have suffered local recurrences, despite surgical resection in one and electron boost in the other. All patients developed a desquamative perineal skin reaction necessitating a mean treatment break of 15 days. No severe hematological toxicity was encountered, and only one patient had grade 3 small bowel toxicity. One patient required surgical debridement for groin wound breakdown. CONCLUSION: The use of BID chemoradiation resulted in complete or partial responses in all cases. Post-treatment groin dissection can be performed without significant post-operative complications.