Aim: To determine the influence of age on disease presentation, treatment, and outcome in breast ... more Aim: To determine the influence of age on disease presentation, treatment, and outcome in breast cancer patients who are not routinely screened by mammography, women younger than 40 and women older than 69 years. Methods: The records of 272 breast cancer patients who presented to the Emory University Department of Radiation Oncology between 1997 and 2010 were reviewed. We excluded women with inflammatory or Stage IV breast cancer and those diagnosed between the ages of 40 and 69. We compared presentation, staging, treatment, and outcomes in women younger than 40 with those older than 69. Results: The median age of the young and older patient groups were 31 (range 16–40) and 76 years (range 70–91), respectively. Young women more often presented with a symptomatic breast mass than older women whose cancers were more frequently detected on screening mammography (p<.001). Young women were less likely than older women to present with significant co-morbidities including hypertension, diabetes, or cardiac disease (2% vs 76%, p<.001). A higher proportion of young women had high grade (50% vs 25%), T2/T3 tumors (69% vs 26%), and node positive disease (50% vs 23%) (p<.001 for all comparisons) than older women. Also, more young women had triple negative (25% vs 12.5%, p=.048) or HER2 positive breast cancers (34.4% vs. 18.3%, p=.02). Regarding treatment, older patients were less likely to undergo surgical axillary nodal staging (72% vs. 88%, p<.04) or chemotherapy (23% vs 84%, p<.001). Among women treated with chemotherapy, older women more often received a non-anthracycline based regimen (82% vs 7% of young patients, p<.001). Following neoadjuvant chemotherapy, significantly more young women had a complete pathological response (23% vs 13% in older women, p<.03). Fifty-two percent of young women received mastectomy versus 14% of older women (p<.001). In part due to their low rates of breast conserving surgery, younger women trended toward less radiation treatment (81% vs 90% in older women, p=.12). Among estrogen receptor positive patients, more young women received adjuvant endocrine therapy than older women (91.4% vs 72%, p=.05). The median follow-up period for the entire group was 38 months (range 1–160). At 3 years, young women were more likely to recur locoregionally (10% vs. 2%, p=.06) and distantly (16% vs 5%, p=.04) than older women, though both groups had comparable breast cancer-specific (96% vs 96%, p=0.2) and overall survival (96% vs 93%, p=.3). On multivariate analysis, old age was a significant predictor of poorer overall survival (p=.05), whereas initial tumor size and nodal status were independent predictors of breast cancer recurrence (p<.05). Discussion: Our data suggest that young women present with more advanced stage tumors than older patients and are subsequently treated with more aggressive surgery and systemic treatments, including chemotherapy and endocrine therapy. In spite of this, young women are more likely to develop breast cancer recurrence largely due to their higher T and N stages at diagnosis. Select women less than the age of 40 may benefit from screening and early detection of their breast cancers. Regardless, future studies aimed at developing better systemic treatments for younger breast cancer patients are warranted. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-14-25.
Purpose-Although the 21-gene recurrence score (RS) assay has been validated to assess the risk of... more Purpose-Although the 21-gene recurrence score (RS) assay has been validated to assess the risk of distant recurrence in hormone receptor-positive breast cancer patients, the relationship between RS and the risk of locoregional recurrence (LRR) remains unclear. The purpose of this study was to determine if RS is associated with LRR in breast cancer patients and whether this relationship varies based on the type of local treatment [mastectomy or breast-conserving therapy (BCT)]. Methods-163 consecutive estrogen receptor-positive breast cancer patients at our institution had an RS generated from the primary breast tumor between August 2006 and October 2009. Patients were treated with lumpectomy and radiation (BCT) (n = 110) or mastectomy alone (n = 53). Patients were stratified using a predetermined RS of 25 and then grouped according to local therapy type. Results-Median follow-up was 68.2 months. Patients who developed an LRR had stage I or IIA disease, >2 mm surgical margins, and received chemotherapy as directed by RS. While an RS > 25 did not predict for a higher rate of LRR, an RS > 24 was associated with LRR in our subjects. Among mastectomy patients, the 5-year LRR rate was 27.3 % in patients with an RS > 24 versus 10.7 % (p = 0.04) in those whose RS was ≤24. RS was not associated with LRR in patients who received BCT. Conclusions-Breast cancer patients treated with mastectomy for tumors that have an RS > 24 are at high risk of LRR and may benefit from post-mastectomy radiation.
This article presents the results of a retrospective multiple-case pilot study (6 families: 4 Cau... more This article presents the results of a retrospective multiple-case pilot study (6 families: 4 Caucasian and 2 African American) designed to uncover how parents and their adolescent children (ages 11–18) were affected by non-terminal parental cancer, and how they adjusted to and coped with cancer. Drawing from phenomenology and the collective case study approach, findings suggest that parents were often
International Journal of Radiation Oncology*Biology*Physics, 2021
PURPOSE/OBJECTIVE(S) In the UK START and Canadian hypofractionated whole breast radiotherapy (RT)... more PURPOSE/OBJECTIVE(S) In the UK START and Canadian hypofractionated whole breast radiotherapy (RT) trials, few patients were Black, received prior chemotherapy, or had large breast size, all factors associated with RT-induced breast toxicity. The purpose of this prospective trial was to assess the safety and efficacy of delivering 15 fractions of hypofractionated simultaneous integrated boost (SIB) RT to patients under-represented on trials of hypofractionated breast RT and who have characteristics which increase their risk for local recurrence and cutaneous toxicity from breast RT. MATERIALS/METHODS We conducted a prospective, single-arm pilot study to evaluate a once daily 15 fraction SIB RT regimen of 39.9 Gy in 2.66 Gy fractions to the breast/chest wall with or without regional nodal irradiation (RNI) and SIB of 8.1 Gy in 0.54 Gy fractions. Women with Stage 0-IIIB breast cancer who had one or more of the following characteristics were approached for enrollment: 1) prior chemotherapy for breast cancer; 2) > 25 cm breast/chest wall separation; 3) non-White race; 4) ≤ 50 years old; or 5) requiring RNI. Primary endpoint was Grade 3 cutaneous toxicity rate by CTCAE v.5. Among patients who received RNI (n = 30), rates of Grade 3 brachial plexopathy by RTOG criteria and 20% or greater increase in arm lymphedema, were additional primary endpoints. Patients were assessed prior to RT, last day of RT, and 3 weeks, 9 weeks and 1 year post RT. Local regional recurrence free survival (LRFS) was a secondary endpoint. RESULTS Among 74 participants, 57% received prior chemotherapy, 19% had breast/chest wall separation > 25cm, 39% were Black, 36% were ≤ 50 years old, and 41% were prescribed RNI. Median body mass index was 30.0 (range 17.3 - 54.9). Ten patients received post mastectomy RT. One patient developed Grade 3 radiation dermatitis 3 weeks post RT. No other Grade 3 or higher cutaneous toxicities were observed up to 1 year post RT. One patient developed a grade 3 axillary infection 3 weeks post RT, which resolved after intravenous antibiotics. No patients who received RNI developed grade 3 brachial plexopathy or a 20% increase in the ipsilateral arm volume during the study period. With a median follow up of 60 months (range 12-113 months), one in-breast recurrence with simultaneous distant metastases occurred. Two additional patients developed distant metastases alone. The 5-year LRFS and overall survival rates were 98.6% and 98.5%, respectively. CONCLUSION Our results indicate that SIB radiation therapy is well-tolerated with acceptable cutaneous toxicity rates up to 1 year post RT even among patients who are at high risk for RT-induced breast side effects. The high rates of local control and overall survival following SIB treatment are promising and support condensed courses of RT in patients who would typically receive a sequential boost due to higher risk for local recurrence.
International Journal of Radiation Oncology*Biology*Physics, 2017
Long-term follow-up of several large randomized trials of women with invasive breast cancer have ... more Long-term follow-up of several large randomized trials of women with invasive breast cancer have shown breast conserving surgery followed by radiation was as effective as mastectomy without significant differences in survival. With adjuvant radiation though comes the risk of possible acute skin reactions, namely radiation dermatitis. We aimed to identify possible patient and treatment characteristics that may increase the risk of developing acute dermatitis. Understanding which factors are most highly associated with dermatitis could help individualize the prevention and management of radiation-induced skin toxicities in patients undergoing breast cancer treatment. Materials/Methods: We analyzed 209 women with invasive and noninvasive breast cancer who received adjuvant radiation therapy for acute radiation dermatitis. We selected the following characteristics to evaluate their correlation: age, histology, tumor stage, chemotherapy, hormonal therapy, breast position, whole breast fractionation schedule and dose, tumor bed boost dose, diuretics use, smoking status, type 2 diabetes mellitus, autoimmune disease, chronic immunosuppression, and BMI. Univariate logistic regression was used to compare each factor across grade 1, grade 2, and grade 3 dermatitis groups. Significant factors were then analyzed in a multivariate logistic regression. Results: On univariate analysis, the risk of grade 3 dermatitis increased for every 10 pounds increase over the grade 1 mean weight of 159.8 lbs (OR 1.13, pZ0.02). In addition, for a 1 unit increase in BMI over 27.0, grade 3 dermatitis was more likely (OR 1.09, pZ0.008). For every 100 cGy increase in whole breast dose over 4367 cGy, grades 2 and 3 dermatitis were more likely (OR 1.15 and 1.14, pZ0.015. Total dose over 5818 cGy resulted in a higher risk of grade 2 and grade 3 dermatitis (OR 1.11 and 1.40, pZ0.003). Age, smoking status, years smoked, chemotherapy, hormone therapy, diabetes, autoimmune disease, and chronic immunosuppression did not affect risk for development of dermatitis. On multivariate analysis, there was a higher risk of grade 2 (OR 1.07, pZ0.024) and grade 3 dermatitis (OR 1.18, pZ<0.001) with increasing BMI. Total dose also increased the risk of grade 2 (OR 1.13, pZ0.007) and grade 3 dermatitis as well (OR 1.59, pZ<0.001). Conclusion: Age, smoking status, years smoked, chemotherapy, hormone therapy, diabetes, autoimmune disease, and chronic immunosuppression were not significant risk factors within our patient population. BMI and dose are the most significant risk factors for the development of moderate and severe grades of dermatitis in the early and advanced invasive breast cancer patients examined.
International Journal of Radiation Oncology*Biology*Physics, 2010
52nd Annual Meeting of the American-Society-For-Radiation-Oncology -- OCT 31-NOV 04, 2010 -- San ... more 52nd Annual Meeting of the American-Society-For-Radiation-Oncology -- OCT 31-NOV 04, 2010 -- San Diego, CAWOS: 000288775700462…Amer Soc Radiation Onco
International Journal of Radiation Oncology*Biology*Physics, 2020
surgical pathology, 32% received adjuvant EBRT. Of the 9 patients who experienced IBTR, 5 patient... more surgical pathology, 32% received adjuvant EBRT. Of the 9 patients who experienced IBTR, 5 patients did not undergo indicated EBRT. The 5-year OS rate was 95% with no breast cancer-related deaths. The 5-year RFS rate was 96%. 83% of patients had documented toxicity information and the overall highest reported grade 3 toxicity was 8%; seroma was the most common grade 3 toxicity (4%). Conclusion: IORT for select patients with ESBC has led to acceptable outcomes in regards to ipsilateral breast tumor recurrence and toxicity. We continue to recommend adjuvant EBRT for patients who do not meet IORT suitability criteria upon review of final pathology.
The safety and efficacy of skin-sparing mastectomy (SSM) with immediate reconstruction (IR) in pa... more The safety and efficacy of skin-sparing mastectomy (SSM) with immediate reconstruction (IR) in patients with locally advanced breast cancer are unclear. The purpose of this study is to compare the outcomes of women with noninflammatory Stage III SSM with IR vs. non-SSM-treated women who underwent neoadjuvant chemotherapy and adjuvant radiation therapy (XRT). Between October 1997 and March 2010, 100 consecutive patients (40 SSM with IR vs. 60 non-SSM) with Stage III breast cancer received anthracycline- and/or taxane-based neoadjuvant chemotherapy, mastectomy, and adjuvant XRT. Clinical stage (SSM with IR vs. for non-SSM) was IIIA (75% vs. 67%), IIIB (8% vs. 18%), and IIIC (8% vs. 8%). Tumors greater than 5 cm were found in 74% vs. 69%; 97% of patients in both groups were clinically node positive; and 8% vs. 18% had T4b disease. The time from initial biopsy to XRT was prolonged for SSM-IR patients (274 vs. 254 days, p = 0.04), and there was a trend toward XRT delay of more than 8 weeks (52% vs. 31%, p = 0.07) after surgery. The rate of complications requiring surgical intervention was higher in the SSM-IR group (37.5% vs. 5%, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). The 2-year actuarial locoregional control, breast cancer-specific survival, and overall survival rates for SSM with IR vs. non-SSM were 94.7% vs. 97.4%, 91.5% vs. 86.3%, and 87.4% vs. 84.8%, respectively (p = not significant). In our small study with limited follow-up, SSM with IR prolonged overall cancer treatment time and trended toward delaying XRT but did not impair oncologic outcomes. Complication rates were significantly higher in this group. Longer follow-up is needed.
Journal of the Society for Integrative Oncology, 2006
Complete decongestive therapy (CDT; alternatively known as complete decongestive physiotherapy) i... more Complete decongestive therapy (CDT; alternatively known as complete decongestive physiotherapy) is a treatment program for patients diagnosed with primary or secondary lymphedema. CDT incorporates manual lymphatic drainage (MLD), a technique involving therapeutic manipulation of the affected limb. There are several contraindications to performing CDT. Relative contraindications include hypertension, paralysis, diabetes, and bronchial asthma. General contraindications include acute infections of any kind and congestive heart failure. Malignant disease is also widely considered a general contraindication; a current vogue concept is that MLD will lead to dissemination and acceleration of cancer. However, cancer research supports the contention that this therapy does not contribute to spread of disease and should not be withheld from patients with metastasis. The intent of this article is to review these data.
Scalp angiosarcomas (SA) are rare, representing <1% of soft tissue sarcomas. The optimal manag... more Scalp angiosarcomas (SA) are rare, representing <1% of soft tissue sarcomas. The optimal management of these tumors is unknown, with management based on small case series. We sought to assess the impact of different therapies on overall survival (OS), the practice patterns nationally, and identify factors associated with OS for non-metastatic scalp angiosarcomas. A prospectively maintained database was used to identify non-metastatic scalp angiosarcomas who received some form of definitive therapy. Logistics regression, Kaplan-Meier, and Cox proportional-hazard models were utilized. A total of 589 patients met study entry criteria with a median follow-up of 4.2 years. The majority (482 patients, 81.8%) had upfront definitive resection and an additional 317 patients (65.8%) received postoperative radiation. Of the 107 patients who didn't have surgery, the majority (65 patients, 60.7%) received definitive radiation and 42 patients (39.3%) received radiation and chemotherapy. On...
Soft tissue sarcomas (STS) have minimal expression of PD-L1, a biomarker for PD-1 therapy efficac... more Soft tissue sarcomas (STS) have minimal expression of PD-L1, a biomarker for PD-1 therapy efficacy. Radiotherapy (RT) has been shown to increase PD-L1 expression pre-clinically. We examined the expression of PD-L1, pre- and post-RT, in 46 Stage II-III STS patients treated with pre-operative RT (50-50.4 Gy in 25-28 fractions) followed by resection. Five additional patients who did not receive RT were utilized as controls. PD-L1 expression on biopsy and resection samples was evaluated by immunochemistry using the anti PD-L1 monoclonal antibody (E1L3 N clone; Cell Signaling). Greater than 1% membranous staining was considered positive PD-L1 expression. Changes in PD-L1 expression were analyzed via the Fisher exact test. Kaplan-Meier statistics were used to correlate PD-L1 expression to distant metastases (DM) rate. The majority of STS were T2b (87.0%), high-grade (80.4%), undifferentiated pleomorphic histology (71.7%), and originated from the extremities (84.6%). Zero patients demonstr...
Postoperative complications (POCs) negatively impact oncologic outcomes in some malignancies; how... more Postoperative complications (POCs) negatively impact oncologic outcomes in some malignancies; however, little is known regarding their effect in soft tissue sarcoma (STS). The aim of this study was to determine the impact of POCs on survival after resection of truncal and extremity STS. All patients who underwent resection for a primary truncal or extremity STS at a single academic institution from 2000 to 2015 were included and analyzed. Primary outcome was disease-specific survival (DSS). Among 546 STS patients, POCs occurred in 159 (29%) patients; 57% were major and 55% were surgical site infections. Patients with POCs were older (61 vs. 53 years), had more comorbidities (50 vs. 38%), longer operative time (127 vs. 93 min), higher-grade tumors (93 vs. 86%), and were more likely to receive preoperative radiation (42 vs. 33%; all p &amp;amp;lt; 0.05). There was no difference in receipt of postoperative therapy between the POCs and no POCs groups (19 vs. 18%, p = 0.74). Median follow-up for survivors was 37 months, and the 5-year DSS for the entire cohort was 78%. Compared with patients without POCs, patients with POCs had a worse DSS (68% vs. 81%, p = 0.001). Predictors for decreased DSS on univariate analysis included POCs (hazard ratio [HR] 2.12, 95% confidence interval [CI] 1.37-3.28, p = 0.001), advanced age, neurovascular/bone resection, positive margin, high grade, and preoperative and postoperative therapy (all p &amp;amp;lt; 0.05). POCs (HR 1.76, 95% CI 1.08-2.87, p = 0.02) remained an independent predictor for reduced DSS on multivariate analysis, along with age (HR 1.02, p = 0.046) and tumor grade (HR 7.62, p = 0.046). POCs following resection of truncal and extremity STS are associated with decreased DSS. Efforts to optimize modifiable risk factors and decrease the rate of POCs warrant further investigation.
Journal of nuclear medicine : official publication, Society of Nuclear Medicine, Jan 8, 2016
The purpose was to evaluate the role of the synthetic amino acid positron emission tomography (PE... more The purpose was to evaluate the role of the synthetic amino acid positron emission tomography (PET) radiotracer fluciclovine ((18)F) in modifying the clinical and planning target volume (CTV and PTV) definition in post-prostatectomy patients undergoing salvage radiotherapy and to evaluate the resulting dosimetric consequences to surrounding organs at risk. 96 patients were enrolled in a randomized prospective intention to treat clinical trial for potential salvage radiotherapy for recurrent prostate cancer after prostatectomy. All patients underwent initial treatment planning based on results from conventional abdominopelvic imaging (computed tomography [CT] or magnetic resonance imaging [MRI]). Patients in the experimental arm(n = 45) underwent planning modification after additionally undergoing abdominopelvic fluciclovine ((18)F) PET/CT. For each patient, the target volume (CTV{prostate bed}[or CTV1{pelvis}/CTV2{prostate bed}] and PTV[or PTV1/PTV2]) that would have been treated pr...
International Journal of Radiation Oncology*Biology*Physics, 2016
To analyze the quality of life (QOL) and performance status (PS) (secondary outcome) in patients ... more To analyze the quality of life (QOL) and performance status (PS) (secondary outcome) in patients with stage III to IV head and neck cancer (HNC) enrolled on a prospective randomized phase 3 trial comparing radiation-cisplatin without cetuximab (CIS) or with cetuximab (CET/CIS). The QOL hypothesis proposed a between-arm difference in Functional Assessment of Cancer Therapy-Head and Neck (FACT-HN) total score of ≥10% of the instrument range from baseline to 1 year. Patients who gave consent to the QOL/PS study completed the FACT-HN, Performance Status Scale for HNC (PSS-HN), and EuroQol (EQ-5D) at baseline through to 5 years. The pretreatment QOL/PS scores were correlated with outcome and p16 status in patients with oropharyngeal cancer (OPC). Of 818 analyzable patients, the 1-year change from baseline score for FACT-HN total was -0.41 (CIS arm) and -5.11 (CET/CIS arm) (P=.016), representing a 3.2% between-arm change of the FACT-HN total score. The mean EQ-5D index and PSS-HN scores were not significantly different between arms. The p16-positive OPC patients had significantly higher baseline and 1-year scores for PSS-HN, FACT-HN total, physical and functional subscales, and 2-years for the EQ-5D index compared with p16-negative OPC patients. Higher pretreatment PSS-HN diet, PSS-HN eating, FACT-HN, and EQ-5D index scores were associated with better overall survival (OS) and progression-free (PFS) survival on multivariate analysis. Higher baseline FACT-HN total, functional, physical subscale, and EQ-5D index scores were associated with improved OS and PFS in p16-positive OPC patients but not in p16-negative and non-OPC patients. There was no clinically meaningful difference in QOL/PS between arms. The p16-positive OPC patients had significantly higher QOL/PS than did p16-negative patients. Pretreatment QOL/PS is a significant independent predictor of outcome in locally advanced HNC.
Aim: To determine the influence of age on disease presentation, treatment, and outcome in breast ... more Aim: To determine the influence of age on disease presentation, treatment, and outcome in breast cancer patients who are not routinely screened by mammography, women younger than 40 and women older than 69 years. Methods: The records of 272 breast cancer patients who presented to the Emory University Department of Radiation Oncology between 1997 and 2010 were reviewed. We excluded women with inflammatory or Stage IV breast cancer and those diagnosed between the ages of 40 and 69. We compared presentation, staging, treatment, and outcomes in women younger than 40 with those older than 69. Results: The median age of the young and older patient groups were 31 (range 16–40) and 76 years (range 70–91), respectively. Young women more often presented with a symptomatic breast mass than older women whose cancers were more frequently detected on screening mammography (p&lt;.001). Young women were less likely than older women to present with significant co-morbidities including hypertension, diabetes, or cardiac disease (2% vs 76%, p&lt;.001). A higher proportion of young women had high grade (50% vs 25%), T2/T3 tumors (69% vs 26%), and node positive disease (50% vs 23%) (p&lt;.001 for all comparisons) than older women. Also, more young women had triple negative (25% vs 12.5%, p=.048) or HER2 positive breast cancers (34.4% vs. 18.3%, p=.02). Regarding treatment, older patients were less likely to undergo surgical axillary nodal staging (72% vs. 88%, p&lt;.04) or chemotherapy (23% vs 84%, p&lt;.001). Among women treated with chemotherapy, older women more often received a non-anthracycline based regimen (82% vs 7% of young patients, p&lt;.001). Following neoadjuvant chemotherapy, significantly more young women had a complete pathological response (23% vs 13% in older women, p&lt;.03). Fifty-two percent of young women received mastectomy versus 14% of older women (p&lt;.001). In part due to their low rates of breast conserving surgery, younger women trended toward less radiation treatment (81% vs 90% in older women, p=.12). Among estrogen receptor positive patients, more young women received adjuvant endocrine therapy than older women (91.4% vs 72%, p=.05). The median follow-up period for the entire group was 38 months (range 1–160). At 3 years, young women were more likely to recur locoregionally (10% vs. 2%, p=.06) and distantly (16% vs 5%, p=.04) than older women, though both groups had comparable breast cancer-specific (96% vs 96%, p=0.2) and overall survival (96% vs 93%, p=.3). On multivariate analysis, old age was a significant predictor of poorer overall survival (p=.05), whereas initial tumor size and nodal status were independent predictors of breast cancer recurrence (p&lt;.05). Discussion: Our data suggest that young women present with more advanced stage tumors than older patients and are subsequently treated with more aggressive surgery and systemic treatments, including chemotherapy and endocrine therapy. In spite of this, young women are more likely to develop breast cancer recurrence largely due to their higher T and N stages at diagnosis. Select women less than the age of 40 may benefit from screening and early detection of their breast cancers. Regardless, future studies aimed at developing better systemic treatments for younger breast cancer patients are warranted. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-14-25.
Purpose-Although the 21-gene recurrence score (RS) assay has been validated to assess the risk of... more Purpose-Although the 21-gene recurrence score (RS) assay has been validated to assess the risk of distant recurrence in hormone receptor-positive breast cancer patients, the relationship between RS and the risk of locoregional recurrence (LRR) remains unclear. The purpose of this study was to determine if RS is associated with LRR in breast cancer patients and whether this relationship varies based on the type of local treatment [mastectomy or breast-conserving therapy (BCT)]. Methods-163 consecutive estrogen receptor-positive breast cancer patients at our institution had an RS generated from the primary breast tumor between August 2006 and October 2009. Patients were treated with lumpectomy and radiation (BCT) (n = 110) or mastectomy alone (n = 53). Patients were stratified using a predetermined RS of 25 and then grouped according to local therapy type. Results-Median follow-up was 68.2 months. Patients who developed an LRR had stage I or IIA disease, >2 mm surgical margins, and received chemotherapy as directed by RS. While an RS > 25 did not predict for a higher rate of LRR, an RS > 24 was associated with LRR in our subjects. Among mastectomy patients, the 5-year LRR rate was 27.3 % in patients with an RS > 24 versus 10.7 % (p = 0.04) in those whose RS was ≤24. RS was not associated with LRR in patients who received BCT. Conclusions-Breast cancer patients treated with mastectomy for tumors that have an RS > 24 are at high risk of LRR and may benefit from post-mastectomy radiation.
This article presents the results of a retrospective multiple-case pilot study (6 families: 4 Cau... more This article presents the results of a retrospective multiple-case pilot study (6 families: 4 Caucasian and 2 African American) designed to uncover how parents and their adolescent children (ages 11–18) were affected by non-terminal parental cancer, and how they adjusted to and coped with cancer. Drawing from phenomenology and the collective case study approach, findings suggest that parents were often
International Journal of Radiation Oncology*Biology*Physics, 2021
PURPOSE/OBJECTIVE(S) In the UK START and Canadian hypofractionated whole breast radiotherapy (RT)... more PURPOSE/OBJECTIVE(S) In the UK START and Canadian hypofractionated whole breast radiotherapy (RT) trials, few patients were Black, received prior chemotherapy, or had large breast size, all factors associated with RT-induced breast toxicity. The purpose of this prospective trial was to assess the safety and efficacy of delivering 15 fractions of hypofractionated simultaneous integrated boost (SIB) RT to patients under-represented on trials of hypofractionated breast RT and who have characteristics which increase their risk for local recurrence and cutaneous toxicity from breast RT. MATERIALS/METHODS We conducted a prospective, single-arm pilot study to evaluate a once daily 15 fraction SIB RT regimen of 39.9 Gy in 2.66 Gy fractions to the breast/chest wall with or without regional nodal irradiation (RNI) and SIB of 8.1 Gy in 0.54 Gy fractions. Women with Stage 0-IIIB breast cancer who had one or more of the following characteristics were approached for enrollment: 1) prior chemotherapy for breast cancer; 2) > 25 cm breast/chest wall separation; 3) non-White race; 4) ≤ 50 years old; or 5) requiring RNI. Primary endpoint was Grade 3 cutaneous toxicity rate by CTCAE v.5. Among patients who received RNI (n = 30), rates of Grade 3 brachial plexopathy by RTOG criteria and 20% or greater increase in arm lymphedema, were additional primary endpoints. Patients were assessed prior to RT, last day of RT, and 3 weeks, 9 weeks and 1 year post RT. Local regional recurrence free survival (LRFS) was a secondary endpoint. RESULTS Among 74 participants, 57% received prior chemotherapy, 19% had breast/chest wall separation > 25cm, 39% were Black, 36% were ≤ 50 years old, and 41% were prescribed RNI. Median body mass index was 30.0 (range 17.3 - 54.9). Ten patients received post mastectomy RT. One patient developed Grade 3 radiation dermatitis 3 weeks post RT. No other Grade 3 or higher cutaneous toxicities were observed up to 1 year post RT. One patient developed a grade 3 axillary infection 3 weeks post RT, which resolved after intravenous antibiotics. No patients who received RNI developed grade 3 brachial plexopathy or a 20% increase in the ipsilateral arm volume during the study period. With a median follow up of 60 months (range 12-113 months), one in-breast recurrence with simultaneous distant metastases occurred. Two additional patients developed distant metastases alone. The 5-year LRFS and overall survival rates were 98.6% and 98.5%, respectively. CONCLUSION Our results indicate that SIB radiation therapy is well-tolerated with acceptable cutaneous toxicity rates up to 1 year post RT even among patients who are at high risk for RT-induced breast side effects. The high rates of local control and overall survival following SIB treatment are promising and support condensed courses of RT in patients who would typically receive a sequential boost due to higher risk for local recurrence.
International Journal of Radiation Oncology*Biology*Physics, 2017
Long-term follow-up of several large randomized trials of women with invasive breast cancer have ... more Long-term follow-up of several large randomized trials of women with invasive breast cancer have shown breast conserving surgery followed by radiation was as effective as mastectomy without significant differences in survival. With adjuvant radiation though comes the risk of possible acute skin reactions, namely radiation dermatitis. We aimed to identify possible patient and treatment characteristics that may increase the risk of developing acute dermatitis. Understanding which factors are most highly associated with dermatitis could help individualize the prevention and management of radiation-induced skin toxicities in patients undergoing breast cancer treatment. Materials/Methods: We analyzed 209 women with invasive and noninvasive breast cancer who received adjuvant radiation therapy for acute radiation dermatitis. We selected the following characteristics to evaluate their correlation: age, histology, tumor stage, chemotherapy, hormonal therapy, breast position, whole breast fractionation schedule and dose, tumor bed boost dose, diuretics use, smoking status, type 2 diabetes mellitus, autoimmune disease, chronic immunosuppression, and BMI. Univariate logistic regression was used to compare each factor across grade 1, grade 2, and grade 3 dermatitis groups. Significant factors were then analyzed in a multivariate logistic regression. Results: On univariate analysis, the risk of grade 3 dermatitis increased for every 10 pounds increase over the grade 1 mean weight of 159.8 lbs (OR 1.13, pZ0.02). In addition, for a 1 unit increase in BMI over 27.0, grade 3 dermatitis was more likely (OR 1.09, pZ0.008). For every 100 cGy increase in whole breast dose over 4367 cGy, grades 2 and 3 dermatitis were more likely (OR 1.15 and 1.14, pZ0.015. Total dose over 5818 cGy resulted in a higher risk of grade 2 and grade 3 dermatitis (OR 1.11 and 1.40, pZ0.003). Age, smoking status, years smoked, chemotherapy, hormone therapy, diabetes, autoimmune disease, and chronic immunosuppression did not affect risk for development of dermatitis. On multivariate analysis, there was a higher risk of grade 2 (OR 1.07, pZ0.024) and grade 3 dermatitis (OR 1.18, pZ<0.001) with increasing BMI. Total dose also increased the risk of grade 2 (OR 1.13, pZ0.007) and grade 3 dermatitis as well (OR 1.59, pZ<0.001). Conclusion: Age, smoking status, years smoked, chemotherapy, hormone therapy, diabetes, autoimmune disease, and chronic immunosuppression were not significant risk factors within our patient population. BMI and dose are the most significant risk factors for the development of moderate and severe grades of dermatitis in the early and advanced invasive breast cancer patients examined.
International Journal of Radiation Oncology*Biology*Physics, 2010
52nd Annual Meeting of the American-Society-For-Radiation-Oncology -- OCT 31-NOV 04, 2010 -- San ... more 52nd Annual Meeting of the American-Society-For-Radiation-Oncology -- OCT 31-NOV 04, 2010 -- San Diego, CAWOS: 000288775700462…Amer Soc Radiation Onco
International Journal of Radiation Oncology*Biology*Physics, 2020
surgical pathology, 32% received adjuvant EBRT. Of the 9 patients who experienced IBTR, 5 patient... more surgical pathology, 32% received adjuvant EBRT. Of the 9 patients who experienced IBTR, 5 patients did not undergo indicated EBRT. The 5-year OS rate was 95% with no breast cancer-related deaths. The 5-year RFS rate was 96%. 83% of patients had documented toxicity information and the overall highest reported grade 3 toxicity was 8%; seroma was the most common grade 3 toxicity (4%). Conclusion: IORT for select patients with ESBC has led to acceptable outcomes in regards to ipsilateral breast tumor recurrence and toxicity. We continue to recommend adjuvant EBRT for patients who do not meet IORT suitability criteria upon review of final pathology.
The safety and efficacy of skin-sparing mastectomy (SSM) with immediate reconstruction (IR) in pa... more The safety and efficacy of skin-sparing mastectomy (SSM) with immediate reconstruction (IR) in patients with locally advanced breast cancer are unclear. The purpose of this study is to compare the outcomes of women with noninflammatory Stage III SSM with IR vs. non-SSM-treated women who underwent neoadjuvant chemotherapy and adjuvant radiation therapy (XRT). Between October 1997 and March 2010, 100 consecutive patients (40 SSM with IR vs. 60 non-SSM) with Stage III breast cancer received anthracycline- and/or taxane-based neoadjuvant chemotherapy, mastectomy, and adjuvant XRT. Clinical stage (SSM with IR vs. for non-SSM) was IIIA (75% vs. 67%), IIIB (8% vs. 18%), and IIIC (8% vs. 8%). Tumors greater than 5 cm were found in 74% vs. 69%; 97% of patients in both groups were clinically node positive; and 8% vs. 18% had T4b disease. The time from initial biopsy to XRT was prolonged for SSM-IR patients (274 vs. 254 days, p = 0.04), and there was a trend toward XRT delay of more than 8 weeks (52% vs. 31%, p = 0.07) after surgery. The rate of complications requiring surgical intervention was higher in the SSM-IR group (37.5% vs. 5%, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). The 2-year actuarial locoregional control, breast cancer-specific survival, and overall survival rates for SSM with IR vs. non-SSM were 94.7% vs. 97.4%, 91.5% vs. 86.3%, and 87.4% vs. 84.8%, respectively (p = not significant). In our small study with limited follow-up, SSM with IR prolonged overall cancer treatment time and trended toward delaying XRT but did not impair oncologic outcomes. Complication rates were significantly higher in this group. Longer follow-up is needed.
Journal of the Society for Integrative Oncology, 2006
Complete decongestive therapy (CDT; alternatively known as complete decongestive physiotherapy) i... more Complete decongestive therapy (CDT; alternatively known as complete decongestive physiotherapy) is a treatment program for patients diagnosed with primary or secondary lymphedema. CDT incorporates manual lymphatic drainage (MLD), a technique involving therapeutic manipulation of the affected limb. There are several contraindications to performing CDT. Relative contraindications include hypertension, paralysis, diabetes, and bronchial asthma. General contraindications include acute infections of any kind and congestive heart failure. Malignant disease is also widely considered a general contraindication; a current vogue concept is that MLD will lead to dissemination and acceleration of cancer. However, cancer research supports the contention that this therapy does not contribute to spread of disease and should not be withheld from patients with metastasis. The intent of this article is to review these data.
Scalp angiosarcomas (SA) are rare, representing <1% of soft tissue sarcomas. The optimal manag... more Scalp angiosarcomas (SA) are rare, representing <1% of soft tissue sarcomas. The optimal management of these tumors is unknown, with management based on small case series. We sought to assess the impact of different therapies on overall survival (OS), the practice patterns nationally, and identify factors associated with OS for non-metastatic scalp angiosarcomas. A prospectively maintained database was used to identify non-metastatic scalp angiosarcomas who received some form of definitive therapy. Logistics regression, Kaplan-Meier, and Cox proportional-hazard models were utilized. A total of 589 patients met study entry criteria with a median follow-up of 4.2 years. The majority (482 patients, 81.8%) had upfront definitive resection and an additional 317 patients (65.8%) received postoperative radiation. Of the 107 patients who didn't have surgery, the majority (65 patients, 60.7%) received definitive radiation and 42 patients (39.3%) received radiation and chemotherapy. On...
Soft tissue sarcomas (STS) have minimal expression of PD-L1, a biomarker for PD-1 therapy efficac... more Soft tissue sarcomas (STS) have minimal expression of PD-L1, a biomarker for PD-1 therapy efficacy. Radiotherapy (RT) has been shown to increase PD-L1 expression pre-clinically. We examined the expression of PD-L1, pre- and post-RT, in 46 Stage II-III STS patients treated with pre-operative RT (50-50.4 Gy in 25-28 fractions) followed by resection. Five additional patients who did not receive RT were utilized as controls. PD-L1 expression on biopsy and resection samples was evaluated by immunochemistry using the anti PD-L1 monoclonal antibody (E1L3 N clone; Cell Signaling). Greater than 1% membranous staining was considered positive PD-L1 expression. Changes in PD-L1 expression were analyzed via the Fisher exact test. Kaplan-Meier statistics were used to correlate PD-L1 expression to distant metastases (DM) rate. The majority of STS were T2b (87.0%), high-grade (80.4%), undifferentiated pleomorphic histology (71.7%), and originated from the extremities (84.6%). Zero patients demonstr...
Postoperative complications (POCs) negatively impact oncologic outcomes in some malignancies; how... more Postoperative complications (POCs) negatively impact oncologic outcomes in some malignancies; however, little is known regarding their effect in soft tissue sarcoma (STS). The aim of this study was to determine the impact of POCs on survival after resection of truncal and extremity STS. All patients who underwent resection for a primary truncal or extremity STS at a single academic institution from 2000 to 2015 were included and analyzed. Primary outcome was disease-specific survival (DSS). Among 546 STS patients, POCs occurred in 159 (29%) patients; 57% were major and 55% were surgical site infections. Patients with POCs were older (61 vs. 53 years), had more comorbidities (50 vs. 38%), longer operative time (127 vs. 93 min), higher-grade tumors (93 vs. 86%), and were more likely to receive preoperative radiation (42 vs. 33%; all p &amp;amp;lt; 0.05). There was no difference in receipt of postoperative therapy between the POCs and no POCs groups (19 vs. 18%, p = 0.74). Median follow-up for survivors was 37 months, and the 5-year DSS for the entire cohort was 78%. Compared with patients without POCs, patients with POCs had a worse DSS (68% vs. 81%, p = 0.001). Predictors for decreased DSS on univariate analysis included POCs (hazard ratio [HR] 2.12, 95% confidence interval [CI] 1.37-3.28, p = 0.001), advanced age, neurovascular/bone resection, positive margin, high grade, and preoperative and postoperative therapy (all p &amp;amp;lt; 0.05). POCs (HR 1.76, 95% CI 1.08-2.87, p = 0.02) remained an independent predictor for reduced DSS on multivariate analysis, along with age (HR 1.02, p = 0.046) and tumor grade (HR 7.62, p = 0.046). POCs following resection of truncal and extremity STS are associated with decreased DSS. Efforts to optimize modifiable risk factors and decrease the rate of POCs warrant further investigation.
Journal of nuclear medicine : official publication, Society of Nuclear Medicine, Jan 8, 2016
The purpose was to evaluate the role of the synthetic amino acid positron emission tomography (PE... more The purpose was to evaluate the role of the synthetic amino acid positron emission tomography (PET) radiotracer fluciclovine ((18)F) in modifying the clinical and planning target volume (CTV and PTV) definition in post-prostatectomy patients undergoing salvage radiotherapy and to evaluate the resulting dosimetric consequences to surrounding organs at risk. 96 patients were enrolled in a randomized prospective intention to treat clinical trial for potential salvage radiotherapy for recurrent prostate cancer after prostatectomy. All patients underwent initial treatment planning based on results from conventional abdominopelvic imaging (computed tomography [CT] or magnetic resonance imaging [MRI]). Patients in the experimental arm(n = 45) underwent planning modification after additionally undergoing abdominopelvic fluciclovine ((18)F) PET/CT. For each patient, the target volume (CTV{prostate bed}[or CTV1{pelvis}/CTV2{prostate bed}] and PTV[or PTV1/PTV2]) that would have been treated pr...
International Journal of Radiation Oncology*Biology*Physics, 2016
To analyze the quality of life (QOL) and performance status (PS) (secondary outcome) in patients ... more To analyze the quality of life (QOL) and performance status (PS) (secondary outcome) in patients with stage III to IV head and neck cancer (HNC) enrolled on a prospective randomized phase 3 trial comparing radiation-cisplatin without cetuximab (CIS) or with cetuximab (CET/CIS). The QOL hypothesis proposed a between-arm difference in Functional Assessment of Cancer Therapy-Head and Neck (FACT-HN) total score of ≥10% of the instrument range from baseline to 1 year. Patients who gave consent to the QOL/PS study completed the FACT-HN, Performance Status Scale for HNC (PSS-HN), and EuroQol (EQ-5D) at baseline through to 5 years. The pretreatment QOL/PS scores were correlated with outcome and p16 status in patients with oropharyngeal cancer (OPC). Of 818 analyzable patients, the 1-year change from baseline score for FACT-HN total was -0.41 (CIS arm) and -5.11 (CET/CIS arm) (P=.016), representing a 3.2% between-arm change of the FACT-HN total score. The mean EQ-5D index and PSS-HN scores were not significantly different between arms. The p16-positive OPC patients had significantly higher baseline and 1-year scores for PSS-HN, FACT-HN total, physical and functional subscales, and 2-years for the EQ-5D index compared with p16-negative OPC patients. Higher pretreatment PSS-HN diet, PSS-HN eating, FACT-HN, and EQ-5D index scores were associated with better overall survival (OS) and progression-free (PFS) survival on multivariate analysis. Higher baseline FACT-HN total, functional, physical subscale, and EQ-5D index scores were associated with improved OS and PFS in p16-positive OPC patients but not in p16-negative and non-OPC patients. There was no clinically meaningful difference in QOL/PS between arms. The p16-positive OPC patients had significantly higher QOL/PS than did p16-negative patients. Pretreatment QOL/PS is a significant independent predictor of outcome in locally advanced HNC.
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Papers by Karen Godette