Abstract Background: Regional nodal irradiation (RNI) in addition to the chest wall and/or breast can maximize local regional control and improve overall survival, but has been associated with late cardiac morbidity. We examined NPBC patients treated with RNI using 3D-CT based radiation therapy (RT) to evaluate incidence and type of cardiac events. Methods: Between 2000 and 2007, 156 NPBC patients were treated with RNI following lumpectomy or mastectomy using 3D-CRT. In all cases, treatment target and normal tissue volumes were delineated on treatment CT scans. The heart contour included the left ventricle and the atria. Prescription dose was typically 50Gy in 25 fractions (range 44-54 Gy) to the chest wall and/or breast PTVeval. 37% received a boost to the chest wall and 73% to the lumpectomy cavity. The mean prescription dose to the axilla and supraclavicular lymph nodes was 47.6 Gy (range 43.2 – 54 Gy) and 46.8 Gy to the IMN (range 35.3 – 50.4 Gy). The dose-volume cardiac data and incidence of cardiac events is reported. Results: Median follow-up of surviving patients was 7 years (range, 0.3-10.6). Median patient age was 50 (range, 27-91), 52% were premenopausal, 76% estrogen receptor positive, and 18% were HER-2 positive. The IMN received > 40 Gy in 66%. Chemotherapy was used in 94% of patients, and it was anthracycline-based in 82.3%. At the time of RT, 12.5% smoked, 9% had diabetes, 33% with HTN, and 4.4% had a history of CAD. Average mean heart dose for the cohort was 5.2 Gy (range, 0.2 - 25.3 Gy). Mean cardiac V25 was 5.4% (range, 0-20%), mean cardiac V45 was 1.7% (range, 0-13.3%), and mean maximum cardiac point dose was 45.4 Gy. There was 1 (0.7% of cohort) right sided patient with cardiac events and 8 (5.1% of cohort) left experiencing cardiac events. A total of 18 cardiac diagnoses were experienced among the 9 patients: Coronary artery disease with or without myocardial infarction (4), congestive heart failure (6), cardiomyopathy (3), and arrhythmia (5). Conclusions: The cardiac event rate among these NPBC patients treated with RNI and anthracycline-based chemotherapy was low, but more common in women with left-sided breast cancer compared to right. Additional analysis using 3DCRT volumes are important to validate these findings and better define the dose-volume parameters for cardiac toxicity. Citation Format: Bradley JA, Sparks I, Prior P, Bergom C, Walker A, Wilson JF, Li XA, White J. Analysis of cardiac events among node positive breast cancer (NPBC) patients treated with three-dimensional conformal radiation therapy (3D-CRT) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-11-06.

Our institution has used 3-dimensional conformal radiation therapy (3DCRT) to deliver whole breast irradiation (WBI) in the prone position since 1998 in order to address technical difficulties associated with treating large, pendulous breasts and/or large body habitus, and/or in patients with left-sided cancers to decrease radiation received by the heart. The goal of this study was to review our updated experience using prone breast WBI to determine whether the recurrence rates and survival patterns are acceptable in this set of patients. From 1998-2013, 397 women treated with breast conserving surgery underwent WBI in the prone position using 3DCRT. Patients were treated with a median of 50 Gy to the breast volume +/- a boost of 10 Gy to the lumpectomy planning target volume. All patients had >12 month follow-up. Median follow-up was 43.6 mo. The median age was 59 (27-91); 67% were post-menopausal. Median BMI was 32.4 (18.6-64.6). Tumors were Tis-19.8%, T1-61.5%, T2-17.2%, T3-1.5%, and 3.3% had positive axillary nodes. Eight (2%) patients were diagnosed with an ipsilateral breast tumor (5-yr recurrence rate=1.9%). Mean time to recurrence was 57.5 mo (19-127 mo). The original tumors were DCIS (2), infiltrating lobular (3), and invasive ductal (3). Focal DCIS margin was <2mm in 3 patients. The original tumor location and location of recurrence respectively was: lower outer quadrant (LOQ)-failed in UOQ, UIQ-failed in UIQ (2), central-failed central, UOQ-failed UOQ, LOQ-failed LOQ, UOQ-failed LIQ, and UOQ-failed in skin and with distant metastases. Ipsilateral disease free survival was 97.6% at 5 yr. Distant metastasis free survival was 98.4% at 5 yr. Overall survival was 95.5% at 5 yr. In patients with large pendulous breasts, increased BMI and/or left-sided tumors, delivering WBI in the prone position using 3DCRT results in recurrence rates and failure patterns similar to those anticipated using supine WBI. This series adds to the growing literature demonstrating prone WBI provides local control rates comparable to supine WBI with minimal toxicity to organs at risk.

Several studies have shown increased radiation-related toxicities and suboptimal cosmetic outcomes for patients with large, pendulous breasts undergoing breast conserving therapy. Some of these challenges can be overcome with radiation treatment in the prone position. The purpose of this study is to report toxicity and cosmetic outcomes for patients treated with this technique at our Institution. Between 1998 and 2013, 418 women underwent WBI in the prone position using 3DCRT. Patients were treated to a median 50 Gy to the breast +/- a boost of 10 Gy. Late toxicities and cosmesis were assessed in patients with >12 months follow up. Acute and late toxicities were scored using the Common Toxicity Criteria Version 4.3. Cosmetic outcome was assessed via the Harvard Cosmesis Scale. Univariate analysis was performed to assess the association of variables with outcomes. Median age was 59 and 67.7% were post-menopausal. Median follow-up was 38 mo for all patients and 43.6 mo for those assessed for late toxicity. Median BMI was 32.3 (18.6-64.6). Tumors were Tis-19.8%, T1-61.4%, T2-17.4%, T3-1.4%, and 3.1% had positive axillary nodes. Seventy-eight percent were ER+, 68% were PR+, and 12% were Her2+. Chemotherapy was given to 34% and 72% received anti-endocrine therapy. Acute grade 1 and 2 dermatitis (D) was seen in 48.1% and 42.5%. Grade 1 and 2 moist desquamation (MD) occurred in 8.6% and 0.8%. <2% of patients experienced Grade 3 acute toxicities and there was no Grade 4-5. BMI significantly correlated with D, MD, and breast pain (p < 0.01). For late toxicities, 17%, 3%, 29%, and 1% of patients experienced Grade 1 hyperpigmentation, telangiectasia, fibrosis, and arm lymphedema, respectively. 2%, 1%, 4%, 2%, 0%, and 0% of patients experienced Grade 2 of these same toxicities. <1% of patients experienced Grade 3 late toxicities. Cosmesis was good to excellent in 92%. For the 195 pts with >30 BMI and 45 pts with BMI of 40-45, 90.8% and 91.2% had good to excellent cosmesis. BMI significantly correlated with hyperpigmentation, worse cosmesis, and asymmetry (p<0.02). Axillary dissection was associated with worse cosmesis (p= 0.008) and the number of total lymph nodes removed correlated with hyperpigmentation, telangiectasia, fibrosis, cosmesis, and arm lymphedema (p<0.02). African Americans were more prone to hyperpigmentation and worse cosmesis (p<0.05). For the pts with BMI >40, there were higher rates of dermatitis, MD, pain, hyperpigmentation, and telangiectasias (p<0.03). These results indicate that delivering prone WBI using 3D-CRT results in favorable cosmetic outcomes and long term toxicity. Higher BMI continues is associated with worse, but still acceptable, acute and late toxicities and cosmetic outcomes.

To quantitatively evaluate the interfractional variations of heart and its impact on cardiac dose during whole breast irradiation (WBI) with patients positioned in supine, and determine a parameter to estimate the risk of the dose variation. Analysis was performed on daily CTs acquired using an in-room CT during daily IGRT for 12 left-sided breast cancer patients, who were treated with whole breast irradiation in supine position. For each fraction CT, the lumpectomy cavity (LC), breast, heart, left ventricle, and lung, were generated by populating the contours in the planning CT using a commercial auto-segmentation tool with manually editing if necessary. The heart volume and the distance between centers of mass of the lumpectomy and heart (LC-heart distance) were calculated to measure the inter-fractional variations of heart position. The dose distribution actually received by the patient at a fraction was reconstructed by applying the original plan to the fraction CT considering the repositioning shifts performed during IGRT based on soft-tissue alignment of LC. Dose volume parameters, including the target coverage, mean dose, maximum dose, V5 and V25 of heart, were calculated from the daily dose distributions and were compared with those in the original plan. The correlation between these parameters was analyzed using Spearman rank correlation tests. The interfractional variation in heart volume was small (1.5 ± 3.9%), indicating the respiration and cardiac motions were small. The mean value of the LC-heart distance was 2.3 ± 0.7 cm, but it can be as high as 6 cm. The V95 of the treated breast was reduced by 2.3% on average from the original plan to the daily dose distributions. Compared to the values in the original plans, the mean dose, maximum dose, V5, and V25 of the heart in the daily dose distributions were varied by 12.0 ± 14.6%, 1.8 ± 4.0%, 12.5 ± 14.0%, and 19.1 ± 22.1%, respectively. For about 2/3 of patients, the correlation can be seen between the LC-heart distance and the changes of the mean dose, V5, and V25 of heart (p<0.02). No clear correlation was observed between the LC-heart distance and the maximum dose change. The interfractional variation in cardiac doses for WBI in supine position with left-sided breast cancers can be substantial, mainly due to the interfractional shifts of the heart positions. The LC-heart distance is a critical parameter that can be used to assess the variation in cardiac dose. This dose variation should be considered in analyzing the relationship between cardiac dose and toxicities. .

Preoperative RT is commonly used to treat soft tissue sarcoma (STS), and conventional RT is associated with increased wound complications (43% in the lower extremity (LE)). However, the effect of three dimensional conformal radiation treatment (3D CRT) vs advanced intensity modulated radiation treatment (IMRT) on post-operative complications has yet to be determined. In this study, we assess the rates of post-operative wound complications (WC) in patients (pts) who underwent preoperative 3DCRT or IMRT followed by surgery for STS. From 2000-2012, pts with STS were treated with preoperative RT +/- chemotherapy followed by resection. Pt variables and treatment outcomes were reviewed. WC were defined by the NCIC study. The fisher exact test was used for univariate analysis (UVA) and logistic regression was used for multivariate analysis (MVA). 134 pts underwent preoperative RT followed by limb-salvage surgery. Median follow-up was 3.75 yrs. Median age was 56. Median RT dose was 50 Gy. 52 (38.8%) patients received neoadjuvant chemotherapy. 103 (77%) pts had high grade tumors. 110 (82%) had LE STS. 38 (28.4%) pts were treated with IMRT and 96 (71.6%) were treated with 3D CRT. IMRT was used in 35% of LE tumors and 3D CRT was used in 65% of LE tumors. 64 (48%) pts had tumors ≥10 cm. Median tumor size with 3D CRT was 10 cm vs 11.5 cm with IMRT. 44 (46%) of the pts who got 3D CRT had ≥10 cm tumors and 20 (53%) of the pts who got IMRT had ≥10 cm tumors. Overall, 42 (31.3%) pts developed post-operative WC. 14/38 (36.8%) pts receiving IMRT vs 28/96 (29.1%) receiving 3D CRT developed WC (p = 0.42). When evaluating LE tumors only, 14/31 (45%) of the IMRT pts and 26/71 (37%) of the 3D CRT pts had WC (p = 0.5). 3-year LC in patients receiving IMRT was 97.5% vs 97.6% in those patients receiving 3D CRT (p = 0.8). On UVA and MVA only LE STS predicted for increased WC (p = 0.0003). No other variables predicted for WC (Table). There was no difference in post-operative WC and LC in pts receiving 3D CRT vs IMRT. Further studies and a larger sample size are needed to corroborate these findings.Scientific Abstract 3404; TableVariables assessed for their potential impact on WCVariableP (WC)AgeNSSexNSPerformance StatusNSDiabetesNSCardiovascular DiseaseNSSmoking HistoryNSTumor Location.0003 (OR 2.13)Tumor SizeNSSteroid UseNSChemotherapyNSRotational Flap atTime of SurgeryNS3D CRT vs IMRTNS Open table in a new tab

Skin cancer is the most common malignancy worldwide. Radiation therapy (RT) with either kilovoltage x-rays and/or megavoltage electron and/or photon beams are treatment options for skin cancer, particularly for non-surgical candidates due to comorbidities or cosmetic concern/patient refusal. Our objective is to model tumor control probability (TCP) based on published clinical data of primary basal or squamous cell carcinoma (BCC/SCC) in order to optimize treatment schemes that can take advantage of advanced RT technology (e.g., image-guided delivery). Reports citing crude estimates of local tumor control for primary BCC and SCC of the head/face by tumor size ≤ 2 cm or > 2 cm were considered in our TCP modeling based on a TCP model: TCP = 1/(1+exp(-(BED14 - BEDprolif·T - TD50)/k), where BED is the biological effective dose calculated from the report using the linear quadratic model with α/β = 14 Gy, BEDprolif is the BED recovered per day due to proliferation, T is the treatment time in days, TD50 is the dose required to achieve 50% tumor control, and k is a fitting constant related to the slope of the dose response curve at TD50. These model parameters were estimated using the Chi-squared fitting method. Sample equivalent fractionation schemes and the effect of varying treatment time on TCP were estimated. Literature search yield six reports useful in the development of a TCP model for BCC / SCC. The reported a median total dose of 46.4 Gy (range, 35-61 Gy), dose per fraction of 4.8 Gy/fx (range, 2.5-7.0 Gy/fx), [BED14 = 60.7 Gy, (range, 52.5-79.9 Gy)] and total treatment time of 13.4 days (range, 4-25.9 days). Four TCP models were generated for BCC ≤ 2cm, BCC > 2cm, SCC ≤ 2 cm, and SCC > 2 cm. For BCC, the model parameters were found to be TD50 = 0 Gy, k = 16.823 Gy-1, and BEDprolif = 0.340 Gy/day and TD50 = 48.8 Gy, k = 2.744 Gy-1, and BEDprolif = 0.181 Gy/day for tumor sizes of ≤ 2 cm and > 2 cm, respectively. Model parameters for SCC were: TD50 = 0 Gy, k = 18.986 Gy-1, and BEDprolif = 0.166 Gy/day and TD50 = 49.7 Gy, k = 3.261 Gy-1, and BEDprolif = 0.123 Gy/day for tumors ≤ 2 cm and > 2 cm, respectively. Additional calculations with a fixed BED14 = 60 Gy show that increasing the treatment time from 5 to 30 days has a 1%-2% reduction in TCP for tumors ≤ 2 cm, while this increased time results in an 6%-7% reduction in TCP for tumors > 2 cm. The scheme of 5 x 7.2 Gy in one week is found to be equivalent to 15 x 3 Gy in 3 weeks in term of TCP. A TCP model for primary BCC / SCC was developed based on published clinical data and may be used to design new RT regimens for advanced RT technology. Prolonged treatment times could have a significant effect on control for tumors > 2 cm in size. Shortened treatment times may permit the delivery of larger fractional doses provided the normal tissue tolerance is respected.

Purpose/Objective(s)In whole breast irradiation (WBI) with sequential boost for breast cancer, the dosimetry plans for both WBI and boost are usually generated together before WBI. It has been concerned that the lumpectomy cavity (LC) may change at the time of boost, resulting in deviation in the dose delivery. The purpose of this work is to quantitatively characterize these LC changes.Materials/MethodsDiagnostic-quality planning and treatment CTs acquired for 19 breast cancer patients who received WBI with sequential boost were analyzed in this study. All patients were treated in prone position with initial WBI of 45-50 Gy in 1.8-2.0 Gy daily fractions followed by the boost of 10 Gy in 2 Gy daily fractions. For each boost fraction, diagnostic-quality CT (treatment CT) was acquired using an in-room CT for patient positioning. The contours of LC and treated breast in the treatment CTs were generated by populating the contours in the planning CT to each treatment CT set using an auto-segmentation tool with manual editing. The contours of LC and treated breast in each treatment CT were compared to those in the planning CT. The relative volume ratio (RVR), maximum overlap ratio (MOR) and Dice's coefficient (DC) were calculated to quantify the changes in LC after the initial WBI and during the boost delivery.ResultsSignificant changes in LC volume (p = 0.017, paired two tailed t-test) were observed between the planning CT and boost fraction CTs. In the 19 cases studied, the LC volume at the time of boost was generally reduced by an average of 14% from its original volume on the planning CT, resulting in an average RVR of 85.8%. Exceptions were indicated in 3 cases, where the LC volume increased by 13, 14, and 38%, respectively. Excluding these 3 cases, the average RVR was 79.0%. The maximum overlap volume decreased in either case with an average MOR of 82.0% for cases of expansion and 68.2% for cases of shrinkage, respectively. The corresponding DCs were 76.1% and 76.4%. Compared to these large changes, the inter-fraction LC variation during the boost was much smaller and was negligible. On average the standard deviations of RVR and MOR within a patient's fractions were 4.2% and 2.8%, respectively. Inter-fraction variation in the shape of the treated breast during the boost was also observed. The mean RVR was 91.3 ± 5.4% with a mean MOR of 86.1% and a mean DC of 88.6%.ConclusionsThe volume and shape of the lumpectomy cavity at the time of boost changes significantly after initial WBI during WBI with sequential boost, indicating that adaptive replanning based on the CT acquired at the time of boost should be considered. Although the data collected in this work were on patients treated in prone position, major findings may be applicable to patients treated in supine position. Purpose/Objective(s)In whole breast irradiation (WBI) with sequential boost for breast cancer, the dosimetry plans for both WBI and boost are usually generated together before WBI. It has been concerned that the lumpectomy cavity (LC) may change at the time of boost, resulting in deviation in the dose delivery. The purpose of this work is to quantitatively characterize these LC changes. In whole breast irradiation (WBI) with sequential boost for breast cancer, the dosimetry plans for both WBI and boost are usually generated together before WBI. It has been concerned that the lumpectomy cavity (LC) may change at the time of boost, resulting in deviation in the dose delivery. The purpose of this work is to quantitatively characterize these LC changes. Materials/MethodsDiagnostic-quality planning and treatment CTs acquired for 19 breast cancer patients who received WBI with sequential boost were analyzed in this study. All patients were treated in prone position with initial WBI of 45-50 Gy in 1.8-2.0 Gy daily fractions followed by the boost of 10 Gy in 2 Gy daily fractions. For each boost fraction, diagnostic-quality CT (treatment CT) was acquired using an in-room CT for patient positioning. The contours of LC and treated breast in the treatment CTs were generated by populating the contours in the planning CT to each treatment CT set using an auto-segmentation tool with manual editing. The contours of LC and treated breast in each treatment CT were compared to those in the planning CT. The relative volume ratio (RVR), maximum overlap ratio (MOR) and Dice's coefficient (DC) were calculated to quantify the changes in LC after the initial WBI and during the boost delivery. Diagnostic-quality planning and treatment CTs acquired for 19 breast cancer patients who received WBI with sequential boost were analyzed in this study. All patients were treated in prone position with initial WBI of 45-50 Gy in 1.8-2.0 Gy daily fractions followed by the boost of 10 Gy in 2 Gy daily fractions. For each boost fraction, diagnostic-quality CT (treatment CT) was acquired using an in-room CT for patient positioning. The contours of LC and treated breast in the treatment CTs were generated by populating the contours in the planning CT to each treatment CT set using an auto-segmentation tool with manual editing. The contours of LC and treated breast in each treatment CT were compared to those in the planning CT. The relative volume ratio (RVR), maximum overlap ratio (MOR) and Dice's coefficient (DC) were calculated to quantify the changes in LC after the initial WBI and during the boost delivery. ResultsSignificant changes in LC volume (p = 0.017, paired two tailed t-test) were observed between the planning CT and boost fraction CTs. In the 19 cases studied, the LC volume at the time of boost was generally reduced by an average of 14% from its original volume on the planning CT, resulting in an average RVR of 85.8%. Exceptions were indicated in 3 cases, where the LC volume increased by 13, 14, and 38%, respectively. Excluding these 3 cases, the average RVR was 79.0%. The maximum overlap volume decreased in either case with an average MOR of 82.0% for cases of expansion and 68.2% for cases of shrinkage, respectively. The corresponding DCs were 76.1% and 76.4%. Compared to these large changes, the inter-fraction LC variation during the boost was much smaller and was negligible. On average the standard deviations of RVR and MOR within a patient's fractions were 4.2% and 2.8%, respectively. Inter-fraction variation in the shape of the treated breast during the boost was also observed. The mean RVR was 91.3 ± 5.4% with a mean MOR of 86.1% and a mean DC of 88.6%. Significant changes in LC volume (p = 0.017, paired two tailed t-test) were observed between the planning CT and boost fraction CTs. In the 19 cases studied, the LC volume at the time of boost was generally reduced by an average of 14% from its original volume on the planning CT, resulting in an average RVR of 85.8%. Exceptions were indicated in 3 cases, where the LC volume increased by 13, 14, and 38%, respectively. Excluding these 3 cases, the average RVR was 79.0%. The maximum overlap volume decreased in either case with an average MOR of 82.0% for cases of expansion and 68.2% for cases of shrinkage, respectively. The corresponding DCs were 76.1% and 76.4%. Compared to these large changes, the inter-fraction LC variation during the boost was much smaller and was negligible. On average the standard deviations of RVR and MOR within a patient's fractions were 4.2% and 2.8%, respectively. Inter-fraction variation in the shape of the treated breast during the boost was also observed. The mean RVR was 91.3 ± 5.4% with a mean MOR of 86.1% and a mean DC of 88.6%. ConclusionsThe volume and shape of the lumpectomy cavity at the time of boost changes significantly after initial WBI during WBI with sequential boost, indicating that adaptive replanning based on the CT acquired at the time of boost should be considered. Although the data collected in this work were on patients treated in prone position, major findings may be applicable to patients treated in supine position. The volume and shape of the lumpectomy cavity at the time of boost changes significantly after initial WBI during WBI with sequential boost, indicating that adaptive replanning based on the CT acquired at the time of boost should be considered. Although the data collected in this work were on patients treated in prone position, major findings may be applicable to patients treated in supine position.

Purpose/Objective(s)Quality Research in Radiation Oncology (QRRO) surveyed US radiation therapy (RT) facilities to evaluate the quality of gastric cancer (GC) treatment in 2005-07. The specific aim of this report is to describe sociodemographic (SOC) factors that influence work-up and treatment of GC patients (pts).Materials/MethodsThe QRRO national survey used a two-stage stratified random sample of GC treated with RT: 250 cases from 45 institutions (6 facilities had no eligible pts). Eligibility: RT receipt in 2005-2007 for stomach or gastroesophageal (GE) junction tumors with stages Ib-IV (non-metastatic); histology of adenocarcinoma, squamous, adenosquamous; Karnofsky score ≥60. Exclusions: distant metastases or prior malignancy within 5 yrs. Five SOC variables based on 2000 US Census data were analyzed for association with clinical factors: pts living in urban vs. rural settings (U/R), median household income (HI), % below poverty level (POV), % unemployed (U) and % with college education (CE). U/R had three categories: 100% urban, 100% rural or urban/rural mix. HI, POV, U, and CE were defined as above or below the median values of this sample. Pts were linked to census data values by home ZIP code. Six pts did not link and were excluded from the analysis. National estimates used weighted averages.ResultsOf the 244 cases 96.2% had adenocarcinoma; 13.7% were Stage 1b, 27.4% II, 30.1% IIIA, 9.2% IIIB, 13.5% IV, 6.0% unknown. Primary location was 35.0% antrum, 14.0% corpus, 11.7% cardia, 32.9% GE junction, 6.5% unknown. Median age was 63 yrs; 64.7% were male; 17.3% African American; 14.3% Hispanic. Median RT dose was 45 Gy; median RT duration 36 days. A total of 14.7% had AP/PA technique, 14.2% 3-field, 45.9% 4-field, 19.8% >4 fields. Gastrointestinal bleeding and transfusion use (T) varied by U/R (20.8% no T, 16.4% T in urban; 7.2% No T, 13.8% T U/R mixed; 9.9% No T, 2.7% T rural; p = 0.03). Endoscopy was performed in >95% of cases in each area. Use of endoscopic ultrasound varied by U/R (16.7% in urban, 36.8% U/R mixed, 22.6% rural; p = 0.03). Chest CT was done more in lower U (85.2% vs. 63.8%; p = 0.02), PET more in lower POV (58.0% vs. 38.0%; p = 0.02) and lower U areas (58.3% vs. 37.8%; p = 0.02), MRI more in lower POV and U (both 11.4% vs. 1.7%; p = 0.03). Surgical resection was done less in lower POV (71.7% vs. 87.8%; p = 0.02). External beam technique varied by U/R with AP/PA more common in rural and ≥4-field more common in urban areas (p = 0.02). IMRT use varied by U/R (27.6% urban, 12.5% U/R mixed, 0% rural; p < 0.01).ConclusionsSociodemographic factors, which may be surrogates for multidisciplinary care and/or use of emerging RT treatment planning and delivery, are associated with variations in workup and treatment for GC pts who receive RT. Our next analysis will seek to determine if these findings represent access issues.AcknowledgmentThis project was supported by CURE- PA Dept. of Health & NCI Grant CA65435, Purpose/Objective(s)Quality Research in Radiation Oncology (QRRO) surveyed US radiation therapy (RT) facilities to evaluate the quality of gastric cancer (GC) treatment in 2005-07. The specific aim of this report is to describe sociodemographic (SOC) factors that influence work-up and treatment of GC patients (pts). Quality Research in Radiation Oncology (QRRO) surveyed US radiation therapy (RT) facilities to evaluate the quality of gastric cancer (GC) treatment in 2005-07. The specific aim of this report is to describe sociodemographic (SOC) factors that influence work-up and treatment of GC patients (pts). Materials/MethodsThe QRRO national survey used a two-stage stratified random sample of GC treated with RT: 250 cases from 45 institutions (6 facilities had no eligible pts). Eligibility: RT receipt in 2005-2007 for stomach or gastroesophageal (GE) junction tumors with stages Ib-IV (non-metastatic); histology of adenocarcinoma, squamous, adenosquamous; Karnofsky score ≥60. Exclusions: distant metastases or prior malignancy within 5 yrs. Five SOC variables based on 2000 US Census data were analyzed for association with clinical factors: pts living in urban vs. rural settings (U/R), median household income (HI), % below poverty level (POV), % unemployed (U) and % with college education (CE). U/R had three categories: 100% urban, 100% rural or urban/rural mix. HI, POV, U, and CE were defined as above or below the median values of this sample. Pts were linked to census data values by home ZIP code. Six pts did not link and were excluded from the analysis. National estimates used weighted averages. The QRRO national survey used a two-stage stratified random sample of GC treated with RT: 250 cases from 45 institutions (6 facilities had no eligible pts). Eligibility: RT receipt in 2005-2007 for stomach or gastroesophageal (GE) junction tumors with stages Ib-IV (non-metastatic); histology of adenocarcinoma, squamous, adenosquamous; Karnofsky score ≥60. Exclusions: distant metastases or prior malignancy within 5 yrs. Five SOC variables based on 2000 US Census data were analyzed for association with clinical factors: pts living in urban vs. rural settings (U/R), median household income (HI), % below poverty level (POV), % unemployed (U) and % with college education (CE). U/R had three categories: 100% urban, 100% rural or urban/rural mix. HI, POV, U, and CE were defined as above or below the median values of this sample. Pts were linked to census data values by home ZIP code. Six pts did not link and were excluded from the analysis. National estimates used weighted averages. ResultsOf the 244 cases 96.2% had adenocarcinoma; 13.7% were Stage 1b, 27.4% II, 30.1% IIIA, 9.2% IIIB, 13.5% IV, 6.0% unknown. Primary location was 35.0% antrum, 14.0% corpus, 11.7% cardia, 32.9% GE junction, 6.5% unknown. Median age was 63 yrs; 64.7% were male; 17.3% African American; 14.3% Hispanic. Median RT dose was 45 Gy; median RT duration 36 days. A total of 14.7% had AP/PA technique, 14.2% 3-field, 45.9% 4-field, 19.8% >4 fields. Gastrointestinal bleeding and transfusion use (T) varied by U/R (20.8% no T, 16.4% T in urban; 7.2% No T, 13.8% T U/R mixed; 9.9% No T, 2.7% T rural; p = 0.03). Endoscopy was performed in >95% of cases in each area. Use of endoscopic ultrasound varied by U/R (16.7% in urban, 36.8% U/R mixed, 22.6% rural; p = 0.03). Chest CT was done more in lower U (85.2% vs. 63.8%; p = 0.02), PET more in lower POV (58.0% vs. 38.0%; p = 0.02) and lower U areas (58.3% vs. 37.8%; p = 0.02), MRI more in lower POV and U (both 11.4% vs. 1.7%; p = 0.03). Surgical resection was done less in lower POV (71.7% vs. 87.8%; p = 0.02). External beam technique varied by U/R with AP/PA more common in rural and ≥4-field more common in urban areas (p = 0.02). IMRT use varied by U/R (27.6% urban, 12.5% U/R mixed, 0% rural; p < 0.01). Of the 244 cases 96.2% had adenocarcinoma; 13.7% were Stage 1b, 27.4% II, 30.1% IIIA, 9.2% IIIB, 13.5% IV, 6.0% unknown. Primary location was 35.0% antrum, 14.0% corpus, 11.7% cardia, 32.9% GE junction, 6.5% unknown. Median age was 63 yrs; 64.7% were male; 17.3% African American; 14.3% Hispanic. Median RT dose was 45 Gy; median RT duration 36 days. A total of 14.7% had AP/PA technique, 14.2% 3-field, 45.9% 4-field, 19.8% >4 fields. Gastrointestinal bleeding and transfusion use (T) varied by U/R (20.8% no T, 16.4% T in urban; 7.2% No T, 13.8% T U/R mixed; 9.9% No T, 2.7% T rural; p = 0.03). Endoscopy was performed in >95% of cases in each area. Use of endoscopic ultrasound varied by U/R (16.7% in urban, 36.8% U/R mixed, 22.6% rural; p = 0.03). Chest CT was done more in lower U (85.2% vs. 63.8%; p = 0.02), PET more in lower POV (58.0% vs. 38.0%; p = 0.02) and lower U areas (58.3% vs. 37.8%; p = 0.02), MRI more in lower POV and U (both 11.4% vs. 1.7%; p = 0.03). Surgical resection was done less in lower POV (71.7% vs. 87.8%; p = 0.02). External beam technique varied by U/R with AP/PA more common in rural and ≥4-field more common in urban areas (p = 0.02). IMRT use varied by U/R (27.6% urban, 12.5% U/R mixed, 0% rural; p < 0.01). ConclusionsSociodemographic factors, which may be surrogates for multidisciplinary care and/or use of emerging RT treatment planning and delivery, are associated with variations in workup and treatment for GC pts who receive RT. Our next analysis will seek to determine if these findings represent access issues. Sociodemographic factors, which may be surrogates for multidisciplinary care and/or use of emerging RT treatment planning and delivery, are associated with variations in workup and treatment for GC pts who receive RT. Our next analysis will seek to determine if these findings represent access issues.

Substantial interfraction variations, including changes in the volume and shape of lumpectomy-cavity (LC), can be observed in partial breast irradiation (PBI) with external beams. The purpose of this work is to demonstrate the feasibility and dosimetric benefits of using an online adaptive replanning scheme to address the interfractional variations in PBI. Analysis was made on 100 diagnostic-quality CT sets acquired using an in-room CT during IGRT at each fraction for 10 breast cancer patients treated with PBI in supine position. The LC, treated breast, lung and heart were delineated by populating the contours from the planning CT to each fraction CT using an auto-segmentation tool) with manual editing. An original IMRT plan was designed for each patient on the planning CT. For each fraction CT set, three plans were created: (1) adaptive plan generated with an online replanning tool, (2) repositioning plan generated by copying the original plan with the repositioning shifts (representing the current IGRT practice), and (3) the re-optimization plan obtained by a full scale optimization based with the same constrains used for the original plan. The plan quality for these three plans was compared. Compared to the planning contours, significant changes in the shape and volume of the LC were observed, mostly at the first fraction, for the 10 cases studied. On average, the volume of the LC decreases by 22%. The shape change of the LC, as measured by the maximum overlap rate, ranges from 50% to 90% with the mean value of 72%. For all 10 cases, the adaptive plans were comparable to the re-optimization plans. For 8 of the 10 cases, the three plans were comparable, indicating that the current IGRT repositioning was sufficient to account for the interfractional variations due to the large CTV/PTV margins to cover the variations in LC. For 2 of the 10 cases, the adaptive plans offered improved target coverage and/or normal tissue sparing compared the repositioning plans. In one case, the target V95 was 95.4% for the adaptive plan and 86.1% for the repositioning plan. In another case, the V30 for the ipsilateral lung was reduced from 4.6% to 1.5% and the V50 for the ipsilateral breast minus LC PTV was reduced from 48% to 44% in the adaptive plan compared to the repositioning plan. Significant interfractional variations in the LC were found during PBI. The current practice of IGRT with standard CTV/PTV margins can account for these variations for most cases studied. Online adaptive replanning was needed for cases with extremely large changes in LC.

A general opinion is that protons may achieve higher-quality radiation therapy (RT) plans than can photons. To investigate whether certain disease sites or subsets of patients may be better served with a modern photon modality such as image-guided intensity-modulated RT, we compare the quality of helical tomotherapy plans with that from classic proton plans for certain brain and head and neck tumors, in terms of target dose uniformity and conformity, and organs-at-risk (OAR) sparing. Among the disease sites considered were posterior fossa, orbit, parameningeal, and nasopharynx. All patients were originally planned and treated using helical tomotherapy. Proton plans were generated using a commercial planning system with a passively-scattered proton beam model featuring a maximum range of 32 g/cm2 (225 MeV), range modulation in 0.5 g/cm2 increments, and range compensators with milling tool diameter of 4.8 mm. All proton plans were limited to two beams except for a nasopharynx case which used four non-coplanar beams. Plan quality was compared using dose volume parameters including uniformity index (UI) (the ratio of the minimum doses covering 5% and 95% of the target volume), conformity index (CI) (the ratio of the target volume to the volume encompassed by the prescribed dose), and a EUD-based plan quality index, fEUD (composite value calculated using EUDs for all targets and OARs; larger fEUD indicates higher plan quality). For 8 of 9 targets, UI was improved for the proton plan; on average, UI was 1.04 for protons versus 1.07 for tomotherapy. For 6 of 9 targets, the tomotherapy plan exhibited more favorable CI; on average, CI was approximately 6% higher for tomotherapy than for protons. For proximal OARs, such as the brainstem for posterior fossa and the optic nerves for orbit and nasopharyx, tomotherapy yielded lower maximum dose. For posterior fossa, this was attributed to higher CI from tomotherapy. For distal OARs, such as the eyes and pituitary for posterior fossa and the contralateral eye and inner ear for orbit, the maximum dose was much lower for proton plans; this was attributed to the choice of beam directions. For 4 of 6 cases, near-total avoidance for distal OARs provided by protons leads to improved fEUD. However, for the other two cases (one orbit, one nasopharynx), the fEUDs for the tomotherapy and proton plans were equal. Modern photon modalities such as tomotherapy may have advantages over passively-scattered proton beams in limited disease presentations with regard to target conformity and sparing proximal OARs from high dose for certain target sites. Proton beams may provide slightly more uniform target dose and negligible dose to distal OARs, leading to overall plan quality similar to the modern photon modalities in those cases.

The American College of Radiology (ACR), Quality Research in Radiation Oncology (QRRO) has surveyed US radiation facilities to evaluate the quality of breast cancer treatment in 2007. This report describes sociodemographic (SOC) factors that affect work-up and treatment of breast cancer patients. QRRO used a two-staged stratified random sample to perform a national survey of the treatment of operable breast cancer in 2007: this yielded 442 cases from 45 randomly selected institutions. Eligibility for surveyed cases: receipt of radiation therapy (RT) in 2007 for operable invasive breast cancer (stages I to IIIA) treated with breast conservative surgery (BCS) or mastectomy (M). Exclusions were bilateral disease, prior malignancy or prior RT. SOC variables based on data from the 2000 U.S. census were investigated. These include patients living in urban vs. rural settings (U/R), median household income (HI), percent female unemployed (U) and percent female college educated (CE). U/R had three categories - 100% urban, 100% rural or any urban/rural mix. The other three variables were defined as above or below the medians for this sample. Patients were linked to census data values based on their home ZIP code. Eleven patients could not be linked and were excluded from the analysis. National estimates were based on weighted averages. Of the 431 cases, 69.5% were T1, 20.8% T2, 3.3% T3 and 6.4% unknown, 71.6% node negative/IHC positive only, 28.3% node positive. Median age was 60 years. Surgical treatment was 84.4% BCS and 15.6% M; 80.5% had sentinel lymph node biopsy (SLNB). Of those undergoing M, 16.3% had reconstruction. Accelerated partial breast irradiation (APBI) was done in 5.8%, whole breast RT in 78.1%, post-mastectomy RT in 15.6%. MRI was used in workup in 22.1% of cases. There was no difference in pathologic stage, age, use of systemic therapy, IMRT, or CT based treatment planning across the SOC variables. Patients in areas with higher median income (30.6% vs. 15.0% p = 0.01), urban centers (28.3% vs. 11.2% rural, 21.0% U/R mixed, p = 0.02) and college educated (28.7% vs. 16.4%, p = 0.02) were more likely to undergo breast MRI. Patients living in lower HI areas were more likely to get APBI (11.9% vs. 4.4%, p = 0.02). Of those in rural areas, 19.2% got APBI versus 8.2% for U/R mix and 5.2% for urban settings (p = 0.21). Patients living in areas with more CE had SLNB 84.7% compared to 76.8% in areas with less CE (p < 0.1). Of the SOC factors evaluated in this QRRO survey population, median household income was the most predictive for association with MRI use and APBI. Variability in utilization of newer technologies in the management of breast cancer as they relate to SOC factors requires confirmation and deserves further investigation.

To demonstrate how the American College of Radiology, Quality Research in Radiation Oncology (QRRO) process survey database can serve as an evidence base for assessing quality of care in radiation oncology. QRRO has drawn a stratified random sample of radiation oncology facilities in the USA and invited those facilities to participate in a Process Survey. Information from a prior QRRO Facilities Survey has been used along with data collected under the current National Process Survey to calculate national averages and make statistically valid inferences for national process measures for selected cancers in which radiation therapy plays a major role. These measures affect outcomes important to patients and providers and measure quality of care. QRRO's survey data provides national benchmark data for numerous quality indicators. The Process Survey is “fully qualified” as a Practice Quality Improvement project by the American Board of Radiology under its Maintenance of Certification requirements for radiation oncology and radiation physics.

The Quality Research in Radiation Oncology (QRRO) GU and eData committees established a task group to prospectively demonstrate remote de-identification and common aggregation of prostate brachytherapy treatment plans for comparative quality assessment from a representative cross section of United States radiation oncology facilities. Seventy prostate brachytherapy datasets consisting of DICOM CT images, RT Structure Set, and RT Dose files extracted from a variety of treatment planning systems (TPS), were remotely de-identified and submitted from 16 US sites to a data aggregation control center at the ITC. The de-identified CT image files were separated and accessed by the reference expert center where new structure and dose files were created in a single TPS. The new files were then uploaded, registered to the originally submitted treatment plans, and used as the benchmark to compare the original structure and dose files and to assess quality. In 69 of 70 submitted datasets, submitted (S) and reference expert (R) dataset-pairs were successfully registered for analysis. For 69 evaluable cases, spatial and dose-volume metrics were used to analyze S and R datasets. The spatial similarity of S and R prostate contours was assessed using Dice's coefficient (avg. 0.837, SD 0.043). Dose-volume histograms for S and R contours were computed for both S and R dose distributions and used to assess the accuracy of submitted plans when compared to the reference expert. Average pD90 for prostate as percentage of prescription dose (PD) was 101.5, (SD 17.6); for S contours/doses, and 101.1 (sd18.5) for R contours/doses. The average pV100% and pV150% (% volumes of prostate receiving 100% and 150% PD) were 88.1 (SD 10.7) and 52.6 (SD 16.5), respectively for S contours/doses and 87.9 (SD 11.2) and 53.2 (SD 16.5) respectively for R contours/doses. Rectal pD2cc (min. dose to the hottest 2 cc as percentage of PD) for R contours/doses was 66.6 (SD 20.3) for the entire rectum and 58.8 (SD 17.0) for rectum minus the volume within 5 mm of the prostate. This prospective project demonstrated the feasibility of remote de-identification, common aggregation, and comparative analysis of volumetric TP data for evaluating the quality of prostate brachytherapy seed plans. Tools and methods developed through the Advanced Technology Consortium were successfully adapted for this project to facilitate the export, submission, and dose-volume analysis of data. Export of datasets from TPS as DICOM was largely successful, but required manual effort for surveyors to include prescription and seed data due to imperfect interoperability.

Purpose: This work evaluates the use of target and organs at risk (OAR) dose-volume goals in 3D conformal radiotherapy (3DCRT) planning for node positive breast cancer (NPBC) patients undergoing regional nodal irradiation after lumpectomy/mastectomy. Methods: Dosimetric data for 262 NPBC patients receiving regional nodal and whole breast/chest wall (WB/CW) irradiation from 2000-2009 were analyzed. In all cases, target & OAR volumes were delineated on treatment CT scans for field generation and dose-volume histograms (DVHs) were generated. Cases were analyzed to identify how frequently they met treatment planning institutional dose-volume goals (“institutional guidelines” & standardized in 2005) and how this would affect OAR doses. Results: The incidence of cases from 2000-2009 meeting current institutional guidelines improved over the study period. Target coverage improved from 2005-2009, when guidelines were followed as a part of the plan approval. Those cases from 2000-2004 meeting acceptable target goals were found to be significantly different from those cases from 2005-2009 (p Conclusions: The use of institutional guidelines in 3DCRT for WB/CW and regional nodal irradiation for NPBC patients improved target coverage without a statistically significant increase in heart and lung doses.

Regional nodal irradiation in lymph node (LN) positive breast cancer (BC) post lumpectomy / mastectomy can be subject to controversy due to the potential for treatment morbidity. Three-D-CRT methods have been associated with reduced treatment related toxicity in other disease sites, but little is known about outcomes in LN positive BC. Between 2000 and 2007, 172 women with node positive BC were treated with regional nodal irradiation following lumpectomy or mastectomy using 3DCRT. In all cases, target and normal tissue volumes were delineated on treatment CT scans with field arrangement and beam modification to meet established treatment goals. Patient population and tumor characteristics as well as recurrence rates are reported. Toxicities were scored using the Common Toxicities Criteria for Adverse Effects v3.0. Data was analyzed using summary statistics. Median follow-up (f/u) of surviving patients was 7 (1-10.6) years. Median patient age was 50 (27-91), 52.35% were premenopausal, 75.74% had positive estrogen receptors, 66.27% had positive progesterone receptors, and 15.92% were HER-2 positive (3+ Hercept or amplified by FISH). Mean number of all LNs recovered was 17.1 (1-46), mean positive LNs: 5 (1-29), extra capsular invasion: 47.31%). Mean microscopic tumor size was 3.73 (0.1-21) cm. Staging was pII in 43.3% and pIII in 52%. 52.3% underwent lumpectomy and 45.93% mastectomies. 93.0% had systemic chemotherapy (63.4% adjuvant and 29.7% neoadjuvant), with 90.3% anthracycline based regiment. The grade of acute dermatitis was 1 for 83.0%, 2 for 13.4%, and 3 for 2.91%. Moist desquamations-confined to skin folds-was present in 14% and outside of folds 3.5%. Grade > 2 fatigue occurred in 18.6%. Late toxicities included: Grade 1 (24.7%) and Grade 2 (1.9%) hyperpigmentation, Grade 1 (9%) and Grade 2-3 (3.2%) telangiectasia, and Grade 2-3 fibrosis (5.13%). One case (0.6%) each of pneumonitis and pericarditis occurred. There were no incidences of brachial plexopathy. Decreased range of motion (ROM) at last f/u was 3%, with-overall physical therapy referral post RT for ROM at 16.6%. 96% had arm circumference measurements: 16.4% developed lymphedema as determined by >2 cm arm circumference difference. Local control was achieved in 94.7% (local recurrence rates were 7.9% post-lumpectomy and 2.5% post-mastectomy (p > 0.1) and regional LN control in 99.4% (0% supraclavicular or internal mammary recurrences). Our study demonstrates that the use of 3D-CRT resulted in excellent locoregional cancer control and with low incidences of post RT toxicities in these relatively higher risk node positive BC patients treated comprehensively.

Abstract Background For NPBC patients the use of regional nodal irradiation (RNI) to the supraclavicular, axillary, internal mammary lymph nodes (IMN) in addition to the chest wall and/or breast can maximize locoregional control and improve overall survival. However, comprehensive RNI for breast cancers located on the left side has been linked to late cardiac morbidity, potentially lessening the therapeutic benefit of treatment. The optimal radiation dose-volume constraints for the heart in this setting are not fully understood. We examined NPBC patients treated with RNI using 3D-CT based radiation therapy (RT) to evaluate cardiac dose and incidence of cardiac events. Methods: Between 2000 and 2007, 150 NPBC patients were treated with RNI following lumpectomy or mastectomy using 3D-CRT. In all cases, treatment target and normal tissue volumes were delineated on treatment CT scans. The heart contour included the ventricles and the left atrium. The dose-volume histogram of the cardiac doses delivered and the incidence of cardiac events is reported. Results: Median follow-up of surviving patients is 7 (1-10.6) years. Median patient age is 50 (27-91). 52.35% are premenopausal, 75.7% estrogen receptor positive, 66.3% progesterone receptor positive and 15.92% HER-2 positive. Mean positive lymph nodes is 5 (1-29). Extracapsular extension is present in 47.31%. Mean microscopic tumor size is 3.73 (0.1-21) cm. The IMN receive > 40 Gy in 65.5%. 94% had chemotherapy, and in 82.3% it was anthracycline-based. At the time of RT, 12.2% smoked, 9.5% had diabetes, 32.4% with hypertension, and 4.7% with a history of coronary artery disease. There was 1 (0.7%) right sided patient with cardiac events and 4 (2.7%) left sided experiencing cardiac events (p = 0.121, Fisher's Exact test). A total of 10 cardiac diagnoses were experienced among the 5 patients: coronary artery disease with myocardial infarction (3), congestive heart failure (2), cardiomyopathy (2), and arrhythmia (3). The median time interval to onset of the events is 2.5 years (0-4.3 years). The cardiac doses among 150 patients are as follows: mean V25 is 5.7, (0.0 - 20.0%), V25 is < 9 % in 74.4% of patients, mean V45 is 1.8% (0-13.3%), V45 is < 5.5% in 91.8%. The mean maximum point dose is 42.8 Gy, and the mean heart dose is 5.6 Gy (0.2−25.3 Gy). The mean V25 and V45 in those 5 patients with a cardiac event is 6.7% (0.9−11.9%) and 3.7% (0-6.6%), respectively; in the 145 remaining patients, 5.7% (0-20.0%) and 1.7% (0-13.3%), respectively. The mean heart dose in those with an event is 5.2 Gy (2.4−7.3 Gy) versus 5.6 Gy (0.2−25.3 Gy) in the remaining patients. Conclusions: The cardiac event rate among these NPBC patients treated with RNI and anthracycline-based chemotherapy is low. However, those patients with cardiac events have a higher mean V45. No other dose-volume relationships are discernible. Additional analysis using 3DCRT volumes are important to validate these findings and better define the dose-volume parameters for cardiac toxicity. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-13-05.

209 Background: The WICaRE Program is a part of the cross sectional Patterns of Care Study–Breast and Prostate (PoC-BP) that sought to evaluate the patterns of BC care in the state WI and to identify areas for potential improvement in data collection and factors associated with variation in care. This study was to examine the geographic disparities in SM and the use of RT in female BC patients diagnosed in WI in 2004. Methods: The Wisconsin Cancer Reporting System (WCRS) receives reports from 130+ facilities. Information of patient (disease status, sociodemographic, treatment, county of residence) was obtained from cancer registries and supplemental data was reabstracted from medical charts across 66 counties. Geographic regions were counties grouped by WI Dept. of Health Services (DHS) as Northeastern (NE), Northern (N), Southeastern (SE), Southern (S), Western (W). Results: A total of 1037 cases were reported. 25% age 20-49, 49% age 50-69, and 28% age 70+; Caucasian had 82%, black 10% and others 8%. 34% had T1 stage, 9% T2, 4% T3+, and 53% TX-T0/unknown stage. 46% had reported mild comorbidity, 9% had moderate or severe comorbidity. Majority (73%) lived in the Metropolitan Statistical Area (MSA). 29% patients from NE region, 10% from N, 36% SE, 17% S and 8% W. Patients in the S and W had significantly lower % who received RT (46 and 48% respectively) than those in NE (61%), N (62%) and SE (63%), p=0.01; % mastectomy (MA) by regions were 43% (NE), 42% (N), 33% (SE), 47% (S) and 35% (W), p=0.009. Multivariate models adjusting for disease status, comorbidity, and sociodemographic factors showed that patients in MSA region were more likely to have RT compared to those in non-MSA (odds ratio, OR=1.66, 95%CI=1.14-2.40), but those in S were less likely than those in SE (OR=0.59, 95%CI=0.38-0.91). Patients in MSA had a decreased likelihood of undergoing mastectomy. NE (OR=1.6, 95%CI=1.08-2.29) and S (OR= 2.04, 95%CI=1.31-3.17) had significantly higher odds of having MA than those in SE. Conclusions: This study showed evidence of geographic disparity in medical care for BC patients in Wisconsin. Identifying factors mediating this disparity will help in developing appropriate treatment options and improving outcomes.

Purpose/Objective(s)To investigate the association of the prevalence of co-morbidities with treatment decisions and variations in compliance with recommended disease management guidelines for patients with Stage III NSCLC. The National Cancer Institute (NCI) is striving for the goal of personalized cancer prevention, diagnosis, treatment, and survivorship.Materials/MethodsThe QRRO survey used stratified 2-stage cluster sampling. All radiation oncology facilities operating in the United States in 2007 were stratified, facilities were randomly sampled within each stratum and eligible cases were randomly sampled from each participating facility. 106 facilities were invited to participate, of which 45 (42%) of participated in the study: 14 academic, 13 large nonacademic [(> = 3 active linear accelerators (linac)], 7 medium nonacademic (2 linac), and 11 small nonacademic (1 linac). Data was collected on co-morbidities using the Adult Co-morbidity Evaluation (ACE), a 27-item validated co-morbidity index for multiple organ systems. National estimates were calculated from the survey data using SUDAAN statistical software which incorporates the design elements and weights in the analysis.Results211 Stage III NSCLC patients were sampled for a weighted population estimate of 19,927 and divided into 3 groups according co-morbidity grade: group 1 (53.0%) = Mild (No co-morbidities or only Grade 1 co-morbidity); group 2 (27.2%) = Moderate (any Grade 1 and only 1 Grade 2); group 3 (19.8%) = Severe (at least 2 Grade 2 or at least 1 Grade 3). Median age was 63 years (range: 37 - 90). For groups 1, 2 and 3 respectively, concurrent chemoradiotherapy was given to 85.8% (98/114), 71.5% (40/57) and 64.5% (25/40) patients, respectively (p = 0.0042). Treatment plan was contra-indicated or changed due to co-morbidities in 3.7% (5/114), 20.7% (17/57) and 58.5% (26/40), respectively (p<0.00001). At last contact, 15.8% (18/114), 14.5% (9/57) and 6.6% (3/40) patients, were alive with no evidence of disease, respectively (p>0.05).ConclusionsStage III NSCLC patients with severe co-morbidities had a lower rate of concurrent chemoradiotherapy and a higher incidence in which the original treatment plan was either contra-indicated or changed due to co-morbidities. Analysis of co-morbidity needs to be considered a part of personalized cancer treatment in the future.AcknowledgmentSupported by Pennsylvania Department of Health, Tobacco Settlement Act 77 - 201, Commonwealth Universal Research Enhancement (C.U.R.E.) program and NCI Grant CA065435. Purpose/Objective(s)To investigate the association of the prevalence of co-morbidities with treatment decisions and variations in compliance with recommended disease management guidelines for patients with Stage III NSCLC. The National Cancer Institute (NCI) is striving for the goal of personalized cancer prevention, diagnosis, treatment, and survivorship. To investigate the association of the prevalence of co-morbidities with treatment decisions and variations in compliance with recommended disease management guidelines for patients with Stage III NSCLC. The National Cancer Institute (NCI) is striving for the goal of personalized cancer prevention, diagnosis, treatment, and survivorship. Materials/MethodsThe QRRO survey used stratified 2-stage cluster sampling. All radiation oncology facilities operating in the United States in 2007 were stratified, facilities were randomly sampled within each stratum and eligible cases were randomly sampled from each participating facility. 106 facilities were invited to participate, of which 45 (42%) of participated in the study: 14 academic, 13 large nonacademic [(> = 3 active linear accelerators (linac)], 7 medium nonacademic (2 linac), and 11 small nonacademic (1 linac). Data was collected on co-morbidities using the Adult Co-morbidity Evaluation (ACE), a 27-item validated co-morbidity index for multiple organ systems. National estimates were calculated from the survey data using SUDAAN statistical software which incorporates the design elements and weights in the analysis. The QRRO survey used stratified 2-stage cluster sampling. All radiation oncology facilities operating in the United States in 2007 were stratified, facilities were randomly sampled within each stratum and eligible cases were randomly sampled from each participating facility. 106 facilities were invited to participate, of which 45 (42%) of participated in the study: 14 academic, 13 large nonacademic [(> = 3 active linear accelerators (linac)], 7 medium nonacademic (2 linac), and 11 small nonacademic (1 linac). Data was collected on co-morbidities using the Adult Co-morbidity Evaluation (ACE), a 27-item validated co-morbidity index for multiple organ systems. National estimates were calculated from the survey data using SUDAAN statistical software which incorporates the design elements and weights in the analysis. Results211 Stage III NSCLC patients were sampled for a weighted population estimate of 19,927 and divided into 3 groups according co-morbidity grade: group 1 (53.0%) = Mild (No co-morbidities or only Grade 1 co-morbidity); group 2 (27.2%) = Moderate (any Grade 1 and only 1 Grade 2); group 3 (19.8%) = Severe (at least 2 Grade 2 or at least 1 Grade 3). Median age was 63 years (range: 37 - 90). For groups 1, 2 and 3 respectively, concurrent chemoradiotherapy was given to 85.8% (98/114), 71.5% (40/57) and 64.5% (25/40) patients, respectively (p = 0.0042). Treatment plan was contra-indicated or changed due to co-morbidities in 3.7% (5/114), 20.7% (17/57) and 58.5% (26/40), respectively (p<0.00001). At last contact, 15.8% (18/114), 14.5% (9/57) and 6.6% (3/40) patients, were alive with no evidence of disease, respectively (p>0.05). 211 Stage III NSCLC patients were sampled for a weighted population estimate of 19,927 and divided into 3 groups according co-morbidity grade: group 1 (53.0%) = Mild (No co-morbidities or only Grade 1 co-morbidity); group 2 (27.2%) = Moderate (any Grade 1 and only 1 Grade 2); group 3 (19.8%) = Severe (at least 2 Grade 2 or at least 1 Grade 3). Median age was 63 years (range: 37 - 90). For groups 1, 2 and 3 respectively, concurrent chemoradiotherapy was given to 85.8% (98/114), 71.5% (40/57) and 64.5% (25/40) patients, respectively (p = 0.0042). Treatment plan was contra-indicated or changed due to co-morbidities in 3.7% (5/114), 20.7% (17/57) and 58.5% (26/40), respectively (p<0.00001). At last contact, 15.8% (18/114), 14.5% (9/57) and 6.6% (3/40) patients, were alive with no evidence of disease, respectively (p>0.05). ConclusionsStage III NSCLC patients with severe co-morbidities had a lower rate of concurrent chemoradiotherapy and a higher incidence in which the original treatment plan was either contra-indicated or changed due to co-morbidities. Analysis of co-morbidity needs to be considered a part of personalized cancer treatment in the future. Stage III NSCLC patients with severe co-morbidities had a lower rate of concurrent chemoradiotherapy and a higher incidence in which the original treatment plan was either contra-indicated or changed due to co-morbidities. Analysis of co-morbidity needs to be considered a part of personalized cancer treatment in the future.

High Body mass index (BMI)/obesity and disrupted glucose metabolism have been identified in a number of studies as risk factors for distant recurrence and decreased survival in breast cancer. Our institution aimed to examine whether BMI and/or diabetic status predicts for local recurrence and reduced survival in a cohort of predominantly obese women, as measured by BMI, treated with breast conservation therapy (BCT). From 1998-2006, 109 women with early stage breast cancer were treated with prone whole breast irradiation (WBI) using 3D conformal radiation. A retrospective review was performed examining BMI and diabetic status at diagnosis. The association of BMI and crude recurrence rates was examined using Fisher's Exact test. The association of BMI and diabetes with local recurrence-free survival (LRFS), progression-free survival (PFS), disease-free survival (DFS), distant metastasis-free survival (DMFS), and overall survival (OS) was examined using Cox proportional hazards regression. Median age was 61. Seventy-five percent of patients were post-menopausal, and 79% had invasive disease, with a mean tumor size of 1.6 cm. Nodal disease (N1) was present in 14%, and 77% of patients with invasive disease were ER/PR+. Appropriate systemic therapy was recommended to all patients. Median BMI was 33.6 (mean 34.6); 89% were overweight (BMI≥25), 75% of patients were clinically obese (BMI≥30), and 37% had ≥WHO class II obesity (BMI≥35). Eleven patients had diabetes (10%). Median follow-up was 70 months. For the cohort, 5-year LRFS, PFS, DFS, DMFS, and OS were 96%, 89%, 83%, 92%, and 88%, respectively. Diabetes was not associated with cancer progression or recurrence. The crude recurrence rate for those with greater than the median BMI (33.6) was 9.4%, versus 0% for those with BMI less than the median value (p = 0.057). BMI was significantly associated with decreased DMFS (HR 1.15, p = 0.016), PFS (HR 1.13, p = 0.008), DFS (HR 1.16, p<0.0001), and OS (HR 1.17, p = 0.0003). On multivariate analysis, adjusting for tumor subtype, grade, nodal involvement, chemotherapy, and diabetes, BMI remained a significant predictor of poorer PFS (p = 0.012), DFS (p = 0.0001), DMFS (p = 0.011), and OS (p = 0.0004). In this cohort of early stage breast cancer patients with high BMI, increasing BMI predicted for worse PFS, DFS, DMFS, and OS. In addition, there is a suggestion that BMI impacts the rate of local recurrence that warrants investigation in larger cohorts of patients. This investigation adds to growing evidence that BMI is an important prognostic factor in early stage breast cancer treated with BCT.