Purpose/Objective(s) Management of the axilla continues to move through a paradigm shift for breast cancer patients. It has been established that radiation therapy (RT) can be utilized in lieu of an axillary lymph node dissection (ALND) for positive nodes after sentinel lymph node biopsy (SLNB). In the neoadjuvant setting, it has similarly been established that SLNB and/or targeted axillary dissection (TAD) is safe and effective for staging the axilla after neoadjuvant chemotherapy (NAC) for clinically node negative patients (ycN0). In the setting where a positive node is identified (ypN+), management has defaulted to ALND, and whether we can apply the equivalency of RT in this setting is an active trial question (A011202). However, there is a significant subset of patients that are unable to or otherwise choose not to undergo an ALND in this setting due to the morbidity of the procedure. There is limited direct evidence to support the omission of ALND. Materials/Methods We sought to examine the rate of regional recurrence of ycN0 patients (by surgeon's clinical exam and/or post-NAC imaging) who were subsequently identified to have ypN+ disease as identified on SLNB or TAD from 2013 – 2023. Patients were divided into two groups: Group 1) ALND 10+ nodes and Group 2) SLNB/ALND <10 nodes. We secondarily examined the overall survival (OS), local-regional control (LRC), control of distant metastatic spread (DM) and the impact of axillary management on outcomes using a log-rank method. Patients that received neoadjuvant endocrine therapy were excluded. Results Fifty-eight patients were identified to have ypN+ disease followed neoadjuvant therapy. Of those, 35 were identified to have NAC with ycN0 on their surgeon's examination and were available for analysis. With a median follow-up of 38 months, the 3-year rates of LRC, OS, and DM was 97% (81.4 - 99.6), 96% (69.8 – 97.8), and 90% (64.4- 94.3). Dividing patients by axillary evaluation, group 1 contained 14 patients (40%) and group 2 contained 21 patients (60%). There was no statistical difference between the rate of regional recurrence between groups 1 and 2 (p = 0.22). There were no regional recurrences in Group 2. There was also no difference in OS or DM (p = 0.59, p = 0.92). All patients received nodal-directed RT. Conclusion For patients with ycN0, ypN+ disease there is no difference in disease outcomes between patients managed with ALND or nodal-directed RT in this small retrospective series. RT remains a reasonable option for patients who decline or cannot receive an ALND. Ongoing trials will define if this approach will serve as a new standard of care.

COVID-19 is associated with characteristic lung CT findings, such as rounded ground-glass opacities in certain distributions. Diagnosing COVID-19 is a particular concern in oncology care, since cancer patients are a vulnerable population who receive treatment in close proximity to other patients and staff. Radiotherapy patients routinely undergo CT simulation before starting therapy. We hypothesized that simulation CT scans obtained on patients treated during the pandemic would reveal characteristic COVID-19 findings and represent a tool to identify patients with asymptomatic COVID-19.

Treatment Terminations (TT) adversely impact the clinical outcomes of patients receiving radiation. TTs are frequently monitored as part of QA metrics in radiation oncology departments, but a benchmark TT rate has not been established. Furthermore, the TT rate for each disease site varies significantly due to differences in treatment duration and toxicity, yet data stratified by disease site is not widely available. We had previously reported a composite annual TT rate of 7.1% in our department from 2013-2016. The aim of this study is to review TT rates from 2017-2019 and to establish a baseline TT rate stratified by disease site. Patients with TTs from 01/2017 to 12/2019 in our multi-center department were reviewed. Cases were identified by our chief radiation therapist during routine monthly quality and safety monitoring. TTs were defined as the discontinuation of therapy after CT simulation was completed. All external beam cases treated by our department were reviewed and assigned a disease site based on pre-established treatment directives. TTs in curative cases were stratified by disease site, and TTs in palliative cases were stratified by anatomical location. A total of 8,222 treatments were planned from 2017-2019; 61% of the cases were curative, 34% palliative, and 6% benign. There was a total of 333 TTs during this period, representing 4.1% of all cases; 49.5% of the TTs were curative and 50.5% were palliative. When stratified by intent, the TT rate per new start for curative cases was 3.1%. The disease sites with the highest absolute number of TTs were head and neck (n = 63), lung (n = 25), and breast (n = 17); the disease sites with the highest TT rate were vulva (21.6%, n = 8), head and neck (7.9%, n = 63), esophagus (6.9%, n = 6), and lung (5.8%, n = 25). The sites with the lowest TT rate were prostate (0.75%, n = 5) and breast (1.15%, n = 17). For palliative cases, the TT rate per new start was 6.1%; sites with highest TT rate were spine (18.8%, n = 30), breast (17.5%, n = 7), abdomen (11.5%, n = 11), and thorax (10%, n = 27). Patients in the curative group has the highest risk of terminating treatment after receiving >75% of the prescribed dose (n = 49). A total of 93 patients (27%) were scheduled for treatment but received no radiation prior to TT; within this group 50% were curative and 50% were palliative. Reason for TT in this group included: going elsewhere for treatment, changes in goals of care, and progression of disease. TTs have the potential to impact clinical outcomes in both the curative and palliative setting. Establishing a benchmark TT rate for each disease site can help identify opportunities to improve care. While the TT rate in this study cohort has decreased by about 43% compared to prior, there is still a high percentage of patients not completing care. Given the a priori intent of care, TT's represent substandard opportunities at achieving that intent. Additional analysis is needed to identify the causes for TT's and to formulate interventions to reduce TT rate.

Breast cancer survivors are at increased risk of late cardiotoxicity years after left-sided radiation (RT) which can manifest as coronary artery disease (CAD) or other morbidities; the risk increases with both dosage and time. Classically, left-sided 3-D tangent RT fields deliver dose to the anterior heart and coronary vessels. As part of a multi-modality screening study, we hypothesized an increased incidence of CAD in patients (pts) who received left-sided RT compared to those who received other treatment(s). The CAROLE (CArdiac Related Oncologic Late Effects) Study, a prospective, single-center screening study enrolled 201 pts treated for breast cancer (any stage/treatment), ≥6 years prior (2004-2011), age 18-65 at diagnosis, and with no known cardiac disease at the time of cancer diagnosis. All pts received an electrocardiogram, echocardiogram, and a coronary artery calcium CT scan (CAC CT). Presence of CAD was defined as an Agatston score of >0 on CAC-CT. The individual vessel (left main [LM], left anterior descending [LAD], left circumflex [LCX], and right coronary arteries [RCA]) scores and overall Agatston sum scores were assessed by a single experienced cardiologist. CAD incidence was evaluated among +/-left-sided RT pts using a Chi-squared test. Following 6/2017-7/2018 enrollment, 199/201 pts had sufficient data for CAC CT analysis, 79 pts with left-sided RT and 120 with other treatment(s). Among all, median age at imaging was 63 (37-77). Median interval from diagnosis to imaging was 11.5 years (6.7-14.5). Overall, 38.6% had CAD on CAC CT; 43.6% in left-sided RT pts vs. 36.1% without (p=.70). For individual vessels (left-sided RT vs. without), incidence of CAD was: 17.9% vs. 8.4% LM (p=.04), 39.2% vs. 32.7% LAD (p=.35), 18.9% vs. 12.5% LCX (p=.21), and 18.9% vs. 20% RCA (p=.85). Among breast cancer survivors a median of 11.5 years since diagnosis, 43.6% of left sided RT pts and 36.1% of other pts (NS) had evidence of CAD on CAC CT screening. In this pilot study, there was a trend towards higher CAD in the LM of left-sided RT pts (p=.04, NS after Bonferroni adjustment); other vessels and overall scores were not statistically different among groups. This data provides evidence of high rates of occult CAD in a heterogenous group of breast cancer survivors and warrants consideration of CAC CT for cardiac screening for patients ∼10 years after cancer treatment. Further prospective evaluation with a larger cohort is warranted.

In an academic tertiary care setting, we have developed a multidisciplinary palliative care team, which includes members of radiation oncology, medical oncology, and palliative care, that performs daily inpatient rounds. We look to examine the impact this initiative has had on recommendations for radiation therapy, patient length of stay, and for those patients recommended radiation treatment, treatment completion rates. Multidisciplinary palliative care rounds (MPCR) were initiated in July 2017. We retrospectively reviewed all medical records for patients treated at this inpatient facility from 1/2017 – 12/2017, and recorded demographic data, treatment details, and length of inpatient stay after a radiation oncology consultation. We compared the 6 month baseline data prior to the initiative (1/17-6/17) with that from the 6 months immediately following (7/17-12/17) using Chi-square and two sample, two tailed t-tests. A total of 176 inpatients received radiation therapy during this 12-month interval. There was a 35% increase in number of inpatient radiation treatment courses in the 6 months after development of MPCR as compared to the 6 months prior (104 treatment courses post-MPCR versus 77 treatment courses pre-MPCR). Number of fractions recommended was not different (mean of 6.1 fractions pre-MPCR versus mean of 5.5 fractions post-MPCR, p=0.37). The median number of fractions recommended for both time periods was 5. There was a trend towards increased recommendation of single fraction RT (7 courses pre-MPCR versus 16 courses post-MPCR, p=0.16). Early treatment terminations, defined as patients who received less than the prescribed number of treatments, was not different (11.7% pre-MPCR versus 13.5% post-MPCR, p=0.72). There was, however, a trend towards decreased length of stay (median of 14 days pre-MPCR versus median of 12 days post-MPCR, p=0.36). We found that multidisciplinary palliative care rounds are feasible and result in changes in practice patterns of palliative care patients. There was a large increase in the number of patients treated with radiation therapy and a trend towards decreased length of stay. This likely is due to better recognition of indications for palliative radiation therapy as well as improved communication between the treatment teams. While the median number of treatments recommended was 5, we did see a trend toward increased recommendation of single fraction treatments. Longer term follow-up is needed to confirm these findings.

Active surveillance (AS) for prostate cancer has become an established management option for patients with low-risk prostate cancer. Randomized evidence from the PROTECT trial shows equivalent prostate-specific mortality between AS, radiation (RT), and surgery for prostate cancer detected via prostatic serum antigen (PSA). The main drivers for selection of treatment once a patient is placed on AS remains unclear. We describe the characteristics of our AS cohort and examine the reasons for proceeding with treatment, treatment modality selection, and assess impact of the medical specialist performing AS on patient decision making. Patients seen in consultation with very low-risk and low-risk prostate cancer were offered AS as one management option. A review of 2,545 patient charts with newly diagnosed prostate cancer from 2010-2016 was undertaken. Seven hundred ninety-four of those charts met institutional criteria for AS. One hundred sixty-seven of those meeting criteria chose to undergo AS within the radiation oncology department. Twenty-two of 167 opted to discontinue follow-up before their confirmatory studies, leaving 145 who underwent surveillance. Descriptive statistics were performed to characterize the patients in the cohort, proportion treated, reasons for treatment, and treatment choices. To compare the impact of the following-specialty on treatment choice, an additional 175 patients followed primarily by urology were added to the analysis. Two-sided Fisher’s exact test was used to compare proportions. Out of 145 patients, 138 (81.3%) had Gleason 3+3, 28 (17%) had Gleason 3+4 and 3 (1.8%) had Gleason 4+3. The majority (96.4%) were T1c and 112 (67%) were characterized as having NCCN very low risk with a mean PSA of 5.38ng/mL (± 2.38ng/mL). Ultimately 66 (45.5%) required or chose treatment. Of these, 36 (54.7%) were due to an increase in Gleason score or PSA rise, 14 (21%) electively decided against further AS, 6 (9%) for radiographic progression and 10 (15%) for other. The median time to initiate treatment was 3.8 years from diagnosis. Of the 175 patients followed primarily by urology, 59 (34%) received treatment. In total, 76 patients received RT, 36 patients received surgery, 12 received unknown, and 1 received primary hormone treatment due to PSA doubling-time. In comparing those followed by RT and those followed by surgery, patients were 15x more likely to receive RT if followed by a RT service than if followed by surgery (OR 15.4; p-value <.0001). In our cohort, men with low-risk prostate cancer and eligible for AS elected surveillance 21% of the time with slightly less than half of the cohort converting to treatment within 4 years. The most common reason for receiving treatment was either an increase in Gleason score or rise in PSA followed by patient anxiety regarding diagnosis. The choice of treatment is significantly impacted by the specialty performing the surveillance, which emphasizes the importance of the patient-physician relationship in men undergoing AS.

Purpose/Objective: Radium-223 prolongs survival and decreases symptomatic skeletal events in men with metastatic castrate-resistant prostate cancer and is indicated in patients with painful bone metastases. However, pain responses are rarely reported and often asked about by patients. Further, patients and their physicians are concerned about a lack of pain response portending a poor treatment response and may be inclined to change systemic therapies before completing 6 cycles. We evaluated the likelihood and time course of pain response, potential predictors of response, and its prognostic value in patients receiving radium-223. Materials and Methods: We reviewed the charts of patients who received radium-223 in our department. All patients were planned for 6 cycles with a prescribed dose of 50-55 kBq/kg at each administration. Pain scores, subjective response to pain, analgesic use, treatment toxicities, and laboratory values were recorded at each visit. Symptomatic skeletal events and survival were also recorded. Results: 48 patients received at least one cycle of radium-223 and 27 (56%) received all 6 planned cycles. Median survival from first treatment was 16.0 months (95% CI 8.9 to 19.2 months). 33% experienced at least one symptomatic skeletal event during or after treatment. 62.5% of men reported a decrease in pain from pre-treatment baseline. Of men with improved pain, 96% experienced an improvement before the third cycle. Pain relief was not associated with a decrease in ALK-P or PSA or improved survival. Conclusions: Approximately two-thirds of patients who undergo treatment with radium-223 will experience an improvement in pain and, if it occurs, it will most likely occur within the first two cycles. Patients should be counseled about this timeline and, if pain improvement isn't achieved, palliative radiation and oral analgesic readjustment should be considered. Pain response is not associated with survival and should not be used to evaluate the effectiveness of treatment. (C) 2018 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Treatment terminations (TTs) in radiation oncology can impact the outcomes of patients undergoing curative therapy, as well as the effectiveness of palliative treatments (tx). The causes of TTs are a complex interplay of patient, clinician, and disease factors. There has been little published as to why patients choose, or physicians recommend, TT. As part of ongoing departmental Quality Management, we track these events and seek to understand the causes of TT and opportunities for improvement. We identified 650 unique treatment terminations (TTs) from 6/2013 through 12/2016 within our multi-center department. A TT was defined as the discontinuation of therapy after a virtual simulation (following CT simulation and radiation planning) was scheduled. If a reason for discontinuation was not provided, then a reason was ascertained through chart review. All reasons were categorized into Patient Factors (PF), Clinician Factors (CF), Toxicity Related (TR), Hospice, Death, Disease Progression (DP), or Unknown. Tx intents were categorized into Curative, Palliative, or Benign. Out of 9,100 planned txs, there were 650 TTs representing 7.1% of all txs. Of the TTs, 61% were palliative and 38% curative. The most common reasons for TT was PF (28%) followed by Death (21%) and Hospice (21%). The most common treatment sites for TT were bone (20%) and head and neck (H&N) (19%). 222 txs (34%) were scheduled but received no radiation at the time of discontinuation. Within this group, 59% were palliative and 39% were curative. The most common sites were bone (23%) and H&N (21%). The two most common reasons were PF (36%) and CF (23%). 147 txs (23%) stopped within 25% of the prescribed dose. Of these, 41% were palliative and 59% were curative. The most common site was H&N (27%) followed by CNS (18%) with the two most common reasons being TR (27%) and PF (25%). For patients not receiving a single tx and for those stopping within 25% of the prescribed dose, the combined percentage of hospice/death represent 35% and 28%, respectively. Palliative patients were most likely to discontinue due to death/hospice (58%) and curative patients due to PF (33%). TTs represent a clinical concern not only because the failure to complete a prescribed tx may impact local control, survival, and the effectiveness of treatment, but also because of its impact on patients, families, and health care resources. In our experience, while toxicity and DP play a role, many of the major causes for TTs (PF and CF) within our department can be ascribed in some way to communication at the patient-physician and physician-physician level. Given our data, interventions that may impact this population include thoughtful prognosis discussions, improved patient selection for treatment, and further inclusion of our palliative care colleagues for palliative intent therapy. In the last quarter of treatment, better focus on toxicity management may mitigate these TTs.