These implementation strategies were associated with increased therapeutic trial enrollment in community-based partner sites. With high variation in enrollment between physicians and prior research suggesting limited impact of site-level financial incentives, qualitative research will further investigate non-financial incentives and other facilitators to clinical trial enrollment within community-academic partnerships. Over-representation of minority patients further supports the benefit of enrolling patients on clinical trials in the community-based setting.

Introduction: Single-fraction stereotactic radiosurgery (SF-SRS) is typically used to provide local control of brain metastases. Recently, hypofractionated stereotactic radiotherapy (HF-SRT) has been utilized for large brain metastases. Data comparing these two modalities are limited for brain metastases ≤3 cm. Methods: Patients with brain metastases receiving linear accelerator-based SF-SRS or HF-SRT were identified at three institutions. Local progression-free survival (LPFS), intracranial progression-free survival (ICPFS), overall survival (OS), and radionecrosis-free survival (RNFS) were determined from time of treatment. Results: 108 patients (76 intact, 32 resected) with 184 brain metastases (142 intact, 42 resected) were included. There were no significant differences between SF-SRS and HF-SRT for intact metastases in 1-year LPFS (62.8% vs. 58.5%, p=0.631), ICPFS (56.9% vs. 55.3%, p=0.300), and OS (71.6% vs. 70.6%, p=0.096), or for resected metastases in 1-year LPFS (67.3% vs. 57.8%, p=0.288), ICPFS (64.8% vs. 57%, p=0.291), and OS (64.8% vs. 66.1%, p=0.603). There were also no significant differences in 1-year RNFS between SF-SRS and HF-SRT (92% vs. 92%, p=0.325). Conclusions: There were no significant differences in LPFS, ICPFS, OS, and RNFS between SF-SRS and HF-SRT for brain metastases ≤3 cm suggesting SF-SRS may be preferred due to similar outcomes and reduced number of fractions.

Objectives: A variety of treatment modalities are available for the management of clinically localized prostate cancer in the United States. In addition to clinical factors, treatment modality choice may be influenced by a patient’s insurance status. Using a national data set, we investigated the relationship between insurance status and prostate cancer treatment modality selection among nonelderly men in the United States. Methods: Nonelderly men age 18 to 64 years treated for localized prostate cancer from 2010 to 2014 were identified within the National Cancer Database. Patients with no insurance, Medicaid, or private insurance were included. The χ2 and multivariable logistic regression analyses were used to evaluate the association of insurance status, other demographic and facility factors, and D’Amico risk classification with treatment modality. Results: We identified 135,937 patients with either no insurance (2.8%), Medicaid (4.2%), or private insurance (92.9%) treated for prostate cancer who underwent cancer-directed treatment or active surveillance between 2010 and 2014. Patients with private insurance were more likely to receive minimally invasive surgery (61.4% vs. 35.4%, respectively; P<0.001) and less likely to receive external beam radiotherapy (10.9% vs. 26.9%, respectively; P<0.001) than patients with no insurance. On multivariable analysis, among patients with no insurance and private insurance, private insurance was the strongest predictor of receipt of minimally invasive surgery (adjusted odds ratio, 2.61; 95% confidence interval, 2.44-2.79; P<0.001). Conclusion: Insurance status is a strong predictor of prostate cancer treatment modality among nonelderly men in the United States.

Background: The safety and efficacy of FOLFIRINOX (FX) followed by consolidative chemoradiation (CRT) in borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC) has not been extensively studied.We sought to evaluate outcomes and toxicities of this regimen.Methods: A retrospective review was performed of 33 patients with BRPC or LAPC treated with FX followed by CRT.Radiotherapy was directed at the primary tumor and any involved nodes (84.8% received 50-50.4Gy with standard fractionation and concurrent capecitabine, while 15.2% of patients received 36 Gy in 15 fractions with weekly gemcitabine).Toxicities of FX and CRT were graded using Common Terminology Criteria for Adverse Events (CTCAE v4.0), and radiographic response was evaluated using Response Evaluation Criteria in Solid Tumors (RECIST).Overall survival (OS), distant metastasisfree survival (DMFS), and local control (LC) were calculated using Kaplan-Meier analyses, and a Cox proportional hazards model was used to assess the impact of clinicopathologic factors on OS.Results: Median follow-up was 19.9 months and patients received a median of 6.4 months of chemotherapy (range, 2.2-12.0months).There were more T4 tumors than T3 tumors (70% vs. 30%).Grade ≥3 toxicities were low, including fatigue (9.1%), diarrhea (6.1%), neuropathy (6.1%), and dehydration (6.1%).R0 surgical resection was achieved in 5 patients (15.2%) after CRT.Median OS was 22.0 months (91% at 1 year and 45% at 2 years).Median DMFS was 17.8 months (69% at 1 year and 35% at 2 years).LC was 84% at 1 year and 55% at 2 years.Conclusions: OS is promising with the use of FX in BRPC and LAPC, and consolidative CRT was well tolerated in this cohort.Therefore, the role of radiation after multi-agent chemotherapy should be further evaluated in prospective trials.

BACKGROUNDThe current study was performed to determine whether access to facilities performing accelerated partial breast irradiation (APBI) is associated with differences in the use of adjuvant radiotherapy (RT).METHODSUsing the National Cancer Data Base, the authors performed a retrospective study of women aged 50 years who were diagnosed with early-stage breast cancer between 2004 and 2013 and treated with breast-conserving surgery (BCS). Facilities performing APBI in 10% of their eligible patients within a given year were defined as APBI facilities whereas those not performing APBI were defined as non-APBI facilities. All other facilities were excluded. The authors identified independent factors associated with RT use using multivariable logistic regression with clustering in the overall sample as well as in subsets of patients with standard-risk invasive cancer, low-risk invasive cancer, and ductal carcinoma in situ.RESULTSAmong 222,544 patients, 76.6% underwent BCS plus RT and 23.4% underwent BCS alone. The likelihood of RT receipt in the overall sample did not appear to differ significantly between APBI and non-APBI facilities (adjusted odds ratio [AOR], 1.02; P=.61). Subgroup multivariable analysis demonstrated that among patients with standard-risk invasive cancer, there was no association between evaluation at an APBI facility and receipt of RT (AOR, 0.98; P=.69). However, patients with low-risk invasive cancer were found to be significantly more likely to receive RT (54.4% vs 59.5%; AOR, 1.22 [P<.001]), whereas patients with ductal carcinoma in situ were less likely to receive RT (56.9% vs 55.3%; AOR, 0.89 [P=.04]) at APBI facilities.CONCLUSIONSPatients who were eligible for observation were more likely to receive RT in APBI facilities but no difference was observed among patients with standard-risk invasive cancer who would most benefit from RT. Cancer 2017;123:502-511. (c) 2016 American Cancer Society.Facilities that offer partial breast irradiation are more likely to administer radiotherapy to women eligible for its omission. The availability of partial breast irradiation does not appear to improve compliance with radiation after lumpectomy.

Background. The optimal adjuvant treatment for cT1-2 N0 esophageal cancer patients found to have pathologic nodal involvement after an upfront operation is unclear. This study investigated the effects of postoperative chemotherapy and chemoradiation therapy on overall survival in cT1-2 N0 patients with incidental pN(+) disease stratified by margin status. Methods. We identified cT1-2 N0 M0 esophageal carcinoma patients from 2004 to 2012 from the National Cancer Data Base. Patients were categorized as having received surgical resection alone, surgical resection followed by chemotherapy (SDCT), and surgical resection followed by concurrent chemoradiation therapy (SDCRT). Subset analyses were conducted on margin-negative and margin-positive patients. Overall survival was compared by Kaplan-Meier estimation, the log-rank test, and multivariable Cox regression analysis. Results. Among 443 patients, 52.6% received surgical resection alone, 18.7% received SDCT, and 28.6% received SDCRT. Significantly more adenocarcinoma patients received adjuvant treatment (50.8%) than squamous cell carcinoma patients (27.7%, p = 0.001). On multivariable analysis, SDCT (hazard ratio, 0.64; 95% confidence interval, 0.45 to 0.91; p = 0.014) and SDCRT (hazard ratio, 0.73; 95% confidence interval,. 0.55 to 0.98; p = 0.038) both were associated with significantly increased overall survival. These findings persisted among margin-negative patients. However, in margin-positive patients, SDCRT (hazard ratio, 0.29; p = 0.002) was the only treatment arm that was associated with significantly improved survival compared with surgical resection alone. Conclusions. Among cT1-2 N0 pN(+) esophageal cancer patients, adjuvant chemotherapy may be sufficient for margin-negative patients, whereas adjuvant chemoradiation therapy appears necessary for margin-positive patients. Further prospective studies are needed to confirm the results. (C) 2017 by The Society of Thoracic Surgeons

BACKGROUND:The optimal treatment for early-stage esophageal cancer with positive surgical margins after an upfront esophagectomy is not well-defined. This study investigates the effect of post-operative radiotherapy (PORT) on overall survival (OS) in clinical stage I-II patients with positive margins.METHODS:We identified patients diagnosed between 2004 and 2012 with clinical stage I-II esophageal carcinoma from the National Cancer Data Base (NCDB) who underwent an upfront esophagectomy. For those patients with positive margins, administration of PORT was recorded, and OS was compared by the Kaplan-Meier estimator and log-rank test. Multivariable Cox regression analysis was performed to identify variables associated with improved survival.RESULTS:Among the 3,490 patients identified, 209 (5.8%) had positive margins. One hundred forty-two (67.9%) patients did not receive PORT while 67 (32.1%) did receive PORT. Compared to those receiving PORT, patients who did not receive PORT were significantly older (68.5 vs. 64.0 years, P=0.003), more likely to have pN0 disease (50.7% vs. 35.4%, P=0.026), and less likely to receive postoperative chemotherapy (21.1% vs. 86.6%, P<0.001). On multivariable logistic regression, only receipt of chemotherapy predicted for receipt of PORT (OR: 25.6, 95% CI: 9.9-65.8, P<0.001). OS was significantly higher for patients receiving PORT compared to those who did not (median OS: 32.2 vs. 16.9 months, log-rank P=0.008). Multivariable analysis confirmed an association with PORT and improved OS (HR: 0.39, 95% CI: 0.27-0.60, P<0.001). Subset analysis demonstrated that the OS benefit of PORT persisted in those patients who received adjuvant chemotherapy (HR: 0.33, 95% CI: 0.19-0.57, P<0.001).CONCLUSIONS:PORT is associated with improved OS in clinical stage I-II esophageal cancer patients after an upfront esophagectomy with positive margins. In the absence of prospective randomized data, our findings suggest that PORT should be strongly considered in the setting of early-stage esophageal cancer resected with positive margins.

Background and purposeThe role of concurrent chemoradiotherapy (CRT) for anaplastic gliomas is undefined and patterns of care are under-reported. To address the knowledge gap, we examined use of CRT for grade III gliomas compared to radiotherapy (RT) alone.Material and methodsIn an observational study design cohort from the National Cancer Database, we identified 4437 adult patients receiving surgery followed by either CRT or RT for supratentorial anaplastic glioma in 2003–2011. Univariable and multivariable logistic regression analyses were used to assess factors associated with use of CRT. Overall survival (OS) was assessed by the Kaplan–Meier analysis with log-rank tests, Cox proportional hazards regression modeling, and propensity score matching.ResultsReceipt of CRT (vs. RT) was associated with recent year of diagnosis (OR for 2011 (vs. 2003) 3.36, 95% CI 2.49–4.54) and having astrocytoma (vs. oligodendroglioma) (OR 1.37, 95% CI 1.15–1.63). Patients receiving CRT had a lower adjusted hazard of death (hazard ratio 0.72, 95% CI 0.65–0.79). Outcomes were worse for patients ≥60 (HR 6.94, 95% CI 6.09–7.91) and astrocytomas (HR 2.08, 95% CI 1.85–2.34).ConclusionUse of concurrent CRT is associated with more recent year of diagnosis and improved survival relative to RT alone.

Recent studies have suggested a link between radiation therapy (RT) institutional case volume and clinical outcomes for patients with head and neck cancer (HNC) in the 3D-conformal RT era, but whether such a relationship exists in the intensity-modulated RT (IMRT) era is less clear. Additionally, potential explanations underlying this difference have yet to be elucidated. We sought to determine whether annual facility case volume (AFCV) impacts overall survival in HNC for patients receiving definitive IMRT with concurrent chemotherapy and to identify factors driving this association. We identified patients diagnosed in 2004-2012 with locally advanced (Stage III-IVB except cT1N1) squamous cell HNC using the National Cancer Data Base. Additional inclusion criteria were primary site other than oral cavity, no definitive resection prior to RT initiation, RT dose 66.0-76.0 Gy in 1.8-2.2 Gy fractions completed within 30-180 days, receipt of concurrent chemotherapy, administration of all RT at the reporting facility, no previous diagnoses of cancer, and complete records of all covariates and outcomes. AFCV was defined as the average annual number of HNC cases receiving head and neck RT by each reporting facility. Overall survival was assessed with multivariable Cox proportional hazards regression with bootstrapping and then re-evaluated with propensity score matching. 9,817 patients met all inclusion criteria. Median AFCV was 23 cases/year (interquartile range 13-50). Patients treated at higher-volume facilities were more likely to have shorter RT duration than those at lower-volume facilities (mean 50.6 vs. 53.3 days, P<0.001). On Cox regression, there was a 5.7% decreased hazard of death per additional 20 patients treated per year per facility (HR 0.943, 95% CI 0.925-0.962, P<0.001). When AFCV was analyzed as a dichotomous variable at the 90thpercentile (95 cases/year), there was a 17.5% decreased hazard of death for higher-volume vs. lower-volume facilities (HR 0.825, 95% CI 0.727-0.936, P = 0.003). RT duration was independently associated with an 11.0% increased hazard of death per additional week (HR 1.110, 95% CI 1.085-1.134, P<0.001). RT dose-fractionation and academic facility type were not associated with survival. Propensity score matching confirmed the robustness of the results. Our findings confirm a relationship between higher RT facility case volume and improved overall survival for patients treated with IMRT for locally advanced HNC. This association appears to be significantly affected by shorter RT duration at higher-volume facilities. Further investigation should focus on the role of other modifiable factors such as RT contouring education, toxicity management, and availability of salvage therapy.

Background: Metastatic melanoma often involves the brain. Radiotherapy is an important treatment of melanoma brain metastases, although melanoma radiosensitivity is considered heterogeneous. Thus, identifying subsets with differential radiosensitivity is essential.Materials and Methods: Patients with metastatic melanoma were identified in a prospective stereotactic radiosurgery (SRS) database. Tumor were tested for alterations in B-RAF, N-RAS, and c-KIT. Standardized imaging following SRS was reviewed for recurrence. Differences in local and distant failure were determined using modified Cox proportional hazards models.Results: 102 patients and 1,028 brain metastases were included. N-RAS mutated patients were significantly less likely to develop local recurrence after SRS than wild type patients (HR 0.17, 95% CI 0.04-0.72, p=0.017). B-RAF and c-KIT mutations were not associated with altered rates of local recurrence. Lower local recurrence rates for N-RAS mutated tumors persisted on multivariate analysis (HR 0.18, 95% CI 0.04-0.84p=0.029).Conclusions: N-RAS mutation is associated with improved local control following SRS. Local recurrence is more common in wild type patients and those with B-RAF or c-KIT mutations. Further research is needed to validate these findings and integrate into practice.