Purpose: There currently are no established formal mentorship and training programs for radiation oncology (RO) trainees to learn trial design, creation, writing, or implementation. There only exists informal training on analyzing clinical trials in RO residency programs. The integration of a longitudinal formal training and mentorship program for clinical trialists—consisting of clinical trial education, design, mentorship, and implementation during the RO residency education—will give residents not only formal teaching in the subject but also strong tools and requisite mentorship in hopes to help them succeed as future academic physicians and leaders in the field of RO. Methods and Materials: We developed a clinical trial training pathway in 2018 at MD Anderson Cancer Center, proposing it as a pilot program. The “Fletcher-Cox Pathway” was accepted with a highly positive response by trainees and is now offered as a standard option to RO trainees at our institution. Results: With the guidance of their principal investigator, residents participating in this pathway design and submit a clinical trial for institutional review board review. In 2019, after implementation of the pilot program, 4 of the incoming 7 residents joined the pathway. The program continues, and the current cohort of trainees have received training in clinical trial design and worked with dedicated mentor(s) regarding clinical trial ideas; their studies are currently accruing patients. Conclusions: This pilot program has been viewed by trainees and mentors as successful; it highlights how a structured approach meets a clear need within RO training. We envision the creation of a national platform to increase access, whereby programs adopt this clinical trialist educational pathway, which ultimately leads to the development of a robust clinical trial community with communal resources. We hope that this not only improves and provides educational initiatives to all trainees but also initiates further collaboration.

INTRODUCTION:The historical standard of care for brain metastases (BMs) from small cell lung cancer (SCLC) has been whole-brain radiotherapy (WBRT). However, there is growing interest in upfront stereotactic radiosurgery (SRS) for select SCLC patients. MATERIALS AND METHODS:We invited United State-based Radiation Oncologists (ROs) via email to answer an anonymous survey using a branching logic system addressing their use of SRS and WBRT for SCLC BMs. Wilcoxon rank-sum test and Fisher's exact test were used to compare differences in continuous and categorical variables, respectively. Multivariable logistic regression analyses were fitted for outcome variables including covariates with P < .10 obtained on univariable analysis. RESULTS:In total, 309 ROs completed the survey and 290 (95.7%) reported that they would consider SRS for SCLC BMs under certain clinical circumstances. Across patient characteristics, the number of BMs was the most heavily weighted factor (mean 4.3/5 in importance), followed by performance status, cognitive function, and response to prior therapy. Fewer BMs were correlated with increased SRS use (55.8% offered SRS "very frequently" [>75% of cases] or "often" [51%-75% of cases] for 1 BM vs. 1.1% for >10 BM, P < .001). In situations where WBRT was preferred, concern for rapid intracranial progression (45.3%) and lack of high-level data (36.9%) were the most important factors. The majority (60.6%) were aware of a large recent international retrospective analysis (the FIRE-SCLC study) reporting similar OS between upfront SRS and WBRT; awareness of this study was the only respondent variable predictive of SRS use for limited BMs (19.2% of those aware of the study preferring SRS for limited [≤4] BMs before vs. 61% preferring SRS after the publication, P < .001). The majority of respondents (88.2%) expressed a willingness to enroll patients on a recently opened recently opened randomized trial, NRG-CC009, comparing SRS versus hippocampal-avoidance WBRT. CONCLUSIONS:In the first survey of SRS for SCLC BMs, we observed a high level of physician openness to upfront SRS in SCLC, particularly for patients with limited numbers of BMs, as well as significant interest in generating prospective randomized data to clarify the role of SRS in this population.

Postoperative radiation therapy (PORT) for non-small-cell lung cancer remains controversial and is associated with elevated cardiopulmonary toxicity. Recent advances in PORT techniques including proton beam therapy (PBT) may improve toxicity. We evaluated 136 patients treated with PORT at our institution. PBT resulted in improved heart and lung sparing with reduced toxicity rates. Proton-based PORT should be evaluated prospectively. Introduction: Postoperative radiation therapy (PORT) for non-small-cell lung cancer remains controversial with studies showing no overall survival (OS) benefit in the setting of excessive cardiopulmonary toxicity. Proton beam therapy (PBT) can potentially reduce toxicity with improved organ-at-risk sparing. We evaluated outcomes of PORT patients treated with PBT and intensity-modulated radiation therapy (IMRT). Materials and Methods: This is a retrospective review of 136 PORT patients (61 PBT, 75 IMRT) treated from 2003 to 2016. A Kaplan-Meier analysis was performed to assess oncologic outcomes. A Cox regression was conducted to identify associated factors. Total toxicity burden (TTB) was defined as grade >= 2 pneumonitis, cardiac, or esophageal toxicity. Results: Median OS was 76 and 46 months for PBT and IMRT with corresponding 1- and 5-year OS of 85.3%, 50.9% and 89.3%, 37.2% (P =.38), respectively. V30 Gy heart (odds ratio [OR], 144.9; 95% confidence interval [CI], 2.91-7214; P=.013) and V5 Gy lung (OR, 15.8; 95% CI, 1.22-202.7; P=.03) were predictive of OS. Organ-at-risk spar ing was improved with PBT versus IMRT; mean heart 2.0 versus 7.4 Gy (P<.01), V30 Gy heart 2.6% versus 10.7% (P<.01), mean lung 7.9 versus 10.4 Gy (P =.042), V5 Gy lung 23.4% versus 42.1% (P<.01), and V10 Gy lung 20.4% versus 29.6% (P<.01). TTB was reduced with PBT (OR, 0.35; 95% CI, 0.15-0.83; P=.017). Rates of cardiac toxicity were 14.7% IMRT and 4.9% PBT (P =.09). Rates of = grade 2 pneumonitis were 17.0% IMRT and 4.9% PBT (P=.104). Conclusion: PBT improved cardiac and lung sparing and reduced toxicity compared with IMRT. Considering the impact of cardiopulmonary toxicity on PORT outcomes, PBT warrants prospective evaluation. (C) 2021 The Authors. Published by Elsevier Inc.

ABSTRACT PURPOSE: To analyze rates of brachytherapy use for prostate cancer over time and evaluate patient characteristics, demographics and factors predictive for its utilization. METHODS: Data was retrospectively analyzed from the National Cancer Database (NCDB) for patients with localized prostate cancer treated between 2010 and 2015. Patients were included if they had biopsy confirmed localized adenocarcinoma of the prostate, were treated with radiation as definitive local therapy, and were at least 18 years old. Utilization rates of external beam radiation (EBRT), brachytherapy (BT) and combination (EBRT + BT) were evaluated over time. Univariable (UVA) and backwards elimination multivariable (MVA) analysis were performed to determine characteristics predictive for brachytherapy use. RESULTS: We analyzed 178,837 patients with localized adenocarcinoma of the prostate treated between 2010 and 2015 with radiation therapy. During this period, the use of EBRT increased from 67% to 78%, BT (both monotherapy and combination with EBRT) decreased from 33% to 22%, BT monotherapy decreased from 25% to 16% and EBRT + BT decreased from 8% to 6%. Age 70, government funded insurance or lack of insurance, intermediate or high-risk disease and treatment at an academic center were associated with significantly lower utilization of brachytherapy (all p < 0.001), while higher median zip code income was associated with increased use ( p = 0.02). On multivariable analysis patients who were younger, had private insurance, were lower NCCN risk category and treated in non-academic cancer centers, had a higher rate of brachytherapy utilization. Notably, on both UVA and MVA brachytherapy practice decreased with increasing year of diagnosis (OR 0.881, 95% CI 0.853-0.910, p < 0.001). CONCLUSION: Rates of brachytherapy utilization for the treatment of prostate cancer continue to decrease over time. Treatment at an academic center was associated with reduced likelihood of brachytherapy use. This has significant implications for the training of future radiation oncology residents/fellows and direct consequences for both our patients and healthcare expenditure. (c) 2021 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

Introduction: The highest concentration of military personnel in the United States is located in Hawaii where occupational exposures, such as to asbestos in the Pacific Fleet shipyards, predispose them to thoracic malignancies. For this reason, Veterans Affairs (VA) insurance outcomes for lung cancer in Hawaii are of interest.Methods: All cases of lung cancer in the Hawaii Tumor Registry from 2000 to 2015 were evaluated. The selection criterion included evidence of extensive-stage SCLC (ES-SCLC) or metastatic NSCLC. Overall survival was compared using the Kaplan-Meier log-rank method. Univariate analysis and multivariable analysis (MVA) were carried out to understand the variables associated with overall survival.Results: There were 434 cases of ES-SCLC and 2139 cases of metastatic NSCLC identified. VA insurance (median survival [MS], 2 mo), Medicaid (MS, 4 mo), and Medicare (MS, 4 mo) had worse survival (log-rank p < 0.001) than private insurance (MS, 8 mo). In ES-SCLC, VA insurance (hazard ratio [HR], 2.74; 95% confidence interval [CI]: 1.50-5.01; p = 0.001) and Medicaid (HR, 1.46; 95% CI: 1.04-2.03; p = 0.027) had significantly worse survival compared with private insurance on MVA. VA insurance (HR, 1.84; 95% CI: 1.34-2.53; p < 0.001) and Medicaid (HR, 1.40; 95% CI: 1.20-1.63; p < 0.001) also had worse survival compared with private insurance in metastatic NSCLC on MVA.Conclusions: VA insurance coverage was associated with dismal survival for metastatic lung cancer that was effectively similar to hospice or supportive care, compelling further investigation to identify reasons for this disparity.(c) 2020 The Authors. Published by Elsevier Inc. on behalf of the International Association for the Study of Lung Cancer. This is an open access article under the CC BY NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/).

Abstract Purpose: The benefit of chemotherapy in older women with breast cancer is not well defined. The aim of this study was to explore the effect of chemotherapy on overall survival (OS) in women ≥ 70 years old with triple-negative breast cancer (TNBC) using the National Cancer Database (NCDB). Methods: The NCDB was queried for older women (≥ 70 years of age) with surgically treated, AJCC Stage I-III invasive TNBC diagnosed from 2004-2014. Patient demographics, performance status as defined by the Charlson Deyo co-morbidity score, pathologic characteristics, treatment data, and OS were examined. Non-invasive, T1aN0, and any M1 patients were excluded. Multivariate regression analysis and propensity score matching were utilized to minimize bias. Results: 16,062 elderly women with TNBC met the inclusion criteria, and 7,485 (47.1%) received chemotherapy. Chemotherapy was recommended, but ultimately not administered to 2,659 (16.6%). Chemotherapy was not recommended to 5,732 (35.7%). On multivariate analysis, significantly improved OS was associated with lower co-morbidity score, smaller tumor size, negative lymph node status, infiltrating lobular histology, relatively younger age, and either having received or being recommended to receive chemotherapy (but not administered) [Table 1]. The benefit of chemotherapy was confirmed by conducting a multivariate, propensity score matched analysis of those who received chemotherapy with those who were recommended (but did not receive) chemotherapy (HR 0.70, 0.61 – 0.80) [Table 2]. Within the propensity matched cohort, statistical significance persisted when stratified by nodal status, and the 5-year overall survival of node negative women was 71% vs 74%, and for node positive women was 35% vs 42%. Conclusion: These data support the consideration of adjuvant chemotherapy in the treatment of women ≥70 years of age with TNBC, especially in those with lymph node involvement. These results can further inform the complex discussion about the benefits and toxicities associated with the administration of chemotherapy in older women with TNBC. Table 1: Multivariate Cox Regression Overall survival analysis of 16,062 surgically treated women, ≥ 70 years of age, with invasive, triple-negative breast cancer in the National Cancer Database from 2004-2014.p-valueHR95% CILowerUpperComorbidity Score = 010.0001.3181.2121.43520.0001.8251.6212.055Primary Tumor Size ≤5mm6 - 10mm0.7301.0970.6471.86111 - 20mm0.0711.6080.9602.69621 - 50mm0.0002.7281.6324.559>50mm0.0004.0522.4116.807pN0 pN10.0001.6261.4861.779pN20.0002.8622.5483.215pN30.0003.8163.3354.366NX0.0701.3350.9761.824Chemo, Not Received Chemo Received0.0000.5580.5090.611Chemo Recommended, not received0.0000.7860.7120.868Histology, IDCILC0.0000.6270.4960.794Age, 70 - 74 75 - 800.0031.1591.0511.27780 - 840.0001.3451.2101.49485 - 890.0001.7551.5631.97190+0.0002.5512.2012.956XRT not received XRT Received0.0000.6170.5720.665Well Differentiated Moderately Differentiated0.1931.2030.9111.589Poorly Differentiated/Anaplastic0.0051.4771.1271.936 Table 2: Multivariate Cox Regression overall survival analysis of propensity matched sample of surgically treated women, ≥ 70 years of age, with invasive, triple-negative breast cancer in the National Cancer Database from 2004-2014 who received chemotherapy with those who were recommended to received chemotherapy but did not.p-valueHR95% CILowerUpperChemo recommended but not receivedChemo received<0.0050.6980.6100.798pN0pN10.0002.0031.7022.358pN20.0003.0562.4763.771pN30.0003.7532.9564.767Well DifferentiatedModerately Differentiated0.3401.3900.7072.734Poorly Differentiated0.0421.9951.0263.877Advancing Age0.0001.0241.0111.038Comorbidity Score = 010.0001.4001.1991.63420.0011.5181.2001.922Primary Tumor Size≤5mm6-10mm0.9481.0400.3183.41011-20mm0.2571.9490.6156.17821-50mm0.0463.2191.02210.137>50mm0.0055.1911.63716.465 Citation Format: Jennifer A Crozier, Todd A Pezzi, Caitlin Hodge, Beth-Ann Lesnikoski, Laila Samiian, Amanda Shreders, William A Hammond, Riccardo A Audisio, Christopher M Pezzi. Exploring the benefit of adjuvant chemotherapy in elderly women with triple negative breast cancer: 16,062 women age 70 and above [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-14-03.

PURPOSE:Here we provide an analysis of the set-up and positioning accuracy of SABR for skull base malignancies to evaluate the use of site- or axis-specific margins to reduce field size.METHODS AND MATERIALS:Data were prospectively collected on 63 patients who received 304 fractions of SABR for recurrent/previously irradiated skull base tumors. Using our custom cushion-mask-bite-block immobilization system combined with ExacTrac x-ray and cone beam computed tomography (CBCT), set-up, residual, CBCT-positioning agreement, and intrafractional errors were measured. The resulting planning target volume (PTV) margins were estimated across 4 skull base subsites: anterior (group 1), central (group 2), posterolateral (group 3), and skull base-associated sites (eg, nasopharynx/retropharyngeal, cervical vertebrae 1-2, occiput) (group 4).RESULTS:On initial set-up, 66% of treatment courses required shifts of >2 mm or >2°, necessitating 4.9 mm PTV margins without image guidance. After correction, only 6 of 304 treatment sessions had residual errors >1 mm. CBCT-ExacTrac agreement was ≤1 mm in 89.1% of treatments and ≤1.5 mm in all but 1 session. Group 4 showed a higher rate of >1 mm or >1° CBCT-positioning differences compared with other groups (24.5% vs 7.8%; P = .0001), and the greatest variations occurred in the craniocaudal translational and the pitch rotational axes. Overall calculated PTV margins (based on intrafractional error) were 1.5 mm across subsites except for group 4, which required 2.0 mm margins.CONCLUSIONS:The use of 2.0 mm PTV margins for skull base SABR appears feasible using ExacTrac x-ray as the sole imaging modality for most subsites. However, PTVs were not uniformly equal, and the use of a site-specific nonuniform margin reduction to optimize critical-organ dose sparing may be feasible for select cases. These findings warrant clinical investigation.

Dose escalation via stereotactic radiation therapy techniques has been necessary for hepatobiliary malignancies in the primary and oligometastatic setting, but such dose escalation is challenging for spine metastases due to spinal cord proximity. Here, we investigate the role of spine stereotactic radiosurgery (SSRS) in the management of such metastases. We retrospectively reviewed patients treated with SSRS to spinal metastases from hepatobiliary malignancies between 2004 and 2017 at our Institution. We used the Kaplan–Meier method to calculate overall survival (OS) and local control (LC) and Cox regression analysis to identify factors associated with disease-related outcomes. We identified 28 patients treated to 43 spinal metastases with SSRS for either HCC or cholangiocarcinoma. The 1-year LC and OS were 85% and 23%, respectively. The median time to death was 6.2 months, while median time to local failure was not reached. Tumor volume > 60 cc (SHR 6.65, p = 0.03) and Bilsky ≥ 1c (SHR 4.73, p = 0.05) predicted for poorer LC, while BED10 > 81 Gy trended towards better local control (SHR 4.35, p = 0.08). Child–Pugh Class (HR 3.02, p = 0.003), higher PRISM Group (HR 3.49, p = 0.001), and systemic disease progression (HR 3.65, p = 0.001) were associated with worse mortality based on univariate modeling in patients treated with SSRS; on multivariate analysis, PRISM Group (HR 2.28, p = 0.03) and systemic disease progression (HR 2.67, p = 0.03) remained significant. Four patients (10%) developed compression deformity and one patient (2%) developed radiation neuritis. SSRS provides durable local control in patients with metastatic hepatobiliary malignancies, with higher BED necessary to ensure excellent LC. PRISM scoring is a promising prognostic tool to aid SSRS patient selection.

PURPOSE:MRI-assisted radiosurgery (MARS) is a modern technique for prostate brachytherapy that provides superior soft tissue contrast. The purpose of this analysis was to evaluate treatment planning factors associated with urinary toxicity, particularly damage to the membranous urethra (MUL) and external urethral sphincter (EUS), after MARS. MATERIAL AND METHODS:We retrospectively reviewed 227 patients treated with MARS. Comparisons were made between several factors including preimplantation length of the MUL and EUS dosimetric characteristics after implantation with longitudinal changes in American Urological Association (AUA) urinary symptom score. RESULTS:Rates of grade 3 urinary incontinence and obstructive urinary symptoms were 4% and 2%. A piecewise mixed univariate model revealed that MUL and V200, V150, V125, and D5 to the EUS were all associated with increased rates of urinary toxicity over time. On univariate logistic regression, MUL >14.2 mm (odds ratio [OR] 2.03 per cm3, 95% confidence interval [CI] 1.10-3.77, p = 0.025), V125 to the EUS (OR 3.21 cm3, 95% CI 1.18-8.71, p = 0.022), and use of the I-125 isotope (OR 3.45, 95% CI 1.55-7.70, p = 0.001) were associated with subacute urinary toxicity (i.e., that occurring at 4-8 months). Optimal dose-constraint limits to the EUS were determined to be V200 < 0.04 cm3 (p = 0.002), V150 < 0.12 cm3 (p = 0.041), V125 < 0.45 cm3 (p = 0.033), D30 < 160 Gy (p = 0.004), and D5 < 218 Gy (p = 0.016). CONCLUSIONS:MARS brachytherapy provides detailed anatomic information for treatment planning, implantation, and quality assurance. Overall rates of urinary toxicity are low; however, several dosimetric variables associated with the EUS were found to correlate with urinary toxicity.

Historical data suggests there is an overall survival benefit of prophylactic cranial irradiation (PCI) in small cell lung cancer (SCLC). However, as the fidelity of magnetic resonance imaging (MRI) of the brain continues to improve, this is now being questioned. A recently published modern, prospective, randomized Japanese trial showed no survival benefit of PCI in extensive stage SCLC (ES-SCLC), however the role for PCI is not clear in those with limited stage SCLC (LS-SCLC). To report the overall survival (OS) and rates of intracranial control for LS-SCLC patients, all staged with MRI, who either did or did not receive PCI. We performed a retrospective analysis of LS-SCLC patients treated with thoracic radiation with (n=205) or without PCI (n=92). Of these patients, a propensity score matching analysis was undertaken in an attempt to adjust for potential bias. All patients were determined to be LS-SCLC, and received at least baseline MRI with restaging brain MRI and/or CT and without disease progression after thoracic RT. Of 297 patients who met the inclusion criteria, we calculated the propensity score for 295 patients, using patient, tumor, and treatment characteristics. After propensity score matching, there was no significant difference of patient, tumor and treatment characteristics between the PCI and no PCI group. The 3-year cumulative incidence rate of brain metastases was marginally higher in the no-PCI group vs. PCI group, when counting death as a competing risk (0.204 vs. 0.112; P=0.096). Overall survival was not significantly different between the PCI and no-PCI groups (HR=0.844, 95% CI 0.604-1.180, P=0.322). In this study, we found that in LS-SCLC patients staged with MRI, the use of PCI after thoracic radiation was associated with a trend towards a significant decline in the risk of developing new brain metastasis but was not associated with an OS benefit.

Key Points Question After staging with magnetic resonance imaging, is there a benefit associated with prophylactic cranial irradiation (PCI) for patients with limited-stage small cell lung cancer? Findings In this single-institution cohort study, a propensity-matched analysis of 297 patients was conducted. The 3-year cumulative incidence rate of brain metastases was higher in the group that did not undergo PCI vs the group that did undergo PCI, but the difference was not statistically significant; PCI was not associated with an overall survival benefit. Meaning Given the neurocognitive toxic effects associated with whole-brain radiation therapy, these data suggest that the benefits of PCI for unselected patients with limited-stage small cell lung cancer are limited.

Background:: Consolidative radiotherapy (RT) has been shown to improve overall survival in oligometastatic non-small cell lung cancer (NSCLC), as demonstrated by a growing number of prospective trials. Objective:: We quantified the costs of delivery of consolidative RT for common clinical pathways associated with treating oligometastatic NSCLC, by applying time-driven activity-based costing (TDABC) methodology. Methods:: Full cycle costs were evaluated for 4 consolidative treatment regimens: (Regimen #1) 10-fraction 3D conformal radiation therapy (3D-CRT) as palliation of a distant site; (#2) 15-fraction intensity-modulated RT (IMRT) to the primary thoracic disease; (#3) 15-fraction IMRT to the primary plus 4-fraction stereotactic ablative radiotherapy (SABR) to a single oligometastatic site; and (#4) 15-fraction IMRT to the primary plus two courses of 4-fraction SABR for two oligometastatic sites. Results:: For each of the four treatment regimens, personnel represented a greater proportion of total cost when compared with equipment, totaling 61.0%, 65.9%, 66.2%, and 66.4% of the total cost of each care cycle, respectively. In total, a 10-fraction regimen of 3D-CRT to a distant site represented just 37.2% of the total cost of the most expensive course. Compared to total costs for 15-fraction IMRT alone, each additional sequential course of 4-fraction SABR imparted a cost increase of 43%. Conclusion:: This analysis uses TDABC to estimate the relative internal costs of various RT strategies associated with treating oligometastatic NSCLC. This methodology will become increasingly relevant to each organization in context of the anticipated mandate of alternative/bundled payment models for radiation oncology by the Centers for Medicare and Medicaid Services.

Background There is a scarcity of data exploring the benefits of adjuvant or neoadjuvant chemotherapy in the treatment of breast cancer in older women. We aimed to explore the effect of adding chemotherapy to local therapy on overall survival in older women with triple-negative breast cancer. Methods For this propensity-matched analysis, we used data from the National Cancer Database, a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. We included data from women aged 70 years or older with surgically treated, American Joint Committee on Cancer (AJCC) Stage I-III invasive triple-negative breast cancer diagnosed from 2004 to 2014. Patients with T1aN0M0 disease and those with incomplete data on oestrogen receptor status, progesterone receptor status, or HER2 status were excluded. To reduce bias, patients were subdivided into three groups: those who were recommended chemotherapy but did not receive it; those who received chemotherapy; and those for whom chemotherapy was not recommended and not given. The primary outcome was overall survival. Multivariate Cox regression analysis and propensity score matching were done to minimise bias. Findings Between Jan 1, 2004, and Dec, 31, 2014, 16 062 women with triple-negative breast cancer in the database met the inclusion criteria for this analysis. Median follow-up was 38.3 months (IQR 20.7-46.1, range 0-138.0; 95% CI 37.8-38.7). Collectively, the 5-year overall survival estimate of the 16 062 patients in the study cohort was 62.3% (95% CI 59.7-64.4). 5-year estimated overall survival was 68.5% (95% CI 66.4-70.6) for patients receiving chemotherapy, 61.1% (59.0-63.2) for patients recommended but not given chemotherapy, and 53.7% (51.8-55.8) for patients not recommended chemotherapy and not given chemotherapy (pooled log rank p<0.0001). Multivariate Cox regression analysis of a propensity score-matched sample comparing those who received chemotherapy with those who were recommended but not given chemotherapy (n=1884 matched pairs) identified improved overall survival with chemotherapy (hazard ratio [HR] 0.69 [95% CI 0.60-0.80]; p<0.0001). After stratifying the propensity score matching sample, this benefit persisted for node-negative women (HR 0.80 [95% CI 0.66-0.97]; p=0.007), node-positive women (0.76 [0.64-0.91]; p=0.006), and those with a comorbidity score greater than 0 (HR 0.74 [95% CI 0.59-0.94]; p=0.013). Interpretation These data support consideration of chemotherapy in the treatment of women aged 70 years or older with triple-negative breast cancer. Copyright (C) 2020 Elsevier Ltd. All rights reserved.

This cohort study examines the association of Medicaid coverage with survival, compared with other insurance statuses, among patients with small cell lung cancer. Importance Small cell lung cancer (SCLC) is an aggressive neoplasm requiring rapid access to subspecialized multidisciplinary care. For this reason, insurance coverage such as Medicaid may be associated with oncologic outcomes in this disproportionately economically vulnerable population. With Medicaid expansion under the Affordable Care Act, it is important to understand outcomes associated with Medicaid coverage among patients with SCLC. Objective To determine the association of Medicaid coverage with survival compared with other insurance statuses. Design, Setting, and Participants This cohort study included adult patients with limited-stage (LS) and extensive-stage (ES) SCLC in the US National Cancer Database from 2004 to 2013. Data were analyzed in January 2019. Main Outcomes and Measures Patients were analyzed with respect to insurance status. Associations of insurance status with survival were interrogated with univariate analyses, multivariable analyses, and propensity score matching. Results A total of 181 784 patients with SCLC (93 131 [51.2%] female; median [interquartile range] age; 67 [60-75] years for patients with LS-SCLC and 68 [60-75] years for patients with ES-SCLC) were identified, of whom 70 247 (38.6%) had LS-SCLC and 109 479 (60.2%) had ES-SCLC. On univariate analyses of patients with LS-SCLC, Medicaid coverage was not associated with a survival advantage compared with being uninsured (hazard ratio, 1.02; 95% CI, 0.96-1.08; P = .49). Likewise, on multivariable analyses of patients with ES-SCLC, compared with being uninsured, Medicaid coverage was not associated with a survival advantage (hazard ratio, 1.00; 95% CI, 0.96-1.03; P = .78). After propensity score matching, median survival was similar between the uninsured and Medicaid groups both among patients with LS-SCLC (14.4 vs 14.1 months; hazard ratio, 1.05; 95% CI, 0.98-1.12; P = .17) and those with ES-SCLC (6.3 vs 6.4 months; hazard ratio, 1.00; 95% CI, 0.96-1.04; P = .92). Conclusions and Relevance Despite of billions of dollars in annual federal and state spending, Medicaid was not associated with improved survival in patients with SCLC compared with being uninsured in the US National Cancer Database. These findings suggest that there are substantial outcome inequalities for SCLC relevant to the policy debate on the Medicaid expansion under the Affordable Care Act. Question Is Medicaid coverage associated with a survival benefit compared with being uninsured among US patients with small cell lung cancer (SCLC)? Findings This cohort registry analysis of 181 784 patients with SCLC included in the US National Cancer Database found no association of Medicaid coverage with a survival advantage compared with no insurance. Patients with private insurance, managed care plans, and Medicare had better survival than did Medicaid recipients or uninsured patients even after adjusting for confounding factors. Meaning Medicaid coverage was not associated with improved overall survival among patients with SCLC, thus highlighting an opportunity for health care policy intervention in this population.

Merkel cell carcinoma has historically had dismal prognosis with limited cytotoxic chemotherapy options that provide durable control of metastatic disease. The advent of anti-programmed death protein (anti-PD1)/anti-programmed death-ligand 1 (anti-PD-L1) directed immunotherapy has shown initial promise in Merkel cell carcinoma and radiation might augment immune responses. We present a case report of a 70-year-old male who underwent resection of Merkel cell carcinoma of the right thigh with a close margin and positive right inguinal involvement. Due to high-risk features, the patient was treated with adjuvant radiation to the right groin and with systemic carboplatin/etoposide, but developed local failure requiring salvage surgical resection. The patient then developed metastatic disease with biopsy proven retroperitoneal involvement refractory to doxorubicin/cyclophosphamide chemotherapy. The patient was then transitioned to single-agent pembrolizumab with a partial response for 10 months until developing progressive disease involving the left inguinal and left external iliac nodal regions. The progressive left inguinal/pelvic disease was treated with conventionally fractionated intensity modulated radiation therapy to a dose of 45 Gy delivered in 25 fractions. Following radiation therapy, the patient had complete response of all sites of disease throughout the body on imaging by RECIST criteria including retroperitoneal and mediastinal disease outside the radiation field. At 20 months post-radiation, the patient remains on pembrolizumab without evidence of disease on imaging. Herein, we present a case of durable response of metastatic Merkel cell carcinoma treated with concurrent radiation and pembrolizumab, providing evidence that radiation might improve systemic responses to anti-PD1/PD-L1 directed immune therapy. Ongoing prospective trials evaluating the utility of radiation in conjunction with immunotherapy for Merkel cell carcinoma are anticipated to provide clarity on the frequency and durability of abscopal responses when radiation is combined with immune checkpoint inhibitors.

e20099 Background: A recent phase III trial (Takahashi et al., 2017) showed no overall survival (OS) benefit in patients with extensive-stage small cell lung cancer (ES-SCLC) treated with prophylactic cranial irradiation (PCI), casting doubt on the practice of PCI as established in a prior phase III trial (Slotman et al., 2007). We undertook a nationwide survey of radiation oncologists to ascertain the impact of the Takahashi trial on the utilization of PCI for ES-SCLC patients. Methods: A total of 3,646 ASTRO-registered radiation oncologists in the United States were invited to answer an anonymous survey on their use of PCI in ES-SCLC, and the impact of the recent Takahashi et al. trial on their practice. The survey consisted of 35 questions created using a branching logic system via RedCAP. Results: A total of 438 (12%) radiation oncologists completed the survey. Responders were well-distributed across geographic regions, practice environment, age, gender, practice size and lung cancer volume. Most respondents (92%) were aware of the Takahashi trial. While 71% routinely offered PCI to ES-SCLC patients prior to the publication of this trial, only 43% continue to do so after its publication (p < 0.001). Most respondents (66%) had altered their practice in response to the study. There was no difference in post-publication practice patterns between academic and private practice radiation oncologists (43% vs. 44%, p = 0.81). While 43% of participants who were aware of the Takahashi trial still offered PCI after its publication, 82% of those unaware of the trial still continued to offer PCI (p < 0.001). Additionally, 25% of participants noted that they have experienced a decrease in medical oncology referrals for PCI for ES-SCLC patients. Twenty-two percent of participants stated that the Takahashi trial impacted their practice with regards to limited-stage SCLC patients as well. Looking toward the future, 47% of respondents reported that they would be willing to enroll both LS- and ES-SCLC patients on a randomized trial comparing active MRI-surveillance to PCI; 15% stated that they would enroll only LS-SCLC patients on such a trial, and 20% would enroll only ES-SCLC patients. Conclusions: The phase III data from Takahashi et al. (2017) has markedly impacted the current practice patterns in the US by reducing PCI utilization for ES-SCLC patients across all practice settings and measured demographic variables. Most respondents expressed openness to a randomized trial comparing active MRI surveillance to PCI for SCLC patients.

OBJECTIVE:Patients with metastatic thyroid cancer have prolonged survival compared to those with other primary tumors. The spine is the most common site of osseous involvement in cases of metastatic thyroid cancer. As a result, obtaining durable local control (LC) in the spine is crucial. This study aimed to evaluate the efficacy of spine stereotactic radiosurgery (SSRS) in patients with metastatic thyroid cancer. METHODS:Information on patients with metastatic thyroid cancer treated with SSRS for spinal metastases was retrospectively evaluated. SSRS was delivered with a simultaneous integrated boost technique using single- or multiple-fraction treatments. LC, defined as stable or reduced disease volume, was evaluated by examining posttreatment MRI, CT, and PET studies. RESULTS:A total of 133 lesions were treated in 67 patients. The median follow-up duration was 31 months. Dose regimens for SSRS included 18 Gy in 1 fraction, 27 Gy in 3 fractions, and 30 Gy in 5 fractions. The histology distribution was 36% follicular, 33% papillary, 15% medullary, 13% Hurthle cell, and 3% anaplastic. The 1-, 2-, and 5-year LC rates were 96%, 89%, and 82%, respectively. The median overall survival (OS) was 43 months, with 1-, 2-, and 5-year survival rates of 86%, 74%, and 44%, respectively. There was no correlation between the absolute biological equivalent dose (BED) and OS or LC. Patients with effective LC had a trend toward improved OS when compared to patients who had local failure: 68 versus 28 months (p = 0.07). In terms of toxicity, 5 vertebral compression fractures (2.8%) occurred, and only 1 case (0.6%) of greater than or equal to grade 3 toxicity (esophageal stenosis) was reported. CONCLUSIONS:SSRS is a safe and effective treatment option with excellent LC and minimal toxicity for patients with metastatic thyroid cancer. No association with increased radiation dose or BED was found, suggesting that such patients can be effectively treated with reduced dose regimens.