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1.  Impact of neck dissection on long-term feeding tube dependence in head and neck cancer patients treated with primary radiation or chemoradiation 
Head & neck  2010;32(3):341-347.
Background
The impact of post-treatment neck dissection on prolonged feeding tube dependence in head and neck squamous cell cancer (HNSCC) patients treated with primary radiation or chemoradiation remains unknown.
Methods
Retrospective cohort study using propensity score adjustment to investigate the effect of neck dissection on prolonged feeding tube dependence.
Results
A review of 67 patients with node positive HNSCC (T1-4N1-3), treated with primary radiation or chemoradiation, with no evidence of tumor recurrence and follow-up of at least 24 months was performed. Following adjustment for covariates, the relative risk of feeding tube dependence at 18 months was significantly increased in patients treated with post-treatment neck dissection (RR 4.74, 95% CI 2.07-10.89). At 24 months, the relative risk of feeding tube dependence in the patients having undergone neck dissection increased further (RR 7.66, 95% CI 2.07-10.89). Of patients with feeding tubes two years after completing treatment, 75% remained feeding tube dependent.
Conclusion
Neck dissection may contribute to chronic oropharyngeal dysphagia in HNSCC patients treated with primary radiation or chemoradiation.
doi:10.1002/hed.21188
PMCID: PMC3457780  PMID: 19693946
2.  Impact of the radiation boost on outcomes after breast-conserving surgery and radiation 
Purpose
We examined the impact of radiation tumor bed boost parameters in early stage breast cancer on local control and cosmetic outcomes.
Materials and Methods
3,186 women underwent postlumpectomy whole-breast radiation with a tumor bed boost for Tis – T2 breast cancer from 1970 to 2008. Boost parameters analyzed included size, energy, dose, and technique. Endpoints were local control, cosmesis, and fibrosis. Kaplan-Meier method was used to estimate actuarial incidence, and a Cox proportional hazard model was used to determine independent predictors of outcomes on multivariate analysis (MVA). The median follow-up was 78 months (range 1–305).
Results
The crude cosmetic results were excellent in 54%, good in 41%, and fair/poor in 5% of patients. The 10-year estimate of an excellent cosmesis was 66%. On MVA, independent predictors for excellent cosmesis were use of electron boost, lower electron energy, adjuvant systemic therapy, and whole breast IMRT. Fibrosis was reported in 8.4% of patients. The actuarial incidence of fibrosis was 11% at 5 years and 17% at 10 years. On MVA, independent predictors of fibrosis were larger cup size and higher boost energy. The 10-year actuarial local failure was 6.3%. There was no significant difference in local control by boost method, cut-out size, dose or energy.
Conclusion
Likelihood of excellent cosmesis or fibrosis are associated with boost technique, electron energy, and cup size. However, because of high local control and rare incidence of fair/poor cosmesis with a boost, anatomy of the patient and tumor cavity should ultimately determine the necessary boost parameters.
doi:10.1016/j.ijrobp.2010.04.067
PMCID: PMC2992091  PMID: 20732766
Breast Cancer; Radiation Therapy; Radiation Boost
3.  The Use of a Conventional Low Neck Field (LNF) and Intensity-Modulated Radiation Therapy (IMRT): No Clinical Detriment of IMRT to an Anterior LNF during the Treatment of Head and Neck Cancer 
Purpose
Appropriate treatment of the lower neck when using IMRT is controversial. Our study tried to determine differences in clinical outcomes using IMRT or a standard LNF to treat low neck.
Methods and Materials
This is a retrospective, single institution study. Ninety-one patients with squamous cell carcinoma of head and neck cancer were treated with curative intent. Based on physician preference, some patients were treated with LNF (PTV3) field using a single anterior photon field matched to the IMRT field. Field junctions were not feathered. The endpoints were time to failure and use of PEG tube (as a surrogate of laryngeal edema causing aspiration) and analysis done with chi-square and the log-rank tests.
Results
Median follow up 21 months (range 2 – 89). The median age 60 years. Thirty seven (41%) were treated with LNF, 84% were stage III or IV. PEG tube was required in 30% as opposed to 33% without the use of LNF. N2 or 3 neck disease was treated more commonly without a LNF (38% vs. 24%, p = 0.009). Failures occurred in 12 patients (13%). Only one patient treated with LNF failed regionally, 4.5 cm above the match line. The 3-year disease-free survival rate was 87%, 79% with LNF and without LNF respectively (p = 0.2) and the 3-year LR failure rate was 4%, 21% respectively, (p = 0.04).
Conclusions
Using LNF to treat the low neck did not increase the risk of regional failure “in early T& early N diseases” or decrease PEG tube requirements.
doi:10.1016/j.ijrobp.2009.10.034
PMCID: PMC3339153  PMID: 20385457
IMRT; Head and Neck cancer; Low neck field; RT toxicities; PEG tube
4.  Health States of Women after Conservative Surgery and Radiation for Breast Cancer 
Purpose
To use the EQ-5D instrument to evaluate the long-term health states of women with early stage breast cancer treated by breast-conserving surgery and radiation.
Materials and methods
1,050 women treated with conservative surgery and radiation with or without systemic therapy completed 2480 questionnaires during follow-up visits. The EQ-5D is a standardized and validated instrument for measuring quality of life outcomes. The descriptive system uses 5 dimensions of health with three possible levels of response that combine into 243 (35) possible unique health states that are each assigned a values-based index score from 0 to 1. The visual analog scale (VAS) rates health on a simple vertical line from 0 – 100. Higher scores correspond to better health status.
Results
The mean index scores were 0.89 (95% CI: 0.87-0.91) at 5 years, 0.9 (95% CI: 0.86-0.94) at 10 years, and 0.9 (95% CI: 0.83-1.0) at 15 years. There were no significant differences in health states between patients by age or compared with U.S. controls. There was a statistically significant positive correlation between the results of the VAS and descriptive system. Significant trends in health dimensions over 15 years were increased problems with self care and decreased problems with anxiety/depression, pain/discomfort, and performing usual activities.
Conclusions
This study of EQ-5D is unique and demonstrates very high quality of life in patients long-term after breast-conserving surgery and radiation. These health states are comparable to the adult female U.S. population. These data will provide valuable patient utility information for informing decision analyses investigating new treatments in women with breast cancer.
doi:10.1007/s10549-009-0552-5
PMCID: PMC2874617  PMID: 19768651
Breast cancer; radiation therapy; EQ-5D; EuroQol; Health States
5.  Quality of Life Supersedes the Classic Prognosticators for Long-Term Survival in Locally Advanced Non–Small-Cell Lung Cancer: An Analysis of RTOG 9801 
Journal of Clinical Oncology  2009;27(34):5816-5822.
Purpose
To determine the added value of quality of life (QOL) as a prognostic factor for overall survival (OS) in patients with locally advanced non–small-cell lung cancer (NSCLC) treated on Radiation Therapy Oncology Group RTOG-9801.
Patients and Methods
Two hundred forty-three patients with stage II/IIIAB NSCLC received induction paclitaxel and carboplatin (PC) and then concurrent weekly PC and hyperfractionated radiation (to 69.6 Gy). Patients were randomly assigned to amifostine (AM) or no AM during chemoradiotherapy. The following pretreatment factors were analyzed as prognostic factors for OS: Karnofsky performance status, stage, sex, age, race, marital status, histology, tumor location, hemoglobin, tobacco use, treatment arm (AM v no AM) and QOL scores (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 [QLQ-C30] and Lung Cancer 13 [LC-13]). A multivariate (MVA) Cox proportional hazards model was performed using a backwards selection process.
Results
Of the 239 analyzable patients, 91% had a baseline global QOL score. Median follow-up time was 59 months for patients still alive and 17 months for all patients. Median baseline QLQ-C30 global QOL score was 66.7 on both treatment arms. Whether the global QOL score was treated as a dichotomized variable (based on the median score) or a continuous variable, all other variables fell out of the MVA for OS. Patients with a global QOL score less than 66.7 had an approximately 70% higher rate of death than patients with scores ≥ 66.7 (P = .004). A 10-point higher baseline global QOL score corresponded to a decrease in the hazard of death by approximately 10% (P = .004). The other independent QOL predictors for OS were the QLQ-C30 physical functioning (P = .011) and LC-13 dyspnea scores (P = .012).
Conclusion
In this analysis, baseline global QOL score replaced known prognostic factors as the sole predictor of long-term OS for patients with locally advanced NSCLC.
doi:10.1200/JCO.2009.23.7420
PMCID: PMC2793002  PMID: 19858383
6.  Local-Regional Recurrence of Triple Negative Breast Cancer after Breast-Conserving Surgery and Radiation 
Cancer  2009;115(5):946-951.
Purpose
To study results of radiation on the local control of triple receptor negative breast cancer (negative estrogen (ER), progesterone (PR) and HER-2/neu receptors).
Materials and Methods
Conservative surgery and radiation were used in 753 patients with T1–T2 breast cancer. Three groups were defined by receptor status: ER or PR (+) group 1; ER and PR (−) but HER-2 (+) group 2; and triple negative (TN) group 3. Factors analyzed were age, menopause, race, stage, tumor size, node status, presentation, grade, extensive in-situ disease, margins, and systemic therapy. The primary endpoint was 5-year local-regional recurrence (LRR) isolated or total with distant metastases.
Results
ER and PR negative patients were statistically significantly more likely to be black, T2, have tumors detectable on both mammogram and physical exam, grade 3, and receive chemotherapy. There were no significant differences in ER and PR negative patients by Her-2 status. There was a significant difference in rates of first distant metastases (3%, 12% and 7% for groups 1, 2 and 3, respectively, p=0.009). However, the isolated 5-year LRR was not significantly different (2.3%, 4.6%, and 3.2%, respectively, p=0.36) between the 3 groups..
Conclusions
Patients with TN breast cancer are not at significantly increased risk for isolated LRR at 5-years so remain appropriate candidates for breast conservation.
doi:10.1002/cncr.24094
PMCID: PMC2993502  PMID: 19156929
Breast Cancer; Radiation Therapy; Hormone Receptor Negative; HER-2/neu; Basal-like Breast Cancer
7.  Young Age is Not Associated with Increased Local Recurrence for DCIS Treated by Breast-Conserving Surgery and Radiation 
Journal of surgical oncology  2009;100(1):25-31.
Background
We report local recurrence (LR) after breast-conserving surgery and radiation (BCS + RT) for ductal carcinoma in situ (DCIS) to determine outcomes for patients aged ≤ 40 years compared with older women.
Methods
The study included 440 women with DCIS treated from 1978 to 2007. All patients received whole-breast radiotherapy with a boost in 95% of cases. Demographics, characteristics, surgical and adjuvant treatments were analyzed for an effect on LR.
Results
Median age was 56.5 years with 24 patients aged ≤ 40. Median DCIS size was 0.8 cm. Re-excision was required in 62% of patients, and in 75% of those aged ≤ 40. Tamoxifen was used in 22%, but only 1 patient aged ≤ 40. Median follow-up was 6.8 years. Actuarial LR was 7% (95% confidence interval of 4–11%) at 10 years and 8% (5–14%) at 15 years. There was no difference in LR by age (p=0.76).
Conclusions
The long-term risk of LR after BCS + RT for DCIS is low, even in patients ≤ 40 years. This may be due to patient selection for small size, high utilization of re-excision and radiation boost. Young age may be a smaller contributor to LR risk in DCIS than previously suggested.
doi:10.1002/jso.21284
PMCID: PMC2945304  PMID: 19373863
Breast cancer; radiation therapy; DCIS; young age
8.  Breast IMRT Reduces Time Spent with Acute Dermatitis For Women of All Breast Sizes During Radiation 
Purpose
To study the time spent with radiation-induced dermatitis during a course of radiation therapy for breast cancer in women treated with conventional or intensity-modulated radiation therapy (IMRT).
Materials and methods
The study population consisted of 804 consecutive women with early-stage breast cancer treated with breast-conserving surgery and radiation from 2001 – 2006. All patients were treated with whole-breast radiation followed by a boost to the tumor bed. Whole-breast radiation consisted of conventional wedged photon tangents (n=405) earlier in the study period and mostly of photon IMRT (n=399) in later years. All patients had acute dermatitis graded each week of treatment.
Results
The breakdown of the cases of maximum acute dermatitis by grade was as follows: 3%, grade 0; 34%, grade 1; 61%, grade 2; and 2%, grade 3. The breakdown of cases of maximum toxicity by technique was as follows: 48%, grade 0/1, and 52%, grade 2/3, for IMRT, and 25%, grade 0/1, and 75%, grade 2/3, for conventional radiation therapy (p<0.0001). IMRT patients spent 82% of weeks during treatment with grade 0/1 dermatitis and 18% with grade 2/3 dermatitis, compared with 29% and 71% of patients, respectively, treated with conventional radiation (p<0.0001). Further, the time spent with grade 2/3 toxicity was decreased in IMRT patients with small (p=0.0015), medium (p<0.0001), and large (p<0.0001) breasts.
Conclusions
Breast IMRT is associated with both a significant decrease in the time spent during treatment with grade 2/3 dermatitis and in the maximum severity of dermatitis compared with conventional radiation regardless of breast size.
doi:10.1016/j.ijrobp.2008.08.071
PMCID: PMC2720600  PMID: 19362779
Breast cancer; radiation therapy; IMRT

Results 1-8 (8)