The Use of Breast Cup Immobilization in Radiation Therapy and Patient Reported Outcomes on Cosmesis and Pain

Purpose/Objective(s): Breast cosmesis and pain are among the most reported outcomes in patients undergoing breast irradiation. There is variability in the degree of adverse reactions based on different patient specific characteristics. It has been found that women with large body habitus, African American race, and larger breast size tend to have an increased chance of experiencing worse toxicity from treatment. Attempts to improve cosmesis and pain have been highly explored. We explore here whether the use of a breast cup for treatment leads to worse cosmesis and pain when compared to those treated without a breast cup. This is an important topic as it is felt that the use of a breast cup would provide a significant dosimetric advantage (i.e., organ at risk dosing) during treatment. We now explore this treatment option through a retrospective analysis of patient reported outcomes experienced during and after completing post-operative radiation therapy to the breast. Materials/Methods: 645 patients undergoing adjuvant breast irradiation were evaluated from 2011 through 2019. 79 patients were treated using a breast cup. Mean heart dose was analyzed and compared between the two treatment groups and was found to be comparable in each arm. Additionally, patient reported outcomes among the entire cohort were collected via survey documentation forms during treatment, at 1 month post treatment, and at 1 year after treatment. These results were collected using the Michigan Radiation Oncology Quality Consortium (MROQC) database as each patient was consented to enroll in MROQC prior to starting treatment. The outcomes of skin changes, lymphedema, and breast pain among the two treatment groups were then compared for statistically significant differences via a logistic regression analysis. Results: Patients were evaluated at 3 time points; during treatment, 1-month post-treatment and at 1 year after treatment. Of the 79 patients treated with a breast cup, when compared to the no cup patients, grade 2 pruritus and grade 1 alteration in skin texture were not significantly different at any time point (p \u3e 0.05). With regards to lymphedema, no statistically significant difference was seen between the two groups of patients outside of the 1 month after treatment survey time point; all p values greater than 0.05 except for the 1-month mark (p value 0.03). Lastly, breast pain survey remarks at the pre-specified time points failed to show a significant difference in the symptom between the two analyzed treatment groups (p\u3e 0.05). Conclusion: From our patient\u27s perspective, the use of a breast cup during radiation therapy did not negatively impact breast cosmesis or pain when compared to patients treated without a cup. Breast cup use was also found to produce similar dosimetric coverage to the heart as non-cup patients, even in left sided breast cancers

Mediators of Racial Disparities in Heart Dose among Whole Breast Radiotherapy Patients

BACKGROUND: Racial disparities in survival of patients with cancer motivate research to quantify treatment disparities and evaluate multilevel determinants. Prior research has not evaluated cardiac radiation dose in large cohorts of breast cancer patients by race, nor examined potential causes or implications of dose disparities. METHODS: We used a statewide consortium database to consecutively sample 8,750 women who received whole breast radiotherapy between 2012 and 2018. We generated laterality- and fractionation-specific models of mean heart dose. We generated patient and facility-level models to estimate race-specific cardiac doses. We incorporated our data into models to estimate disparities in ischemic cardiac event development and death. All statistical tests are 2-sided. RESULTS: Black and Asian race independently predicted higher mean heart dose for most laterality-fractionation groups, with disparities of up to 0.42 Gy for Black and 0.32 Gy for Asian women (left-sided disease and conventional fractionation: 2.13 Gy for Black v. 1.71 Gy for White women, p \u3c .001, two-sided; left-sided disease and accelerated fractionation: Asian 1.59 Gy v. 1.27 Gy for White women, p = .002). Patient clustering within facilities explained 22-30% of the variability in heart dose. The cardiac dose disparities translated to estimated excesses of up to 2.6 cardiac events and 1.3 deaths per 1000 Black and 0.7 cardiac events and 0.3 deaths per 1000 Asian v. White women. CONCLUSIONS: Depending on laterality and fractionation, Asian and Black women experience higher cardiac doses than White women. This may translate into excess radiation-associated ischemic cardiac events and deaths. Solutions include addressing inequities in baseline cardiac risk factors and facility-level availability and use of radiation technologies

The Role of Facility Variation on Racial Disparities in Use of Hypofractionated Whole Breast Radiotherapy

INTRODUCTION: Hypofractionated radiotherapy is a less burdensome and less costly approach that is efficacious for most patients with early-stage breast cancer. Concerns about racial disparities in adoption of medical advances motivate investigation of the use of hypofractionated radiation in diverse populations. The goal of our study was to determine whether hypofractionated whole breast radiotherapy after breast conserving surgery was being similarly used across racial groups in the state of Michigan. METHODS AND MATERIALS: A prospectively collected statewide quality consortium database from 25 institutions was queried for breast cancer patients who completed hypofractionated (HF) or conventionally fractionated (CF) whole breast radiotherapy (RT) from 1/2012-12/2018. We used patient-level multivariable modeling to evaluate associations between HF use and race, controlling for patient and facility factors, and multilevel modeling to account for patient clustering within facilities. RESULTS: Of 9,634 patients analyzed, 81% self-reported race as White, 17% as Black and 2% as Asian, similar to statewide and national distributions. 31.7% of Whites were treated at teaching centers compared to 66.7% of Blacks and 64.8% of Asians. In 2018, HF was utilized in 72.7% of Whites versus 56.7% of Blacks and 67.6% of Asians (p=0.0411). On patient-level multivariable analysis, Black and Asian races were significantly associated with a lower likelihood of HF receipt (p\u3c0.001), despite accounting for treatment year, age, laterality, BMI, breast volume, comorbidities, stage, triple-negative status, IMRT use, teaching center treatment, and 2011 ASTRO Hypofractionation Guideline eligibility. On multilevel analysis, race was no longer significantly associated with HF receipt. CONCLUSIONS: We observed that Black and Asian patients receive hypofractionated RT less often than Whites, despite more frequent treatment at teaching centers. Multilevel modeling eliminated this disparity, suggesting that differences in facility-specific HF use appear to have contributed. Further inquiry is needed to determine if reduction of facility-level variation may reduce disparities in accessing HF treatment

The role of facility variation on racial disparities in use of hypofractionated whole breast radiotherapy

Background: Concerns about racial disparities in the adoption of medical advances motivate investigation of the use of hypofractionated radiotherapy, a less burdensome and less costlyapproach that is efficacious for most patients with early-stage breast cancer. Methods: A prospectively collected statewide quality consortium database from 25 institutions was queried for breast cancer patients who completed hypofractionated (HF) or conventionally fractionated whole breast radiotherapy (RT) from 1/2012-12/2018. We used patient-level multivariable modeling to evaluate associations between HF use and race, controlling for patient and facility factors, and multilevel modeling to account for patient clustering within facilities. Results: Of 10,318 patients analyzed, 80% self-reported their race as White, 18% as Black, and 2% as Asian, similar to statewide and national distributions. 31% of Whites were treated at academic centers compared to 65% of Blacks and 65% of Asians. In 2018, HF was utilized in 75% of Whites versus 60% of Blacks and 68% of Asians. On patient-level multivariable analysis (see Table), Black and Asian race were significantly associated with a lower likelihood of HF receipt, despite accounting for treatment year, age, laterality, BMI, breast volume, comorbidities, stage, triple-negative status, IMRT use, academic center treatment, and 2011 ASTRO Hypofractionation Guideline eligibility. On multilevel analysis, race was no longer significantly associated with HF receipt. Conclusions: We observed thatBlack and Asian patients receive hypofractionated RT less often, despite more frequent treatment at academic centers. Multilevel modeling eliminated this disparity, suggesting that differences in facility-specific HF use may contribute. Further inquiry is needed to determine if reduction of facility-level variation may reduce disparities in accessing HF treatment

The value of performance metrics in a large statewide consortium: using planning target volumes towards improvements in breast planning.

Purpose: While several ICRU reports recommend planning target volumes (PTVs) in radiation therapy, the frequency of PTV use in routine clinical practice for patients who have undergone breast-conserving surgery is not known. A statewide consortium, focused on quality improvement, evaluated whether or not a PTV was created for the lumpectomy cavity for these patients. Methods: Baseline data regarding lumpectomy cavity PTV delineation use was acquired from 22 institutions for patients who underwent breast-conserving surgery from 2011 through mid-2016. In 2017, a consortium- wide performance metric was established requiring PTVs for the lumpectomy cavity with the purpose of ensuring adequate target coverage when cardiac dose is considered. The PTV delineation rate was evaluated before and after introduction of the performance metric. Starting in August 2017, the expansion size was captured. Results: For patients who completed radiotherapy before the intervention (2011- mid-2016; N = 6278), 35.0% had a PTV delineated. For patients who completed radiotherapy after the intervention was required (2017; N = 1890), this percentage increased to 77.8%. During that time, PTV adoption rates varied by institution (N = 22) with 9 institutions delineating a PTV for 90% or more of their patients, 8 between 50-90%, and 5 less than 50% at the end of 2017. The median PTV expansion used by institutions was 1 cm (range 0.1-2 cm). Conclusion: Introduction of a consortium-wide performance metric was an effective intervention, increasing the PTV delineation rate for the lumpectomy cavity for radiation therapy patients who have undergone breast-conserving surgery. This increase in PTV use will allow the consortium to make target dose homogeneity and coverage recommendations which may aid in weighing clinical tradeoffs between target and heart doses. Future work will investigate the relationship between lumpectomy cavity expansion size as a function of whether or not daily or weekly imaging is used amongst clinics within the consortium

Contemporary Practice Patterns for Radiotherapy of Bone Metastases: Preliminary Analysis of Prospective Data from a Statewide Consortium Focusing on Extended Fractionation

Purpose/Objective(s): National guidelines recommend various effective dose and fractionation schemes for palliative radiotherapy (RT) of bone metastases, including noninferior outcomes with single fraction regimens. For Choosing Wisely, ASTRO advocated against use of extended fractionation schemes with greater than 10 fractions. We previously reported a retrospective assessment of heterogeneity in RT management of bone metastases. Herein, we sought to prospectively analyze current practice patterns of palliative RT in the treatment of bone metastases in diverse clinical settings. Specifically, we investigated possible predictors of extended treatment courses. Materials/Methods: Within a statewide radiation oncology quality consortium, patients were consecutively enrolled between March 2018 and February 2019 in both academic and non-academic facilities. Data on patient characteristics, provider and facility characteristics, dose and fractionation schedules, treatment planning and delivery techniques and image guidance were collected. Multivariable binary logistic regression was employed to assess use of extended fractionation (\u3e10 fractions) RT. Results: A total of 444 consecutive patients were enrolled by 24 treating facilities. The median case volume per center was 15 (range, 1-55), with a total of 608 plans from 411 patients available for analysis. The median number of plans per patient was 1 (range, 1-4). The most commonly employed dose and fractionation schedules were 3 Gy x 10 fractions (54%), 4 Gy x 5 fractions (14%), and 8 Gy x 1 fraction (11%). A minority of plans (5%) used extended fractionation. IMRT was utilized for 9% of plans, while cone beam CT image guidance was used in 14% of cases. A majority of plans (64%) were designed for uncomplicated osseous metastatic lesions. For uncomplicated lesions 13% of plans were prescribed 8 Gy x 1 fraction, while 5% were prescribed greater than 10 fractions. The only significant predictor of use of extended fractionation was type of treatment facility with academic centers significantly less likely to use more than 10 fractions per plan (OR=0.16, 95% CI: 0.04-0.72, p\u3c0.02). Conclusion: This is our initial analysis of contemporary practice patterns of palliative RT for bone metastases using prospective data recently collected from our statewide consortium. Within a large, consecutively enrolled patient cohort, we demonstrate that palliative RT for management of bone metastases remains diverse. Resource-intensive treatments including image guidance and extended fractionation exist, with type of treatment facility significantly predicting use of extended fractionation. Taken together, these preliminary results support our ongoing collection of the prospective data needed to more clearly understand the barriers to high value RT approaches in this setting

Uptake of Adjuvant Durvalumab After Definitive Concurrent Chemoradiotherapy for Stage III Nonsmall-cell Lung Cancer

OBJECTIVES: The addition of adjuvant durvalumab improves overall survival in locally advanced nonsmall-cell lung cancer (NSCLC) patients treated with definitive chemoradiation, but the real-world uptake of adjuvant durvalumab is unknown. MATERIALS AND METHODS: We identified patients with stage III NSCLC treated with definitive concurrent chemoradiation from January 2018 to October 2020 from a statewide radiation oncology quality consortium, representing a mix of community (n=22 centers) and academic (n=5) across the state of Michigan. Use of adjuvant durvalumab was ascertained at the time of routine 3-month or 6-month follow-up after completion of chemoradiation. RESULTS: Of 421 patients with stage III NSCLC who completed chemoradiation, 322 (76.5%) initiated adjuvant durvalumab. The percentage of patients initiating adjuvant durvalumab increased over time from 66% early in the study period to 92% at the end of the study period. There was substantial heterogeneity by treatment center, ranging from 53% to 90%. In multivariable logistic regression, independent predictors of durvalumab initiation included more recent month (odds ratio [OR]: 1.05 per month, 95% confidence interval [CI]: 1.02-1.08, P=0.003), lower Eastern Cooperative Oncology Group score (OR: 4.02 for ECOG 0 vs. 2+, 95% CI: 1.67-9.64, P=0.002), and a trend toward significance for female sex (OR: 1.66, 95% CI: 0.98-2.82, P=0.06). CONCLUSION: Adjuvant durvalumab for stage III NSCLC treated with definitive chemoradiation was rapidly and successfully incorporated into clinical care across a range of community and academic settings in the state of Michigan, with over 90% of potentially eligible patients starting durvalumab in more recent months