Global Pattern of Nasopharyngeal Cancer: Correlation of Outcome With Access to Radiation Therapy

Purpose: This study aimed to estimate the treatment outcome of nasopharyngeal cancer (NPC) across the world and its correlation with access to radiation therapy (RT). Methods and Materials: The age-standardized mortality (ASM) and age-standardized incidence (ASI) rates of NPC from GLOBOCAN (2012) were summarized, and [1−(ASM/ASI)] was computed to give the proxy relative survival (RS). Data from the International Atomic Energy Agency (IAEA) and the World Bank were used to assess the availability of RT in surrogate terms: the number of RT equipment units and radiation oncologists per million population. Results: A total of 112 countries with complete valid data were analyzed, and the proxy RS varied widely from 0% to 83% (median, 50%). Countries were categorized into Good, Median, and Poor outcome groups on the basis of their proxy RS (55%). Eighty percent of new cases occurred in the Poor outcome group. Univariable linear regression showed a significant correlation between outcome and the availability of RT: proxy RS increased at 3.4% (P<.001) and 1.5% (P=.001) per unit increase in RT equipment and oncologist per million population, respectively. The median number of RT equipment units per million population increased significantly from 0.5 in the Poor, to 1.5 in the Median, to 4.6 in the Good outcome groups, and the corresponding number of oncologists increased from 1.1 to 3.3 to 7.1 (P<.001). Conclusions: Nasopharyngeal cancer is a highly treatable disease, but the outcome varies widely across the world. The current study shows a significant correlation between survival and access to RT based on available surrogate indicators. However, the possible reasons for poor outcome are likely to be multifactorial and complex. Concerted international efforts are needed not only to address the fundamental requirement for adequate RT access but also to obtain more comprehensive and accurate data for research to improve cancer outcome.postprin

Comparison of post-treatment plasma EBV DNA with nasopharyngeal biopsy in patients after radical (chemo) radiotherapy for non-metatatic nasopharyngeal cancer

This journal suppl. entitled: Proceedings of the American Society for Radiation Oncology 56th Annual Meeting, ASTRO's 56th Annual Meeting ... 2014Oral Scientific SessionPURPOSE/OBJECTIVE(S): Random nasopharyngeal biopsy after completion of intensity-modulated radiation therapy (IMRT) for non-metastatic nasopharyngeal cancer (NPC) is routinely practiced in Hong Kong to confirm local remission. Plasma EBV DNA is proven an accurate marker for NPC. We carried out a prospective study comparing the correlation between post-IMRT nasopharyngeal biopsy and EBV DNA, to investigate if EBV DNA can substitute biopsy to confirm local remission. MATERIALS/METHODS: Patients with non-metastatic NPC treated with definitive (chemo) IMRT diagnosed between January 2011 and March 2013 were recruited. After baseline workup ...postprin

RapidArc radiotherapy planning for prostate cancer: Single-arc and double-arc techniques vs. intensity-modulated radiotherapy

RapidArc is a novel technique using arc radiotherapy aiming to achieve intensity-modulated radiotherapy (IMRT)-quality radiotherapy plans with shorter treatment time. This study compared the dosimetric quality and treatment efficiency of single-arc (SA) vs. double-arc (DA) and IMRT in the treatment of prostate cancer. Fourteen patients were included in the analysis. The planning target volume (PTV), which contained the prostate gland and proximal seminal vesicles, received 76 Gy in 38 fractions. Seven-field IMRT, SA, and DA plans were generated for each patient. Dosimetric quality in terms of the minimum PTV dose, PTV hotspot, inhomogeneity, and conformity index; and sparing of rectum, bladder, and femoral heads as measured by V70, V-40, and V20 (% of volume receiving >70 Gy, 40 Gy, and 20 Gy, respectively), treatment efficiency as assessed by monitor units (MU) and treatment time were compared. All plan objectives were met satisfactorily by all techniques. DA achieved the best dosimetric quality with the highest minimum PTV dose, lowest hotspot, and the best homogeneity and conformity. It was also more efficient than IMRT. SA achieved the highest treatment efficiency with the lowest MU and shortest treatment time. The mean treatment time for a 2-Gy fraction was 4.80 min, 2.78 min, and 1.30 min for IMRT, DA, and SA, respectively. However, SA also resulted in the highest rectal dose. DA could improve target volume coverage and reduce treatment time and MU while maintaining equivalent normal tissue sparing when compared with IMRT. SA achieved the greatest treatment efficiency but with the highest rectal dose, which was nonetheless within tolerable limits. For busy units with high patient throughput, SA could be an acceptable option. © 2012 American Association of Medical Dosimetrists.link_to_subscribed_fulltex

Predictive factors and radiological features of radiation-induced cranial nerve palsy in patients with nasopharyngeal carcinoma following radical radiotherapy

Objectives: To identify the key predictive factors of radiation-induced cranial nerve palsy in patients with nasopharyngeal carcinoma (NPC). Method and materials: From November 1998 to December 2007, all consecutive patients with newly diagnosed NPC who were curatively treated with radiotherapy and subsequently developed radiation-induced cranial nerve palsy (RICNP) were included in our study. Patients with cranial nerve palsy due to disease recurrence were excluded. Their records were retrospectively reviewed. Results: Amongst 965 patients with NPC treated with radical radiotherapy, 41 developed new cranial nerve palsy. After exclusion of 5 patients with cranial nerve palsy due to recurrence, 36 (3.7%) developed RICNP. The median follow-up was 8.9 years (range, 3.2-11.3 years). Ten of the 36 patients had cranial nerve palsy at presentation. Twenty-seven patients had single cranial nerve palsy and 9 patients had multiple cranial nerve palsy. The most commonly involved cranial nerve was cranial nerve XII, with 30 patients having palsy of cranial nerve XII and 6 of them having bilateral cranial nerve XII palsies. Magnetic resonance imaging features of radiation-induced hypoglossal nerve palsy were demonstrated in our study. Multivariate analysis revealed that cranial nerve palsy at presentation was an independent prognostic factor for the development of RICNP. Other factors including T staging, N staging, gender, age, radiotherapy technique and the use of chemotherapy have no significant relationship with the risk of developing RICNP. Conclusion: RICNP in patients with NPC is not a rare complication, and cranial nerve palsy at presentation is an important prognostic factor. © 2012 Elsevier Ltd. All rights reserved.link_to_subscribed_fulltex

Radical radiotherapy for nasopharyngeal carcinoma in elderly patients: The importance of co-morbidity assessment

Elderly patients represent a unique challenge for radical treatment in nasopharyngeal carcinoma (NPC) because of age and co-morbid conditions. We sought to evaluate the outcome of this particular group of patients and to identify key factors affecting treatment outcome. From 1998 to 2008, 990 consecutive NPC patients without distant metastasis were treated with radical radiotherapy with planned total dose >66 Gy. Among them, 103 (10.4%) patients were elderly aged >70 (group A). Their clinical characteristics and outcome were compared with those aged <70 (group B). Mortality at 90 days was used as a proxy of early deaths related to treatment. Co-morbidities were measured by the Adult Co-morbidity Evaluation 27 (ACE-27). Group A presented more commonly with poorer performance status. They showed higher rates of acute reaction, radiotherapy incompletion and mortality at 90 days (7.8% vs. 1.2%, p < 0.001). The 5-year overall survival rates were 43.9% and 78.1% for groups A and B, respectively (p < 0.001). No difference in failure free survival rates was noted. For group A, ACE-27 was the only predicting factor for mortality at 90 days [ACE-27 2-3 vs. 0-1: HR 15.86 (2.68-93.95), p = 0.002], and the most important prognostic factors for overall survival included age, presenting stage and ACE-27 (p < 0.05). Elderly NPC patients had poorer tolerance to radiotherapy. Early deaths related to treatment were not uncommon. A reasonable disease control can still be attained after radical radiotherapy for those who were able to survive through the peri-radiotherapy period. Patient selection and treatment approach with reference to ACE-27 should be considered. © 2011 Elsevier Ltd. All rights reserved.link_to_subscribed_fulltex

Regorafenib for metastatic colorectal cancer in community setting: a multicenter retrospective analysis in Hong Kong

This free journal suppl. entitled: ESMO 17th World Congress on Gastrointestinal Cancer, 1-4 July 2015, Barcelona, SpainPoster Presentation: no. P-270INTRODUCTION: The efficacy of regorafenib in refractory metastatic colorectal cancer has been demonstrated in two international phase III randomized controlled trials, the CORRECT and the CONCUR study, but the data in community setting is scarce. To evaluate the use of regorafenib in community setting, we perform a multicenter retrospective analysis in Hong Kong. METHODS: Patients were eligible for treatment with regorafenib if they have failed all available systemic agents including fluoropyrimidine, oxaliplatin, irinotecan, bevacizumab, and cetuximab or panitumumab if RAS wild-type tumor. Individual patient data was retrieved from the Department of Clinical Oncology and the Department of Medicine, Queen Mary Hospital and the Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong. Beside demographic, efficacy and toxicity data, pattern of prescription and treatment suspension were collected. RESULTS: From July 2013 to January 2015, 28 patients were treated with regorafenib for metastatic colorectal cancer in a non-clinical trial setting. The median age of patients was 62 (Range 45-77) and most of them had good performance status (ECOG 0-1: 89.3%). Majority of patients presented with synchronous metastasis (64.3%) and had metastases involving multiple organs at the time of regorafenib treatment (92.9%). Sixty-four percent of tumors were RAS wild-type. Patients have received a median of three prior lines of treatment and the median time interval from date of first line therapy to the start of regorafenib was 24.3 months. A total of 87 treatment cycles were prescribed in the 28 patients. Fifteen patients were started at 160mg daily and 9 of them required further dose reduction or suspension during subsequent cycles. Irrespective of the starting dose, 77% of additional dose reduction occurred at the first and second cycles. The main reason for dose reduction or treatment suspension was due to hand-foot syndrome followed by deranged liver function. For those who started at lower dose or required dose reduction during treatment, 14 of 22 patients were able to re-escalate the dose. Adverse events of any grade occurred in all patients. There was one case of grade 4 anaemia due to per rectal bleeding but no treatment related death was observed. The commonest grade 3 non-haematologic adverse event were hand-foot syndrome (25%), elevated AST (14.3%)/ ALT (10.7%), elevated bilirubin (3.6%), hypoalbuminaemia (3.6%), fatigue (3.6%), diarrhea (3.6%) and bleeding (3.6%). The most common grade 3 haematologic adverse events were anaemia (7.1%) and thrombocytopenia (3.6%). After a median follow-up of 4.9 months: 18 patients have progressed and the median progression-free survival was 3.2 months (95% CI 2.5-3.9 months) while 11 patients have died and the median survival was 6.1 months (95% CI: 1.4-10.9 months). Treatment response was uncommon and only 1 patient (3.6%) achieved a partial response and another 17 patients (60.7%) had stable disease at 8 weeks. Nine of nineteen patients were able to receive further systemic treatment after stopping regorafenib. CONCLUSION: The efficacy and toxicity profile of regorafenib in the community setting were comparable to those reported in phase III clinical trials. Dose reduction and treatment interruption was common but dose re-escalation is feasible.link_to_OA_fulltex

The use of Denosumab for breast cancer patients with bone metastases: experience from a tertiary center

A total of 43 patients suffering from breast cancer with bone metastases were treated with subcutaneous denosumab every 4 weeks within the study period from Jan 2012 to Mar 2014. All patients were given calcium and vitamin D supplement. Their tumor characteristics, exposure to bisphosphonate, control of bone metastases, skeletal related events and side effects from denosumab were retrospectively reviewed. Results: The median age at the time of diagnosis of bone metastases was 51 (range: 30 - 81), and that at the initiation of denosumab was 54 (range: 31 - 81). The proportion of patients with endocrine responsive, HER2 positive and triple negative diseases were 81.4%, 41.9% and 11.6%, respectively. Among them, 67.4% had previous exposure to bisphosphonate, most commonly zoledronic acid. The median duration of treatment with denosumab was 7.4 months (range: 1-26.3). Seven patients died of breast cancer during the study period. The median time to radiological bone progression was not reached yet. Within the study period, 4 patients (9.3%) required palliative radiotherapy to the bone while none of them developed cord compression or required surgery to the bone. No clinically significant hypocalcaemia or deterioration of renal function was noted. One patient was found to have grade 2 osteonecrosis of jaw after 5 months of denosumab. Conclusion: Denosumab is commonly used for patients who suffer from breast cancer with bone metastases. Side effect was infrequent but high clinical alertness should be maintained