Findlay, OH, United States
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Hahn C.,Duke University | Kavanagh B.,University of Colorado at Denver | Bhatnagar A.,Cancer Treatment Services International | Jacobson G.,West Virginia University | And 4 more authors.
Practical Radiation Oncology | Year: 2014

To highlight 5 interventions that patients should question, as part of the Choosing Wisely campaign. This initiative, led by the American Board of Internal Medicine Foundation, fosters conversations between physicians and patients about treatments and tests that may be overused, unnecessary, or potentially harmful. Methods and materials: Potential items were initially compiled using an online survey. They were then evaluated and refined by a work group representing the American Society for Radiation Oncology (ASTRO) Clinical Affairs and Quality, Health Policy, and Government Relations Councils. Literature reviews were carried out to support the recommendation and narrative, as well as to provide references for each item. A final list of 5 items was then selected by the ASTRO Board of Directors. Results: ASTRO's 5 recommendations for the Choosing Wisely campaign are the following: (1) Don't initiate whole-breast radiation therapy as a part of breast conservation therapy in women age ≥. 50 with early-stage invasive breast cancer without considering shorter treatment schedules; (2) don't initiate management of low-risk prostate cancer without discussing active surveillance; (3) don't routinely use extended fractionation schemes (>. 10 fractions) for palliation of bone metastases; (4) don't routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry; and (5) don't routinely use intensity modulated radiation therapy to deliver whole-breast radiation therapy as part of breast conservation therapy. Conclusions: The ASTRO list for the Choosing Wisely campaign highlights radiation oncology interventions that should be discussed between physicians and patients before treatment is initiated. These 5 items provide opportunities to offer higher quality and less costly care. © 2014 American Society for Radiation Oncology.


Chow E.,Odette Cancer Center | Hoskin P.,Mount Vernon Hospital | Mitera G.,Odette Cancer Center | Zeng L.,Odette Cancer Center | And 6 more authors.
International Journal of Radiation Oncology Biology Physics | Year: 2012

Purpose: To update the international consensus on palliative radiotherapy endpoints for future clinical trials in bone metastases by surveying international experts regarding previous uncertainties within the 2002 consensus, changes that may be necessary based on practice pattern changes and research findings since that time. Methods and Materials: A two-phase survey was used to determine revisions and new additions to the 2002 consensus. A total of 49 experts from the American Society for Radiation Oncology, the European Society for Therapeutic Radiology and Oncology, the Faculty of Radiation Oncology of the Royal Australian and New Zealand College of Radiologists, and the Canadian Association of Radiation Oncology who are directly involved in the care of patients with bone metastases participated in this survey. Results: Consensus was established in areas involving response definitions, eligibility criteria for future trials, reirradiation, changes in systemic therapy, radiation techniques, parameters at follow-up, and timing of assessments. Conclusion: An outline for trials in bone metastases was updated based on survey and consensus. Investigators leading trials in bone metastases are encouraged to adopt the revised guideline to promote consistent reporting. Areas for future research were identified. It is intended for the consensus to be re-examined in the future on a regular basis. © 2012 Elsevier Inc.


Lutz S.T.,Blanchard Valley Regional Cancer Center | Jones J.,University of Pennsylvania | Chow E.,University of Toronto
Journal of Clinical Oncology | Year: 2014

Radiotherapy is a successful, time-efficient, well-tolerated, and cost-effective intervention that is crucial for the appropriate delivery of palliative oncology care. The distinction between curative and palliative goals is blurred in many patients with cancer, requiring that treatments be chosen on the basis of factors related to the patient (ie, poor performance status, advanced age, significant weight loss, severe comorbid disease), the cancer (ie, metastatic disease, aggressive histology), or the treatment (ie, poor response to systemic therapy, previous radiotherapy). Goals may include symptom relief at the site of primary tumor or from metastatic lesions. Attention to a patient's discomfort and transportation limitations requires hypofractionated courses, when feasible. Innovative approaches include rapid response palliative care clinics as well as the formation of palliative radiotherapy specialty services in academic centers. Guidelines are providing better definitions of appropriate palliative radiotherapy interventions, and bone metastases fractionation has become the first radiotherapy quality measure accepted by the National Quality Forum. Further advances in the palliative radiation oncology subspecialty will require integration of education and training between the radiotherapy and palliative care specialties. © 2014 by American Society of Clinical Oncology.


Jones J.A.,University of Pennsylvania | Lutz S.T.,Blanchard Valley Regional Cancer Center | Chow E.,University of Toronto | Johnstone P.A.,Indiana University
CA Cancer Journal for Clinicians | Year: 2014

When delivered with palliative intent, radiotherapy can help to alleviate a multitude of symptoms related to advanced cancer. In general, time to symptom relief is measured in weeks to months after the completion of radiotherapy. Over the past several years, an increasing number of studies have explored rates of radiotherapy use in the final months of life and have found variable rates of radiotherapy use. The optimal rate is unclear, but would incorporate anticipated efficacy in patients whose survival allows it and minimize overuse among patients with expected short survival. Clinician prediction has been shown to overestimate the length of survival in repeated studies. Prognostic indices can provide assistance with estimations of survival length and may help to guide treatment decisions regarding palliative radiotherapy in patients with potentially short survival times. This review explores the recent studies of radiotherapy near the end of life, examines general prognostic models for patients with advanced cancer, describes specific clinical circumstances when radiotherapy may and may not be beneficial, and addresses open questions for future research to help clarify when palliative radiotherapy may be effective near the end of life. © 2014 American Cancer Society.


Longo J.,Medical College of Wisconsin | Lutz S.,Blanchard Valley Regional Cancer Center | Johnstone C.,Medical College of Wisconsin
Cancer Management and Research | Year: 2013

Bone metastases are prevalent among cancer patients and frequently cause significant morbidity. Oncology providers must mitigate complications associated with bone metastases while limiting therapy-related adverse effects and their impact on quality of life. Multiple treatment modalities, including chemotherapy, surgery, external beam radiation therapy, and radioisotopes, among others, have been recommended and utilized for palliative treatment of bone metastases. Radioisotopes such as samarium-153 are commonly used in the setting of multifocal bone metastases due to their systemic distribution, affinity for osteoblastic lesions, acceptable toxicity profile, and convenience of administration. This review focuses on samarium-153, first defining its radiobiologic and pharmacokinetic properties before describing many clinical trials that support its use as a safe and effective tool in the palliation of patients with bone metastases. © 2013 Longo et al.


von Gunten C.F.,Institute for Palliative Medicine at San Diego Hospice | Lutz S.,Blanchard Valley Regional Cancer Center | Ferris F.D.,Institute for Palliative Medicine at San Diego Hospice
Oncology | Year: 2011

The majority of patients with advanced malignancy die with a predictable disease trajectory. Increasing use of chemotherapy and radiotherapy near the end of life has not changed that trajectory. For adults with advanced solid tumors, the period from becoming symptomatic to death of the patient is 4 to 6 weeks. Poor performance status is still the most important prognostic factor, among others that have been described. The data are now in; hospice care is the best standard of care for cancer patients, it is not an alternative to standard care. Payers for high-quality cancer care will expect referral with an interval of care-generally on the order of 4 to 6 weeks of enrollment-as a measure of quality cancer care given by the oncologist. In this article, prognostic data are summarized and a suggested approach for discussing hospice enrollment with patients is presented.


Chow E.,University of Toronto | Zeng L.,University of Toronto | Salvo N.,University of Toronto | Dennis K.,University of Toronto | And 2 more authors.
Clinical Oncology | Year: 2012

Aims: To update previous meta-analyses of randomised palliative radiotherapy trials comparing single fractions versus multiple fractions. Materials and methods: All published randomised controlled trials comparing single fraction versus multiple fraction schedules for the palliation of uncomplicated bone metastases were included in this analysis. Odds ratios and 95% confidence intervals were calculated for each trial. Forest plots were created using a random effects model and the Mantel-Haenszel statistic. Results: In total, 25 randomised controlled trials were identified. For intention-to-treat patients, the overall response rate was similar in patients receiving single fractions (1696 of 2818; 60%) and multiple fractions (1711 of 2799; 61%). Complete response rates were 620 of 2641 (23%) in the single fraction arm and 634 of 2622 (24%) in the multiple fraction arm. No significant difference was seen in overall or complete response rates. Pathological fracture did not favour either arm, but spinal cord compression trended towards favouring multiple fractions; however, neither was statistically significant (P=0.72 and P=0.13, respectively). Retreatment rates favoured patients in the multiple fraction arm, where the likelihood of requiring re-irradiation was 2.6-fold greater in the single fraction arm (95% confidence interval: 1.92-3.47; P<0.00001). Repeated analyses excluding drop-out patients did not alter these findings. In general, no significant differences in acute toxicities were seen. Conclusion: Overall and complete response rates were similar in both intention-to-treat and assessable patients. Single and multiple fraction regimens provided equal pain relief; however, significantly higher retreatment rates occurred in those receiving single fractions. © 2011 The Royal College of Radiologists.


Lutz S.,Blanchard Valley Regional Cancer Center | Chow E.,University of Toronto
Journal of Bone Oncology | Year: 2012

Bone metastases are a common manifestation of malignancy, and external beam radiotherapy (EBRT) effectively and safely palliates the pain caused by this clinical circumstance. The myriad of EBRT dosing schemes and complexities involved with coordinating radiotherapy with other interventions necessitated the need for bone metastases treatment guidelines. Here we compare and contrast the bone metastases radiotherapy treatment guidelines recently published by the American Society for Radiation Oncology (ASTRO) and the American College of Radiology (ACR). These evaluations acknowledge current controversies in treatment approaches, they evaluate the nuances of ASTRO and ACR task force decisionmaking regarding standard approaches to care, and they project the upcoming research results that may clarify approaches to palliative radiotherapy for bone metastases. The results of these two dedicated radiotherapy guidelines are compared to the brief mentions of radiotherapy for bone metastases in the National Comprehensive Cancer Network (NCCN) guidelines. Finally, the paper describes how treatment guidelines may influence patterns of care and reimbursement by their use as quality measures by groups such as the National Quality Forum (NQF). © 2012 Elsevier GmbH.


Estabrook N.C.,Indiana University | Lutz S.T.,Blanchard Valley Regional Cancer Center | Johnson C.S.,Indiana University | Henderson M.A.,Indiana University
Journal of Supportive Oncology | Year: 2013

Background: Patients with brain metastases from solid tumors can be subdivided by characteristics into separate prognostic groups, such as the Radiation Therapy Oncology Group's Recursive Partitioning Analysis (RPA) or the Graded Prognostic Assessment (GPA). At our institution, patients falling into the poorest prognostic groups are often treated with whole brain radiotherapy (WBRT). Objective: To determine if observed survival of poor prognosis patients treated with WBRT for brain metastases at our institution matches the survival predicted by RPA and GPA prognostic indices. Methods: The charts of 101 consecutive patients with newly diagnosed brain metastases from solid tumors who received WBRT were retrospectively reviewed. We calculated each patient's RPA and GPA and compiled treatment and survival data. Observed median survival was compared to that predicted by the RPA and GPA prognostic indices. Results: RPA III patients (n = 25) had a median survival of 2.4 months in our study. GPA 0.0-1.0 patients (n = 35) had a median survival of 2.4 months in our study. These values did not vary significantly from those predicted by the respective indices. Limitations This is a retrospective analysis and subject to selection bias. Conclusion: Given the delivery time for WBRT and the potential side effects associated with the treatment, the predictably short overall survival in poor prognosis patients calls into question the value of WBRT in this patient subgroup. © 2013 Frontline Medical Communications.


Lutz S.,Blanchard Valley Regional Cancer Center
Current Pain and Headache Reports | Year: 2012

The management of painful bone metastases requires multidisciplinary care, with external beam radiation therapy (EBRT) providing relief that is effective and time efficient. Patients with bone metastases may require interventions including surgical decompression, osteoclast inhibitors, radiopharmaceuticals, and kyphoplasty or vertebroplasty, though EBRT should be included in the care of most of these patients, as well. Recent treatment-guideline publications for bone metastases greatly define the appropriate use of EBRT for this patient group, and they create a means by which treatment approaches may serve as quality measures of radiotherapy departments. © Springer Science+Business Media, LLC 2012.

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