October, 2016

Binding Me With Science

By Michael J. Katin, MD

As anticipated, the 58th Annual Meeting of the American Society for Radiation Oncology went on as scheduled, from September 25 to 28 in Boston, Massachusetts, bravely undeterred by events occurring elsewhere in the world. Inauspiciously, the first day of the meeting was also the day of the deaths of both Miami Marlins star pitcher Jose Fernandez AND the King, Arnold Palmer. That day also witnessed continuation of the bombing of Aleppo by Syrian military forces. The New York Times endorsed Hillary Clinton for President, identifying Donald Trump as "the worst nominee put forward by a major party in modern American history." The next day featured the first Presidential debate.. On September 27, the first case of Zika virus-induced microcephaly in Southeast Asia was identified in Thailand, and on the same day the World Health Organization announced that 92% of the world's population lives in areas in which air pollution levels exceed the WHO 's limits. Finally, on Getaway Day, September 28, Typhoon Megi struck China after having produced extensive destruction in Taiwan, and former Israeli President and Prime Minister Simon Peres died.

Sort of puts things into perspective.

It was an incredibly eventful several days, eliminating any chance that the proceedings of the ASTRO meeting would be covered by any news organizations. Fortunately, there was one person able to review the presentations and offer comments on their significance. Here goes:
Actually, before going any further, it seems pertinent to note that the trend now is for the majority of accepted submissions (2,579 out of 4,127) to be deemed not worthy to be put into print in the Proceedings of the American Society for Radiation Oncology Supplement to the International Journal of Radiation Oncology, Biology, and Physics (the organizational equivalent of the Long Branch branch of the Red Bank Bank ). There are 368 items (plus #263.5...??) in the "oral scientific sessions" and then the first 1180 ePoster sessions are in the supplement. All the rest need to be accessed on line at astro.org Was this a way of telling the authors of the final 2,579 accepted scientific works, "Thank you for participating. We'll go through the motion of making it look as if you're involved but maybe this will give you the encouragement to do something worthwhile next time?" Is this the standard of today's society in which trophies are given for participation rather than for winning? Or is it possible that buried in the 2,579 additional works of science are profound discoveries that we condemn our species to additional years of illness because we haven't been able to properly process and absorb this knowledge? In any event, what are the criteria, probably some as subjective as in figure skating, that allows ePoster #1179 that "Pharmacologic
Ascorbate Enhances the Response of Non-Small Cell Lung Cancer (NSCLC) to Radiation and Chemotherapy Via Disruptions of Redox Active Iron Leading to Increased H202," to make it into print whereas the very next one, "Prognostic Value of HER2/New Overexpression and Genetic Category in Patients 70 and Older with Breast Cancer: Ten-Year Results," is available only in the aether. Was this because #1179 dealt with treatment of NCI-H292, H1299, and HBEpC cells and the next ePoster involved decisions made about real people and was therefore not as interesting? I suppose someone had to be the last one onto the lifeboat.

Now, before running out of space in this column and needing to continue on a less easily-accessed modality, here are this year's special recognitions:

  1. Please Let Us Be Relevant: 285. Radiation Sensitizes Tumor Cells to CAR T Cell Immunotherapy. C. J. DeSelm et al. Neoadjuvant radiation two days before CAR T cell treatment dramatically increases tumor cell killing. Maybe we can still stay in business in the 2020's!
  2. Your Money or Your Life. 305 "Going for Broke" Out-of-Pocket Costs, Financial Distress, and Patient-Reported Willingness to Pay and Sacrifice in Cancer Care. F. Chino et al. 94% were willing to spend less on vacations in order to afford cancer treatments.
  3. Your Money or Your Life, Runner-up. 365. Cost-Effectiveness of Proton Therapy for Esophageal Cancer. Retrospective analysis showed an increase of 0.15 QALY s (quality-adjusted life years) for proton therapy over IMRT with an incremental cost-effectiveness ratio of $84,000/QALY compared to $40,000/QALY for IMRT. May need to cancel some very long vacations.
  4. Best Title That Suggests Clinical Impact But Doesn't Deliver. 2007 Spironolactone Ameliorates the Cardiovascular Toxicity Induced by Concomitant Trastuzumab and Thoracic Radiation Therapy. G. Yavas et al. Although may not be that helpful since it doesn't prevent damage to the thoracic aorta. In albino rats.
  5. Wouldn't Have Possibly Expected Department. 302 Emergency Department Utilization Among Patients with Cancer. H. C. Quon et al. Emergency Department (ED ) use increases in cancer patients at the time of diagnosis and also post-diagnosis in patients with breast, colorectal, and lung cancers compared to matched cancer-free cohort. Although why would they have used the ED before if there wasn't anything wrong with them? For practice?
  6. Extreme Determination/Enviable Cooperative Staff Award. 2202 Cumulative Dose to Brain After Multisession Gamma Knife Stereotactic Radiosurgery for Treatment of Multiple Metastatic Tumors. Y. Watanabe et al. Ten patients in their series received Stereotactic Radiosurgery in a mean of 3.9 sessions (range 3-6) to 10 or more intracranial metastases (mean 23.9, range 10 to 53. Comment made to "please note that the patient with the highest cumulative dose to the brainstem and chiasm was treated to 53 metastases."
  7. Anachronism Award. 282 Late Cardiac Toxicity After Mediastinal Radiation Therapy for Hodgkin Lymphoma: Will Evaluating Dose to Coronary Arteries Improve Risk Estimates? E. Hahn et al. Analysis of 599 patients treated between 1988 and 2003. Radiation therapy techniques and emphasis of systemic therapy vs radiation therapy including doses seem to have changed somewhat slightly since then. However, it turns out that "estimating dose to CA (coronary arteries) will not add significant explanatory power to predict LCT (late cardiac toxicity)...compared with documenting dose to the whole heart only." No waste, though, since a publication was generated.
  8. Point and Shoot. 262 Quality of Radiation Therapy Reporting in Randomized Controlled Trials for Head and Neck Cancer. M. S. F. Tseng, et al. Compulsively went over 64 randomized controlled trial reports which accrued 200 or more patients and found that only 69% defined the target volume, 6% specified adherence to the quality assurance program including reporting major or minor deviations, and only 1 out of 64 met all six quality measures that were evaluated!
  9. It's Not Easy Seeing Green. 2398. K. Suresh et al. Using Indocyanine Green to Predict Liver Toxicity After Stereotactic Body Radiation Therapy. ICGR 15 (Indocyanine Green Retention 15 (at 15 minutes) was a significant additional prognostic factor in estimating potential liver toxicity in patients treated with adaptive stereotactic radiation therapy for hepatocellular carcinoma. Actually done on real people, with real results, in a disease increasing in incidence, and with the report buried near the end of the non-print published ePosters.

    And, last, for now,
  10. What was I Thinking? 362 Long-Term Decision Regret After Postprostatectomy Image Guided Intensity Modulated Radiation Therapy. T. P. Shakespeare et al. Evaluation done of 83 patients who were treated with radiation therapy following radical prostatectomy. Analysis was made for DR (decision regret). 16.9% were regretful, and 83.1% had no regrets. There was "four-fold more regret" about having had the radical prostatectomy than having had the post-operative radiation therapy. Not much of a surprise in this report by a famous name in medical investigation.

The real research project will be to analyze DR in Drs. who decide to read through thousands of ePosters.

Emanuel Countdown: Dr. Ezekiel Emanuel's biographies list his birth year as 1957 but, interestingly, do not list a birth date. He has expressed that he does not wish to live past his 75th birthday. Giving him every benefit of the doubt, he will have his 75th birthday no later than December 31, 2032. Including October 1, 2016, this leaves 5,936 days to his goal.