October, 2017

San Diego Checking

By Michael J. Katin, MD

The 59th Annual Meeting of the American Society for Radiation Oncology has now passed into the history books, months after the 59th Annual Grammy Awards, also held in Southern California. At this point the two differ, with only one of them provoking widespread public interest It is left once again up to this column to call attention to the accomplishments of ASTRO 2017.

Of passing interest is that the event nearly needed to be rescheduled as the city of San Diego should have plunged into morning about the death on August 15 of Kasatka, the matriarch of the orca prisoners at Sea World, who had nearly reached the age of 42 despite spending the past 39 years in a large bathtub. Kasatka was moved out to her final resting place, although there are still vile rumors about the "salmon" entrée at the September 26 business meeting luncheon.

The slogan for the 2017 meeting (does anybody ever notice these?) was "the healing art and science of radiation oncology," all in small letters, presumably reflecting an appropriate dose of humility. The session, as always, consisted of attention to business items, awarding of gold medals to highly deserving persons, and didactic sessions, the last particularly appropriate since San Diego was named after Saint Didacus (except according to Anchorman Ron Burgundy ). Breakthroughs to result in the elimination of cancer continue to develop gradually, unfortunately, with no obvious bombshells having been revealed in the 361 oral scientific sessions and the 161 e-poster sessions, not to mention the 1,806 e-abstracts, PLUS 3 "Late-Breaking Abstracts" for the Plenary Session, 4 for the Clinical Trials Session, 9 for the Late-Breaking Abstracts Special Session, and 1 Recusal for Attorney General Jeff Sessions.

Getting through all this material is a Sisyphean effort, but it's time to give credit to the more outstanding submissions:

  1. Hit me with your best shot. 224. The International Atomic Energy Agency Randomized Trial on Chemotherapy With or Without Radiation Therapy I Advanced Non-small Cell Lung Cancer (NCT00864331). B. Jeremic et al. Palliative radiation therapy doesn't have impact on patients with advanced NSCLC treated with chemotherapy, Compared 10 Gy in one fraction to 18 Gy in two fractions. Whatever happened to comparisons of one fraction to ten or even five fractions to 30? Guess we were lucky to be allowed to give any. 342. The Risk of Radiation Necrosis Following Stereotactic Radiosurgery with Concurrent Systemic Therapies. J. M. Kim et al. VEGFR and EGFR TKIs implicated as agents increasing risk of radiation necrosis from SRS with or without whole brain irradiation. Probably true considering 343. Use of Concurrent TKIs with RS Is Associated With an Increased Rate of Radiation Necrosis Among Patients With Renal Cell Carcinoma Brain Metastasis. A. Juloori et al.
  2. Rise of the Machines. 1017. e-Rekha: A High-Performance Software System for Auto Contouring Head and Neck Anatomy in Adaptive Radiation Therapy. X. Wu et al. Will radiation oncologists become obsolete? Even more probable considering 233. A Deep Neural Network for Automated Normal Structure Segmentation Derived from Normal Clinical Operations. L. Zamdborg et al. Is that Zambdborg or Cyborg?
  3. Land Down Under. 2303. Employment for Radiation Oncologists in Australia and New Zealand -- The Recent Graduates Study on Employment, Experiences, and Perspectives. J. Leung. Seven per cent dissatisfied! Should have been in a plenary session. Not to be confused with a more literal report of treatment down under: 2530. Toxicity After Post-Prostatectomy Image-Guided Intensity-Modulated Radiation Therapy Using Australian Guidelines. S. Chin et al., including the most famous name in radiation oncology, the fourth author, T.P. Shakespeare
  4. Pasteur Award for addressing major public health issue: 118. Mutational Landscape of Radiation-Induced Angiosarcoma in Breast Cancer Patients. Z. A. Siddiqui, Jr., et al. Describes that angiosarcomas make up 1% of all soft tissue sarcomas and 40% of these may be related to adjuvant irradiation for breast cancer. The number of patients surveyed to locate 13 cases was not stated, but detailed analysis was done of 160 cancer-related genes comprising 7,951 amplicons. Five genes were found in all 13 cases, with changes differing (but not stated how) from 3 sporadic cases studied. Will hope that publication of full study is not delayed.
  5. Till death do us part: 299. Cardiac Disease and Lifestyle Risk Factors Following Hodgkin Lymphomas: An EORTC Lymphoma Group and GELA Follow-Up Study. M. V. Maraldo et al. Amazingly, cardiac risk in patients who had received treatment for Hodgkin lymphoma is affected by hypertension, dyslipidemia, and diabetes mellitus. Quite unlike persons never treated for Hodgkin lymphoma. Median duration of follow-up was 14 years, indicating that radiation oncologists need to follow these patients to monitor these other parameters. Even more important based on 1082. Low-Dose-Rate Brachytherapy for Prostate Cancer: Outcomes Beyond 10-years of Follow-Up. S. Lazarev et al. "Notably, 18% cent of patients with biochemical relapse will fail more than 10 years after treatment, which justifies their continued follow-up." Remarkable to take credit for treatment failure rather than consider a second occurrence. If you break your leg once you can actually do it again. In any event, we might as well follow them since often nobody else does.
  6. Care giving makes life worth living: 189. Informal Caregiver Quality of Life in a Palliative Oncology Population. A. Duimering et al. Yes, there is a Caregiver Quality of Life Index -- Cancer (CQOLC). An informal caregiver is someone who is not paid to do it, plus, presumably, not wearing a jacket and tie. However, there's another group that's just as much in need of caregiving: 155. A Needs Assessment of Social Support Among Medical Physicists: Stress, Medical Error, and Burnout. J. L. Johnson et al. No surprise, however, that "compared to their physician colleagues, MPs are more willing to seek social support in all surveyed situations."
  7. And we do what with this information?: Four (!) very deserving abstracts!! 1040. Vitamin D Levels in Blood and Survival in Glioblastoma. M. A. Berenguer Frances et al. Patients with Vitamin D levels higher than 30 ng/ml did better than those with lower values. Were they simply in better condition to start? Late-Breaking Abstract 11: Quality of Life After Active Surveillance, Radical Prostatectomy, and External Beam Radiation -- 4 Year Results of a Prospective, Population-Based Cohort. R. C. Chen et al. Maybe it's just me, but I don't think too many people are influenced by results at four years for (presumably) early or intermediate stage prostate cancer. QOL assessment was done, but not CQOLC. Come back in another 6 years. Finally, 218. Prospective Trial of Quantitative Neuroimaging Correlates of Verbal and Nonverbal Memory Decline. K. R. Tringale et al. Concludes that damage to medial temporal lobe white matter may serve as a biomarker for radiation therapy-associated memory decline This is immediately followed by 219 Atrophy of Entorhinal Cortex After Radiation Therapy Associated With Memory Decline. T. M. Seibert et al. with both abstracts from UCSD and with the second one describing that the entorhinal cortex may be critical to radiation therapy-associated memory decline. Are these different areas to generate two abstracts and, probably, a plethora of journal articles? I hope I can remember the different anatomic structures the next time I design a treatment volume, especially if they happen to be right IN the treatment volume.
  8. Clueless (us, not them): 23. Marijuana Utilization in Cancer Patients: A Comprehensive Analysis of National Health and Nutrition Examination Survey Data from 2005-2014. K. R. Tringale, et al. UCSD again!!! A survey had been done of persons age 20-60 between 2005 and 2014 and of 19,604 respondents, 826 cancer patients and 1,652 controls were evaluated. 40.3% of the cancer patients CURRENTLY used marijuana compared to 38.0% of controls. Would anyone have guessed that high (sorry, no pun intended)? Marijuana was decriminalized in California in 1975, approved for medical use in 1996, and will be legal for recreational use on January 1, 2018. Could this be contributing to memory loss in their patients in Abstracts 218 and 219?
  9. HHS Secretary Tom Price Health Policy Award: unanimously given to Late Breaking Abstract 15. Healthcare Disparities In Cancer Patients Receiving Radiation: Changes in Insurance Status After Medicaid Expansion Under the Affordable Care Act. F. Chino et al. Very creative project of analyzing 197,290 patients, undoubtedly individually, ages 18 to 64, from the SEER database from 2011-2014. With Medicaid expansion in 2014 the number of uninsured patients dropped by 52% in states that accepted Medicaid expansion, compared to 5% in states that did not. However, that constituted a drop from 4.4 to 2.1%. The absolute numbers of persons was not given, and, more importantly, there was no comment as to whether this made any difference in the care these persons received. Abstract 2940, banished to the non-print internet-only morass of unloved abstracts, is titled Insurance Status and Clinical Outcomes Following Cancer Therapy: Are We Being Penny Wise? N. Ohri et al. It refers to "inferior survival rates in patients with Medicaid." Perhaps the Medicaid card Is not by itself therapeutic.
  10. Finally, recognition of the two abstracts that might have a role in daily clinical practice, and two that may immediately negate them. 158. Pravastatin Reverses Established Radiation-Induced Cutaneous and Subcutaneous Fibrosis in Head and Neck Cancer Patients: Results of a Biology-Driven Clinical Trial, Pravacur Phase 2. C. Bourgier et al. Wow! How many times have we been encouraged that a patient with head and neck cancer is cured and then have him or her put up with long-term effects of fibrosis? 40 mg of pravastatin in 12 months reduced fibrosis grade in 51% of patients! Patients' self-perception, mood state, and social functioning were similarly improved. CQOLC was not mentioned. Plus they were getting their lipids under control! Unfortunately we probably should factor in Abstract 1028: Weekly Integral Dose and Use of Lipid Lowering Drugs Are Associated With Worsening of Functional Outcomes in Prostate Cancer Patients Treated With IMRT. A. Cicchetti et al. Higher weekly integral pelvic dose was found to produce worsening of functional and non-functional quality of life symptoms, but so was the use of lipid-lowering drugs even when comorbidities were controlled. This could lead to some frustrating situations.
    At least the controversy should be less with giving a an anti-seizure medication, valproic acid, to patients with glioblastoma multiforme. 217. Does the Addition of Valproic Acid to Concurrent Radiation Therapy and Temazolamide Improve Patient Outcome? Correlative Analysis of RTOG 0525, SEER, and a Phase 2 NCI Trial. A. V. Krauze et al. This admirable review identified 37 patients given 25 mg/kg valproic acid along with radiation therapy and temazolamide compared to 411 who did not receive this medication, and saw an enhanced progression-free survival and overall survival. Obviously, this should become the anticonvulsant of choice from now on, until one sees Abstract 2206: Controversy in Anti-epileptic Drug as Radio-Sensitizer to Improve Survival in High Grade Malignant Glioma: A Nationwide Population-Based Cohort Study. P. Y. Lee et al. In fairness, this assessed all anti-epileptic drugs including valproic acid and showed a slight but not significant increased death rate for the group taking the medications (or was it the fact that they had been placed on these drugs indicate they had a different degree of involvement?). Unfortunately, this was not analyzed for valproic acid alone.

It is not possible to do justice to the thousands of projects that resulted in the abstracts at the 59th Annual Meeting of the American Society for Radiation Oncology, and recognition needs to be given to the persons who reviewed all this material and made the selections, since we have to be mindful that we are in dire need of having a profile to match other specialties. Is it, indeed, possible to compete with the impact of a publication such as Effect of Mindfulness-Based Stress Reduction vs. Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain; a Randomized Clinical Trial, considering the application this could have to millions of persons and the probability it will be picked up on Yahoo!, the Huffington Post, MSN, and Drudge? Rhetorical question.

Note: to preserve authenticity, the irregular and occasionally quaint capitalization scheme of the abstracts and journal articles have been reproduced as originally printed. Emerson was right.

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, 2017, this leaves 5,571 days to his goal.