ASTRO News Brie iefin ing: In Innovations in in RT Deliv livery - PowerPoint PPT Presentation

ASTRO News Brie iefin ing: In Innovations in in RT Deliv livery ry Tuesday, September 27, 1:30-2:30pm ET Moderator: Geraldine M. Jacobson, MD, MPH, MBA, FASTRO, West Virginia University • A Pha hase II III I Ra Randomiz ized Tria rial l Com omparin ing Pati tient Rep eport rted Toxi xicit ity and and Qua uali lity ty of of Life (Q (QOL) Duri uring Pelv elvic IM IMRT T as as Com ompared to o Con onventio ional l RT RT Ann H. Klopp, MD, PhD, MD Anderson Cancer Center • Ra Radia iatio ion Boo oost for or Duc uctal l Car arcin inoma In In Situ tu Aft fter r Who hole le Breast Ra Radiatio ion Th Ther erapy (W (WBRT) T) https://www.astro.org/uploadedFiles/_MAIN_SITE/Meetings_a nd_Education/ASTRO_Meetings/2016/Annual_Meeting/Conten Im Impr proves Loc ocal Con ontr trol: Ana nalysis is fr from om Ten en Poo oole led Academic ic Ins Instit itutio ions t_Pieces/AllDisclosures.pdf Meena S. Moran, MD, Yale University • Res esult lts of of COG ACNS0331: A Pha hase II III Tria rial l of of In Involv lved-Field ld Ra Radiotherapy (I (IFRT) T) and and Low Dose ose Cran aniospinal Irr Irradia iatio ion (LD (LD-CSI) with Che hemotherapy in n Aver erage-Ris isk Med edullo lobla lastoma: A Rep eport t from the Children’s Oncology Group Jeff M. Michalski, MD, MBA, FASTRO, Washington University in St. Louis

A Phase III III Randomized Trial Comparing Pati tient Reported Toxicity and Quality of f Li Life (Q (QOL) During Pelvic IM IMRT as Compared to Conventional RT A. H. Klopp 1 , A. R. Yeung 2 , S. Deshmukh 3 , K. M. Gil 4 , L. Wenzel 5 , S. N. Westin 1 , K. Gifford 1 , D. K. Gaffney 6 , W. Small Jr 7 , S. Thompson 8 , D. E. Doncals 9 , G. H. C. Cantuaria 10 , B. Yaremko 11 , A. Chang 12 , V. Kundapur 13 , D. S. Mohan 14 , M. L. Haas 15 , Y. B. Kim 16 , C. L. Ferguson 17 , and D. W. Bruner 18 1 MD Anderson Cancer Center, Houston, TX, 2 Department of Radiation Oncology, University of Florida, Gainesville, FL, 3 American College of Radiology, Philadelphia, PA, 4 Summa Health System, Akron, OH, 5 University of California, Irvine, Irvine, CA, 6 Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, 7 Stritch School of Medicine, Loyola University Chicago, Maywood, IL, 8 Stephenson Cancer Center, Oklahoma City, OK, 9 SUMMA Akron City Hospital, Akron, OH, 10 Northside Hospital, St. Petersburg, FL, 11 London Regional Cancer Program, London, ON, Canada, 12 Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong, 13 Saskatoon Cancer Centre, Saskatoon, SK, Canada, 14 Kaiser Permanente Cancer Treatment Center, San Francisco, CA, 15 Reading Hospital, Reading, PA, 16 Yonsei University Health System-Severance Hospital, Sinchon-dong, Korea, The Republic of, 17 Georgia Regents University, Augusta, GA, 18 Nell Hodgson Woodruff School of Nursing, Winship Cancer Institute at Emory University, Atlanta, GA

IM IMRT for post-operative pelvic RT RT • IMRT reduces the dose delivered to small bowel in center of pelvis. • Retrospective studies show lower rates of acute and chronic GI toxicity with IMRT as compared to standard 4-field RT. • RTOG 0418 found IMRT to be feasible with a favorable rate of acute 2+ GI toxicity (25%).

Study Schema Eligibility IMRT pelvic Women with endometrial or cervical radiation treatment cancer requiring post-op pelvic RT or chemoRT RANDOMIZE Stratification Factors XRT Dose: 45 Gy, 50.4 Gy 4-field pelvic Chemo: No chemo, 5 cycles of weekly radiation treatment cisplatin at 40mg/m 2 Disease Site: Endometrial, Cervix

Treatment Planning • IMRT planning • Standard RT  Nodal CTV -RTOG atlas  Vaginal -ITV w bladder full and empty  7mm PTV expansion  OARs: Bone marrow, bowel, bladder, rectum Rapid review of contours and plans required on the first case on each arm for a site.

EPIC Bowel Questions Bowel Function: - rectal urgency? How often have you had… - uncontrolled leakage of stool? - stools that were loose? - bloody stools? - your bowel movements been painful? How many bowel movements have you had on a typical day? How often have you had crampy pain in your abdomen or pelvis? Bowel Bother: - has each of these issues been for you? How big of a problem… - have your bowel habits been for you?

EPIC Bowel Score 90 IMRT 70 p-value = 0.048 4-field 50 Baseline Week 3 of RT Week 5 of RT 4-6 weeks post-RT IMRT 128 113 111 102 4 Field 148 132 130 125

Pro-CTCAE Results * 60 standard IMRT Percent of patients with PRO- 50 CTCAE Score ≥3 at 5 weeks 40 30 * * 20 10 0 Frequency Interference Frequency Interference *, p <0.05 Abdominal pain Diarrhea Fecal incontinence

Use of f Anti-Diarrheal Medications 70% Percentage of patients 60% 50% 40% standard IMRT 30% 20% p <0.05 10% 0% 0 or 1 2 or 3 4 or more Number of anti-diarrheal medications daily

Quality of Life: FACT CT-Cx Cx Trial Outcome Index Physical well-being Energy, pain, feeling ill, time in bed, nausea, meeting needs of family Social well-being Emotional well-being Functional well-being Work, enjoy life, accept illness, sleep well Additional treatment related concerns Vaginal symptoms, interest in sex, body appearance, urinary fxn, appetite

Quality of Life: FACT CT-Cx Cx Change in FACT-Cx IMRT 4 Field p-value Trial Outcome Index (n=86) (n=106) Mean -8.8 -12.8 0.06 Std. Dev. 14.4 14.3 Physical Well-Being (n=86) (n=106) Mean -4.2 -6.1 0.03 Std. Dev. 6.0 6.1 Add’l treatment concerns (n=87) (n=104) Mean -2.7 -4.9 0.01 Std. Dev. 6.1 6.5

Conclusions • Pelvic IMRT reduces acute patient reported GI and GU toxicity compared to standard pelvic RT. • Pelvic IMRT reduces need for anti-diarrheal medications as compared to standard pelvic RT. • Pelvic IMRT improves quality of life with regard to physical functioning and other treatment effects during treatment . • Longer term follow up will be needed to determine if these differences in acute toxicity result in lower rates of late toxicity.

ASTRO News Brie iefin ing: In Innovations in in RT Deliv livery ry Tuesday, September 27, 1:30-2:30pm ET Moderator: Geraldine M. Jacobson, MD, MPH, MBA, FASTRO, West Virginia University • A Phase III Randomized Trial Comparing Patient Reported Toxicity and Quality of Life (QOL) During Pelvic IMRT as Compared to Conventional RT Ann H. Klopp, MD, PhD, MD Anderson Cancer Center • Ra Radia iatio ion Boo oost for or Duc uctal l Car arcin inoma In In Situ tu Aft fter r Who hole le Breast Ra Radiatio ion Th Ther erapy (W (WBRT) T) Im Impr proves Loc ocal Con ontr trol: Ana nalysis is fr from om Ten en Poo oole led Academic ic Ins Instit itutio ions Mee eena S. S. Moran, MD, Yale le Unive iversity • Results of COG ACNS0331: A Phase III Trial of Involved-Field Radiotherapy (IFRT) and Low Dose Craniospinal Irradiation (LD-CSI) with Chemotherapy in Average-Risk Medulloblastoma: A Report from the Children’s Oncology Group Jeff M. Michalski, MD, MBA, FASTRO, Washington University in St. Louis

Radiation Boost for Ductal Carcinoma In In Si Situ Aft fter Whole Breast Radiation Th Therapy (W (WBRT) ) Im Improves Lo Local Control: Analysis fr from Ten Pooled Academic In Institutions M. S. Moran 1 , Y. Zhao 1 , S. Ma 1 , Y. M. Kirova 2 , A. Fourquet 3 , P. Y. Chen 4 , K. E. Hoffman 5 , K. K. Hunt 6 , J. S. Wong 7 , L. M. Halasz 8 , G. M. Freedman 9 , R. G. Prosnitz 10 , M. Yassa 11 , D. H. A. Nguyen 11 , T. Hijal 12 , B. G. Haffty 13 , E. S. Wai 14 , and P. Truong 15 1 Yale University, New Haven, CT, 2 Institut Curie, Paris, France, 3 Institut Curie, Paris 75005, France, 4 Beaumont Health System, Royal Oak, MI, 5 The University of Texas MD Anderson Cancer Center, Division of Radiation Oncology, Houston, TX, 6 MD Anderson Cancer Center, Houston, TX, 7 Brigham and Women's Hospital, Boston, MA, 8 University of Washington, Department of Radiation Oncology, Seattle, WA, 9 University of Pennsylvania, Department of Radiation Oncology, Philadelphia, PA, 10 Allentown Radiation Oncology Associates, Allentown, PA, 11 Maisonneuve-Rosemont Hospital, Montreal, QC, Canada, 12 McGill University Health Centre, Montreal, QC, Canada, 13 Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, 14 BC Cancer Agency, Surrey, BC, Canada, 15 British Columbia Cancer Agency, Victoria, BC, Canada

Background • Breast Conservation Therapy (BCT), defined as local excision to remove the tumor followed by whole breast radiation therapy (WBRT), is a standard treatment option for early-stage breast cancers • After WBRT, a common practice is delivery of a “radiation boost” directed to the tumor bed whereby an additional 4-8 fractions allow for dose-escalation to the region at highest risk for local recurrence • The practice of ‘boosting’ has been demonstrated to provide a small but statistically significant reduction in IBTR risk in all age groups for invasive cancers (4% at 20 years) but robust data for DCIS specifically are lacking

Background • Because DCIS has an excellent prognosis with very few recurrences after WBRT, demonstrating similar results specific to DCIS require large numbers of patients with very long follow up • The purpose of this study was to create a DCIS database of patients treated with WBRT with and without a boost, to analyze the effects of the boost specifically for DCIS