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Article ; Online: Proton Therapy in the Treatment of Men with Breast Cancer

Julie A. Bradley, MD, MHCDS / Jayden Gracie, MD / Raymond B. Mailhot Vega, MD, MPH / Eric D. Brooks, MD, MHS / Tenna Burchianti, ARNP / Oluwadamilola T. Oladeru, MD, MA, MBA / Xiaoying Liang, PhD / Nancy P. Mendenhall, MD

International Journal of Particle Therapy, Vol 10, Iss 2, Pp 94-

2023 Volume 104

Abstract: Purpose: Male breast cancer treatment involves multimodality therapy, including radiation therapy; nevertheless, few men have received proton therapy (PT) for it. Further, heart disease is an established leading cause of death in men, and radiation ... ...

Abstract	Purpose: Male breast cancer treatment involves multimodality therapy, including radiation therapy; nevertheless, few men have received proton therapy (PT) for it. Further, heart disease is an established leading cause of death in men, and radiation therapy heart dose correlates with cardiac toxicity, highlighting the need for cardiac-sparing radiation techniques. Thus, we provide a descriptive analysis of PT in a male breast cancer cohort. Patients and Methods: Men who received PT for localized breast cancer between 2012 and 2022 were identified from a prospective database. Toxicities were prospectively recorded by using the Common Terminology Criteria for Adverse Events (CTCAE), version 4.0. Results: Five male patients were identified. All had estrogen receptor (ER)–positive, Her2neu-negative disease and received adjuvant endocrine therapy. One had genetic testing positive for BRCA2, one had a variant of unknown significance (VUS) in the APC gene, and one had a VUS in MSH2. Median age was 73 years (range, 41–80). Baseline comorbidities included obesity (n = 1), diabetes (n = 1), hypertension (n = 4), history of deep vein thrombosis (n = 1), personal history of myocardial infarction (n = 3; 1 with a pacemaker), and a history of lung cancer (n = 1). All received PT to the left chest wall and comprehensive regional lymphatics. One received passive-scattering PT, and 4 received pencil beam scanning. One patient received a boost to the mastectomy incision via electrons. Median heart dose was 1 GyRBE (range, 0–1.0), median 0.1-cm3 dose to the left anterior descending artery was 7.5 GyRBE (range, 0–14.2), and median follow-up was 2 years (range, 0.75–6.5); no patient experienced a new cardiac event, and all remain free from breast cancer recurrence and progression. Conclusion: In a small case series for a rare diagnosis, PT to the chest wall and regional lymphatics, including internal mammary nodes, resulted in low cardiac exposure, high local regional disease control rates, and minimal toxicity. Proton therapy should ...
Keywords	male breast cancer ; proton therapy ; radiation therapy ; cardiac toxicity ; Medical physics. Medical radiology. Nuclear medicine ; R895-920 ; Nuclear and particle physics. Atomic energy. Radioactivity ; QC770-798
Subject code	610 ; 616
Language	English
Publishing date	2023-10-01T00:00:00Z
Publisher	Particle Therapy Co-operative Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Intrafractional Displacement of Cardiac Substructures Among Patients With Mediastinal Lymphoma or Lung Cancer

Lidia Guzhva, BS / Stella Flampouri, PhD / Nancy P. Mendenhall, MD / Christopher G. Morris, MS / Bradford S. Hoppe, MD, MPH

Advances in Radiation Oncology, Vol 4, Iss 3, Pp 500-

2019 Volume 506

Abstract: Purpose: The radiation dose to specific substructures of the heart may be more critical than the dose to the whole heart. Yet, these substructures are sensitive to intrafractional motion from breathing and cardiac motion, which can affect their dose- ... ...

Abstract	Purpose: The radiation dose to specific substructures of the heart may be more critical than the dose to the whole heart. Yet, these substructures are sensitive to intrafractional motion from breathing and cardiac motion, which can affect their dose-volume histograms. We sought to investigate intrafractional motion of the heart and its substructures among free-breathing patients undergoing radiation for mediastinal lymphoma or lung cancer. Methods and materials: After institutional review board approval, the medical records of 20 patients (12 with mediastinal lymphoma; 8 with lung cancer) were retrospectively reviewed. Patients underwent 4-dimensional computed tomography simulation and a contrasted scan for treatment planning. Using MIMVista software, the heart, coronary arteries, chambers, and valves were contoured on the 50% phase, and these contours were propagated to the other phases and edited. Each substructure was graded on the basis of its ease of contouring across all phases (1 = no difficulty; 2 = minor difficulty; 3 = moderate difficulty; and 4 = very difficult). The centroid position and volume of each substructure for all phases were exported to Excel to calculate basic statistics and the independent t test. Results: The heart, 4 chambers, and atrioventricular valves were easily identified with a mean score of 1 to 1.2, and the pulmonic valve, left anterior descending artery, aortic valve, circumflex, and right coronary artery were minor-to-moderately difficult with a mean score of 2.1 to 3.2. The smallest centroid displacement was seen in the 4 chambers and mitral and pulmonic valves (0.7-1.1 cm). Greater displacement was seen in the coronary vessels and tricuspid and aortic valves (1.2-1.5 cm). The greatest displacement was in the Z direction (craniocaudal) for all substructures; however, the displacement was significantly greater among patients with lymphoma for the right ventricle, aortic valve, and left anterior descending artery (P < .05). However, patients with lung cancer had more displacement in the X and Y directions, which was statistically significant for the right atrium, tricuspid valve, right ventricle, and heart. When calculating overall displacement, no statistically significant difference was observed between patients with lymphoma and patients with lung cancer. Conclusions: Intrafractional motion of the cardiac substructures ranged from 0.7 to 1.5 cm, mostly in the Z direction. Further investigation of the respiratory motion effect on the dose-volume histogram of the substructures is needed for patients treated with contemporary radiation techniques.
Keywords	Medical physics. Medical radiology. Nuclear medicine ; R895-920 ; Neoplasms. Tumors. Oncology. Including cancer and carcinogens ; RC254-282
Subject code	610
Language	English
Publishing date	2019-07-01T00:00:00Z
Publisher	Elsevier
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Strategic Operational Redesign Improves Prior Authorization Access

Eric D. Brooks, MD, MHS / Fantine Giap, MD / Vincent Cassidy, MD / Matthew S. Ning, MD, MPH / Bradlee Robbert, FACHE, MHA, RT(R)(T) / Polly Redding, MBS, CPC, CHONC / Matthew Palmer, MBA / L. Montreal Turner, MBA, MHA, CMD, PMP / William M. Mendenhall, MD / Stuart Klein, MHA / Nancy P. Mendenhall, MD

International Journal of Particle Therapy, Vol 10, Iss 2, Pp 65-

A Validation Study

2023 Volume 72

Abstract: Purpose: Obtaining prior authorization (PA) before treatment is becoming increasingly burdensome in oncology, especially in radiation oncology. Here, we describe the impact of a strategic novel operational PA redesign to shorten authorization time and to ...

Abstract	Purpose: Obtaining prior authorization (PA) before treatment is becoming increasingly burdensome in oncology, especially in radiation oncology. Here, we describe the impact of a strategic novel operational PA redesign to shorten authorization time and to improve patient access to cancer care at a large United States academic proton therapy center. We ask whether such a redesign may be replicable and adoptable across oncology centers. Materials and Methods: Our PA redesign strategy was based on a 3-tiered approach. Specifically, we (1) held payors accountable to legally backed timelines, (2) leveraged expertise on insurance policies and practices, and (3) updated the submission, appeal writing, and planning procedures for PA. Metrics were compared at the following 3 time points: 6 months before, at phase-in, and at 6 months after intervention. Results: In analyzing the impact of improving PA access to care, the percentage of approvals for commercial proton beam therapy improved by an absolute 30.6% postintervention (P < .001). The proportion of commercially insured patients treated with proton beam therapy also increased by 6.2%, and the number of new starts rose by 11.7 patients/mo. Overall patient census increased by 13 patients/d. Median authorization time was 1 week, and 90% of surveyed providers reported reduced PA burden and improved patient care. Conclusion: This is the first validated, comprehensive operational strategy to improve access to cancer therapy while reducing the burden of PA. This novel approach may be helpful for addressing barriers to PA in medical and surgical oncology because the redesign is predicated on laws that regulate PA across disciplines.
Keywords	prior authorization ; independent review organization ; proton ; radiation ; approval ; Medical physics. Medical radiology. Nuclear medicine ; R895-920 ; Nuclear and particle physics. Atomic energy. Radioactivity ; QC770-798
Subject code	616
Language	English
Publishing date	2023-11-01T00:00:00Z
Publisher	Particle Therapy Co-operative Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Comparative Effectiveness of Proton Therapy versus Photon Radiotherapy in Adolescents and Young Adults for Classical Hodgkin Lymphoma

James E. Bates, MD / Stephanie Terezakis, MD / Christopher G. Morris, MS / Avani D. Rao, MD / Shuchi Sehgal, BA / Rahul Kumar, MBBS / Raymond B. Mailhot Vega, MD, MPH / Nancy P. Mendenhall, MD / Bradford S. Hoppe, MD, MPH

International Journal of Particle Therapy, Vol 8, Iss 3, Pp 21-

2021 Volume 27

Abstract: Purpose: Early stage (stages I-II) classical Hodgkin lymphoma (cHL) is a highly curable disease typically diagnosed in adolescents and young adults (AYAs). Proton therapy can also reduce the late toxicity burden in this population, but data on its ... ...

Abstract	Purpose: Early stage (stages I-II) classical Hodgkin lymphoma (cHL) is a highly curable disease typically diagnosed in adolescents and young adults (AYAs). Proton therapy can also reduce the late toxicity burden in this population, but data on its comparative efficacy with photon radiotherapy in this population are sparse. We assessed outcomes in AYAs with cHL in a multi-institution retrospective review. Materials and Methods: We identified 94 patients aged 15 to 40 years with stages I and II cHL treated with radiotherapy as part of their initial treatment between 2008 and 2017. We used Kaplan-Meier analyses and log-rank testing to evaluate survival differences between groups of patients. Results: A total of 91 patients were included in the analysis. The 2-year progression-free survival (PFS) rate was 89%. Of the 12 patients who experienced progression after radiotherapy, 4 occurred out-of-field, 2 occurred in-field, and 6 experienced both in- and out-of-field progression. There was no significant difference in 2-year PFS among AYA patients by radiotherapy dose received (≥ 30 Gy, 91%; < 30 Gy, 86%; P = .82). Likewise, there was no difference in 2-year PFS among patients who received either proton or photon radiotherapy (proton, 94%; photon, 83%; P = .07). Conclusion: Our cohort of AYA patients had comparable outcomes regardless of radiotherapy dose or modality used. For patients with significant risk of radiation-induced late effects, proton therapy is a reasonable treatment modality.
Keywords	pediatrics ; hodgkin lymphoma ; outcomes ; radiation therapy ; proton therapy ; Medical physics. Medical radiology. Nuclear medicine ; R895-920 ; Nuclear and particle physics. Atomic energy. Radioactivity ; QC770-798
Subject code	616 ; 610
Language	English
Publishing date	2021-07-01T00:00:00Z
Publisher	Particle Therapy Co-operative Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Pericardial Effusion during Proton Therapy in a Patient with Chemorefractory Hodgkin Lymphoma

Ashley Way, MD / Savas Ozdemir, MD / Barbara Berges, RN / Nataliya Getman, MS / Xiaoying Liang, PhD / Nancy P. Mendenhall, MD / Graham Collins, MA, MBBS, MRCP, FRCPath, DPhil / David Cutter, MRCP, FRCR, DPhil / Raymond B. Mailhot Vega, MD, MPH

International Journal of Particle Therapy, Vol 8, Iss 4, Pp 76-

2021 Volume 81

Abstract: We present a case of recurrent pericardial effusion presenting during proton therapy in a 24-year-old female receiving mediastinal treatment for classical Hodgkin lymphoma. Pericardial effusion is typically considered an event accompanying lymphoma ... ...

Abstract	We present a case of recurrent pericardial effusion presenting during proton therapy in a 24-year-old female receiving mediastinal treatment for classical Hodgkin lymphoma. Pericardial effusion is typically considered an event accompanying lymphoma diagnosis or as a subacute or late effect of radiotherapy. Rarely has it been described as occurring during radiation treatment with photon-based radiotherapy, let alone proton therapy. It is unclear what underlying cause triggered recurrent effusion in this patient. Identifying and managing pericardial effusion during treatment delivery is important to consider as it may affect radiation dosimetry, particularly with proton therapy. Doing so will help ensure patients receive optimal treatment and minimize the risks of morbidity and mortality.
Keywords	hodgkin lymphoma ; particle therapy ; proton therapy ; pericardial effusion ; radiotherapy ; Medical physics. Medical radiology. Nuclear medicine ; R895-920 ; Nuclear and particle physics. Atomic energy. Radioactivity ; QC770-798
Language	English
Publishing date	2021-10-01T00:00:00Z
Publisher	Particle Therapy Co-operative Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Insurance Approval for Definitive Proton Therapy for Prostate Cancer

William M. Mendenhall, MD / Eric D. Brooks, MD, MHS / Stephanie Smith / Christopher G. Morris, MS / Curtis B. Bryant, MD, MPH / Randal H. Henderson, MD / Romaine C. Nichols, Jr., MD / Kathy McIntyre / Stuart L. Klein, MHA / Nancy P. Mendenhall, MD

International Journal of Particle Therapy, Vol 8, Iss 3, Pp 36-

2021 Volume 42

Abstract: Purpose: To determine factors that influence insurance approval for definitive proton therapy (PT) for prostate cancer. Materials and Methods: Between 2014 and 2018, 1592 insured patients with localized prostate cancer were evaluated and recommended to ... ...

Abstract	Purpose: To determine factors that influence insurance approval for definitive proton therapy (PT) for prostate cancer. Materials and Methods: Between 2014 and 2018, 1592 insured patients with localized prostate cancer were evaluated and recommended to undergo definitive PT; 547 patients (34.4%) had commercial insurance, whereas 1045 patients (65.6%) had Medicare/ Medicaid. Of those with Medicare, 164 patients (15.7%) had Medicare alone; 677 (64.8%) had supplemental plans; and 204 (19.5%) had secondary commercial insurance. Insurance that ‘‘covered’’ PT for prostate cancer implied that it was an indication designated in the coverage policy. ‘‘Not covered’’ means that the insurance policy did not list prostate cancer as an indication for PT. Of all 1592 patients, 1263 (79.3%) belonged to plans that covered PT per policy. However, approval for PT was still required via medical review for 619 patients (38.9%), comparative dosimetry for 56 patients (3.5%), peer-to-peer discussion for 234 patients (14.7%), and administrative law judge hearings for 3 patients (<0.1%). Multivariate analyses of factors affecting approval were conducted, including risk group (low/intermediate versus high), insurance type (commercial versus Medicare/Medicaid), whether PT was included as a covered benefit under the plan (covered versus not covered), and time period (2014-16 versus 2017 versus 2018). Results: On multivariate analysis, factors affecting PT approval for prostate treatment included coverage of PT per policy (97.1% had approval with insurance that covered PT versus 48.6% whose insurance did not cover PT; P < .001); insurance type (32.5% had approval with commercial insurance versus 97.4% with Medicare; P < .001); and time, with 877/987 patients (88.9%) approved between 2014 and 2016, 255/312 patients (81.7%) approved during 2017, and 255/293 patients (87.0%) approved thereafter (P = .02). Clinical factors, including risk group, had no bearing on insurance approval (P = .44). Conclusion: Proton insurance approval for ...
Keywords	insurance ; proton therapy ; prostate cancer ; Medical physics. Medical radiology. Nuclear medicine ; R895-920 ; Nuclear and particle physics. Atomic energy. Radioactivity ; QC770-798
Subject code	610
Language	English
Publishing date	2021-07-01T00:00:00Z
Publisher	Particle Therapy Co-operative Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Does the Incidence of Treatment-Related Toxicity Plateau After Radiation Therapy

Adam L. Holtzman, MD / John M. Stahl, MD / Simeng Zhu, MD / Christopher G. Morris, MS / Bradford S. Hoppe, MD, MPH / Jessica E. Kirwan, MA / Nancy P. Mendenhall, MD

Advances in Radiation Oncology, Vol 4, Iss 4, Pp 699-

The Long-Term Impact of Integral Dose in Hodgkin's Lymphoma Survivors

2019 Volume 705

Abstract: Background: Conventional radiation therapy (RT) has produced unprecedented cure rates in patients with Hodgkin's lymphoma (HL) but exposed large volumes of nontargeted tissue to radiation (integral dose). Objective: Our goal was to report the effects of ... ...

Abstract	Background: Conventional radiation therapy (RT) has produced unprecedented cure rates in patients with Hodgkin's lymphoma (HL) but exposed large volumes of nontargeted tissue to radiation (integral dose). Objective: Our goal was to report the effects of integral radiation dose on health outcomes in patients with at least 20 years of potential follow-up time. Methods and Materials: We reviewed the medical records of 365 patients who were treated with RT for HL between 1965 and 1995. All patients were confirmed to have received primary RT with curative intent at our institution for de novo HL. Serious adverse events were classified as HL progression or death, grade ≥3 treatment- or staging-related acute or late effects, second malignancies, or cardiovascular events. Results: The minimum potential follow-up time was 20 years, and the actual median follow-up time 22 years (range, <1-49 years) for all patients and 27 years (range, 5-49 years) for surviving patients. The overall survival rates at 5, 10, 20, 30, and 40 years were 86%, 76%, 64%, 44%, and 27%, respectively. The observed-to-expected ratio for second malignancy was 3.6 (95% confidence interval, 2.9-4.4). Grade ≥3 cardiovascular events occurred in 31% of all patients (n = 112). At the time of the most recent follow up, serious adverse events occurred in 70% of the entire cohort (n = 256) and 58% (n = 103), 77% (n = 103), and 93% (n = 50) among those with a potential 20, 30, and 40 years of follow up, respectively. Conclusions: With increased survivorship, the long-term impact of the integral radiation dose may result in clinically significant adverse events, which suggests the importance of surveillance and affirms advances in both chemotherapy and RT that minimize the integral dose in future patients with HL.
Keywords	Medical physics. Medical radiology. Nuclear medicine ; R895-920 ; Neoplasms. Tumors. Oncology. Including cancer and carcinogens ; RC254-282
Subject code	616
Language	English
Publishing date	2019-10-01T00:00:00Z
Publisher	Elsevier
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Postoperative or Salvage Proton Radiotherapy for Prostate Cancer After Radical Prostatectomy

Shivam M. Kharod, MD / Catherine E. Mercado, MD / Christopher G. Morris, MS / Curtis M. Bryant, MD, MPH / Nancy P. Mendenhall, MD / William M. Mendenhall, MD / R. Charles Nichols, MD / Bradford S. Hoppe, MD, MPH / Xiaoying Liang, PhD / Zhong Su, PhD / Zuofeng Li, DSc / Randal H. Henderson, MD, MBA

International Journal of Particle Therapy, Vol 7, Iss 4, Pp 52-

2021 Volume 64

Abstract: Purpose: Postprostatectomy radiation improves disease control, but limited data exist regarding outcomes, toxicities, and patient-reported quality of life with proton therapy. Method and Materials: The first 102 patients who were enrolled on an outcome ... ...

Abstract	Purpose: Postprostatectomy radiation improves disease control, but limited data exist regarding outcomes, toxicities, and patient-reported quality of life with proton therapy. Method and Materials: The first 102 patients who were enrolled on an outcome tracking protocol between 2006 and 2017 and treated with double-scattered proton therapy after prostatectomy were retrospectively reviewed. Eleven (11%) received adjuvant radiation, while 91 (89%) received salvage radiation. Seventy-four received double-scattered proton therapy to the prostate bed only. Twenty-eight received a double-scattered proton therapy prostate-bed boost after prostate-bed and pelvic-node treatment. Eleven adjuvant patients received a median dose of 66.6 GyRBE (range, 66.0–70.2). Ninety-one salvage patients received a median dose of 70.2 GyRBE (range, 66.0–78.0). Forty-five patients received androgen deprivation therapy for a median 9 months (range, 1–30). Toxicities were scored using Common Terminology Criteria for Adverse Events v4.0 criteria, and patient-reported quality-of-life data were reviewed. Results: The median follow-up was 5.5 years (range, 0.8–11.4 years). Five-year biochemical relapse-free and distant metastases-free survival rates were 72% and 91% for adjuvant patients, 57% and 97% for salvage patients, and 57% and 97% overall. Acute and late grade 3 or higher genitourinary toxicity rates were 1% and 7%. No patients had grade 3 or higher gastrointestinal toxicity. Acute and late grade 2 gastrointestinal toxicities were 5% and 2%. The mean values and SDs of the International Prostate Symptom Score, International Index of Erectile Function, and Expanded Prostate Cancer Index Composite bowel function and bother were 7.5 (SD = 5.9), 10.2 (SD = 8.3), 92.8 (SD = 11.1), and 91.2 (SD = 6.4), respectively, at baseline, and 12.1 (SD = 9.1), 10.1 (SD = 6.7), 87.3 (SD = 18), and 86.7 (SD = 13.8) at the 5-year follow-up. Conclusion: High-dose postprostatectomy proton therapy provides effective long-term biochemical control and freedom from ...
Keywords	proton therapy ; radiotherapy ; prostate cancer ; quality of life ; Medical physics. Medical radiology. Nuclear medicine ; R895-920 ; Nuclear and particle physics. Atomic energy. Radioactivity ; QC770-798
Subject code	610
Language	English
Publishing date	2021-03-01T00:00:00Z
Publisher	Particle Therapy Co-operative Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Consensus Statement on Proton Therapy for Prostate Cancer

Curtis M. Bryant, MD, MPH / Randal H. Henderson, MD, MBA / R. Charles Nichols, MD / William M. Mendenhall, MD / Bradford S. Hoppe, MD, MPH / Carlos E. Vargas, MD / Thomas B. Daniels, MD / C. Richard Choo, MD / Rahul R. Parikh, MD / Huan Giap, MD, PhD / Jerry D. Slater, MD / Neha Vapiwala, MD / William Barrett, MD / Akash Nanda, MD, PhD / Mark V. Mishra, MD / Seungtaek Choi, MD / Jay J. Liao, MD / Nancy P. Mendenhall, MD / the Genitourinary Subcommittee of the Particle Therapy Co-Operative Group

International Journal of Particle Therapy, Vol 8, Iss 2, Pp 1-

2021 Volume 16

Abstract: Proton therapy is a promising but controversial treatment in the management of prostate cancer. Despite its dosimetric advantages when compared with photon radiation therapy, its increased cost to patients and insurers has raised questions regarding its ... ...

Abstract	Proton therapy is a promising but controversial treatment in the management of prostate cancer. Despite its dosimetric advantages when compared with photon radiation therapy, its increased cost to patients and insurers has raised questions regarding its value. Multiple prospective and retrospective studies have been published documenting the efficacy and safety of proton therapy for patients with localized prostate cancer and for patients requiring adjuvant or salvage pelvic radiation after surgery. The Particle Therapy Co-Operative Group (PTCOG) Genitourinary Subcommittee intends to address current proton therapy indications, advantages, disadvantages, and cost effectiveness. We will also discuss the current landscape of clinical trials. This consensus report can be used to guide clinical practice and research directions.
Keywords	prostate cancer ; radiation therapy ; proton therapy ; particle therapy ; Medical physics. Medical radiology. Nuclear medicine ; R895-920 ; Nuclear and particle physics. Atomic energy. Radioactivity ; QC770-798
Subject code	610
Language	English
Publishing date	2021-04-01T00:00:00Z
Publisher	Particle Therapy Co-operative Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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