Economic Impact of Palliative Radiation Therapy of Bone Metastases With a Single Fraction Dose: A One-Institution Experience

Volume 96  Number 2S  Supplement 2016 response, while pain remained stable in 8.3%, and progressed in 8.3%. A neurological response was achieved in 60% of patients, with 20% remaining stable and 20% progressing. Local control based on radiological imaging was achieved in 78.6% of cases, while progression was noted in 21.4%. Recurrence within the PTV occurred in 1 treated vertebral body (2.1%) while marginal recurrence occurred in 3 vertebral bodies (6.3%) with a median time to recurrence of 4.5 months. A total of 5 vertebral compression fractures (9.6%) were a potential complication of SRS, no other toxicities were noted. Conclusion: Our data shows SRS to be an effective treatment modality for hepatocellular spinal metastasis providing fair pain, neurological, and local control with minimal associated toxicities and a low rate of recurrence. Author Disclosure: D. Boyce-Fappiano: None. E. Elibe: None. I.Y. Lee: Consultant; Medtronic. Speaker Honorarium with travel expenses; Varian Medical Systems. J. Rock: None. M.U. Siddiqui: HFHS rad-onc department receives research funding from entity; Varian Medical Systems, Philips Medical. Leads QA efforts in HFHS rad-onc clinic; Henry Ford Health System. F. Siddiqui: HFHS rad-onc department receives research funding from entity; Varian Medical Systems, Philips Medical. Assist in leading rad-onc department; Henry Ford Health System.

3273 Population-Based Analysis of Stereotactic Body Radiation Therapy for Oligometastatic Lymph Node Disease R. Yeung,1 J. Hamm,1 M.C. Liu,1 and D. Schellenberg2; 1British Columbia Cancer Agency, Vancouver, BC, Canada, 2British Columbia Cancer Agency, Surrey, BC, Canada Purpose/Objective(s): In the setting of limited metastatic burden of disease, stereotactic body radiation therapy (SBRT) has been shown to achieve high local control rates. It has been hypothesized that SBRT may translate to better quality of life by delaying the need for systemic chemotherapy and possibly increased survival. There is limited published literature on the efficacy of SBRT in limited nodal metastases. The primary objective is to report the clinical outcome of SBRT in a series of patients with either solitary or oligometastases from various tumors to lymph nodes. Materials/Methods: A retrospective study of patients treated on a provincial protocol with SBRT to metastatic lymph nodes (March 2010 and June 2015) was conducted. Primary endpoint was local control (LC) and chemotherapy free survival following SBRT. Secondary endpoints included toxicities, progression free survival (PFS), and overall survival (OS). Results: Eighteen patients underwent SBRT to a metastatic lymph node with a mean age of 61.8 years (range: 20-84 years) and a median follow-up of 22 months. There were 4 (22%) liver, seven (39%) colorectal, four (22%) pancreatic, one (6%) esophageal, 1 (6%) gallbladder and 1 (6%) lung primary. Eleven (61%) patients had lymph node metastases as part of their initial presentation of metastatic disease. Seven patients (39%) had systemic therapy prior to SBRT, with the majority of patients (71%) receiving 2 lines of chemotherapy. Eight patients had solitary metastatic disease at the time of SBRT, with all patients having 4 or fewer total sites of metastases. Average size of the lymph node metastases was 2.3cm (range: 0.8-6.2cm). RT doses were 31 to 60 Gy in 4 to 10 fractions, with 44% of patients receiving 35 Gy in 5 fractions. At 1 year, LC was 93% and chemotherapy-free survival from the time of SBRT was 58%. PFS at 1 and 2 years were 42% and 18% respectively. One and 2 year OS were 92% and 84%. There were no grade 3 or higher toxicities reported. On univariate analysis, absence of prior chemotherapy and non-colorectal primary approached significance for improved local control (both PZ0.052) while solitary metastases was associated with improved PFS (PZ0.029) and trended to improved chemotherapy-free survival (PZ0.066). Conclusion: In this single institution study, SBRT to oligometastatic lymph nodes provides high local control and a moderate chemotherapy-free interval with acceptable toxicities. Progression of disease remains prominent in these patients. Larger cohort studies are required to better identify a

Poster Viewing E519 subset of patients with oligometastatic nodal disease who benefit the most from SBRT. Author Disclosure: R. Yeung: None. J. Hamm: None. M. Liu: None. D. Schellenberg: Research Grant; Varian. Honoraria; Varian.

3274 Single-Fraction Stereotactic Radiosurgery for Renal Cell Carcinoma Spine Metastasis D. Boyce-Fappiano, E. Elibe, I.Y. Lee, J. Rock, M.S.U. Siddiqui, and F. Siddiqui; Henry Ford Health System, Detroit, MI Purpose/Objective(s): Renal cell carcinoma (RCC) is a radio-resistant tumor histology that often metastasizes to the spine causing severe pain, vertebral compression fractures, and neurological deficits due to cord compression. Due to the radio-resistant nature of RCC it is believed that SRS offers an advantage over traditional fractionated radiation therapy. We reviewed our institutional experience to determine the efficacy and safety of SRS for RCC spinal metastases. Materials/Methods: Electronic medical records of clinical exams, and computed tomography/magnetic resonance imaging were evaluated with IRB approval. Post treatment pain control, neurological improvement, and radiographic tumor control were the primary endpoints of this analysis. Results: A total of 40 patients (83 vertebral bodies) underwent SRS between 06/2001 and 12/2015 for pathologically confirmed renal cell carcinoma spinal metastasis. The patient population consisted of 72.5% males and 27.5% females with a median age of 58.2 years. 72.5%, 20%, and 7.5% of patients are white, African American, and of other ethnicities respectively. 25 (62.5%) patients are deceased with a median survival time of 3.5 months. Tumor locations included: 3.4% cervical, 52.5% thoracic, 40.7% lumbar, and 3.4% sacral. Median dose of SRS was 18 Gy (range 10 e 18 Gy). Median target volume was 68 cc (range 17 e 208 cc). 85% of patients presented with back pain, while 45% of patients had a recognizable neurological deficit. 23.1% of patients had surgical resection of their spinal tumor prior to SRS, while 25.6% of patients received fractionated RT prior to SRS. Follow-up for treatment response was available in 24 (60%) patients (40 vertebral bodies) with a median follow-up time of 5.2 months. Local failure (within the PTV) occurred in 5 treated vertebral bodies (14.7%). 45.5% of cases achieved a notable pain response, while pain remained stable in 22.7%, and progressed in 31.8%. A neurological response was achieved in 37.5% of patients, with 25% remaining stable and 37.5% progressing. Local control based on radiological imaging was achieved in 76.3% of cases, while progression was noted in 23.7%. Recurrence occurred in 3 treated vertebral bodies (8.8%) with a median time to recurrence of 14.6 months. A total of 4 vertebral compression fractures (10%) were a potential complication of SRS, no other toxicities were noted. Conclusion: Our data shows SRS to be an effective treatment modality for RCC spinal metastasis providing fair pain, neurological, and local control with minimal associated toxicities and a low rate of recurrence. Author Disclosure: D. Boyce-Fappiano: None. E. Elibe: None. I.Y. Lee: Consultant; Medtronic. Speaker Honorarium with travel expenses; Varian Medical Systems. J. Rock: None. M.U. Siddiqui: HFHS rad-onc department receives research funding from entity; Varian Medical Systems, Philips Medical. Leads QA efforts in HFHS rad-onc clinic; Henry Ford Health System. F. Siddiqui: HFHS rad-onc department receives research funding from entity; Varian Medical Systems, Philips Medical. Assist in leading rad-onc department; Henry Ford Health System.

3275 Economic Impact of Palliative Radiation Therapy of Bone Metastases With a Single Fraction Dose: A One-Institution Experience E. Jorda, C. Domingo, M.D.M. Alcala´, A. Ciafre, D. Dualde Beltran, and E. Ferrer Albiach; Hospital Clinico Universitario, Valencia, Spain Purpose/Objective(s): Approximately a quarter of patients treated in a radiation oncology department are palliative patients. Bone metastases are

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International Journal of Radiation Oncology  Biology  Physics

one of the most common events during disease progression. It is estimated that this event appears from 15% to 70% of the overall oncology patients. Classical procedures to treat bone metastases are 20 Gray (Gy) in 5 fractions or 30Gy in 10 fractions. In recent years, a lot of data supports using a dose of 8Gy in 1 fraction (single-fraction radiation therapy (SFRT)) being as optimal as multifractionated radiation therapy (MFRT0) to palliate bone metastases symptoms. The RTOG trial 97-14 showed no difference between radiation delivered for painful bone metastases at a dose of 8Gy in 1 fraction SFRT and 30 Gy in 10 fractions [MFRT] in pain relief or narcotic use 3 months after randomization. SFRT for painful vertebral bone metastasis has not been well accepted, possibly because of concerns about efficacy and toxicity. We aimed to determine the total economic savings to our institution if SFRT becomes a standard treatment for selected patients. Materials/Methods: The number of palliative patients (stage IV) accepted to our department from January to December of 2014 was 263. One hundred and thirty six patients (51.71%) had bone metastases and were selected for our study. The exclusion criteria, following ASTRO recommendations, were: cortical affectation more than 3 cm, spinal cord compression, radicular compression, surgical fixation, caudal equine syndrome or same area previously irradiated. Total number of patients excluded was 32 (24%). Finally, 104 patients (76%) were selected for our study. Main features are shown in Table1. The total economic savings was estimated by multiplying the number of sessions given to patients if their schedules overcome more than 1 fraction by the stipulated cost of each RT session for that year. Results: Total sessions that could have been saved were 591 fractions. The cost of one fraction of RT per case was estimated at $48.29, according to the law in force in 2014 for the prices of RT treatments and rates according to economic department from our institution. This translated into an annual saving of approximately $32,821. Conclusion: Radiation therapy provides an 80% pain relief in palliative patients. Since there are no conclusive differences between MFRT and SFRT on the literature, we have concluded that it might represents significant savings to the health care system if SFRT becomes a standard practice for palliative patients who accomplish ASTRO criteria; also by shortening the time of treatment, other aspects as patient discomfort, transportation issues and psychological distress will decrease as well.

advance care planning for oncology patients is a new quality initiative at our hospital. However, we did not know whether radiation medicine patients were currently being captured in this initiative. Materials/Methods: We first did a random chart check of 50 patients being treated in our radiation oncology clinic in the past month to assess for the presence of an advance directive. To assess the utilization and awareness of the advance directive, surveys were then distributed to both patients and radiation medicine patient care providers. Questionnaires containing multiple choice questions were distributed among 34 patients visited the radiation oncology clinic over a month. A second survey was conducted among staff members of the clinic to assess the knowledge and awareness of advance directives: 14 staff members including physicians, radiation therapists, and administrative assistants participated. Results: Our initial chart check revealed that none of the 50 patients checked had advance directives in their chart. In an analysis of 34 patients, 15 patients had completed advance directives and 19 patients did not complete advance directives. Among patients with incomplete advance directives, 6 patients were interested in discussing the topic of advance directives with their health care provider and 2 patients were unware of advance directives. Interestingly, among patients who had completed advance directives, only 8 patients had given a copy to a provider at our hospital or their primary care doctor, indicating an inconsistency in communication with health care providers. Staff surveys showed that among 14 participants, 13 participants stated awareness of all the components of an advance directive form. However, only 5 members knew the essential parts of the advance directive form in subsequent specific questions. Furthermore, only 10 participants were aware how to access a patient’s advance directive information in the medical record. Conclusion: Despite the initiative to integrate advance directives into oncology at our hospital, most our patients do not have documentation of these forms in our medical records. In addition, our staff members have limited education on the components of an advance directive and many of them do not know where to find the form. This problem is multifactorial, but could limit care discussions and radiation treatment decisions resulting in sub-optimal care. Our future directions will include an implementation and education plan to increase awareness amongst patients and staff, and improve documentation in the health care record. Author Disclosure: S. Bornstein: None. V. Perera: None. C.R. Thomas: None.

Abstract 3275; Table 1. Patients Characteristics Variables Mean age, years Gender (%) Site of primary tumor (%)

N 104 64.5 (6.36)

Men (n 72)

Woman (n32)

66.3 (6.53) 69.2

60.5 (5.96) 30.8

Liver n 1 (0.98)Salivary gland n 1 (0.98) Gynecological n 1 (0.98)Paraganglioma n 3 (2.9)Myeloma n 4 (3.92)G.I n 13 (12.66)Breast n 16 (15.68)Lung n 29 (28.4)G.U n 34 (33.32)

Author Disclosure: E. Jorda: None. C. Domingo: None. M. Alcala´: None. A. Ciafre: None. D. Dualde Beltran: None. E. Ferrer Albiach: None.

3276 Integration of Advance Directives in a Radiation Medicine Clinic S. Bornstein,1 V. Perera,2 and C.R. Thomas, Jr1; 1Oregon Health and Science University, Portland, OR, 2Oregon Health & Science University, Portland, OR Purpose/Objective(s): One of the goals of radiation medicine is to provide the best quality of life to patients and their families based on their wishes, particularly given w50% of radiation medicine patients are treated with palliative intent. One of the most accessible methods to communicate and document advance care planning is by using an advance directive form. Integration of advance directives into the patient chart to improve

3277 Immediate 90-Day Stress-Related Cardiovascular Mortality: The Shock of Lung Cancer Diagnosis C. Patel,1 A. Attia,2 E.T. Shinohara,1 and S.M. Perkins3; 1Vanderbilt University Medical Center, Nashville, TN, 2Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, 3 Washington University School of Medicine, St. Louis, MO Purpose/Objective(s): Fang et al. published a retrospective cohort study which showed an increased incidence of stress-related cardiovascular death in the immediate 3 months following diagnosis of prostate cancer (JNCI 2009). As the dismal prognosis in lung cancer may result in greater incidence of stress-related cardiac death, combined with the high prevalence of smoking, we aimed to quantify the incidence of cardiac mortality in nonsmall cell lung cancer patients in the immediate post-diagnosis period. Materials/Methods: A retrospective study was conducted using the Texas Cancer Registry. Patients were diagnosed between 2004 and 2010. Patients were included if they had non-metastatic non-small cell lung cancer and underwent external beam radiation therapy or surgery, with or without chemotherapy. Patients who received other forms of radiation, chemotherapy alone, or had multiple lung cancers were excluded. A total of 16,213 patients met eligibility criteria. Statistical analysis was conducted using Stata 14.0 (College Station, TX). To focus on the immediate postdiagnosis period, incidence rates of cardiac death were computed with respect to less than 90-days post-diagnosis, 90 days to less than 1 year, and beyond 1 year after diagnosis of non-small cell lung cancer. Results: There was a substantial increase in cardiac mortality in the first 90 days following treatment for the entire cohort. To explore if this may be