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Predictors of Breast Radiation Therapy Plan Modifications: Quality Assurance Rounds in a Large Cancer Center
S254
International Journal of Radiation Oncology Biology Physics
Results: Median age was 65 years (range 40-85). Minorities comprised 83.7% of patients (31/37), with 54.4% (20) identified as African American and 27% (10) Hispanic. White women comprised 16.2% (6), and Asian 2.7% (1). The majority of lesions were low (14/37, 37.8%) or intermediate (17/37, 45.9%) grade; there were 6 (16.2%) G3 lesions. Median DCIS size was 0.5cm (range 0.1-2.4cm), and all margins were negative. All lesions were ER+/PR+ with the exception of one (ER+/ PR-). The DCIS Scores ranged from 0 to 53, corresponding to risks of ipsilateral breast events at 10 years of 9% to 21%; Median and mean DCIS Scores differed among Whites (0 and 12.8, respectively), African American (8 and 18.2), and Hispanics (26 and 23.1). Adjuvant RT was recommended to 8 patients, all but one of whom was African American or Hispanic. Five of these 8 women underwent treatment, and 3 declined therapy (1 White and 2 minority patients). In addition, 6 minority patients whose recurrence risk was below 15% (5/6 were 14%) chose to undergo RT. The median age for the patients recommended for RT was 68.5 years (58-85). Conclusions: To the best of our knowledge, this is the only evaluation of the use of DCIS Scores in the management of DCIS in a predominately minority population. Patient outcomes, as well as issues specific to this population, will be further evaluated. Author Disclosure: R. Young: None. N. Ohri: None. M. Garg: None. S. Patel: None. S. Kalnicki: None. J. Fox: None.
Author Disclosure: L. Li: None. T. Zhu: None. I. Dragomir: None. A. Hanlon: None. U. Mahmood: None. R.J. Cohen: None. S. Gupta: None. A. Barrio: None.
2093 Squamous Cell Carcinoma of the Breast: An Analysis of a Rare Tumor Type in the SEER Database L. Li,1 T. Zhu,2 I. Dragomir,3 A. Hanlon,4 U. Mahmood,5 R.J. Cohen,6 S. Gupta,1 and A. Barrio1; 1Bryn Mawr Hospital, Bryn Mawr, PA, 2 Princeton University, Princeton, NJ, 3Thomas Jefferson University, Philadelphia, PA, 4University of Pennsylvania, Philadelphia, PA, 5The University of Texas MD Anderson Cancer Center, Houston, TX, 6University of Maryland, Baltimore, MD Purpose/Objective(s): Squamous cell carcinoma of the breast is a rare subgroup of breast cancers with little published data on its presentation and prognosis. The purpose of this study is to describe the presentation and outcome of this rare tumor type through a large population database. Materials/Methods: Between 1990 through 2010, the Surveillance, Epidemiology, and End Results Database was used to extract a case listing of squamous cell carcinoma of the breast. The data were analyzed to determine demographic and treatment information and overall survival. Results: The search resulted in 396 patients with a pathologic diagnosis of squamous cell carcinoma of the breast. Median age of diagnosis is 66 (range: 24-93). Racial breakdown showed 80.8% White, 14.6% Black, 3.3% Asian, and 1.3% unknown. Patients typically present with local regional disease; with 16.7% Stage I, 43.4% Stage II, 17.4% Stage III, 9.3% Stage IV, and 13.13% unknown stage. The majority of patients was lymph node negative (62.6%) and had tumors less than 5 cm (61.6%). Estrogen receptor status was negative in 58.8%, positive in 12.9% and unknown in 28.3% of patients. Progesterone status was negative in 61.6%, positive in 8.8%, and unknown in 29.0% of patients. Surgery treatment was 34.8% lumpectomy, 54.5% mastectomy, and 11.6% not performed or unknown. Radiation treatment was given to 34.4% of patients. Kaplan Meier overall survival for the group is 9.7 years; for Stage I is 14.6 years (SE: 1.1), Stage II is 9.4 years (SE: 0.5), Stage III is 4.8 years (SE: 0.63), and Stage IV is 1.1 years (SE: 0.2). Conclusions: This represents the largest reported case series of squamous cell carcinoma of the breast. The majority of patients present with node negative disease with tumor size less than 5 cm. Tumors also tend to be estrogen and progesterone receptor negative. Survival outcomes are inferior to common breast cancer histologies. Further research is necessary to improve outcomes for this rare tumor type.
2094 Predictors of Breast Radiation Therapy Plan Modifications: Quality Assurance Rounds in a Large Cancer Center T.D. Lymberiou,1 S. Galuszka,2 G. Lee,2 W. Xu,3 S. Su,3 A. Fyles,1 T. Purdie,2 P. Catton,1 C. Chung,1 R. Dinniwell,1 K. Han,1 A. Koch,1 W. Levin,1 L. Manchul,1 J. Sappiatzer,1 P. Mackenzie,1 and F. Liu1; 1 Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada, 2Princess Margaret Cancer Centre, Toronto, ON, Canada, 3 University Health Network, Toronto, ON, Canada Purpose/Objective(s): Quality assurance (QA) in modern radiation therapy (RT) aims to detect inconsistencies that might adversely affect treatment outcome. A recent survey of 14 community cancer centers demonstrated uniform agreement on the importance of QA rounds, but significant variations in the proportion of curative cases being reviewed, as well as timing of such reviews. Another North American study reported that only 1% of its reviewed plans required modification; the type of tumor and fewer years of experience of the practicing radiation oncologist (RO) were the only variables associated with modifications. The objectives of the current study are to report the process and outcomes of our own breast QA rounds, and identify patient, tumor, or treatment factors that were associated with RT plan modifications. Materials/Methods: The current practice at our institution is that all curative-intent breast RT plans be presented at weekly QA rounds prior to commencement of RT (or within the first few fractions). Data were prospectively collected from all radical cases from January 1, 2010 to December 31, 2012; comments regarding the plan were documented in real-time. Descriptive statistics were utilized to determine the proportion of cases requiring no (A), minor (B), or major (C) modifications. Univariate and multivariate logistic regression and Cochran-Armitage trend test were applied to each variable. Results: A total of 2223 breast QA cases were reviewed over this period; 47 cases (2.1%) underwent a minor change (B), and 52 cases (2.3%) required a major modification (C). The most common changes involved volume coverage, seroma contouring, addition of a boost, and the use of bolus. On univariate analysis, plans using more than 2 fields (OR Z 2.57, p Z 0.0011), triple negative disease (OR Z 2.49, p Z 0.017), axillary node dissection (OR Z 1.76, p Z 0.045), and tumor size more than 2 cm (OR Z 2.01, p Z 0.025) were significantly associated with category C. After multivariate analysis, only the number of fields (OR Z 2.09, p Z 0.017), and triple negative disease (OR Z 2.34, p Z 0.027) remained significant. No relationship was observed between experience of RO and plan modifications (B and C). An important observation related to patient cases that were node negative, margin negative, and 2 fields with no boost (n Z 561), wherein modifications were required in only 0.89% of instances. Conclusions: It is feasible to conduct weekly QA review for all radically treated breast cancer cases prior to commencing RT in a busy cancer center. Radiation technique using more than 2 fields and triple negative disease predicted for a higher likelihood of plan modifications. Conversely, less than 1% of node-negative cases with negative surgical margins treated with a 2-field technique and no boost required adjustments. Predicting the probability of a radical breast RT plan requiring modifications will direct future re-structuring of QA rounds. Author Disclosure: T.D. Lymberiou: None. S. Galuszka: None. G. Lee: None. W. Xu: None. S. Su: None. A. Fyles: None. T. Purdie: None. P. Catton: None. C. Chung: None. R. Dinniwell: None. K. Han: None. A. Koch: None. W. Levin: None. L. Manchul: None. J. Sappiatzer: None. P. Mackenzie: None. F. Liu: None.
International Journal of Radiation Oncology Biology Physics
Results: Median age was 65 years (range 40-85). Minorities comprised 83.7% of patients (31/37), with 54.4% (20) identified as African American and 27% (10) Hispanic. White women comprised 16.2% (6), and Asian 2.7% (1). The majority of lesions were low (14/37, 37.8%) or intermediate (17/37, 45.9%) grade; there were 6 (16.2%) G3 lesions. Median DCIS size was 0.5cm (range 0.1-2.4cm), and all margins were negative. All lesions were ER+/PR+ with the exception of one (ER+/ PR-). The DCIS Scores ranged from 0 to 53, corresponding to risks of ipsilateral breast events at 10 years of 9% to 21%; Median and mean DCIS Scores differed among Whites (0 and 12.8, respectively), African American (8 and 18.2), and Hispanics (26 and 23.1). Adjuvant RT was recommended to 8 patients, all but one of whom was African American or Hispanic. Five of these 8 women underwent treatment, and 3 declined therapy (1 White and 2 minority patients). In addition, 6 minority patients whose recurrence risk was below 15% (5/6 were 14%) chose to undergo RT. The median age for the patients recommended for RT was 68.5 years (58-85). Conclusions: To the best of our knowledge, this is the only evaluation of the use of DCIS Scores in the management of DCIS in a predominately minority population. Patient outcomes, as well as issues specific to this population, will be further evaluated. Author Disclosure: R. Young: None. N. Ohri: None. M. Garg: None. S. Patel: None. S. Kalnicki: None. J. Fox: None.
Author Disclosure: L. Li: None. T. Zhu: None. I. Dragomir: None. A. Hanlon: None. U. Mahmood: None. R.J. Cohen: None. S. Gupta: None. A. Barrio: None.
2093 Squamous Cell Carcinoma of the Breast: An Analysis of a Rare Tumor Type in the SEER Database L. Li,1 T. Zhu,2 I. Dragomir,3 A. Hanlon,4 U. Mahmood,5 R.J. Cohen,6 S. Gupta,1 and A. Barrio1; 1Bryn Mawr Hospital, Bryn Mawr, PA, 2 Princeton University, Princeton, NJ, 3Thomas Jefferson University, Philadelphia, PA, 4University of Pennsylvania, Philadelphia, PA, 5The University of Texas MD Anderson Cancer Center, Houston, TX, 6University of Maryland, Baltimore, MD Purpose/Objective(s): Squamous cell carcinoma of the breast is a rare subgroup of breast cancers with little published data on its presentation and prognosis. The purpose of this study is to describe the presentation and outcome of this rare tumor type through a large population database. Materials/Methods: Between 1990 through 2010, the Surveillance, Epidemiology, and End Results Database was used to extract a case listing of squamous cell carcinoma of the breast. The data were analyzed to determine demographic and treatment information and overall survival. Results: The search resulted in 396 patients with a pathologic diagnosis of squamous cell carcinoma of the breast. Median age of diagnosis is 66 (range: 24-93). Racial breakdown showed 80.8% White, 14.6% Black, 3.3% Asian, and 1.3% unknown. Patients typically present with local regional disease; with 16.7% Stage I, 43.4% Stage II, 17.4% Stage III, 9.3% Stage IV, and 13.13% unknown stage. The majority of patients was lymph node negative (62.6%) and had tumors less than 5 cm (61.6%). Estrogen receptor status was negative in 58.8%, positive in 12.9% and unknown in 28.3% of patients. Progesterone status was negative in 61.6%, positive in 8.8%, and unknown in 29.0% of patients. Surgery treatment was 34.8% lumpectomy, 54.5% mastectomy, and 11.6% not performed or unknown. Radiation treatment was given to 34.4% of patients. Kaplan Meier overall survival for the group is 9.7 years; for Stage I is 14.6 years (SE: 1.1), Stage II is 9.4 years (SE: 0.5), Stage III is 4.8 years (SE: 0.63), and Stage IV is 1.1 years (SE: 0.2). Conclusions: This represents the largest reported case series of squamous cell carcinoma of the breast. The majority of patients present with node negative disease with tumor size less than 5 cm. Tumors also tend to be estrogen and progesterone receptor negative. Survival outcomes are inferior to common breast cancer histologies. Further research is necessary to improve outcomes for this rare tumor type.
2094 Predictors of Breast Radiation Therapy Plan Modifications: Quality Assurance Rounds in a Large Cancer Center T.D. Lymberiou,1 S. Galuszka,2 G. Lee,2 W. Xu,3 S. Su,3 A. Fyles,1 T. Purdie,2 P. Catton,1 C. Chung,1 R. Dinniwell,1 K. Han,1 A. Koch,1 W. Levin,1 L. Manchul,1 J. Sappiatzer,1 P. Mackenzie,1 and F. Liu1; 1 Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada, 2Princess Margaret Cancer Centre, Toronto, ON, Canada, 3 University Health Network, Toronto, ON, Canada Purpose/Objective(s): Quality assurance (QA) in modern radiation therapy (RT) aims to detect inconsistencies that might adversely affect treatment outcome. A recent survey of 14 community cancer centers demonstrated uniform agreement on the importance of QA rounds, but significant variations in the proportion of curative cases being reviewed, as well as timing of such reviews. Another North American study reported that only 1% of its reviewed plans required modification; the type of tumor and fewer years of experience of the practicing radiation oncologist (RO) were the only variables associated with modifications. The objectives of the current study are to report the process and outcomes of our own breast QA rounds, and identify patient, tumor, or treatment factors that were associated with RT plan modifications. Materials/Methods: The current practice at our institution is that all curative-intent breast RT plans be presented at weekly QA rounds prior to commencement of RT (or within the first few fractions). Data were prospectively collected from all radical cases from January 1, 2010 to December 31, 2012; comments regarding the plan were documented in real-time. Descriptive statistics were utilized to determine the proportion of cases requiring no (A), minor (B), or major (C) modifications. Univariate and multivariate logistic regression and Cochran-Armitage trend test were applied to each variable. Results: A total of 2223 breast QA cases were reviewed over this period; 47 cases (2.1%) underwent a minor change (B), and 52 cases (2.3%) required a major modification (C). The most common changes involved volume coverage, seroma contouring, addition of a boost, and the use of bolus. On univariate analysis, plans using more than 2 fields (OR Z 2.57, p Z 0.0011), triple negative disease (OR Z 2.49, p Z 0.017), axillary node dissection (OR Z 1.76, p Z 0.045), and tumor size more than 2 cm (OR Z 2.01, p Z 0.025) were significantly associated with category C. After multivariate analysis, only the number of fields (OR Z 2.09, p Z 0.017), and triple negative disease (OR Z 2.34, p Z 0.027) remained significant. No relationship was observed between experience of RO and plan modifications (B and C). An important observation related to patient cases that were node negative, margin negative, and 2 fields with no boost (n Z 561), wherein modifications were required in only 0.89% of instances. Conclusions: It is feasible to conduct weekly QA review for all radically treated breast cancer cases prior to commencing RT in a busy cancer center. Radiation technique using more than 2 fields and triple negative disease predicted for a higher likelihood of plan modifications. Conversely, less than 1% of node-negative cases with negative surgical margins treated with a 2-field technique and no boost required adjustments. Predicting the probability of a radical breast RT plan requiring modifications will direct future re-structuring of QA rounds. Author Disclosure: T.D. Lymberiou: None. S. Galuszka: None. G. Lee: None. W. Xu: None. S. Su: None. A. Fyles: None. T. Purdie: None. P. Catton: None. C. Chung: None. R. Dinniwell: None. K. Han: None. A. Koch: None. W. Levin: None. L. Manchul: None. J. Sappiatzer: None. P. Mackenzie: None. F. Liu: None.