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Use of Anticoagulants Predict Late Rectal Bleeding Following Definitive External Beam Radiation Therapy for Prostate Cancer
Volume 87 Number 2S Supplement 2013
Oral Scientific Sessions
Oral Scientific Abstract 221; Table
Local therapy for skin metastases by treatment modality
Local palliative therapy
Studies (n Z)
Skin metastases treated (n Z)
22 13 17 17 30 50
177 840 1192 341 1223 56
RT PDT ECT TT IT Surgery
Complete response rate (95% CI) *54.3% *70.1% *57.1% *44.2% *25.9%
(35.2-72.2%) (57.2-80.5%) (44.8-68.5%) (24.0-66.6%) (17.2-37.2%) n/a
Overall response rate (95% CI) *75.1% *81.9% *87.9% *58.9% *51.6%
(61.9-84.9%) (74.0-87.8%) (80.7-92.7%) (40.0-75.5%) (48.3-54.8%) n/a
S91
Recurrence rate (95% CI) 4.5% *9.9% *5.7% 3.6%
(2.1-9.4%) (4.8-19.5%) (2.5-12.8%) (1.5-8.1%) n/a 5.8% (1.7-18.5%)
*P < .05 for heterogeneity; n/a Z not available
Results: Ninety-eight RO care providers responded (RR Z 88% for physicians, 83% for nurses). Large majorities believed that SPRO improved the following PCC quality measures: overall quality of care (physician/nurse, 98%/96%); time spent on technical aspects of PCC (e.g., reviewing imaging) (88%/60%); communication with patients and families (95%/96%); appropriateness of treatment recommendations (85%/88%); appropriateness of dose/fractionation (78%/60%); patient follow-up (65/ 72%); and staff experience (93%/84%). Large minorities reported improvement in attention to cost (42%/32%). Compared to physicians practicing in departments without dedicated palliative RO services, physicians practicing with a dedicated service rated PCC quality more highly, including time to consultation (p < 0.01), time spent with patients (p < 0.01), communication with care providers (p < 0.0001), and time spent on technical aspects of PCC (p Z 0.02). Similarly, there was a trend for physicians with a dedicated service to more highly rate communication with patients (p Z 0.08) and appropriateness of treatment recommendations (p Z 0.06). Conclusions: The implementation of a dedicated palliative RO service is viewed by clinicians as having improved the quality of PCC. Furthermore, physicians practicing within this dedicated service rate multiple measures of PCC quality higher than do physicians practicing at academic centers without a dedicated service. These findings demonstrate that dedicated palliative RO services can improve the quality of PCC. Author Disclosure: M.S. Krishnan: None. Y. Tseng: None. A. Sullivan: None. J. Jones: None. D. Gorman: None. A. Taylor: None. M. Pacold: None. B. Kalinowski: None. H. Mamon: None. T. Balboni: None.
221 Palliative Local Therapy for Skin Metastases: A Meta-Analysis D.E. Spratt,1 E.A. Gordon Spratt,2 S. Wu,3 M. Lacouture,1 and C.A. Barker1; 1Memorial Sloan-Kettering Cancer Center, New York, NY, 2New York University Langone Medical Center, New York, NY, 3Stony Brook University Cancer Center, New York, NY Purpose/Objective(s): Approximately 82,000 cases of skin metastases occur annually in the United States and can be associated with significant cancer associated morbidity. While treatment algorithms have been developed for metastases in other organs (brain, bone, etc.), little is known regarding the optimal approach to palliate skin metastases with local therapy. Therefore, we conducted a meta-analysis of palliative local therapies for skin metastases. Materials/Methods: Data sources included Medline and Cochrane systematic reviews from 1963 to 2011. Searches were limited to the English language combining the terms cutaneous metastasis or skin metastasis and radiation therapy, brachytherapy, surgery, electrochemotherapy (ECT), radiation (RT), topical (TT), intralesional (IT), or photodynamic (PDT) therapy. Studies were included only if the local therapy was provided for a clearly described and documented skin metastasis. Level of evidence was graded using the United States Preventive Services Task Force (USPSTF) criteria. Data on complete and overall response, and recurrence were extracted from eligible studies. Frequent side effects of each therapy were noted. Extent of heterogeneity between studies was performed with the Cochran Q test, and an I2 test for heterogeneity between subgroups was calculated. All probability values were 2-tailed and p Z .05 was considered statistically significant.
Results: Our search yielded 1,274 articles; 143 (11.2%) met criteria for analysis and provided a wide spectrum of level I-III evidence. Among the 6 types of local treatment, outcome for 3829 skin metastases were reported among level I-IIB studies. Response and recurrence rates based on random-effects modeling are presented in the Table. Significant heterogeneity was noted in the results of the studies on each local therapy. Characteristic toxicity of each local treatment, outcome by cancer origin and drug will be presented. Conclusions: This is the first meta-analysis to describe response and recurrence rates for skin metastases. With overall response rates of 50%90% and recurrence rates of 3%-10% across treatment modalities, local therapy for skin metastases may be considered a successful treatment option to palliate this important cause of cancer associated morbidity. Author Disclosure: D.E. Spratt: None. E.A. Gordon Spratt: None. S. Wu: None. M. Lacouture: None. C.A. Barker: None.
222 Use of Anticoagulants Predict Late Rectal Bleeding Following Definitive External Beam Radiation Therapy for Prostate Cancer M.A. Kollmeier, P. Soni, X. Pei, and M.J. Zelefsky; Memorial SloanKettering Cancer Center, New York, NY Purpose/Objective(s): To determine the relationship between hematologic modifying drugs and the risk of acute and late radiation proctitis in patients undergoing definitive external beam radiation therapy for prostate cancer. Materials/Methods: A total of 2900 patients with clinically localized prostate cancer received definitive external beam radiation therapy at our institution between 1988 and 2011. One thousand four hundred forty received neoadjuvant and concurrent androgen deprivation therapy (ADT). Medication information was collected at consultation and patients taking anti-platelet medication (n Z 820), anticoagulants (n Z 184), and nitrates (n Z 93) were recorded. Acute and late gastrointestinal (GI) toxicity was recorded using CTCAE v 3.0. Median follow-up was 89.5 months. Cox regression and Kaplan Meier methods were used for statistical analysis. Results: The overall incidence of acute and late grade 2 GI toxicity for the entire cohort was 2.4% and 6.4% respectively at 10years. Few late grade 3 GI events occurred (n Z 14). For patients taking anticoagulant medications, there was a significant increase in the risk of late rectal bleeding compared to those not taking these medications (2.9% v 5.7% at 10y; p Z 0.03). There was no significant increase in acute or late GI toxicity in patients taking antiplatelet medication (p Z 0.89) or nitrates (p Z 0.09). On multivariate analysis, only use of anticoagulant medication (RR: 2.17; p Z 0.02) and non-IMRT modality (RR: 6.42; p < 0.001) were significant predictors of late GI toxicity. There was no significant correlation noted with RT dose 81 Gy or use of ADT. Conclusions: Patients taking anticoagulant medication have a 2.2 fold higher risk of late rectal bleeding than those not taking these medications. Use of non-IMRT treatment planning confers a 6.4 fold higher risk of late rectal bleeding. There was no significant correlation between use of antiplatelet medication or nitrates with respect to acute or late GI toxicity. Appropriate counseling of patients taking anticoagulants regarding risk of rectal bleeding is recommended. Author Disclosure: M.A. Kollmeier: None. P. Soni: None. X. Pei: None. M.J. Zelefsky: None.
Oral Scientific Sessions
Oral Scientific Abstract 221; Table
Local therapy for skin metastases by treatment modality
Local palliative therapy
Studies (n Z)
Skin metastases treated (n Z)
22 13 17 17 30 50
177 840 1192 341 1223 56
RT PDT ECT TT IT Surgery
Complete response rate (95% CI) *54.3% *70.1% *57.1% *44.2% *25.9%
(35.2-72.2%) (57.2-80.5%) (44.8-68.5%) (24.0-66.6%) (17.2-37.2%) n/a
Overall response rate (95% CI) *75.1% *81.9% *87.9% *58.9% *51.6%
(61.9-84.9%) (74.0-87.8%) (80.7-92.7%) (40.0-75.5%) (48.3-54.8%) n/a
S91
Recurrence rate (95% CI) 4.5% *9.9% *5.7% 3.6%
(2.1-9.4%) (4.8-19.5%) (2.5-12.8%) (1.5-8.1%) n/a 5.8% (1.7-18.5%)
*P < .05 for heterogeneity; n/a Z not available
Results: Ninety-eight RO care providers responded (RR Z 88% for physicians, 83% for nurses). Large majorities believed that SPRO improved the following PCC quality measures: overall quality of care (physician/nurse, 98%/96%); time spent on technical aspects of PCC (e.g., reviewing imaging) (88%/60%); communication with patients and families (95%/96%); appropriateness of treatment recommendations (85%/88%); appropriateness of dose/fractionation (78%/60%); patient follow-up (65/ 72%); and staff experience (93%/84%). Large minorities reported improvement in attention to cost (42%/32%). Compared to physicians practicing in departments without dedicated palliative RO services, physicians practicing with a dedicated service rated PCC quality more highly, including time to consultation (p < 0.01), time spent with patients (p < 0.01), communication with care providers (p < 0.0001), and time spent on technical aspects of PCC (p Z 0.02). Similarly, there was a trend for physicians with a dedicated service to more highly rate communication with patients (p Z 0.08) and appropriateness of treatment recommendations (p Z 0.06). Conclusions: The implementation of a dedicated palliative RO service is viewed by clinicians as having improved the quality of PCC. Furthermore, physicians practicing within this dedicated service rate multiple measures of PCC quality higher than do physicians practicing at academic centers without a dedicated service. These findings demonstrate that dedicated palliative RO services can improve the quality of PCC. Author Disclosure: M.S. Krishnan: None. Y. Tseng: None. A. Sullivan: None. J. Jones: None. D. Gorman: None. A. Taylor: None. M. Pacold: None. B. Kalinowski: None. H. Mamon: None. T. Balboni: None.
221 Palliative Local Therapy for Skin Metastases: A Meta-Analysis D.E. Spratt,1 E.A. Gordon Spratt,2 S. Wu,3 M. Lacouture,1 and C.A. Barker1; 1Memorial Sloan-Kettering Cancer Center, New York, NY, 2New York University Langone Medical Center, New York, NY, 3Stony Brook University Cancer Center, New York, NY Purpose/Objective(s): Approximately 82,000 cases of skin metastases occur annually in the United States and can be associated with significant cancer associated morbidity. While treatment algorithms have been developed for metastases in other organs (brain, bone, etc.), little is known regarding the optimal approach to palliate skin metastases with local therapy. Therefore, we conducted a meta-analysis of palliative local therapies for skin metastases. Materials/Methods: Data sources included Medline and Cochrane systematic reviews from 1963 to 2011. Searches were limited to the English language combining the terms cutaneous metastasis or skin metastasis and radiation therapy, brachytherapy, surgery, electrochemotherapy (ECT), radiation (RT), topical (TT), intralesional (IT), or photodynamic (PDT) therapy. Studies were included only if the local therapy was provided for a clearly described and documented skin metastasis. Level of evidence was graded using the United States Preventive Services Task Force (USPSTF) criteria. Data on complete and overall response, and recurrence were extracted from eligible studies. Frequent side effects of each therapy were noted. Extent of heterogeneity between studies was performed with the Cochran Q test, and an I2 test for heterogeneity between subgroups was calculated. All probability values were 2-tailed and p Z .05 was considered statistically significant.
Results: Our search yielded 1,274 articles; 143 (11.2%) met criteria for analysis and provided a wide spectrum of level I-III evidence. Among the 6 types of local treatment, outcome for 3829 skin metastases were reported among level I-IIB studies. Response and recurrence rates based on random-effects modeling are presented in the Table. Significant heterogeneity was noted in the results of the studies on each local therapy. Characteristic toxicity of each local treatment, outcome by cancer origin and drug will be presented. Conclusions: This is the first meta-analysis to describe response and recurrence rates for skin metastases. With overall response rates of 50%90% and recurrence rates of 3%-10% across treatment modalities, local therapy for skin metastases may be considered a successful treatment option to palliate this important cause of cancer associated morbidity. Author Disclosure: D.E. Spratt: None. E.A. Gordon Spratt: None. S. Wu: None. M. Lacouture: None. C.A. Barker: None.
222 Use of Anticoagulants Predict Late Rectal Bleeding Following Definitive External Beam Radiation Therapy for Prostate Cancer M.A. Kollmeier, P. Soni, X. Pei, and M.J. Zelefsky; Memorial SloanKettering Cancer Center, New York, NY Purpose/Objective(s): To determine the relationship between hematologic modifying drugs and the risk of acute and late radiation proctitis in patients undergoing definitive external beam radiation therapy for prostate cancer. Materials/Methods: A total of 2900 patients with clinically localized prostate cancer received definitive external beam radiation therapy at our institution between 1988 and 2011. One thousand four hundred forty received neoadjuvant and concurrent androgen deprivation therapy (ADT). Medication information was collected at consultation and patients taking anti-platelet medication (n Z 820), anticoagulants (n Z 184), and nitrates (n Z 93) were recorded. Acute and late gastrointestinal (GI) toxicity was recorded using CTCAE v 3.0. Median follow-up was 89.5 months. Cox regression and Kaplan Meier methods were used for statistical analysis. Results: The overall incidence of acute and late grade 2 GI toxicity for the entire cohort was 2.4% and 6.4% respectively at 10years. Few late grade 3 GI events occurred (n Z 14). For patients taking anticoagulant medications, there was a significant increase in the risk of late rectal bleeding compared to those not taking these medications (2.9% v 5.7% at 10y; p Z 0.03). There was no significant increase in acute or late GI toxicity in patients taking antiplatelet medication (p Z 0.89) or nitrates (p Z 0.09). On multivariate analysis, only use of anticoagulant medication (RR: 2.17; p Z 0.02) and non-IMRT modality (RR: 6.42; p < 0.001) were significant predictors of late GI toxicity. There was no significant correlation noted with RT dose 81 Gy or use of ADT. Conclusions: Patients taking anticoagulant medication have a 2.2 fold higher risk of late rectal bleeding than those not taking these medications. Use of non-IMRT treatment planning confers a 6.4 fold higher risk of late rectal bleeding. There was no significant correlation between use of antiplatelet medication or nitrates with respect to acute or late GI toxicity. Appropriate counseling of patients taking anticoagulants regarding risk of rectal bleeding is recommended. Author Disclosure: M.A. Kollmeier: None. P. Soni: None. X. Pei: None. M.J. Zelefsky: None.