Viet Do

PURPOSE: Resource-stratified guidelines (RSG) for cancer provide a hierarchy of interventions, based on resource availability. We quantify treatment need and cost if National Comprehensive Cancer Network (NCCN) RSGs for breast cancer (BC) are adopted globally. METHODS: We developed decision trees for first-course systemic therapy, merged with SEER and Global Cancer Observatory 2018 incidence data to estimate treatment need and cost if NCCN RSG are implemented globally based on country-level income. Simulations were used to quantify need and cost of globally scaling up services to Maximal. RESULTS: Based on NCCN RSG, first-course chemotherapy is indicated in 0% (Basic), 87% (Core), and 86% (Enhanced) but declined to 50% (Maximal) because of incorporation of genomic profiling. First-course endocrine therapy (ET) is indicated in 80% in all settings. In 2018, treatment need was 1.4 million people for chemotherapy, 183,943 for human epidermal growth factor receptor 2 (HER2) therapies and 1.6 million for ET. The cost per person for chemotherapy or HER2 or immunotherapy increased by 17-fold from Core to Maximal ($1,278-$22,313 Australian dollars [AUD]). The cost of ET per person rose eight-fold from Basic to Maximal ($1,236-$9,809 AUD). If all patients with BC globally were treated with Maximal resources, the need for chemotherapy would decline by 28%, whereas cost of first-course treatment would rise by 1.8-fold ($21-$37 billion AUD) because of more costly therapies. CONCLUSION: NCCN RSGs for BC could result in chemotherapy overtreatment in Core and Enhanced settings. The absence of chemotherapy in Basic settings should be reconsidered, and future iterations of RSG should perform cross-tumor comparisons to ensure equitable resource distribution and maximize population-level outcomes. Our model is flexible and can be tailored to the costs, population attributes, and resource availability of any institution or country for health-services planning.

Introduction: Optimal definitive treatment of prostate cancer is controversial, especially in high‐risk patients. We report the largest prospective cohort of Australian patients treated with radiotherapy for localised prostate cancer.Methods: One thousand, one hundred and twenty‐one patients with prostate cancer were prospectively registered and treated to a dose of 70–74 Gy. Patients were classified as low, intermediate or high risk based on PSA, clinical staging and Gleason score. Intermediate‐risk patients were treated with 0–6 months of hormonal therapy (ADT) and high‐risk patients were offered neoadjuvant and adjuvant ADT. Overall survival (OS) and biochemical relapse‐free survival (bNED) were calculated using the Kaplan–Meier method.Results: Median follow‐up was 92 months. Eight‐year OS and bNED were 78.4% and 68.1% respectively in the entire cohort. OS for the low, intermediate and high‐risk groups was 84.5%, 78.4% and 68% respectively. For these risk groups, bNED was 80.3%, 65.7% and 53.7% respectively. In the intermediate and high‐risk group, OS and bNED decreased with increasing number of risk factors.Conclusion: Definitive radiotherapy is an effective treatment for prostate cancer, including in high‐risk cases.

Treatment of gynecological cancer commonly involves pelvic radiation therapy (RT) and/or brachytherapy. A commonly observed side effect of such treatment is radiation-induced vaginal stenosis (VS). This review analyzed the incidence, pathogenesis, clinical manifestation(s) and assessment and grading of radiation-induced VS. In addition, risk factors, prevention and treatment options and follow-up schedules are also discussed. The limited available literature on many of these aspects suggests that additional studies are required to more precisely determine the best management strategy of this prevalent group after RT.

Ga-prostate-specific membrane antigen (PSMA) PET/CT is increasingly used to evaluate recurrent prostatic malignancy due to its high specificity. A 56-year-old man with previous history of treated prostate cancer 4 years earlier presented with rising prostate-specific antigen level and underwent Ga-PSMA PET/CT, which demonstrated an enlarging pulmonary nodule without PSMA avidity. The pulmonary nodule, however, showed moderate uptake on a corresponding FDG PET/CT study, suspicious of primary lung malignancy. Cytological and histopathological examination of the pulmonary nodule confirmed a metastatic deposit from ductal prostatic adenocarcinoma, an uncommon variant of prostatic malignancy.

Introduction: Image‐based brachytherapy for cervical cancer using MRI has been implemented in Australia and New Zealand. The aims of this study were to measure variability in High‐risk CTV (HR‐CTV) delineation and evaluate dosimetric consequences of this.Methods: Nine radiation oncologists, one radiation therapist and two radiologists contoured HR‐CTV on 3T MRI datasets from ten consecutive patients undergoing cervical brachytherapy at a single institution. Contour comparisons were performed using the Dice Similarity Coefficient (DSC) and Mean Absolute Surface Distance (MASD). Two reference contours were created for brachytherapy planning: a Simultaneous Truth and Performance Level Estimation (STAPLE) and a consensus contour (CONSENSUS). Optimized plans (8 Gy) for both these contours were applied to individual participant's contours to assess D90 and D100 coverage of HR CTV. To compare variability in dosimetry, relative standard deviation (rSD) was calculated.Results: Good concordance (mean DSC≥0.7, MASD≤5 mm) was achieved in 8/10 cases when compared to the STAPLE reference and 6/10 cases when compared to the CONSENSUS reference. Greatest variation was visually seen in the cranio‐caudal direction. The average mean rSD across all patients was 27% and 34% for the STAPLE HR‐CTV D90 and D100, respectively, and 28% and 35% for the CONSENSUS HR‐CTV D90 and D100. Delineation uncertainty resulted in an average dosimetric uncertainty of ±1.5–1.6 Gy per fraction based on an 8 Gy prescribed fraction.Conclusions: Delineation of HR‐CTV for cervical cancer brachytherapy was consistent amongst observers, suggesting similar interpretation of GEC‐ESTRO guidelines. Despite the good concordance, there was dosimetric variation noted, which could be clinically significant.