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J. Descallar



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    MO23 - Radiotherapy II: Lung Toxicity, Target Definition and Quality Assurance (ID 107)

    • Event: WCLC 2013
    • Type: Mini Oral Abstract Session
    • Track: Radiation Oncology + Radiotherapy
    • Presentations: 1
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      MO23.08 - Inter-observer Variability in Gross Tumour Volume Delineation on Kilo-voltage Cone Beam Computed Tomography (CBCT) Scans for Lung Cancer Radiotherapy Treatment Verification (ID 3294)

      11:15 - 11:20  |  Author(s): J. Descallar

      • Abstract
      • Presentation
      • Slides

      Background
      The use of CBCT is essential for precise treatment delivery of radiotherapy for lung cancer. The current work practice at many centres is to use bony landmarks to match on-treatment CBCT to the radiotherapy planning CT to verify treatment. To take full advantage of this imaging modality for lung cancer, soft-tissue matching is preferred as it ensures that the actual lung cancer is within the radiotherapy fields regardless of bony anatomy. However Radiation Therapists (RTs) are trained in bony matching and not soft tissue matching. The purpose of this study was to determine the level of inter-observer variability in lung cancer gross tumour volume (GTV) delineation on CBCT and alignment of the CBCT with a planning GTV between Radiation Therapists (RTs), a Radiation Oncologist (RO) and a Radiologist (RD)

      Methods
      Ten RTs, one RO and one RD independently delineated the lung cancer GTV for fifteen lung cancer patients on Elekta Synergy CBCT image datasets taken on the first treatment fraction. The window and level settings used by each observer were recorded. Each observer then performed an alignment of the CBCT GVT to the radiotherapy planning GTV and translational errors were recorded. The difference in the isocentre corrections for the alignment shifts and Centre of Volume, Volume and Concordance Index (CI) for the contoured volumes were calculated to determine the level of agreement between the RT’s and the RD and between the RTs and the RO, in comparison to the variation between the RD and RO. In an ideal setting the difference between the RTs and the RO and the RTs and the RD would be at least equivalent to the difference between the RD and RO.

      Results
      The difference between the RT’s and RO and RD was found to be not statistically equivalent to the difference between the RD and RO. The mean isocentre difference between the RO and RD was 0.40cm, compared with 0.42cm and 0.51cm between the RT’s and the RO and RD respectively. The mean CI between the RD and RO was 0.56 (0.44,0.69), which was smaller than the lower bound of the 95 % confidence intervals (95%) of the RT’s compared to the RD (0.5, 0.56) and RO (0.52,0.59). The mean log COV difference was -0.82cm between the RD and RO and -0.54 and -0.65cm between the RT’s and RO and RD respectively. The volume results showed that only 6 of thirty comparisons were equivalent. The mean volume difference between the RD and RO was 0.44cm[3] and 4.73 cm[3] and 5.7cm[3] between the RT’s and RO and RD respectively.

      Conclusion
      The variation between the RTs and the RO and RD was greater than the variation between the RO and RD. Advanced training is necessary to educate the RTs on soft-tissue matching on CBCT for lung cancer radiotherapy.

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    P1.09 - Poster Session 1 - Combined Modality (ID 212)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Combined Modality
    • Presentations: 1
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      P1.09-020 - Clinical guideline adherence in locally advanced non-small cell lung cancer: A south western Sydney perspective (ID 3171)

      09:30 - 09:30  |  Author(s): J. Descallar

      • Abstract

      Background
      Stage III non-small cell lung cancer (NSCLC) typically represents up to one third of all new NSCLC diagnoses, and can be a technically difficult and controversial group of patients to definitively manage. In 2004, the National Health and Medical Research Council published a set of evidence based clinical guidelines for the management of lung cancer in Australia. This study aims to investigate adherence to these national guidelines in the treatment of Stage III cancers and identify factors associated with the receipt of guideline recommended therapy (GRT) and patient survival.

      Methods
      A retrospective cohort of newly diagnosed, Stage III NSCLC was identified from the South Western Sydney (SWS) Local Health District Clinical Cancer Registry. Cases were diagnosed between 2006 and 2011 and resided within SWS local postcode boundaries. Pre-2010 diagnosed “wet” stage IIIB cases with malignant pleural effusion were excluded from analysis. GRT was assigned to each case based on stage group and performance status (ECOG) at diagnosis. Significant factors associated with adherence to GRT and the effect these factors had on patient survival was determined using univariate analysis and Cox proportional hazards regression model.

      Results
      Of 316 eligible cases identified, 19 patients (6%) had no ECOG documentation found, and were excluded from the analysis. Median age of the remaining cohort was 69 years, and 64% were male. Disease stage distribution was 58% for IIIA cases and 42% for IIIB. 85% of patients were identified as having Good ECOG (0-2) at diagnosis. Overall 55% of the total; 63% of IIIA and 46% of IIIB patients received GRT. 24% of IIIA patients received surgery alone in combination with chemotherapy and/or radiotherapy. 31% of IIIB patients received either concurrent or combination chemo-radiation. On univariate analysis, the receipt of GRT was associated with patient age (p <0.001), disease stage (p 0.003), and performance status (p <0.001). Morphological subtype was trending (p 0.056). Overall median survival was 11.4 months. Patient survival was not significantly improved with the receipt of GRT.

      Conclusion
      Adherence to GRT was associated with tumour stage, patient age and performance status. In this cohort of patients, the receipt of GRT did not have a significant impact on survival.

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    P3.09 - Poster Session 3 - Combined Modality (ID 214)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Combined Modality
    • Presentations: 1
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      P3.09-012 - A decade of community-based outcomes of patients treated with curative radiotherapy (RT) +/- chemotherapy for Non-Small Cell Lung Cancer (NSCLC). (ID 2046)

      09:30 - 09:30  |  Author(s): J. Descallar

      • Abstract

      Background
      There are many clinical trials reporting good outcomes of patients treated with curative RT. However, clinical trials populations are highly selected and there are limited data on whether these outcomes are seen in community practice in the Australian setting. The aim of the study was to evaluate the outcomes and toxicity of patients treated with curative RT +/- chemotherapy for NSCLC.

      Methods
      Electronic medical records at Liverpool and Macarthur Cancer Therapy Centres, NSW, Australia were queried to retrieve data on patients with Stage I-III NSCLC who were treated with curative RT (minimum dose 60Gy) between 1/1/2000-31/12/2010. Patient death records were available up until 16/1/2013 with a minimum follow up time for patients of 2 years. Patient demographic data, tumour, and treatment details were retrieved. The records were retrospectively reviewed to collect data on patient comorbidities and treatment toxicities. The Simplified Comorbidities Score (SCS) was used to score comorbidity. The median follow up time was 22 months. For Cancer Specific Survival (CSS), patients were censored if they had died from another cause or survived until the last date of follow up, and for Overall Survival (OS), patients were censored if they survived until the end of the study. Univariate and multivariate Cox proportional hazards models were used to assess predictors of CSS and OS.

      Results
      One hundred and sixty patients were treated with curative RT over this period. The median age was 69 years (range 36-89). Seventy-six patients received RT alone, 59 received concurrent chemo-radiation, and 25 received sequential chemo-radiation. Twenty-nine patients had stage I disease, 28 had stage II, and 103 had stage III. Median overall survival was 29 months for patients with stage I NSCLC, 26 months for stage II, and 18 months for stage III. For stage II and III patients treated with concurrent chemo-radiation, median survivals were 29 and 18 months and 2-year OS were 64 and 42% respectively. On multivariate analysis, stage II or III and weight loss ≥5% were predictive of cancer specific survival with hazard ratio 4.47 (95% CI: 10.8-18.55, p=0.039) and 2.23 (95% CI: 1.13-4.39, p=0.021). Toxicity was acceptable with 2% grade ≥3 radiation pneumonitis, 6% grade ≥3 oesophagitis, and 2% grade ≥3 febrile neutropenia. There was no treatment-related death. Performance status, age, SCS, respiratory function, pathology, and grade were not predictive of survival.

      Conclusion
      Curative intent RT +/- chemotherapy is well tolerated and effective treatment for inoperable or locally advanced NSCLC. Tumour outcomes and toxicities were comparable to those reported in clinical trials. Higher SCS was not correlated with worse survival in this cohort.

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    P3.12 - Poster Session 3 - NSCLC Early Stage (ID 206)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 1
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      P3.12-009 - Patterns of care in patients receiving adjuvant chemotherapy for resected non-small cell lung cancer (NSCLC) in South Western Sydney Local Health District (SWSLHD) (ID 2093)

      09:30 - 09:30  |  Author(s): J. Descallar

      • Abstract

      Background
      Randomised controlled trials have shown that adjuvant chemotherapy is the standard of care for patients with resected, stages II and IIIA NSCLC. The benefit in stage IB disease remains inconclusive. There are limited data regarding the patterns of care, benefits and toxicities of adjuvant chemotherapy in the non-clinical trial population. We reviewed patterns of care and survival outcomes in patients with resected NSCLC receiving adjuvant chemotherapy.

      Methods
      We retrospectively reviewed medical records for patients with resected, pathologic stages IB-IIIA NSCLC diagnosed between 1/1/2005 and 31/12/2012 in SWSLHD. Patients were identified using an institutional electronic database. Staging was according to the American Joint Commission on Cancer (AJCC) 6[th] edition tumour-node-metastasis (TNM) system. Information was extracted on baseline patient and tumour characteristics, treatment modalities, chemotherapy delivery, treatment-related toxicities and patient outcomes. Survival analysis was performed using Kaplan-Meier method.

      Results
      We identified 137 patients who underwent surgical resection, 63 (46%) received adjuvant chemotherapy and are presented in this analysis. The main reasons that patients did not receive adjuvant chemotherapy included stage IB disease (32%), advanced age/comorbidities (24%), patient preference (14%), prior neoadjuvant treatment (7%) and non referral (7%). The median age at diagnosis was 64 (range 45 - 77) with 57% male, 81% were ex- or current smokers and 80% had an ECOG performance status of 0 or 1. Adenocarcinoma and squamous cell carcinoma histology accounted for 54% and 27%, respectively. Forty one patients (65%) had lobectomy and 22 (35%) had pneumonectomy. Pathological stage was: 1B 5 patients (7.9%), IIA 11 (17.5%), IIB 13 (20.6%) and IIIA 34 (54%). Adjuvant chemotherapy commenced within 90 days of surgery in 94% with a median time to treatment of 60 days (range 25-110). Adjuvant radiotherapy was given to 18 patients (29%), with 52% of patients with N2 disease receiving radiotherapy. Platinum doublet chemotherapy was administered to 62 patients (98%) and cisplatin/vinorelbine was the most common regimen given to 41 patients (65%). The number of planned treatment cycles was completed by 40 patients (63%), and of these, 11 patients (17%) completed all chemotherapy on schedule without dose modification. Eighteen patients (29%) required hospitalisation during treatment. Febrile neutropaenia occurred in 10 (16%), with an additional 24 (38%) developing non-febrile neutropaenia, thrombocytopenia or anaemia. Other clinically significant non-haematological toxicities included: vomiting (11%); renal impairment (10%); ototoxicity (6%); peripheral neuropathy (16%); fatigue (6%); allergy (2%) or myalgias (3%). There were no toxic deaths. With a median follow-up of 18.6 months (range 3.4 to 96 months), 56% had developed recurrent disease with a median disease-free survival of 18.9 months. The majority (94%) developed recurrent disease within 3 years. The median overall survival was 25.6 months. A total of 34 (54%) had died, including 3 non-cancer related deaths.

      Conclusion
      The utilisation of adjuvant chemotherapy rate is moderate but is consistent with other reports. Our results demonstrated a higher rate of febrile neutropenia and shorter median overall survival than the clinical trial population. Therefore, careful selection of patients to undergo adjuvant chemotherapy is essential.

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    P3.24 - Poster Session 3 - Supportive Care (ID 160)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Supportive Care
    • Presentations: 1
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      P3.24-007 - Do patients discussed at Lung Cancer Multidisciplinary Team Meetings receive guideline-recommended treatment? (ID 321)

      09:30 - 09:30  |  Author(s): J. Descallar

      • Abstract

      Background
      Many clinical practice guidelines recommend that all lung cancer patients should be discussed at a multidisciplinary team meeting (MDM) to determine a management plan. Previous studies have shown that lung cancer MDM recommendations are largely concordant with guidelines. There are limited data on whether these recommendations are translated into actual treatment received. The aim of this study was to evaluate whether patients discussed at a lung cancer MDM actually received guideline-recommended treatment (GRT) and determine reasons for not receiving GRT.

      Methods
      The Liverpool/Macarthur lung cancer MDM prospectively collects data on new lung cancer patients including patient and tumour characteristics, staging investigations, referrals and treatment recommendations. All new lung cancer patients discussed at the MDM between 1/12/05 – 31/12/2010 were identified. Details of patient demographics, tumour characteristics and treatment were obtained from the MDM database and the Area Clinical Cancer Registry. GRT was assigned to each patient according to pathology, stage and ECOG performance status as per the 2004 Australian Lung Cancer Guidelines. This was compared to actual treatment received to determine adherence to GRT. For those who did not receive GRT, the medical record was reviewed to determine the reason why. Survival was compared between patients who did and did not receive GRT.

      Results
      808 patients were discussed at the MDM. 64% were male and the median age was 68 years. Pathology was NSCLC in 657 (81%), SCLC in 119 (15%) and not confirmed in 32 (4%). 128 (16%) had Stage I or II NSCLC, 306 (38%) Stage III NSCLC or limited stage SCLC and 372 (46%) metastatic disease. GRT could be assigned in 98% of patients who had both stage and ECOG performance status documented. Overall 411 (51%) of patients received GRT, and 380 (47%) did not receive GRT. The main reasons for not receiving GRT were decline in performance status (24%), large tumour volume precluding radical RT (17%), co-morbidities (14%) and patient preference (13%). On multivariate analysis, ECOG performance status, stage and age were significantly associated with receipt of GRT. GRT, ECOG performance status and stage were significant predictors of survival.

      Conclusion
      Despite discussion at an MDM, a significant proportion of patients were unable to receive GRT due to legitimate reasons. This may reflect the characteristics of the underlying lung cancer population who are older and have coexisting comorbidities. Alternative treatment strategies are needed for patients who are not suitable for GRT.