Browsing by Author "McClelland, Shearwood, III."

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    A real pain in the neck
    (VM Media Group, 2022-05-19) McClelland, Shearwood, III.; Mitin, Timur; Radiation Oncology, School of Medicine
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    Baseline Karnofsky performance status is independently predictive of death within 30 days of intracranial radiation therapy completion for metastatic disease
    (Elsevier, 2020) McClelland, Shearwood, III.; Agrawal, Namita; Elbanna, May F.; Shiue, Kevin; Bartlett, Gregory K.; Lautenschlaeger, Tim; Zellars, Richard C.; Watson, Gordon A.; Ellsworth, Susannah G.; Radiation Oncology, School of Medicine
    Introduction: For patients with brain metastases, palliative radiation therapy (RT) has long been a standard of care for improving quality of life and optimizing intracranial disease control. The duration of time between completion of palliative RT and patient death has rarely been evaluated. Methods: A compilation of two prospective institutional databases encompassing April 2015 through December 2018 was used to identify patients who received palliative intracranial radiation therapy. A multivariate logistic regression model characterized patients adjusting for age, sex, admission status (inpatient versus outpatient), Karnofsky Performance Status (KPS), and radiation therapy indication. Results: 136 consecutive patients received intracranial palliative radiation therapy. Patients with baseline KPS <70 (OR = 2.2; 95%CI = 1.6-3.1; p < 0.0001) were significantly more likely to die within 30 days of treatment. Intracranial palliative radiation therapy was most commonly delivered to provide local control (66% of patients) or alleviate neurologic symptoms (32% of patients), and was most commonly delivered via whole brain radiation therapy in 10 fractions to 30 Gy (38% of patients). Of the 42 patients who died within 30 days of RT, 31 (74%) received at least 10 fractions. Conclusions: Our findings indicate that baseline KPS <70 is independently predictive of death within 30 days of palliative intracranial RT, and that a large majority of patients who died within 30 days received at least 10 fractions. These results indicate that for poor performance status patients requiring palliative intracranial radiation, hypofractionated RT courses should be strongly considered.
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    Computational simulations establish a novel transducer array placement arrangement that extends delivery of therapeutic TTFields to the infratentorium of patients with brainstem gliomas
    (Elsevier, 2021-12-30) Ramirez-Fort, Marigdalia K.; Naveh, Ariel; McClelland, Shearwood, III.; Gilman, Casey K.; Fort, Migdalia; Mendez, Melissa; Matta, Jaime; Bomzon, Ze’ev; Lange, Christopher S.; Radiation Oncology, School of Medicine
    Background and purpose: Tumor treating fields (TTFields) are a non-invasive, efficacious treatment modality currently approved for supratentorial glioblastomas. Despite their ability to improve overall survival in supratentorial tumors, the current placement of arrays is limited to the supratentorial head, precluding its use in infratentorial tumors. Infratentorial malignancies are in need of new therapy modalities given their poor prognoses in both children and adults. The aim of this research is to determine whether rearrangement of TTFields may allow for management of infratentorial tumors. Materials and methods: Delivery of TTFields using Novocure's prototype Optune™ device human male head model was simulated based on brain MRIs from patients with brainstem gliomas to develop a novel array layout designed to extend adequate infratentorial coverage. Results: Array placement on the vertex, bilateral posterolateral occiput, and superior-posterior neck achieved intensities above 1.1 V/cm (average 1.7 V/cm; maximum 2.3 V/cm) in the vertical field direction and above 1 V/cm (average 2 V/cm; maximum 2.8 V/cm) in the horizontal field direction of the infratentorium. The calculated field intensity within the simulated tumors were in the therapeutic range and demonstrated the effective delivery of TTFields to the infratentorial brain. Conclusions: Our findings suggest that rearrangement of the TTFields standard array with placement of electrodes on the vertex, bilateral posterolateral occiput, and superior-posterior neck allows for adequate electric field distribution in the infratentorium that is within the therapeutic range.
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    Disparities in the Utilization of Radiation Therapy for Prostate Cancer in the United States: A Comprehensive Review
    (Elsevier, 2022-03-18) Gardner, Ulysses, Jr.; McClelland, Shearwood, III.; Deville, Curtiland, Jr.; Radiation Oncology, School of Medicine
    Purpose: Major advances in radiation therapy (RT) for prostate cancer increase the importance of equity in the use of RT. We sought to assess the evolution of RT utilization disparities in prostate cancer to inform clinicians and health care organizations of persistent areas of need that can be addressed in their practices and policies. Methods and materials: A comprehensive PubMed literature search was undertaken in June 2020 and subsequently in March 2021. Studies were excluded that were not based in the United States, did not examine health disparities or inequities, did not examine RT or related resource utilization, or did not examine prostate cancer. Discussion: Of 257 studies found, 32 met inclusion criteria. Health disparities were most prominently reported by race, socioeconomic status, geographic location, insurance status, practice characteristics, and age. Older men were less likely to receive definitive RT or prostatectomy. Black men were less likely to receive curative therapy or dose-escalated RT. Black, Hispanic, and Asian men were less likely to receive proton therapy. Lower income was associated with decreased prostate-specific antigen testing and treatment with proton therapy or stereotactic body RT. Medicaid patients were less likely to receive definitive treatments. Rural residents were less likely to receive RT. Minority-serving hospitals were less likely to offer definitive treatments for prostate cancer. Conclusions: Sociodemographic disparities and inequities in RT for prostate cancer persist. Robust efforts are imperative to eliminate disparities to improve outcomes for all patients with prostate cancer.
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    Evidence-based methodology for obtaining commercial insurance coverage of stereotactic radiosurgery for intractable epilepsy
    (Elsevier, 2020) McClelland, Shearwood, III.; Verma, Vivek; Radiation Oncology, School of Medicine
    Objectives: The coverage policies of many commercial insurers in the United States do not include coverage of stereotactic radiosurgery (SRS) for intractable epilepsy despite recent Level I evidence supporting its efficacy. We sought to assess the efficacy of an evidence-based methodology in obtaining coverage approval of SRS for intractable epilepsy. Patients and methods: The clinical policy guidelines from five of the largest United States commercial insurers were reviewed for their language regarding coverage of SRS for epilepsy. An evidence-based questionnaire was created for temporal lobe epilepsy and extratemporal lobe epilepsy based on recent evidence. Telephone interviewers of Insurers assessed the likelihood of SRS coverage for an epilepsy patient meeting the clinical inclusion criteria in the questionnaire. This likelihood was assessed numerically based on interviewee response (2 = yes, 1 = dependent on peer-to-peer, 0 = no). Results: Of the five policy guidelines, none included literature more recent than 2017. For TLE, 3/5 insurance companies indicated likely SRS coverage; 2/5 indicated peer-to-peer discussion dependence for patients meeting questionnaire criteria for a score of 8/10. For extratemporal TLE, 2/5 companies indicated likely SRS coverage and 3/5 indicated peer-to-peer discussion dependence for a total score of 7/10. Conclusion: Creation of an evidence-based methodology in approaching commercial insurers greatly increased the likelihood of SRS coverage for an indication (intractable epilepsy) widely perceived as investigational. These results should pave the way for epilepsy patients to receive coverage should they be appropriate SRS candidates.
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    Impact of hospital volume on mortality for brain metastases treated with radiation
    (Elsevier, 2021-08-12) McClelland, Shearwood, III.; Degnin, Catherine; Chen, Yiyi; Jaboin, Jerry J.; Radiation Oncology, School of Medicine
    Background: The impact of hospital volume on cancer patient survival has been demonstrated in the surgical literature, but sparsely for patients receiving radiation therapy (RT). This analysis addresses the impact of hospital volume on patients receiving RT for the most common central nervous system tumor: brain metastases. Materials and methods: Analysis was conducted using the National Cancer Database (NCDB) from 2010-2015 for patients with metastatic brain disease from lung cancer, breast cancer, and colorectal cancer requiring RT. Hospital volume was stratified as high-volume (≥ 12 brain RT/year), moderate (5-11 RT/year), and low (< 5 RT/year). The effect of hospital volume on overall survival was assessed using a multivariable Cox regression model. Results: A total of 18,841 patients [9479 (50.3%) men, 9362 (49.7%) women; median age 64 years] met the inclusion criteria. 16.7% were treated at high-volume hospitals, 36.5% at moderate-volume, and the remaining 46.8% at low-volume centers. Multivariable analysis revealed that mortality was significantly improved in high-volume centers (HR: 0.95, p = 0.039) compared with low-volume centers after accounting for multiple demographics including age, sex, race, insurance status, income, facility type, Charlson-Deyo score and receipt of palliative care. Conclusion: Hospitals performing 12 or more brain RT procedures per year have significantly improved survival in brain metastases patients receiving radiation as compared to lower volume hospitals. This finding, independent of additional demographics, indicates that the increased experience associated with increased volume may improve survival in this patient population.
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    Improving the Clinical Treatment of Vulnerable Populations in Radiation Oncology
    (Elsevier, 2020-08-06) McClelland, Shearwood, III.; Petereit, Daniel G.; Zeitlin, Ross; Takita, Cristiane; Suneja, Gita; Miller, Robert C.; Deville, Curtiland; Siker, Malika L.; Radiation Oncology, School of Medicine
    The increasing role of radiation oncology in optimal cancer care treatment brings to mind the adage that power is never a gift, but a responsibility. A significant part of the responsibility we in radiation oncology bear is how to ensure optimal access to our services. This article summarizes the discussion initiated at the 2019 American Society for Radiation Oncology Annual Meeting educational panel entitled "Improving the Clinical Treatment of Vulnerable Populations in Radiation Oncology: Latin, African American, Native American, and Gender/Sexual Minority Communities." By bringing the discussion to the printed page, we hope to continue the conversation with a broader audience to better define the level of responsibility our field bears in optimizing cancer care to the most vulnerable patient populations within the United States.
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    National trends in management of adult myxopapillary ependymomas
    (Elsevier, 2020-03) Scarpelli, Daphne B.; Turina, Claire B.; Kelly, Patrick D.; Khudanyan, Arpine; Jaboin, Jerry J.; McClelland, Shearwood, III.; Radiation Oncology, School of Medicine
    Myxopapillary ependymomas (MPE) are WHO Grade I ependymomas that annually occur in 0.05–0.08 per 100,000 people. Surgical resection is the recommended first line therapy. Due to the rarity of the disease, there is a relatively poor understanding of the use of radiotherapy (RT) in managing this disease. The National Cancer Database (NCDB) was analyzed for patterns of care for adult MPE diagnosed between 2002 and 2016. Of 753 qualifying cases, the majority of patients underwent resection (n = 617, 81.9%). A relatively small portion received RT (n = 103, 13.3%) with most receiving RT post-operatively (n = 98, 95.1%). The likelihood of patients to undergo resection and RT was associated with patient age at diagnosis (p = 0.002), tumor size (p < 0.001), and race (p = 0.017). Chemotherapy was not widely utilized (0.27% of patients). One limitation of our analysis is that there was no data on progression free survival (PFS), an important outcome given the high survival rate in this disease. Surgery remains the primary means to manage adult MPE. For spinal MPE, it is understood that gross total resection (GTR) should be attempted whenever possible as GTR has been associated with improved PFS in several studies. The impact of RT on overall survival (OS) is indeterminate given the 1.6% death rate in the cohort. Analyses of the impact of RT on PFS in a larger database would be beneficial for determining an algorithm for post-operative and definitive RT in this disease entity.
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    Predictors of linear accelerator versus Gamma Knife stereotactic radiosurgery use for brain metastases in the United States
    (Oxford Academic, 2019-11) McClelland, Shearwood, III.; Degnin, Catherine; Chen, Yiyi; Watson, Gordon A.; Jaboin, Jerry J.; Radiation Oncology, School of Medicine
    INTRODUCTION Stereotactic radiosurgery (SRS) for brain metastases is predominantly delivered via single-fraction Gamma Knife SRS (GKRS) or linear accelerator (LINAC) in 1–5 fractions. Predictors of SRS modality have been sparsely examined on a nationwide level. METHODS The 2010–2016 National Cancer Database identified brain metastases patients from non-small cell lung cancer throughout the United States (US) having undergone SRS. A multivariable logistic regression model characterized SRS receipt, adjusting for patient age, dose, geographic location of treatment, facility type, and distance from treatment facility. RESULTS A total of 1,760 patients received GKRS, while 1,064 patients received LINAC SRS. Treatment at non-academic facilities was associated with increased LINAC SRS receipt, most prominently in the Midwestern (OR= 6.23; p< 0.001), Northeastern (OR= 4.42; p< 0.001), and Southern US (OR= 1.96;p< 0.001). Administered doses of 18–19 Gy (OR= 1.42;p= 0.025), 20–21 Gy (OR= 1.82;p< 0.001), and 22–24 Gy (OR= 3.11;p< 0.001) were associated with increased LINAC SRS receipt, as was patient location within 20 miles of a radiation treatment facility (OR= 1.27;p= 0.007). CONCLUSIONS Despite Gamma Knife being more prominently used over LINAC for SRS, patients treated at non-academic facilities outside of the Western US were substantially more likely to receive LINAC over Gamma Knife. Patients located in the Midwest were 523% more likely, Northeast 342% more likely, and South 96% more likely to receive LINAC when treated at a non-academic facility. Increasing dose independently predicted LINAC over GKRS, indicating that smaller tumors – particularly those less than two centimeters (consistent with RTOG 90-05 recommendations) – are being treated with LINAC. Finally, patients residing in close proximity to a treatment center were 27% more likely to receive LINAC, likely indicative of the increased geographic accessibility of LINAC compared with GKRS. These findings should result in hypothesis-generating questions to further explore predictors of LINAC versus GKRS.
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    Radiation oncology should be a partner to medical oncology in end-of-life care
    (Elsevier, 2020) McClelland, Shearwood, III.; Mitin, Timur; Radiation Oncology, School of Medicine