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Management of resectable pancreatic adenocarcinoma continues to present a challenge due to a paucity of high-quality randomized studies. Administration of adjuvant chemotherapy is widely accepted due to the high risk of systemic spread associated with pancreatic adenocarcinoma, but the role of radiation therapy is less clear. This paper reviews literature associated with resectable pancreatic cancer to include prognostic factors to aid in the selection of patients appropriate for adjuvant therapies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

To determine the outcomes of postoperative radiation therapy on survival in gastric cancer.An analysis of patients with surgically resected and nonmetastatic gastric cancer from the Surveillance, Epidemiology, and End Results database from 1990 to 2003 was carried out. Survival curves were calculated according to the Kaplan-Meier method. Multivariate analysis was carried out by the Cox proportional hazard model.We identified 11,630 patients who met inclusion criteria. Radiation therapy was associated with increased survival in patients with American Joint Committee on Cancer stage IB to IV. The median survival for stage IB and II patients treated with radiation was 96 months and 37 months, respectively, versus 56 months and 23 months for patients who did not receive adjuvant radiation (P=0.0281 for stage IB and0.0001 for stage II). The 5-year overall survival for node-positive patients treated with radiation was 30.4% versus 21.4% for patients who did not receive adjuvant radiation (P0.0001). The survival benefit of radiation therapy was maintained even if ≥15 lymph nodes were removed for N1 and N2 disease and if ≥30 lymph nodes were removed for N3 disease. For node-positive patients with ≥15 lymph nodes removed, adjuvant radiation was linked to increase survival in patients who underwent partial gastrectomy, total gastrectomy, and en bloc gastrectomy with other organs removed. Radiation was a strong independent factor for survival on multivariate analysis.There is a correlation between survival and radiation therapy in node-positive gastric cancer patients and is independent of the extent of surgical resection and lymph node dissection.

Low anterior resection or abdominoperineal resection are considered standard treatments for early rectal cancer but may be associated with morbidity in selected patients who are candidates for early distal lesions amenable to local excision (LE). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The panel recognizes the importance of accurate staging to identify patients who may be candidates for a LE approach. Patients who may be candidates for LE alone include those with small, low-lying T1 tumors, without adverse pathologic features. Several surgical approaches can be utilized for LE however none include lymph node evaluation. Adjuvant radiation±chemotherapy may be warranted depending on the risk of nodal metastases. Patients with high-risk T1 tumors, T2 tumors not amenable to radical surgery may also benefit from adjuvant treatment; however, patients with positive margins or T3 lesions should be offered abdominoperineal resection or low anterior resection. Neoadjuvant radiation±chemotherapy followed by LE in higher risk patients results in excellent local control, but it is not clear if this approach reduces recurrence rates over surgery alone.

Purpose: The purpose of this phase II study was to prospectively determine the efficacy of preoperative chemoradiation with a hyperfractionated (Hfx) RT boost to 61.8 Gy in locally advanced rectal cancer. Methods: Eligibility stipulated that the primary lesion had to be either T4; or T3 and >4 cm or 40% of the bowel circumference. Radiation (RT) consisted of 45 Gy to the pelvis (1.8 Gy per fraction) followed by 1.2 Gy twice daily (to the gross tumor volume) to a total RT dose of 61.8 Gy. There was 5-FU infused at 1 g/m 2 /24 hours for 4 days during the 1st and 6th weeks of RT (concurrent with the Hfx boost). Surgical resection was planned 4 to 6 weeks later. Adjuvant chemotherapy (bolus 5-FU/leucovorin) was scheduled for 4 cycles at 28-day intervals. Results: There were 22 patients, ages 22 to 81 years (median, 64) enrolled in the study. Of the 20 patients evaluable for response, 10 (50%) had evidence of clinical downstaging and 5 patients (25%) had ≥90% fibrosis in the resected specimen. With a median f/u of 40 months (7-158), the 4 years actuarial rate for all patients (n = 22) of OS was 64%, of DFS 62%, and of LC 84%. 3/21 patients (14%) had positive margins, all of whom developed a local failure (P < 0.001). Conclusion: This regimen of high dose preoperative chemoRT with a Hfx RT boost (to 61.8 Gy) in patients with bulky, locally advanced rectal cancer results in clinical downstaging in half of the patients with significant fibrosis in the operative specimen.

Objectives An evaluation was performed linking an administrative database to clinical information to determine the clinical and economic outcomes of women presenting with breast cancer in a managed care organization (MCO). Methods Administrative claims records were linked to clinical information obtained from hospital and tumor registry data for women diagnosed with adenocarcinoma or carcinoma in situ of the breast between 1990 and 1997. Results Only 3 of 53 mammogram-diagnosed women had developed recurrences compared with 12 of 69 self-diagnosed women. Self-diagnosed women with commercial insurance incurred more treatment-related cost, 30,557 dollars, compared with mammogram-diagnosed women, 13,913 dollars (P = 0.005). Conclusion Women with commercial insurance had better clinical outcome at less cost when diagnosed by mammography as compared with women who detected the breast cancer by breast self-examination.

Hospitals and other healthcare facilities are focusing resources on the care of the cancer patient. Physicians should become involved in all aspects of the development of oncology programs. Physicians need to be involved from the initial program development, through the strategic planning to the formulation of the business plan. Strong physician leadership is needed to coordinate care provided by physicians and ancillary staff. Educational programs for patients, their families, and physicians need to be developed by the medical director, physicians, and ancillary staff. Continuing evaluation and assessment of the entire cancer program is essential to monitor the achievement of goals and objectives set forth in the strategic plan.

The abdomens of 16 patients with para-aortic nodal metastases were explored in the Clement O. Miniger Radiation Oncology Center's (COMROC) intraoperative radiation therapy suite. At the time of initial diagnosis 8 patients were found to have para-aortic metastases, and 8 developed para-aortic disease after completion of primary treatment. The median age of patients in the "initial group" was 37.5 years: 7 of these 8 patients had radiation only, and 1 patient had radiation and chemotherapy as initial treatment. Bulk disease in the para-aortic region was noted in 2 patients, microscopic disease in 5 patients, and prophylactic radiation was given to the para-aortic area in 1 patient. Ten para-aortic fields in 8 patients were treated with a median dose of 20 (range 10-25) Gy with 6-18 MeV electrons. Median survival from time of diagnosis was 31 (range 9-59) months and 27 (range 8-56) months from the date of IOEBRT. The median time to recurrence after IOEBRT was 8 (range 4-32) months. One patient is alive without disease 59 months and 1 is alive with disease 44 months from IOEBRT, with neither patient failing in the treated area. Eight patients were treated for recurrent disease in the para-aortic area: 5 cervical primaries, 2 endometrial adenocarcinoma primaries, and 1 uterine sarcoma. The median age was 60.5 (range 45-70) years. Median time to recurrence from initial diagnosis was 20 (range 7-37) months. In seven fields 6 of 8 patients received IOEBRT, median dose 20 (range 10-25) Gy. After IOEBRT, 4 of 6 patients received 45 Gy external beam irradiation. Median survival from IOEBRT was 9 (range 3-23) months, 37.5 (range 11-56) months from diagnosis. One patient is alive without disease at 11 months and one is alive with disease 19 months after IOEBRT. Toxicity of the IOEBRT is discussed.

Radiation Therapy Oncology Group 97-14 concluded that a single fraction of radiation was as effective in relieving pain as multiple fractions in the treatment of patients with bone metastases. A statistically significant higher retreatment rate, however, was noted in patients undergoing a single fraction treatment. The purpose of the analysis was to determine whether multiple fraction treatment is cost-effective in treating patients with bone metastasis, by preventing further retreatment.A Markov model was used to evaluate the cost-effectiveness of 30 Gy in 10 fractions in comparison with 8 Gy in 1 fraction. Transition probabilities, cost, and utilities were obtained from the clinical trial. Costs and outcomes were not discounted because of the short time line for the study.The expected mean cost and quality-adjusted survival in months for patients receiving 8 Gy in 1 fraction and 30 Gy in 10 fractions was 998 US dollars and 7.26 months and 2316 US dollars and 9.53 months, respectively. The incremental cost-effectiveness ratio was 6973 US dollars/quality-adjusted life year. The results were sensitive to the utility of the posttreatment state for both single and multiple fraction treatments.Single fraction treatment was the less expensive treatment in the treatment of patients with bone metastasis treated on Radiation Therapy Oncology Group 97-14.