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Baseline intraprostatic calcification (IC) has been shown to be associated with a higher rate of biochemical recurrence (BCR) in men treated with iodine-125 prostate brachytherapy (PB). We evaluated this association in a cohort of men treated with cesium-131 PB. We retrospectively reviewed the charts of all low- and intermediate-risk prostate cancer patients treated with cesium-131 PB +/- external beam radiotherapy (EBRT) at our institution from 2/2011 to 7/2018. Patients with < 24 months of follow up or those who received androgen deprivation therapy were excluded. Baseline IC status (defined as one or more ICs ≥ 5 mm) was determined on post-PB CT scans. Cox analysis was used to assess predictors of BCR and Kaplan–Meier survival curves were calculated. Two hundred and sixteen low- and intermediate-risk prostate cancer patients treated with cesium-131 PB +/- EBRT were included. Median follow up was 56.9 months (range 24.1–111.4). Overall, 76 (35.2%) patients had baseline IC and 140 (64.8%) did not. Baseline disease characteristics did not differ significantly between groups. On univariate Cox analysis, only risk group (p = 0.047) and initial PSA (p = 0.016) were significant predictors of BCR, whereas baseline IC was not (p = 0.11). The 5-year BCR-free survival in patients with versus without baseline IC was 97.7% versus 93.8% (p = 0.405), respectively. In a cohort of low- and intermediate-risk prostate cancer patients treated with cesium-131 PB, the rate of BCR in men with baseline IC was low and baseline IC was not associated with a higher risk of BCR. [ABSTRACT FROM AUTHOR]

Studies examining temporal trends in cervical brachytherapy use are conflicting and examined different health insurance populations. This study examined brachytherapy utilization over time by health insurance type and whether reported declines in brachytherapy have reversed. The National Cancer Database (NCDB) was queried for patients with FIGO IIB-IVA cervical cancer treated with definitive chemoradiotherapy between 2004 and 2014, identifying 17,442 patients. Brachytherapy utilization over time and by insurance type and other sociodemographic factors were compared using binary logistic regression. A sensitivity analysis was done in a sub-cohort of patients using the boost modality variable in the NCDB. Brachytherapy utilization declined during 2008–10 (52.6%) compared to 2004–2007 (54.4%; odds ratio [OR] 0.93, 95% confidence interval [CI] 0.86–1.01) and declines were disproportionately larger for patients with government insurance (49.4% vs 52.3%, respectively) than privately-insured patients (57.6% vs 58.9%, respectively). However, rates of brachytherapy use subsequently recovered during 2011–14 in all insurance groups (58.0%, OR 1.24, 95% CI 1.16–1.34) and was especially improved for Medicaid (OR 1.44, 95% CI 1.26–1.65) and uninsured patients (OR 1.28, 95% CI 1.03–1.57). Sensitivity analysis using the boost modality variable confirmed these trends. In patients with FIGO IIB-IVA cervical cancer treated with definitive chemoradiotherapy from 2004 to 2014, brachytherapy utilization declined during the late 2000s and disproportionately affected patients with government insurance, but subsequently recovered in the early 2010s. Since government insurance covers vulnerable patient populations at-risk for future declines in brachytherapy use, proposed alternative payment models should incentivize cervical brachytherapy to solidify gains in brachytherapy utilization. • Use of cervical brachytherapy (BT) declined in the late 2000s and disproportionately affected government-insured patients. • However, trends reversed in the early 2010s such that patients of all insurance types had increased BT use. • Awareness of declining BT use raised by researchers and the Affordable Care Act may have facilitated this improvement. • Proposed alternative payment models should incentivize cervical BT to encourage and solidify these gains. [ABSTRACT FROM AUTHOR]

Brachytherapy (BT) boost with vaginal packing (VP) is standard of care for locally advanced cervical cancer. The goals of VP are to physically displace bladder and rectum (OARs) from the high dose radiation region and to stabilize the BT applicators. The BrachyGel Vaginal Hydrogel Packing System (BrachyGel) was developed as a new technique to improve the quality of VP for cervical cancer BT, including OAR dosimetry, patient comfort, ease of physician use, reproducibility, and visibility on MRI. The purpose of this study was to determine how the use of BrachyGel compares to standard gauze during high dose rate (HDR) BT for cervical cancer. This is a prospective randomized cross-over study. Patients with stage IB1 - IVB cervical cancer receiving definitive chemo-radiation with HDR BT boost (intracavitary +/- interstitial) were enrolled. All patients received gauze for their 1st fraction (Fx) and were subsequently randomized to BrachyGel for either the 3rd and 5th Fx (Arm A) or 2nd and 4th Fx (Arm B). Patient reported discomfort on a 4-point Likert scale was collected. Physicians and physicists evaluated imaging properties, completeness of packing, and ease of use. Adverse events (AEs) were prospectively collected and scored per CTCAE. MRI was not performed after VP insertion for this cohort, but was asynchronously obtained for BT planning. 20 evaluable patients were enrolled. The majority of patients had squamous cell histology (70%), and FIGO IIB (35%) or IIIC (35%) disease. For the primary endpoint of D2cc dosimetry comparison, the mean difference of Bladder D2cc (gauze - BrachyGel) in Fx 2 & 3 was 0.117 Gy ± 0.54 and 0.013 Gy ± 1.24 in Arms A and B, respectively, both in favor of BrachyGel. The mean difference of Rectum D2cc was -0.189 Gy ± 0.48 and -0.19 Gy ± 0.62 in Arms A and B, respectively, both in favor of gauze. The high risk clinical target volume (HR-CTV) D90 mean difference (gauze - BrachyGel) was -0.120 Gy ± 1.48 in Arm A and 0.601 Gy ± 1.48 in Arm B. There were no clinically relevant observed differences between gauze and BrachyGel between arms. Figure 1 displays the OAR dosimetry across 5 Fx for each arm and plots the variability of dosimetry. Patient reported discomfort with the VP experience was scored as none, mild, moderate, or severe for BrachyGel 23.3%, 36.7%, 33.3%, 6.7% as compared to 7.4%, 44.4%, 29.6%, 18.5% with gauze, respectively. The clarity of VP was similar between BrachyGel and gauze with 86.8% and 60.5% of BrachyGel cases scored as "very clear" or "clear" by physicists and physicians, respectively, compared to 89.7% and 66.7% in gauze cases. Completeness of VP was more frequently "excellent" or "good" with BrachyGel (79.0%) compared to gauze (56.4%). The ease of packing was considered "extremely easy" (21.2%) or "somewhat easy" (66.7%) more frequently with BrachyGel cases compared to gauze (0% and 72.4%, respectively). We observed no increase in AEs associated with BrachyGel. This prospective randomized cross-over study of BrachyGel VP for cervical cancer BT reports no difference between gauze and BrachyGel in OAR dosimetry or HR-CTV coverage. Imaging clarity on CT is similar between gauze and BrachyGel, but BrachyGel performs well compared to gauze for the patient and physician experience, including patient-reported discomfort, completeness, and ease of use. [ABSTRACT FROM AUTHOR]

Precision breast intraoperative radiation therapy (PB -IORT) is a novel approach to adjuvant radiation therapy for early-stage breast cancer performed as part of a phase II clinical trial at two institutions. One institution performs the entire procedure in an integrated brachytherapy suite which contains a CT-on-rails imaging unit and full anesthesia capabilities. At the other, breast conserving surgery and radiation therapy take place in two separate locations. Here, we utilize time-driven activity-based costing (TDABC) to compare these two models for the delivery of PB-IORT. Process maps were created to describe each step required to deliver PB -IORT at each institution, including personnel, equipment, and supplies. Time investment was estimated for each step. The capacity cost rate was determined for each resource, and total costs of care were then calculated by multiplying the capacity cost rates by the time estimate for the process step and adding any additional product costs. PB -IORT costs less to deliver at a distributed facility, as is more commonly available, than an integrated brachytherapy suite ($3,262.22 vs. $3,996.01). The largest source of costs in both settings ($2,400) was consumable supplies, including the brachytherapy balloon applicator. The difference in costs for the two facility types was driven by personnel costs ($1,263.41 vs. $764.89). In the integrated facility, increased time required by radiation oncology nursing and the anesthesia attending translated to the greatest increases in cost. Equipment costs were also slightly higher in the integrated suite setting ($332.60 vs. $97.33). The overall cost of care is higher when utilizing an integrated brachytherapy suite to deliver PB- IORT. This was primarily driven by additional personnel costs from nursing and anesthesia, although the greatest cost of delivery in both settings was the disposable brachytherapy applicator. These differences in cost must be balanced against the potential impact on patient experience with these approaches. [ABSTRACT FROM AUTHOR]