Novel Radiation Oncology Research Makes Population Health Strategies Smarter

Shalom Kalnicki, MD

Professor and Chair

Department of Radiation Oncology

Montefiore Health System and Albert Einstein College of Medicine

Bronx, NY

At Montefiore Health System, we consider every diagnosis or suspicion of cancer a psychosocial emergency for that patient. Every person who comes through our doors is cared for in a timely manner and receives the highest quality cancer treatment regardless of their ability to pay. To enhance our population impact, we are not just studying and treating cancer, we are also identifying and evaluating confounding variables that could contribute to poor outcomes, such as socioeconomic status and dietary and mood disorders.

Using Noncompliance Data to Improve Care

That emphasis on the patient experience is evident in research conducted in the Department of Radiation Oncology at Montefiore Einstein Center for Cancer Care and Albert Einstein Cancer Center, a National Cancer Institute—designated cancer center that is part of Albert Einstein College of Medicine.An example of this research is a study recently published in the International Journal of Radiation Oncology Biology Physics, which found that noncompliance with radiotherapy (RT) treatment plans was associated with significantly inferior clinical outcomes in patients with cancer undergoing curative-intent therapy.¹

Our team reviewed data from 1227 patients who completed external beam RT from 2007 to 2012 for cancers of the head and neck, breast, lung, cervix, uterus, or rectum. We found that RT noncompliance, defined as missing 2 or more scheduled treatments, was associated with inferior outcomes compared with completion of therapy for recurrence risk (5-year cumulative incidence of 16% vs 7%, respectively; P <.001), recurrence-free survival (5-year actuarial rate 63% vs 79%; P <.001), and overall survival (5-year actuarial rate 72% vs 83%; P <.001).

New Studies Featured at ASTRO

Based on our data, we now consider noncompliance with scheduled treatments as a behavioral biomarker for identifying high-risk patients who require additional interventions to achieve optimal care outcomes. We are taking this research a step further by correlating the prevalence of nonadherence with provider recommendations in our patient population. We are also systematically identifying how to curb noncompliance and guide interventions that might improve patient outcomes.Our team will present new research findings at the 2017 American Society for Radiation Oncology (ASTRO) Annual Meeting, scheduled to take place September 24-27 in San Diego, California. These include study results about predictors for how patients comply with and respond to chemotherapy and radiation treatments, particularly for spine, lung, liver, and head and neck cancers. We will also showcase new strategies for improving patients’ long-term health outcomes.

Additionally, 4 investigator-initiated studies will be proffered in oral presentation sessions at ASTRO, including 2 studies that examined the use of adaptive radiotherapy.

Figure 1. Patient With Metastatic Prostate Cancer Presenting With Spinal Cord Compression Treated With Adaptive SBRT

The first study looks at patients presenting with spinal cord compression from metastatic disease who are not good candidates for surgery. These patients were treated in a prospective phase I/II trial evaluating adaptive staged stereotactic body radiation therapy (SBRT) using novel imaging coregistration and target delineation techniques (Figure 1). The principal investigator, Madhur K. Garg, MD, clinical director of the Department of Radiation Oncology at Montefiore and a professor of clinical radiation oncology at Einstein, will present preliminary data. Rafi Kabarriti, MD, an attending physician at Montefiore, will discuss outcomes prediction in patients with locally advanced head and neck cancers based on early biological imaging response to radiation and chemotherapy (Figure 2).

Figure 2. Adaptive Radiotherapy for Head and Neck Cancers

Montefiore was among the pioneers in reporting the benefits of biologically planned adaptive RT as early as 2008. Adaptive RT has both the potential to reduce adverse effects and improve disease control, and can also serve as a valuable tool for predicting long-term oncologic outcomes. In addition, the world-renowned MontefioreEinstein multidisciplinary head and neck cancer team is working on several novel therapies—such as robotic surgery, immunotherapy, and molecular targeted treatments&mdash;to improve outcomes and quality of life.

Patients presenting with locally advanced lung cancer have limited therapeutic options, with most of them failing either locally or distantly within months of treatment. A prospective phase II study designed by Nitin Ohri, MD, attending physician at Montefiore and an assistant professor of radiation oncology at Einstein, probed the use of PET-CT metrics such as maximum-tolerated dose of radiation and standardized uptake value to modify and sculpt radiation dose. This treatment protocol has the potential not only to improve disease control, but also to decrease normal tissue irradiation while reducing overall treatment time, thus increasing compliance and outcomes.

The fourth presentation reports on the spatial distribution of liver injury using MRI enhanced with gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid following SBRT for liver cancer. This work expands on our translational research investigating mechanisms and potential ways to ameliorate radiation-induced liver disease. The principal investigator is Chandan Guha, PhD, MBBS, director of the Einstein Institute for Onco-Physics, professor and vice chair of radiation oncology, and professor of urology and pathology at Montefiore and Einstein.

Montefiore’s Mission

As a follow-up study, Montefiore physician scientists are working on combining SBRT with novel immunotherapy using autologous in-situ cancer vaccines in patients who have failed conventional treatment regimens (Figure 3). This approach, which works by activating the patient’s immune system against cancer, is a result of a true benchto-bedside translational approach to innovations in cancer treatment and was first conceptualized in our research laboratories, under the leadership of Dr Guha, almost 15 years ago.We look forward to sharing this research at ASTRO and having a rich dialogue with our colleagues from around the globe about the implications of these findings for our ongoing research and clinical practices. Our participation at the ASTRO meeting is among the ways that the Montefiore Health System helps lead the effort to increase access, optimize costs, and improve treatment outcomes for patients with cancer through pioneering research and innovative care coordination programs.

Figure 3. Epigenetic Priming and High-Dose Radiation for Enhanced Immune Response in Solid Tumors

More than 200 cutting-edge clinic trials studying various types and stages of cancer are ongoing at Montefiore and Einstein. Montefiore Health System providers see more than 8000 new patients with cancer a year, and the system is home to several nationally and internationally renowned physician scientists working tirelessly to take care of patients and design novel treatment protocols.

For the past 5 years, Montefiore has been a leading Pioneer Accountable Care Organization (ACO) in CMS’ ACO program, which aims to improve the quality of care for Medicare beneficiaries while identifying ways to save healthcare dollars. Montefiore is also participating in the Next Generation ACO Model program.

Ohri N, Rapkin BD, Guha C, Kalnicki S, Garg M. Radiation therapy noncompliance and clinical outcomes in an urban academic cancer center. Int J Radiat Oncol Biol Phys. 2016;95(2):563-570. doi: org/10.1016/j. ijrobp.2016.01.043.