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Background: Definitive radiotherapy (dRT) has been shown to be an effective option for patients with oligometastatic and oligoprogressive cancers; however, this approach has not been well-studied in metastatic thyroid cancer. Methods: This retrospective cohort included 119 patients with oligometastatic (34%) and oligoprogressive (66%) metastatic thyroid cancer treated from 2005 to 2024 with 207 dRT courses for 344 sites (50% thoracic, 37% bone, 7.5% brain, 4% abdominopelvic, and 1.5% neck/skull base). Histologies included 61% papillary, 15% poorly differentiated, 13% follicular, and 10% oncocytic, and 114 (96%) patients had radioiodine-refractory disease prior to dRT. Each course involved 1 to 5 sites, with prescriptions intended for definitive control (median BED10, 72 Gy), and palliative RT was excluded. Somatic mutation testing for oncologic drivers was performed in 103 (87%) patients. Results: Each patient had an average of 3 sites (range, 1–23) treated over 2 courses (range, 1–9). Follow-up from first dRT was a median 2.5 years, with overall survival at 3 and 5 years of 81.5% and 70%, respectively. Actuarial local control per site was 91% at 3 years. Median progression-free survival (PFS) after first course was 17 months (95% CI, 10–24 months), with poorly differentiated histology associated with worse outcomes (hazard ratio [HR], 2.20; 95% CI, 1.24–3.90; P=.007), BRAF mutation with improved PFS (HR, 0.59; 95% CI, 0.37–0.95; P=.029), and no significant findings with respect to systemic therapy. At initial dRT, 92 (77%) patients were not on systemic therapy; and after first dRT, freedom from systemic therapy escalation was a median 4.1 years (95% CI, 1.7–6.5 years), with 2- and 5-year continued deferral rates of 73% and 46%, respectively. Grade 3 toxicities were noted for 1.5% of courses, with no grade 4–5 events observed. Conclusions: This study underscores the potential of dRT as a feasible strategy for deferring systemic therapy escalation in patients with oligometastatic and oligoprogressive metastatic thyroid cancer, demonstrating that sequential dRT courses impart excellent local control and are safe to deliver repeatedly for multiple distant sites. Further studies are warranted to validate these findings and elucidate the full benefit of dRT as part of a multidisciplinary approach for metastatic thyroid cancer.

Background: Frailty is emerging as an important determinant for quality of life (QoL) and emotional health in older patients with cancer, and specifically in long-term prostate cancer survivors, but quantitative studies are lacking. The current study assesses the prevalence of frailty and its association with QoL and emotional health in long-term prostate cancer survivors after radical prostatectomy. Patients and Methods: A total of 2,979 prostate cancer survivors from the multicenter German Familial Prostate Cancer cohort completed questionnaires on frailty (Groningen Frailty Indicator [GFI]), QoL (EORTC QoL Questionnaire-Core 30), and emotional health (anxiety/depression symptoms via the Patient Health Questionnaire-4). Modified Poisson regression analysis was used to assess factors associated with frailty. Results: Average patient age was 79.4 years [SD, 6.4 years] and average time since radical prostatectomy was 17.4 years [SD, 3.8 years]. Among the cohort, 33.1% (n=985) of patients were classified as frail (GFI ≥4). Frail patients reported worse emotional health than nonfrail patients (depression symptoms: 24.0% vs 4.0%; anxiety symptoms: 20.6% vs 2.0%; both P<.001) and lower QoL (mean [SD], 53.4 [19.2] vs 72.7 [16.0]); P<.001). Higher age (relative risk [RR], 1.02; 95% CI, 1.01–1.03) and worse depressive (RR, 1.18; 95% CI, 1.12–1.24) and anxiety symptoms (RR, 1.17; 95% CI, 1.11–1.23) were associated with frailty. Living in a partnership (RR, 0.76; 95% CI, 0.67–0.86) and a higher QoL (RR, 0.86 for a 10-point increase; 95% CI, 0.84–0.89) were associated with nonfrailty. Conclusions: In a large German cohort, every third long-term prostate cancer survivor after radical prostatectomy was frail. The association of frailty with lower QoL and poorer mental health indicates the need for an integrated care approach including further geriatric assessment and possible interventions to improve health outcomes targeted to frail patients.

Background: Ontario has publicly funded biosimilar bevacizumab for first-line metastatic colorectal cancer (mCRC) since 2019. Clinical trials demonstrate comparable efficacy and safety of bevacizumab biosimilars to originator bevacizumab. The objective of this study was to assess real-world safety and effectiveness of the implementation of bevacizumab biosimilars compared with originator bevacizumab in patients with mCRC. Methods: This was a population-based, retrospective study comparing Ontario patients starting treatment with bevacizumab biosimilars between August 12, 2019, and March 31, 2021, and starting treatment with originator bevacizumab between July 2, 2008, and August 11, 2019. Safety outcomes included death within 30 days of the last dose received, any hospitalization, direct hospitalization, and hospitalization resulting from bevacizumab-related toxicity, chemotherapy-related toxicity, and febrile neutropenia. Event rates were assessed using negative binomial and logistic regression. The effectiveness outcome was overall survival, calculated using Kaplan-Meier and Cox proportional hazards regression. A subgroup analysis compared safety and effectiveness outcomes between patients on bevacizumab biosimilar products and matched comparators. Results: We identified 8,996 patients who initiated first-line treatment of bevacizumab for mCRC. Accounting for duration of follow-up, no significant differences were observed in the rate of hospitalization between treatment groups. No differences in overall survival (log-rank P>.05) or hazard ratios (propensity score–matched hazard ratio, 1.03; 95% CI, 0.92–1.16) were observed in the crude and propensity score–matched cohorts. Subgroup analysis demonstrated similar safety and effectiveness patterns. Conclusions: The demonstrated similarity in safety and effectiveness between bevacizumab biosimilars and originator bevacizumab provides further support for the use of and confidence in biosimilar products.

Background: Widespread adoption of secure messaging (SM) provides patients with cancer with unprecedented access to medical providers at the expense of increased workload for oncologists. Herein, we analyze oncology SM clinical content and acuity and translate these to estimated cost savings from reduced appointments. Methods: This population-based retrospective cohort study examined the content of patient-initiated SM threads exchanged through the patient portal website or app over 1 year (June 1, 2021–May 31, 2022) at 21 Kaiser Permanente Northern California oncology practices, which typically do not have patient copayments associated with SM. A random sample of 500 SM threads were reviewed and categorized by message content, acuity, and appropriate level of service. Cost and time estimates were used to compare the cost of SM management by oncologists alone versus assisted by medical assistants and nurses. Results: During the study, 41,272 patients initiated 334,053 unique SM threads to 132 oncologists. Of the SM threads reviewed, only 26.8% required oncologist expertise. Based on thread content, the remaining 73.2% may have been better managed by a nurse (38.2%), medical assistant (28.4%), primary care physician (5.4%), or another subspecialty provider (1.2%). Emergency care was recommended in 2.4% of the threads reviewed. Significant medical care was provided to patients in 24.4% of the reviewed threads that would typically require an appointment. We estimate that the SM exchanges provided $11.2 million in care, including $3.6 million in avoided out-of-pocket copayment costs to patients and $7.6 million in missed billing codes. Conclusions: High utilization of SM generates additional workload for oncologists that could mostly be appropriately managed by alternate providers. The magnitude of unreimbursed medical care provided via SM and the use of SM for emergent medical situations creates an urgent need for new practice models. An alternative architecture for triaging, managing, and billing SM could reduce costs and oncologist burnout.

Background: Historically, Asia had a lower prostate cancer (PCa) incidence and mortality compared with Western countries, but the gap is narrowing. Paradoxically, Asians have been reported to present with more advanced disease though more favorable outcomes. Despite PCa becoming an emerging health priority in East Asia, our knowledge remains limited. We compared the prevalence of high-grade PCa on biopsy and disease progression after radical prostatectomy (RP) in East Asian men from Asia and non-East Asian men from Western countries. Methods: This retrospective cohort study included men who underwent prostate biopsy and RP at academic centers in Shanghai, China, and Toronto, Canada (2014–2019). The expanded RP cohort included East Asian men from Singapore (n=282) and non-East Asians from Paris (n=192). Primary endpoints included the proportion of men with Gleason score (GS) ≥8 on biopsy and metastasis-free survival (MFS) after RP for GS ≥8. Multivariable logistic regression and Cox proportional hazard models were performed. Propensity score matching was used to reduce imbalances between cohorts. Results: PCa was found on biopsy in 2,343 of 4,905 (48%) East Asians and 2,317 of 3,482 (67%) non-East Asians (P<.001). Prostate-specific antigen (PSA) levels at presentation and the proportion of men with GS ≥8 were higher in East Asians than non-East Asians (12.4 vs 6.6 ng/mL and 15.0% vs 8.8%, respectively; both P<.001). On multivariable analysis, there was no difference in the proportion of men with GS ≥8 between matched cohorts with PSA <20 ng/mL (n=3,572; odds ratio, 1.05 [95% CI, 0.77–1.43]; P=.76). No difference in MFS was found after RP between matched cohorts (hazard ratio, 0.97 [95% CI, 0.55–1.70]; P=.92). Conclusions: This contemporary study demonstrates that East Asian men are equally as likely to harbor aggressive PCa on biopsy as non-East Asian men at PSA levels observed in screening programs, with no difference in disease aggressiveness after RP. The assumption that unfavorable PCa at diagnosis is more common but less aggressive in East Asians should be revisited and viewed in the context of the expected increase in the PCa burden worldwide.

Background: Melanoma guidelines recommend surgical excision with 2-cm margins for melanomas >2 mm in thickness. However, this procedure may be problematic at critical anatomic sites. We aimed to compare the outcomes of wide (2 cm) versus narrow (1 cm) excision margins in patients with melanoma >2 mm in thickness near critical structures. Patients and Methods: We retrospectively examined 736 patients undergoing excision with wide versus narrow margins at the National Cancer Institute in Milan, Italy, between 2001 and 2015. Results: A total of 265 (36.0%) patients received a wide local excision—82 (30.9%) with linear repair and 183 (69.1%) with flap or graft reconstruction. A total of 471 (64.0%) patients received a narrow excision—320 (67.9%) with linear repair and 151 (32.1%) with flap or graft reconstruction (P<.001). The 10-year overall survival rate was 69.5% (95% CI, 63.3%–76.2%) in the wide group and 68.7% (95% CI, 63.8%–74.0%) in the narrow group (P=.462); 10-year crude cumulative incidence (CCI) of local recurrence was 5.4% (95% CI, 3.2%–9.2%) in the wide and 8.8% (95% CI, 6.4%–12.1%) in the narrow group (P=.150). Multivariable Fine-Gray modeling of the CCI of local recurrence showed that Breslow thickness (P=.010) was the only statistically significant parameter. Multivariable Cox models for overall survival showed that age (P<.001), Breslow thickness (P<.001), and sentinel lymph node status (P=.019) were statistically significant covariates. Excision margin was not a significant parameter affecting patients’ outcome. Conclusions: Wide local excision with 1-cm margins for melanoma >2 mm in thickness was not associated with an increased risk of local recurrence and did not affect overall survival.

Background: It is estimated that there are >18 million cancer survivors in the United States, and there is a growing number of survivorship programs across the country to care for these individuals. There is a clear need for survivorship care; however, evidence is still emerging on how to best operationalize the guidance from nationally recognized organizations and clinical practice guidelines. Methods: The NCCN Best Practices Committee (BPC) recently conducted a survey to better understand survivorship clinics at NCCN Member Institutions. Representatives from 24 of the 33 NCCN Member Institutions (73%) submitted responses to the survey. Results: Although all responding centers see cancer survivors, most (92%) have ≥1 dedicated survivorship clinics. Of those centers with dedicated survivorship clinics (n=22), 9 (41%) reported general survivorship clinics for all cancer types, and 13 (59%) indicated their center offered ≥1 disease-specific survivorship clinics. Most centers (55%) use a mix of physicians and advanced practice providers (APPs; nurse practitioners and/or physician assistants) to staff survivorship clinics; however, 9 (41%) are staffed entirely by APPs and 1 (4%) is staffed entirely by physicians. The vast majority (91%) have dedicated scheduling templates, and most (73%) have dedicated clinic space for survivorship clinics. The referral process for survivorship clinics varies across centers, with 16 (73%) using algorithms, guidelines, or pathways to determine when a patient is referred to a survivorship clinic. Findings may reflect the evolution of survivorship care and indicate a move toward standardizing which patients are seen and when. It is notable that >50% of institutions reported a model in which they follow survivors for their lifetime. Conclusions: Given the number of patients impacted by cancer, these data highlight the need to continue refining how survivorship care models are integrated into cancer centers to best serve patients with cancer and cancer survivors.

Peripheral and deep en face margin assessment (PDEMA), formerly termed by NCCN as complete circumferential peripheral and deep margin assessment (CCPDMA), has the advantages of histologic visualization of the entire marginal surface, highly accurate resection of involved tissue, and sparing of uninvolved tissue. Owing to its highest reported cure rates, PDEMA is the NCCN-preferred treatment for dermatofibrosarcoma protuberans, high-risk basal cell carcinoma, and very-high-risk cutaneous squamous cell carcinoma. In the United States, Mohs micrographic surgery (Mohs) is the most common method of PDEMA. In Germany and some other countries, non-Mohs methods of PDEMA referred to as the Tubingen torte and muffin techniques are more widely used. The Tubingen methods of PDEMA require close communication between surgeon and pathologist. This article describes the background of both Mohs and Tubingen PDEMA, reviews what constitutes PDEMA, and provides a protocol for Tubingen PDEMA detailing critical components in a stepwise fashion using illustrative photos and diagrams. We hope to broaden understanding of the NCCN Guidelines and their rationale, align practice, and optimize patient outcomes.