The Effect of Surgeon Referral and a Radiation Oncologist Productivity-Based Metric on Radiation Therapy Receipt Among Elderly Women With Early Stage Breast Cancer: Analysis From a Tertiary Cancer Network.

Purpose: : Guidelines for early-stage breast cancer allow for radiation therapy (RT) omission after breast conserving surgery among older women, though high utilization of RT persists. This study explored surgeon referral and the effect of a productivity-based bonus metric for radiation oncologists in an academic institution with centralized quality assurance review. Methods and materials: : We evaluated patients ≥70 years of age treated with breast conserving surgery for estrogen receptor (ER)+ pT1N0 breast cancer at a single tertiary cancer network between 2015 and 2018. The primary outcomes were radiation oncology referral and RT receipt. Covariables included patient and physician characteristics and treatment decisions before versus after productivity metric implementation. Univariable generalized linear effects models explored associations between these outcomes and covariables. Results: : Of 703 patients included, 483 (69%) were referred to radiation oncology and 273 (39%) received RT (among those referred, 57% received RT). No difference in RT receipt pre- versus post-productivity metric implementation was observed (P = .57). RT receipt was associated with younger patient age (70-74 years; odds ratio [OR], 2.66; 95% confidence interval [CI], 1.54-4.57) and higher grade (grade 3; OR, 7.75; 95% CI, 3.33-18.07). Initial referral was associated with younger age (70-74; OR, 5.64; 95% CI, 3.37-0.45) and higher performance status (Karnofsky performance status ≥90; OR, 5.34; 95% CI, 2.63-10.83). Conclusions: : Nonreferral to radiation oncology accounted for half of RT omission but was based on age and Karnofsky performance status, in accordance with guidelines. Lack of radiation oncologist practice change in response to misaligned financial incentives is reassuring, potentially reflecting incentive design and/or centralized quality assurance review. Multi-institutional studies are needed to confirm these findings.

Changes in the survival of adult patients with metastasized melanoma with the approval of immune checkpoint inhibitors: A retrospective study from the United States database.

BACKGROUND: Immune-checkpoint inhibitors (ICI) have revolutionized the treatment of metastatic melanoma. Ipilimumab and Ipilimumab-Nivolumab combination therapies were approved by the United States Food and Drug Administration in 2011 and 2015, respectively. We aimed to evaluate potential changes in the survival of patients with metastatic melanoma following the approval of these agents. METHODS: We extracted data from the Surveillance, Epidemiology, and End Results (SEER) database (Nov 2021 submission). All patients aged 20 and above who were diagnosed with 'distant' melanoma (per 'combined summary stage') from 2007 through 2018 were included in the study. This time period was further sub-categorized into 2007-2010 (pre-ICI era), 2011-2014 (single-agent ICI era), and 2015-2018 (combination ICI era) based on the approval timeline of ICI. RESULTS: The median overall survival (OS) was 8, 10, and 14 months in the pre-ICI, single-agent ICI, and combination ICI eras respectively (log-rank test, χ² = 189.03, p < 0.001). On Cox-proportional hazard analysis, patients diagnosed in the single-agent and combination ICI eras had a significantly lower risk of dying [HR 0.82 (95% CI 0.78-0.87) and 0.67 (0.64-0.71), respectively] compared to patients diagnosed in the pre-ICI era. Patients who were of the male gender, aged ≥ 65 years, and those receiving chemotherapy and/or radiotherapy were at a significantly higher risk of dying. Married individuals had a significantly lower risk of dying compared to patients who were divorced, separated, or widowed at the time of diagnosis. There was no significant difference in survival demonstrated among non-Hispanic blacks versus non-Hispanic whites. CONCLUSION: Survival of patients with metastatic melanoma has improved in the era of immune checkpoint inhibitors. It implies that the survival of patients reported in trials can be correlated at a population level as well. Future analysis from the SEER database is needed when new data becomes available to see if there is a further increase in OS.

Attitudes and access to resources and strategies to improve quality of radiotherapy among US radiation oncologists: A mixed methods study.

INTRODUCTION: We aimed to assess contouring-related practices among US radiation oncologists and explore how access to and use of resources and quality improvement strategies vary based on individual- and organization-level factors. METHODS: We conducted a mixed methods study with a sequential explanatory design. Surveys were emailed to a random 10% sample of practicing US radiation oncologists. Participating physicians were invited to a semi-structured interview. Kruskal-Wallis and Wilcoxon rank-sum tests and a multivariable regression model were used to evaluate associations. Interview data were coded using thematic content analysis. RESULTS: Survey overall response rate was 24%, and subsequent completion rate was 97%. Contouring-related questions arise in ≥50% of clinical cases among 73% of respondents. Resources accessed first include published atlases (75%) followed by consulting another radiation oncologist (60%). Generalists access consensus guidelines more often than disease-site specialists (P = 0.04), while eContour.org is more often used by generalists (OR 4.3, 95% CI 1.2-14.8) and younger physicians (OR 1.33 for each 5-year increase, 95% CI 1.08-1.67). Common physician-reported barriers to optimizing contour quality are time constraints (58%) and lack of access to disease-site specialists (21%). Forty percent (40%, n = 14) of physicians without access to disease-site specialists indicated it could facilitate the adoption of new treatments. Almost all (97%) respondents have formal peer review, but only 43% have contour-specific review, which is more common in academic centres (P = 0.02). CONCLUSION: Potential opportunities to improve radiation contour quality include improved access to disease-site specialists and contour-specific peer review. Physician time must be considered when designing new strategies.

Bias in Patient Experience Scores in Radiation Oncology: A Multicenter Retrospective Analysis.

PURPOSE: Patient experience scores are increasingly important in measuring quality of care and determining reimbursement from payers, including the Hospital Value-Based Purchasing Program and the Radiation Oncology Model. However, the role of bias in patient experience scores in oncology is unknown, raising the possibility that such payment structures may inadvertently perpetuate bias in reimbursement. Therefore, the authors characterized patient-, physician-, and practice-level predictors of patient experience scores in patients undergoing radiation therapy. METHODS: The authors retrospectively reviewed patient experience surveys for radiation oncology patients treated at two large multisite academic cancer centers. The outcome was responses on four survey questions. Covariates included self-reported patient demographics, physician characteristics, practice setting characteristics, and wait-time rating linked to each survey. Multivariable ordinal regression models were fitted to identify predictors of receiving a higher score on each of the survey questions. RESULTS: In total, 2,868 patients completed surveys and were included in the analysis. Patient experience scores were generally high, with >90% of respondents answering 5 of 5 on the four survey items. Physician gender was not associated with any measured patient experience outcomes (P > 0.40 for all). Independent predictors of higher score included a wait-time experience classified as "good" compared with "not good" (q < .001 for all). CONCLUSIONS: Oncology practices aiming to improve patient experience scores may wish to focus their attention on improving wait times for patients. Although a difference in patient experience scores on the basis of physician gender was not observed, such bias is likely to be complex, and further research is needed to characterize its effects.

Development and Pilot Implementation of a Remote Monitoring System for Acute Toxicity Using Electronic Patient-Reported Outcomes for Patients Undergoing Radiation Therapy for Breast Cancer.

PURPOSE: We aimed to develop and study the implementation of a remote system for toxicity assessment and management of acute side effects of breast radiation using electronic patient-reported outcomes (ePROs). METHODS AND MATERIALS: A response-adapted Patient-Reported Outcomes Common Terminology Criteria for Adverse Events-based assessment for breast radiation toxicity was administered weekly during and for 8 weeks after radiation from June 2019 to July 2020. The care team received alerts when "severe" symptoms were reported by patients, who were then contacted. Treatment, clinic, and sociodemographic characteristics were abstracted from patient records. A subsample of patients and care team members was qualitatively interviewed at follow-up. RESULTS: Overall, 5787 assessments were sent to 678 patients, of whom 489 (72%) completed 2607 assessments (45%). Moderate or greater toxicity was reported by 419 responders (86%; 95% CI, 82%-89%). Clinician alerts for severe toxicity were generated for 264 assessments among 139 unique patients, of which 83% occurred posttreatment. The proportion of surveys that prompted an alert was significantly higher after treatment (219 [13%]) than during treatment (45 [5%]) (P < .001). Survey completion rates in the posttreatment period were higher among patients undergoing partial breast irradiation than postmastectomy radiation (incidence rate ratio, 0.70; 95% CI, 0.60-0.81) (P < .001) despite these patients experiencing less severe toxicity. Interviews (15) found that patients had a positive experience with ePROs, although many thought the primary purpose was for research rather than symptom management. CONCLUSIONS: With the majority of toxicity occurring after breast radiation has ended, remote symptom monitoring with ePROs appears to fill a gap in clinical practice, particularly for patients undergoing shorter courses of radiation. It is important to properly onboard patients and explain that the purpose of ePROs is to aid clinical care. Further research is needed to determine whether the costs associated with ePROs can be offset by reducing routine clinic visits and whether this approach is acceptable and appropriate.

The use of complementary and integrative therapies as adjunct interventions during radiotherapy: a systematic review.

PURPOSE: Literature supporting the efficacy of complementary and integrative medicine (CIM) alongside radiotherapy is fragmented with varying outcomes and levels of evidence. This review summarizes the available evidence on CIM used with radiotherapy in order to inform clinicians. METHODS: A systematic literature review identified studies on the use of CIM during radiotherapy. Inclusion required the following criteria: the study was interventional, CIM therapy was for human patients with cancer, and CIM therapy was administered concurrently with radiotherapy. Data points of interest were collected from included studies. A subset was identified as high-quality using the Jadad scale. Fisher's exact test was used to assess the association between study results, outcome measured, and type of CIM. RESULTS: Overall, 163 articles met inclusion. Of these, 68 (41.7%) were considered high-quality trials. Articles published per year increased over time (p < 0.01). Frequently identified therapies were biologically based therapies (47.9%), mind-body therapies (23.3%), and alternative medical systems (13.5%). Within the subset of high-quality trials, 60.0% of studies reported a favorable change with CIM while 40.0% reported no change. No studies reported an unfavorable change. Commonly assessed outcome types were patient-reported (41.1%) and provider-reported (21.5%). Rate of favorable change did not differ based on type of CIM (p = 0.90) or outcome measured (p = 0.24). CONCLUSIONS: Concurrent CIM may reduce radiotherapy-induced toxicities and improve quality of life, suggesting that physicians should discuss CIM with patients receiving radiotherapy. This review provides a broad overview of investigations on CIM use during radiotherapy and can inform how radiation oncologists advise their patients about CIM.

Clinical implementation of deep learning contour autosegmentation for prostate radiotherapy.

BACKGROUND AND PURPOSE: Artificial intelligence advances have stimulated a new generation of autosegmentation, however clinical evaluations of these algorithms are lacking. This study assesses the clinical utility of deep learning-based autosegmentation for MR-based prostate radiotherapy planning. MATERIALS AND METHODS: Data was collected prospectively for patients undergoing prostate-only radiation at our institution from June to December 2019. Geometric indices (volumetric Dice-Sørensen Coefficient, VDSC; surface Dice-Sørensen Coefficient, SDSC; added path length, APL) compared automated to final contours. Physicians reported contouring time and rated autocontours on 3-point protocol deviation scales. Descriptive statistics and univariable analyses evaluated relationships between the aforementioned metrics. RESULTS: Among 173 patients, 85% received SBRT. The CTV was available for 167 (97%) with median VDSC, SDSC, and APL for CTV (prostate and SV) 0.89 (IQR 0.83-0.95), 0.91 (IQR 0.75-0.96), and 1801 mm (IQR 1140-2703), respectively. Physicians completed surveys for 43/55 patients (RR 78%). 33% of autocontours (14/43) required major "clinically significant" edits. Physicians spent a median of 28 min contouring (IQR 20-30), representing a 12-minute (30%) time savings compared to historic controls (median 40, IQR 25-68, n = 21, p < 0.01). Geometric indices correlated weakly with contouring time, and had no relationship with quality scores. CONCLUSION: Deep learning-based autosegmentation was implemented successfully and improved efficiency. Major "clinically significant" edits are uncommon and do not correlate with geometric indices. APL was supported as a clinically meaningful quantitative metric. Efforts are needed to educate and generate consensus among physicians, and develop mechanisms to flag cases for quality assurance.

Impact of Telemedicine on Patient Satisfaction and Perceptions of Care Quality in Radiation Oncology.

BACKGROUND: The COVID-19 pandemic has transformed cancer care with the rapid expansion of telemedicine, but given the limited use of telemedicine in oncology, concerns have been raised about the quality of care being delivered. We assessed the patient experience with telemedicine in routine radiation oncology practice to determine satisfaction, quality of care, and opportunities for optimization. PATIENTS AND METHODS: Patients seen within a multistate comprehensive cancer center for prepandemic office visits and intrapandemic telemedicine visits in December 2019 through June 2020 who completed patient experience questionnaires were evaluated. Patient satisfaction between office and telemedicine consultations were compared, patient visit-type preferences were assessed, and factors associated with an office visit preference were determined. RESULTS: In total, 1,077 patients were assessed (office visit, n=726; telemedicine, n=351). The telemedicine-consult survey response rate was 40%. No significant differences were seen in satisfaction scores between office and telemedicine consultations, including the appointment experience versus expectation, quality of physician's explanation, and level of physician concern and friendliness. Among telemedicine survey respondents, 45% and 34% preferred telemedicine and office visits, respectively, and 21% had no preference for their visit type. Most respondents found their confidence in their physician (90%), understanding of the treatment plan (88%), and confidence in their treatment (87%) to be better or no different than with an office visit. Patients with better performance status and who were married/partnered were more likely to prefer in-person office visit consultations (odds ratio [OR], 1.04 [95% CI, 1.00-1.08]; P=.047, and 2.41 [95% CI, 1.14-5.47]; P=.009, respectively). Patients with telephone-only encounters were more likely to report better treatment plan understanding with an office visit (OR, 2.25; 95% CI, 1.00-4.77; P=.04). CONCLUSIONS: This study is the first to assess telemedicine in routine radiation oncology practice, and found high patient satisfaction and confidence in their care. Optimization of telemedicine in oncology should be a priority, specifically access to audiovisual capabilities that can improve patient-oncologist communication.

Radiation Oncologist Perceptions of Telemedicine from Consultation to Treatment Planning: A Mixed-Methods Study.

PURPOSE: Telemedicine was rapidly implemented for initial consultations and radiation treatment planning in the wake of the coronavirus disease 2019 (COVID-19) pandemic. In this study, we explore utilization of and physician perspectives on this approach in an attempt to identify patient populations that may benefit most from virtual care. METHODS AND MATERIALS: This is a mixed-methods study with a convergent design. Approximately 6 to 8 weeks after implementation of telemedicine, all radiation oncologists in a single academic radiation oncology department were invited to participate in either semistructured interviews with embedded survey questions or a concurrently administered survey only. Rapid qualitative analysis was used to identify common themes, and quantitative data was assessed using descriptive statistics and univariable analyses. RESULTS: At the apex of the pandemic, 92% of radiation oncology visits were conducted via telemedicine. In total, 51 of 61 radiation oncologists participated in the study (response rate 84%). Most (71%) reported no difference in ability to treat cancer appropriately via telemedicine, which was more common among specialized physicians (P = .01) but not those with higher visit volume or years of experience. Over half (55%) perceived no difference or even improvement in overall visit quality with telemedicine. Virtual visits were deemed acceptable for a median of 70% to 96% of patients, which varied by disease site. Need for physical examination, and availability of an acceptable proxy, factored into telemedicine acceptability. Most (88%) found telemedicine better than expected, but opinions were split on how telemedicine would affect physician burnout. Almost all (96%) foresaw a role for telemedicine beyond the pandemic and would opt for a median of 50% (interquartile range 20%-66%) of visits conducted via telemedicine. CONCLUSIONS: Among radiation oncologists in an academic setting, telemedicine was perceived to be highly appropriate and acceptable for most patients. Future studies should focus on identifying the 5% to 30% of patients whose care may be optimized with in-person visits, and if there is alignment with patient preferences.