Patient engagement in CPD in radiation oncology and radiation therapy across Canada: A national survey.

BACKGROUND: The aim of this study was to investigate patient engagement (PE) in the development and delivery of Continuing Professional Development (CPD) programs for health care providers within radiation oncology, radiation therapy and medical physics across Canada. This study looked at the current state of PE in CPD programs across Canada and how to address the benefits and barriers to PE to advance these programs. METHODS: A quantitative, exploratory survey was conducted among radiation oncologists, radiation therapists and medical physicists across Canada. The questionnaire was developed by a multi-disciplinary team and piloted among interprofessional (IP) faculty with a special interest in patient education. The survey was web-based and disseminated through the Canadian Association of Medical Radiation Technologists (CAMRT) and Canadian Radiation Oncologists (CARO) professional associations. RESULTS: A total of 97 responses were obtained, 43.3% (n = 41) were radiation oncologists 64% (n = 54) were radiation therapists and 2(2%) were medical physicists. There was representation from all provinces, except Newfoundland, with the majority 36% (n = 35) from Ontario. 57% (n = 46) of participants agreed that patients should be involved in CPD, and 11% (n = 9) disagreed. The most agreed-upon barriers are financial costs for patients and clinician bias when selecting patients. The most agreed-upon solutions were improving patient resources and creating training programs for patients. Radiation therapists agreed significantly more (p<0.05) with the potential benefits of PE in CPD, compared to radiation oncologists. DISCUSSION: PE in CPD programs is a novel and controversial topic but is still highly rated and important. We intend to advocate for patients to take an active role in our CPD programs. Further research is warranted.

Dosimetric correlates of toxicities and quality of life following two-fraction stereotactic ablative radiotherapy (SABR) for prostate cancer.

PURPOSE: There is no evidence-based data to guide dose constraints in two-fraction prostate stereotactic ablative radiotherapy (SABR). Using individual patient-data from two prospective trials, we aimed to correlate dosimetric parameters with toxicities and quality of life (QoL) outcomes. MATERIALS AND METHODS: We included 60 patients who had two-fraction prostate SABR in the 2STAR (NCT02031328) and 2SMART (NCT03588819) trials. The prescribed dose was 26 Gy to the prostate+/-32 Gy boost to the dominant intraprostatic lesions. Toxicities and QoL data were prospectively collected using CTCAEv4 and EPIC-26 questionnaire. The outcomes evaluated were acute and late grade ≥ 2 toxicities, and late minimal clinical important changes (MCIC) in QoL domains. Dosimetric parameters for bladder, urethra, rectum, and penile bulb were evaluated. RESULTS: The median follow-up was 56 months (range: 39-78 months). The cumulative incidence of grade ≥ 2 genitourinary (GU), gastrointestinal (GI), and sexual toxicities were 62%, 3%, and 17% respectively in the acute setting (<3 months), and 57%, 15%, and 52% respectively in late setting (>6 months). There were 36%, 28%, and 29% patients who had late MCIC in urinary, bowel and sexual QoL outcomes respectively. Bladder 0.5 cc was significant predictor for late grade ≥ 2 GU toxicities, with optimal cut-off of 25.5 Gy. Penile bulb D5cc was associated of late grade ≥ 2 sexual toxicities (no optimal cut-off was identified). No dosimetric parameters were identified to be associated with other outcomes. CONCLUSION: Using real-life patient data from prospective trials with medium-term follow-up, we identified additional dose constraints that may mitigate the risk of late treatment-related toxicities for two-fraction prostate SABR.

To Boost or Not to Boost: Pooled Analyses From 2-Fraction SABR Trials for Localized Prostate Cancer.

PURPOSE: Focal boost to dominant intraprostatic lesion (DIL) is an approach for dose escalation in prostate radiation therapy. In this study, we aimed to report the outcomes of 2-fraction SABR ± DIL boost. METHODS AND MATERIALS: We included 60 patients with low- to intermediate-risk prostate cancer enrolled in 2 phase 2 trials (30 patients in each trial). In the 2STAR trial (NCT02031328), 26 Gy (equivalent dose in 2-Gy fractions = 105.4 Gy) was delivered to the prostate. In the 2SMART trial (NCT03588819), 26 Gy was delivered to the prostate, with up to 32 Gy boost to magnetic resonance imaging-defined DIL (equivalent dose in 2-Gy fractions = 156.4 Gy). The reported outcomes included prostate-specific antigen (PSA) response (ie, <0.4 ng/mL) at 4 years (4yrPSARR), biochemical failure (BF), acute and late toxicities, and quality of life (QOL). RESULTS: In 2SMART, median DIL D99% of 32.3 Gy was delivered. Median follow-up was 72.7 months (range, 69.1-75.) in 2STAR and 43.6 months (range, 38.7-49.5) in 2SMART. The 4yrPSARR was 57% (17/30) in 2STAR and 63% (15/24) in 2SMART (P = 0.7). The 4-year cumulative BF was 0% in 2STAR and 8.3% in 2SMART (P = 0.1). The 6-year BF in 2STAR was 3.5%. For genitourinary toxicities, there were differences in grade ≥1 urinary urgency in the acute (0% vs 47%; P < .001) and late settings (10% vs 67%; P < .001) favoring 2STAR. For urinary QOL, no difference was observed in the acute setting, but lower proportion in 2STAR had minimal clinically important changes in urinary QOL score in the late setting (21% vs 50%; P = .03). There were no significant differences in gastrointestinal and sexual toxicities and QOL in both acute and late settings between the 2 trials. CONCLUSIONS: This study presents the first prospective data comparing 2-fraction prostate SABR ± DIL boost. The addition of DIL boost resulted in similar medium-term efficacy (in 4yrPSARR and BF), with impact on late urinary QOL outcomes.

The use of virtual reality hypnosis for prostate cancer patients during transperineal biopsy/gold seed implantation: A needs assessment study.

BACKGROUND: Patients having radiation therapy treatment to the prostate may require invasive preparation procedures under local anesthesia (LA), such as the insertion of gold seeds into the prostate or targeted biopsies. These procedures can induce pain and anxiety for some patients. Virtual Reality Hypnosis (VRH) is the combination of a 360-degree video display with audio and mental guides for relaxation and distraction during medical procedures. The objective of this research was to assess the level of patient interest in the use of VRH during gold seed insertion and biopsy, and to identify a subset of patients that would be most likely to benefit from the use of VRH. METHODS: This single arm, prospective pilot study included patients who were receiving biopsy and/or gold seed insertion using a 2-step LA procedure. Participants were asked to complete a questionnaire about their level of knowledge and interest in VRH before and after their procedure. At the same time, pain and anxiety levels were collected before and after the procedure, as well as during each LA step and at the mid-seed drop/biopsy core extraction. A visual analogue scale for pain and the National Comprehensive Cancer Network's Distress Thermometer were used to verbally rate pain and distress respectively. Descriptive statistics and Pearson's correlation coefficient were calculated for all variables of interest. RESULTS: 24 patients were recruited and 1 had their procedure cancelled, so a total of 23 patients completed this study. 74% of patients (n=23) agreed to try VRH before their procedures, whereas 65% of patients (n=23) were willing to try VRH after the procedure. Pain scores were highest at deep LA injection (mean= 5.48, SD= 2.56) and distress scores were also highest at deep LA injection (mean= 4.28, SD= 2.92). After the procedure, 83% of participants with pain scores above the mean at deep LA injection and 80% with anxiety scores above the mean at deep LA injection agreed that they would be willing to try VRH. CONCLUSIONS: Patients with higher pain and distress scores had more interest in trying VRH with the standard LA for gold seed insertion/biopsy procedures. Patients with a history of lower pain tolerance or who express having experienced high levels of pain during previous biopsies will be the target population for using VRH in future trials to determine feasibility and effectiveness.

Two-fraction stereotactic ablative radiotherapy with simultaneous boost to MRI-defined dominant intra-prostatic lesion - Results from the 2SMART phase 2 trial.

PURPOSE: This is the first report of the 2SMART Phase II trial evaluating the safety of two-fraction stereotactic ablative radiotherapy (SABR) with focal boost to magnetic resonance imaging (MRI) defined dominant intra-prostatic lesion (DIL) for localised prostate cancer. MATERIALS AND METHODS: Men with low or intermediate risk prostate cancer were eligible for the study. The gross tumour volume (GTV) was MRI-defined DIL, and the clinical target volume (CTV) was entire prostate gland. The planning target volume (PTV) was a 2 mm expansion anteroposterior and lateral, and 2.5 mm superoinferior. The prescribed dose was 32 Gy to GTV, and 26 Gy to CTV. Primary endpoint was minimal clinically important change (MCIC) in quality of life (QOL) within 3-months of SABR, assessed using the EPIC-26 questionnaire. Secondary endpoints were acute and late toxicities (assessed using CTCAEv4), PSA nadir, and biochemical failure (based on Phoenix criteria). RESULTS: Thirty men were enrolled in the study - 2 (7%) had low-risk and 28 (93%) had intermediate risk prostate cancer. The median follow-up was 44 months (range:39-49 months). The median PSA nadir was 0.25 ng/mL, with median time to nadir of 37 months. One patient (3%) had biochemical failure at 44 months post-treatment. Ten (33%), six (20%), and three (10%) men had acute MCIC in urinary, bowel, and sexual QOL domains respectively. No acute or late grade ≥ 3 urinary or bowel toxicities were observed. CONCLUSION: This novel protocol of two-fraction prostate SABR with MRI-defined DIL boost is a safe approach for dose-escalation, with minimal impact on acute QOL and no grade ≥ 3 toxicities.

Two-fraction stereotactic ablative radiotherapy (SABR) versus two-fraction high dose rate (HDR) brachytherapy for localized prostate cancer: Does dose heterogeneity matter?

BACKGROUND AND PURPOSE: Contemporary radiotherapy for localized prostate cancer (PCa) is deliverable via stereotactic ablative radiotherapy (SABR) and high dose rate (HDR) brachytherapy. Here we report on a parallel cohort analysis of two prospective, phase II clinical trials of two-fraction prostate SABR versus two-fraction HDR monotherapy. MATERIALS AND METHODS: Enrolled patients had histologically-confirmed PCa (clinical stage T1c-T2b; grade group 1, 2, or 3; and PSA < 20 ng/mL). SABR and HDR doses were 26 Gy and 27 Gy in 2 weekly fractions, respectively. Patient-level data from each cohort was analysed to assess prostate specific antigen (PSA) response kinetics, biochemical failure, toxicity, and quality of life (QOL). RESULTS: Thirty patients receiving SABR and 83 receiving HDR were included. Fifty percent and 30% of patients had unfavourable-intermediate risk disease, respectively. SABR patients had higher mean baseline PSA (8.7 versus 6.8 ng/mL, p = 0.016). Median follow-up was 72.7 and 65.3 months, respectively. Mean dose delivered (Dmean) was 26.6-26.8 Gy for SABR versus 35.5-45.5 Gy for HDR. Both cohorts achieved a median nadir PSA of 0.16 ng/mL at a median of 57 months post-treatment. Cumulative biochemical failure probability (±SE) at 72 months was 3.5% (±3.5%) for SABR versus 12.8% (±4.8%) for HDR (p = 0.19). Low rates of CTCAE grade ≥2 toxicity were observed in both cohorts. No differences in EPIC scores over time were observed between cohorts. CONCLUSIONS: Two-fraction SABR yields similar rates of biochemical failure, acute and late toxicities, and QOL as two-faction HDR brachytherapy. These data support the design of a randomized controlled trial comparing these treatments.

Radiation therapists' knowledge and attitudes regarding specialized clinics for geriatric assessment of older women with early stage breast cancer: A cross sectional study.

INTRODUCTION: Older patients with breast cancer have specialized needs compared to younger patients. Currently, there is disparity of care, with comprehensive cancer centres unable to adequately respond to the needs of this population. Specialized geriatric oncology clinics in Europe focus on care for older patients and are increasingly of interest in Canada due to the aging population. This study examines radiation therapist (RT) views on the need for specialized geriatric oncology clinics for women over age 70 with early stage breast cancer. METHODS: The study utilized a cross sectional survey design, with Likert scale, multiple choice and open ended questions. Surveys were sent out via email to all RTs registered with the Canadian Association of Medical Radiation Technologists. Demographic information was collected. Descriptive statistics were used to analyze quantitative data. Responses to open ended questions were compiled for thematic analysis. RESULTS: 240 therapists completed the survey (17% response rate). 90% of RTs were unaware of specialized geriatric oncology clinics but 66% felt these clinics could be useful. Similarly, 80% of RTs were not familiar with assessment tools geared toward older patients but 86% felt these tools would be useful. Therapists identified both benefits and drawbacks of both geriatric oncology clinics and the use of specialized assessment tools. DISCUSSION: Canadian RTs report that older women with breast cancer could benefit from specialized geriatric oncology clinics and assessment tools geared toward this population. However, most RTs were not familiar with these assessment tools indicating a need for education regarding their application within the clinic environment. Regardless, many RTs felt knowledgeable and confident in recognizing and helping with the special needs of their older patients.

Changing me to we: Developing teambuilding in radiation therapy.

BACKGROUND: There has been a causal link identified within the literature between poor team function and errors, patient outcomes, staff satisfaction and performance. Lacking is supporting evidence on teambuilding and its impact on overall team performance and team dynamics. Within radiation therapy, there is difficulty in understanding the inner workings of team dynamics due to the unique complex nature of teams and with very little evidence on the impact of team building specific to radiation therapy. The focus of this research is to form a better understanding of the effects of teambuilding before and after a teambuilding education session.The knowledge gained can help in future trainings to promote and facilitate teambuilding to develop team dynamics and lead a change in culture. METHODS: Team building sessions were booked and scheduled for 148 radiation therapists. Pre and post session evaluations were distributed to all participants and collected at the end of each team building session. Descriptive statistics were used to analyze Likert scale responses. Open-ended question responses were coded and analyzed for emerging themes using thematic analysis. RESULTS: 110 of 148 radiation therapists attended one of the scheduled team building sessions. Pre-session evaluations indicated radiation therapists have a good understanding of factors that affect teamwork (88% agree); are aware of the multi-generational impact (78% agree); have the skill set to build a respectful team (86% agree); and are comfortable dealing with conflict (67% agree). Post-session evaluations indicated that participants had gained increased knowledge on teamwork (66.3% agree; 30.7% strongly agree); are more aware of the generational impact within teams (59% agree); new strategiesdeveloped to help improve team dynamics and the ability to use the lessons learnt immediately (67% and 71% respectively agree). Open ended comments indicated an interest in additional teambuilding sessions and further education on conflict resolution. CONCLUSION: Results showed an increased awareness of the factors that impact team dynamics amongst radiation therapists and an interest in receiving further education in teambuilding. Findings will be utilized to better inform debate in future development of teambuilding educational sessions to improve overall team dynamics in radiation therapy.

Single-fraction HDR brachytherapy as monotherapy in low and intermediate risk prostate cancer: Outcomes from two clinical trials with and without an MRI-guided boost.

PURPOSE: Single-fraction HDR monotherapy for the treatment of localized prostate cancer is appealing, but published outcomes are discouraging. An approach to improve local control is MRI-guided focal dose-escalation to the dominant intraprostatic lesion (DIL). Here we report a comparison of outcomes from two phase II clinical trials with and without a focal boost. METHODS: Patients had low or intermediate-risk disease. Patients in Trial1 received a single 19 Gy HDR implant to the whole prostate. Trial2 incorporated an additional MRI-guided focal DIL boost to at least 23 Gy. ADT was not allowed. Toxicities (CTCAEv4.0) and quality of life (EPIC) were collected. Biochemical failure (BF) was defined as nadir +2. Univariate and multivariate logistic regression analysis was conducted to search for predictors of BF. RESULTS: Trial1 had 87 patients with a median follow-up of 62 months, while Trial2 had 60 patients with a median follow-up of 50 months. The five-year cumulative BF rate was 32.6% and 31.3%, respectively (p = 0.9). 77.5% of failures were biopsy-confirmed local failures, all of which underwent local salvage therapy. The addition of a DIL boost was not associated with worse toxicity or QOL. Baseline PSA and Gleason score correlated with BF, but none of the dosimetric parameters was a significant predictor of BF. CONCLUSIONS: MRI-guided focal boost was safe and well tolerated, but did not improve local control after 19 Gy single-fraction HDR monotherapy, and the control rates were unacceptable. Single-fraction HDR monotherapy for prostate cancer should not be offered outside of clinical trials.

Prostate high dose-rate brachytherapy as monotherapy for prostate cancer: Late toxicity and patient reported outcomes from a randomized phase II clinical trial.

BACKGROUND AND PURPOSE: Long-term toxicity of high dose-rate brachytherapy as monotherapy for prostate cancer is not well defined. We report late toxicity and health related quality of life (HRQOL) changes from a randomized phase II clinical trial of two different fractionation schemes. MATERIALS AND METHODS: Eligible patients had NCCN low or intermediate risk prostate cancer. 170 patients were randomized to receive either a single 19 Gy or two-fractions of 13.5 Gy one week apart. Toxicity was measured using Common Terminology for Adverse Events (CTCAE) v4.0, and HRQOL was measured using the Expanded Prostate Index Composite (EPIC). RESULTS: Median follow-up was 63 months. The 5-year cumulative incidence of Grade 2 or higher genitourinary (GU) and gastrointestinal (GI) toxicity was 62% and 12% in the single-fraction arm, and 47% and 9% in the two-fraction arm, respectively. Grade 3 GU toxicity was only seen in the single fraction arm with a cumulative incidence of 2%. The 5-year prevalence of Grade 2 GU toxicity was 29% and 21%, in the single- and two-fraction arms, respectively, with Grade 2 GI toxicity of 1% and 2%. Beyond the first year, no significant differences in mean urinary HRQOL were seen compared to baseline in the two-fraction arm, in contrast to the single-fraction arm where a decline in urinary HRQOL was seen at 4 and 5 years. Sexual HRQOL was significantly reduced in both treatment arms at all timepoints, with no changes in the bowel domain. CONCLUSIONS: HDR monotherapy is well tolerated with minimal impact on HRQOL.

Prostate high dose-rate brachytherapy as monotherapy for low and intermediate risk prostate cancer: Efficacy results from a randomized phase II clinical trial of one fraction of 19 Gy or two fractions of 13.5 Gy.

BACKGROUND AND PURPOSE: High dose-rate (HDR) brachytherapy as monotherapy is a treatment option for localized prostate cancer, but optimal dose and fractionation is unknown. We report efficacy results of a randomized phase II trial of HDR monotherapy delivered as either one or two fractions. MATERIALS AND METHODS: Eligible patients had low or intermediate risk prostate cancer, prostate volume <60 cc, and no androgen deprivation use. 170 patients were randomized to receive HDR as either a single fraction of 19 Gy or as two fractions of 13.5 Gy one week apart. Median age was 65 years, median PSA was 6.33 ng/ml, and Grade Group 1, 2 and 3 was present in 28%, 60%, and 12%, respectively. There was no difference in baseline factors between arms and 19%, 51% and 30% had low risk, favourable intermediate and unfavourable intermediate risk disease, respectively. The Phoenix definition was used to define biochemical failure, all local failures were confirmed by biopsy and toxicity was assessed using CTCAE v.4. RESULTS: Median follow-up was 60 months. PSA decreased more quickly in the 2-fraction arm (p = 0.009). Median PSA at 5-years was 0.65 ng/ml in the single fraction and 0.16 ng/ml in the 2-fraction arm. The 5-year biochemical disease-free survival and cumulative incidence of local failure was 73.5% and 29% in the single fraction arm and 95% (p = 0.001) and 3% (p < 0.001) in the 2-fraction arm, respectively. Recurrence was not associated with initial stage, grade group, or risk group. Grade 2 late rectal toxicity occurred in 1% while the incidence of grade 2 and 3 urinary toxicity was 45% and 1%, respectively, with no difference between arms. CONCLUSIONS: HDR monotherapy delivered as two fraction of 13.5 Gy is well tolerated with a high cancer control rate at 5 years. Single fraction monotherapy is inferior and should not be used.

Learning in 360 Degrees: A Pilot Study on the Use of Virtual Reality for Radiation Therapy Patient Education.

BACKGROUND: Patient education for external beam radiation therapy (EBRT) is traditionally delivered in verbal and/or written form, which may not provide a full picture of the complex, technical aspects of treatment. The purpose of this pilot study was to create and evaluate a prototype 360-degree virtual reality (VR) video outlining the technical aspects of EBRT to the pelvis as a supplement to traditional education methods. MATERIALS AND METHODS: A prototype VR video was filmed to simulate the delivery of one fraction of image-guided EBRT to the pelvis. Patients having a radical course of image-guided EBRT to the pelvis were approached while on active treatment to participate in focus groups evaluating the prototype VR video. Focus group discussions were recorded, transcribed, and subjected to thematic analysis. RESULTS: All patients were accrued from a single academic cancer centre in a large metropolitan area. In total, seven patients were enrolled to participate in the focus groups. Thematic analysis revealed 71% of participants felt the traditional patient education met their needs. However, 86% mentioned the education did not fully capture the treatment experience. Participants identified potential benefits of VR could include an increased understanding of the treatment process, specifically the spatial and acoustic aspects of treatment, as well as the potential to reduce anxiety in new patients. Timing was also important, with 86% of participants recommending VR video viewing before the first day of treatment. Participants provided feedback such as including two-dimensional elements in the VR video and other changes which could potentially make the viewing experience more realistic. CONCLUSIONS: Traditional teaching methods are seen as satisfactory by patients at our institution, but it is recognized that there is a gap in current education methods. An immersive VR education tool has the potential to enhance standard patient education, increasing understanding of treatment and decreasing anxiety.

MRI assisted focal boost integrated with HDR monotherapy study in low and intermediate risk prostate cancer (MARS): Results from a phase II clinical trial.

PURPOSE: There is growing concern that single-fraction HDR monotherapy to a dose of 19 Gy is suboptimal for the treatment of localized prostate cancer. We report the results of a phase II prospective trial of single-fraction 19 Gy HDR monotherapy with MRI-guided simultaneous focal boost. METHODS: Eligible patients had low or intermediate risk prostate cancer and an identified lesion on MRI. TRUS based single-fraction HDR monotherapy with MRI fusion was delivered. The dose prescribed was 19 Gy to the prostate and ≥23 Gy to the dominant intraprostatic lesion (DIL). ADT was not used. The purpose is to report early efficacy results. RESULTS: 60 patients were enrolled, with a median follow-up of 39 months. With MRI T-stage incorporated into the risk-group criteria, 8% had low-risk, 35% had favorable intermediate-risk and 57% had unfavorable intermediate-risk disease. The median dose to 90% of the DIL (D90) was 27.2 Gy, and the median prostate V100% was 96.9%. No acute or late grade ≥3 bowel or urinary toxicity was observed. The cumulative BF probability was 15.2% at 36 months and 31.6% at 48 months. All patients that were fully investigated had local failure only, and 88% of the local failures were at the site of original DIL. The median PSA nadir was 0.79 ng/ml, with a median time to nadir of 32 months. CONCLUSIONS: Focal boost to the MRI-specified gross tumor was well tolerated, but did not adequately improve local control. Single-fraction HDR monotherapy to 19 Gy for prostate cancer provides suboptimal local control, and should not be offered outside of clinical trials.

It Only Takes a Minute: The Development and Implementation of a Patient Experience Survey in Radiation Therapy.

INTRODUCTION: Health care services use surveys to assess patient satisfaction and identify areas for improvement. While it is important to assess patient satisfaction to ensure their needs are met, lengthy questionnaires with closed-ended questions often focus on areas that may be considered important by institutions rather than patients. Recently, focus has shifted toward patient and caregiver experience, which institutions address via appreciative inquiry. The aim of this initiative was the development of a patient experience survey (PES) for radiation therapy patients and caregivers which would allow them to express their opinions and priorities. This patient feedback would then be addressed through quality improvement (QI) projects geared toward improving the overall patient and caregiver experience in radiation therapy. METHODS: A three-question minute survey was developed for use as a PES in the radiation therapy department of an academic oncology program located in a large metropolitan area. Feedback was obtained from patient education and person-centred care experts, as well as 10 radiation therapy patients. All feedback was incorporated to create the final PES; respondents rated their agreement on a five-point Likert scale with the statement "My overall experience in Radiation Therapy was great" and two open-ended questions allowed them to highlight departmental strengths and areas for improvement. An initial 3-month pilot was conducted where PESs were available on a self-serve basis to patients and caregivers in waiting areas and at radiation therapy treatment units. All responses were anonymous and completed surveys were returned via drop boxes. Descriptive statistics and thematic analysis were used to analyse responses. RESULTS: A total of 86 surveys were returned. Of those, 80 (93%) responded to the Likert scale question with 83% agreeing or strongly agreeing that their experience in radiation therapy was great. Several strengths were identified by respondents including teamwork, professionalism, and knowledge. Areas identified for improvement included management of appointment delays and communication of delays to patients, as well as environmental improvements. CONCLUSIONS: Although most respondents reported a favourable experience, this pilot demonstrated the minute survey can identify areas for improvement that can be addressed through QI. Including the patient perspective in QI is evidenced to enhance its outcome and aligns with institutional, provincial, and national strategic goals of improving the quality of cancer care through patient engagement.

Evaluation of an Online Education Resource on Radiation Therapy Created for Patients with Postprostatectomy Prostate Cancer and Their Caregivers.

INTRODUCTION: Radiation therapy (RT) after prostatectomy is an important curative treatment option for patients with prostate cancer. It can be delivered immediately after surgery as adjuvant treatment, or after biochemical PSA failure as salvage treatment. There is currently a lack of consensus regarding whether salvage RT in the event of biochemical failure or immediate adjuvant RT is the optimal postprostatectomy RT treatment. Although both types of postprostatectomy RT are generally well tolerated, patients may develop some toxicity that can impact their quality of life and the duration and frequency of treatments can be challenging for patients. It is imperative that patients be provided with evidence-based information so that they are able to make a treatment decision most aligned with their values. METHODS: To help address patients' informational needs, an online education resource was created for patients with prostate cancer considering postoperative RT. Patients and their families were asked to evaluate the effectiveness of this resource using a validated purpose-based information assessment. RESULTS: Nineteen patients were approached and 14 participated, but only five patients returned their evaluations (35%). Sixty percent found the information to be important with regards to each of the six commonly identified purposes in the purpose-based information assessment: organizing, understanding, decision-making, planning, emotional support, and discussing. Only one participant found the information hard to understand and had difficulty finding specific information. DISCUSSION: Patients should be encouraged to actively participate in their treatment decision-making process involving postprostatectomy RT. For patients to make well-informed decisions, patients must be provided with clear and accessible information so that they may understand their disease and the treatment options. CONCLUSION: An online education resource has been developed that most study respondents found clear and helpful for a variety of identified purposes. Overall, this online education resource has the potential to reach a large number of patients and their caregivers who desire specific information and involvement in future treatment decisions.

Assessing the Psychological Impact of Daily Bowel Preparation on Prostate Patients Who Receive Radiation Therapy.

PURPOSE: Evidence has shown that the prostate moves depending on filling of the rectum and, to a lesser extent, the bladder; many radiation therapy departments have adopted standardized bladder filling/rectal emptying protocols for radiotherapy treatment. Daily treatments may be delayed until appropriate volumes are attained; the resultant psychological impact of these delays on patients is unknown. The purpose of this study was to determine levels of anxiety, depression, distress, and bother related to bowel preparation for prostate cancer patients undergoing radiation therapy treatment. METHODS: A prospective cohort analysis of prostate cancer patients undergoing external beam radiation therapy was completed. Patients were assigned to one of three groups; Group A was standard of care, Group B was standard of care plus increased educational information regarding bowel preparation, Group C was standard of care plus increased educational information regarding bowel preparation plus an anti-flatulent medication. Hospital Anxiety and Depression Scale, Distress Thermometer, and a Bowel Status Bother survey were completed by participants at the start of theircourse of radiation treatment, mid-way through, and at the end. Analysis of variance testing was completed to determine differences in mean scores between the three groups. RESULTS: Mean age of patients (N = 30) was 66 years; 50% of the participants had a university education; 80% were married. Anxiety levels decreased over time in all groups (P = .039) with no difference between groups (P = 0.447). Depression levels across time for each group remained low (P = .577). Overall distress levels associated with bowel preparation were low among each group, and no significant differences were reported (P = .978). All groups reported high rates of quality of life. CONCLUSIONS: Findings from this study indicate that collectively across three groups and over time, there were low levels of anxiety, depression, and distress from bowel preparation. Amount, timing, quality, and approach to educational information are important factors to ensure patients feel prepared for their radiation therapy treatments.

To prep or not to prep - that is the question: A randomized trial on the use of antiflatulent medication as part of bowel preparation for patients having image guided external beam radiation therapy to the prostate.

INTRODUCTION: Radiation therapy is a standard treatment option for prostate cancer. With growing use of escalated doses and tighter margins, procedures to limit rectal size variation are needed to reduce prostate motion, increase treatment accuracy, and minimize rectal toxicity. This prospective study was done to determine whether the introduction of an antiflatulent medication would decrease rectal distention at computed tomography (CT) simulation and throughout a course of radiation therapy. METHODS AND MATERIALS: Patients undergoing a radical course of radiation therapy to the prostate/prostate bed were eligible to participate. Participants were randomly assigned to the intervention arm (antiflatulent medication) or the control arm (no medication). For each participant, the number of CT simulation rescans was recorded. Rectal diameters were measured on CT simulation and treatment cone beam CT scans. Acute rectal toxicities were assessed at baseline and weekly using National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE), version 4.0. A χ2 analysis was used to compare the number of participants requiring a rescan in each study arm. Change in rectal diameter over time was assessed using repeated measures analysis of variance. RESULTS: A total of 78 patients participated, with equal numbers assigned to each study arm. There was no significant difference between arms in the number of participants requiring a CT simulation rescan (P = .5551). There was no significant variation in rectal diameter between arms (P = .8999); however, there was a significant effect of time (P = .0017) and a significant interaction effect between study arm and time on rectal diameter (P = .0141). No acute rectal toxicities above grade 2 were reported. CONCLUSIONS: The addition of antiflatulent medication did not affect the frequency of CT simulation rescans. Both time and the interaction between study arm and time had a statistically significant effect on rectal diameter, although neither finding was clinically significant. Instead, standardized bowel preparation education developed for this study may have been sufficient to limit rectal size variation.

Breast Cancer Patients' Preferences for Adjuvant Radiotherapy Post Lumpectomy: Whole Breast Irradiation vs. Partial Breast Irradiation-Single Institutional Study.

This study was conducted to elucidate patients with early breast cancer preference for standard whole breast irradiation (WBI) or partial breast irradiation (PBI) following lumpectomy, as well as identify important factors for patients when making their treatment decisions. Based on relevant literature and ASTRO consensus statement guidelines, an educational tool and questionnaire were developed. Consenting, eligible women reviewed the educational tool and completed the trade-off questionnaire. Descriptive statistics were calculated, as well as chi-squares and a logistic regression model. Of the 90 patients who completed the study, 62 % preferred WBI, 30 % preferred PBI, 4 % required more information, and 3 % had no preferences. Of the patients who chose WBI, 58 % preferred hypofractionated RT, whereas 25 % preferred the conventional RT regimen. The majority of patients rated recurrence rate [WBI = 55/55 (100 %), PBI = 26/26 (100 %)] and survival [WBI = 54/55 (98 %), PBI = 26/26 (100 %)] as important factors contributing to their choice of treatment preference. Financial factors [WBI = 21/55 (38 %), PBI = 14/26 (53 %)] and convenience [WBI = 36/54 (67 %), PBI = 18/26 (69 %)] were rated as important less frequently. Significantly, more patients who preferred WBI also rated standard method of treatment as important when compared to patients who preferred PBI [WBI = 52/54 (96 %), PBI = 16/26 (61 %), χ 2 = 16.63, p = 0.001]. The majority of patients with early breast cancer who were surveyed for this study preferred WBI as an adjuvant treatment post lumpectomy, yet there was a sizeable minority who preferred PBI. This was associated with the importance patients place on standard treatment. These results will help medical professionals treat patients according to patient values.

Pattern of relapse and dose received by the recurrent intraprostatic nodule in low- to intermediate-risk prostate cancer treated with single fraction 19 Gy high-dose-rate brachytherapy.

PURPOSE: The purposes of this study were to investigate the pattern of relapse in patients with low- or intermediate-risk prostate cancer treated with 19-Gy high-dose-rate brachytherapy (HDR-BT) and to calculate the dose received by the area of recurrence. METHODS AND MATERIALS: Patients included in this analysis were treated under a Phase II randomized trial that evaluated the role of 19-Gy HDR-BT monotherapy in low- and intermediate-risk prostate cancers. Multiparametric prostate MRI and prostate biopsy were performed in patients with suspicious local recurrence. The site of local relapse was compared with the initial site of disease. The dose received by the site of recurrence was investigated through registration of the posttreatment multiparametric prostate MRI with the HDR-BT treatment plan. RESULTS: Eight of 87 treated patients were found to have local recurrence after 19-Gy HDR-BT. Seven of the eight recurrences were at the site of initial bulk disease. Seven patients were found to have a more aggressive histology in the posttreatment biopsy. The mean volume of prostate that had received 100% of prescription dose was 97%. Mean dose to area of recurrence was 29.1 Gy, whereas dose to 98% and dose to 90% of the recurrence were 21.6 Gy and 23.2 Gy, respectively. CONCLUSIONS: The relapse pattern after a single 19-Gy HDR-BT is predominantly associated with the site of initial disease. This lends some rationale to future strategies of further focused dose escalation to initial site of disease, notwithstanding the fact that the calculated biologically equivalent dose using linear-quadratic assumptions is already very high.

Prostate high dose-rate brachytherapy as monotherapy for low and intermediate risk prostate cancer: Early toxicity and quality-of life results from a randomized phase II clinical trial of one fraction of 19Gy or two fractions of 13.5Gy.

BACKGROUND AND PURPOSE: Multi-fraction high dose-rate (HDR) brachytherapy as monotherapy is safe and effective for low and intermediate risk prostate cancer. Two or single fraction regimens have some radiobiological rationale. The purpose is to determine toxicity and effect on health related quality of life (HRQOL) of single fraction 19Gy or 13.5Gy×2. MATERIALS AND METHODS: Eligible patients had low or intermediate risk prostate cancer, prostate volume <60cc, and no androgen deprivation use. 170 patients were randomized to receive either a single 19Gy or two fractions of 13.5Gy 1week apart. HRQOL was measured using the Expanded Prostate Index Composite (EPIC), toxicity with Common Terminology for Adverse Events (CTCAE) v4.0 and urinary symptoms with the International Prostate Symptom Score (IPSS). RESULTS: Median follow-up is 20months. Grade 2 urinary toxicity occurred in 51% within the first 3months and in 31% thereafter with no significant difference between treatment arms. Ten patients (6%) developed urinary retention in the acute phase, although only 4 (2.4%) required a catheter for more than 48h. One Grade 3 acute (⩽3months) and late (>3months) urinary toxicity occurred. No more than 1% had any Grade 2 GI toxicity. The 2-fraction arm had a higher occurrence of grade 2 erectile dysfunction (29% vs. 11.5%, p=0.0249) and higher IPSS scores for the first year. Mean EPIC urinary scores at 12months decreased by 4.0 and 4.6, and sexual scores decreased by 8 and 15.9 (p=0.035) in the single and 2-fraction arms, respectively. No change occurred in the bowel or hormonal domains. CONCLUSIONS: Single 19Gy and 13.5Gy×2 are both well tolerated. During the first 12months, urinary symptoms and erectile dysfunction are more common in the 2-fraction arm.