Development of Web-Based Education Modules to Improve Carer Engagement in Cancer Care: Design and User Experience Evaluation of the e-Triadic Oncology (eTRIO) Modules for Clinicians, Patients, and Carers.

BACKGROUND: Carers often assume key roles in cancer care. However, many carers report feeling disempowered and ill-equipped to support patients. Our group published evidence-based guidelines (the Triadic Oncology [TRIO] Guidelines) to improve oncology clinician engagement with carers and the management of challenging situations involving carers. OBJECTIVE: To facilitate implementation of the TRIO Guidelines in clinical practice, we aimed to develop, iteratively refine, and conduct user testing of a suite of evidence-based and interactive web-based education modules for oncology clinicians (e-Triadic Oncology [eTRIO]), patients with cancer, and carers (eTRIO for Patients and Carers [eTRIO-pc]). These were designed to improve carer involvement, communication, and shared decision-making in the cancer management setting. METHODS: The eTRIO education modules were based on extensive research, including systematic reviews, qualitative interviews, and consultation analyses. Guided by the person-based approach, module content and design were reviewed by an expert advisory group comprising academic and clinical experts (n=13) and consumers (n=5); content and design were continuously and iteratively refined. User experience testing (including "think-aloud" interviews and administration of the System Usability Scale [SUS]) of the modules was completed by additional clinicians (n=5), patients (n=3), and carers (n=3). RESULTS: The final clinician module comprises 14 sections, requires approximately 1.5 to 2 hours to complete, and covers topics such as carer-inclusive communication and practices; supporting carer needs; and managing carer dominance, anger, and conflicting patient-carer wishes. The usability of the module was rated by 5 clinicians, with a mean SUS score of 75 (SD 5.3), which is interpreted as good. Clinicians often desired information in a concise format, divided into small "snackable" sections that could be easily recommenced if they were interrupted. The carer module features 11 sections; requires approximately 1.5 hours to complete; and includes topics such as the importance of carers, carer roles during consultations, and advocating for the patient. The patient module is an adaptation of the relevant carer module sections, comprising 7 sections and requiring 1 hour to complete. The average SUS score as rated by 6 patients and carers was 78 (SD 16.2), which is interpreted as good. Interactive activities, clinical vignette videos, and reflective learning exercises are incorporated into all modules. Patient and carer consumer advisers advocated for empathetic content and tone throughout their modules, with an easy-to-read and navigable module interface. CONCLUSIONS: The eTRIO suite of modules were rigorously developed using a person-based design methodology to meet the unique information needs and learning requirements of clinicians, patients, and carers, with the goal of improving effective and supportive carer involvement in cancer consultations and cancer care.

An online intervention to improve oncology health professional self-efficacy in communicating with carers: Hybrid effectiveness-implementation evaluation of the eTRIO program.

OBJECTIVES: Many oncology health professionals (HPs) report communicating with carers as complex; and receive limited carer-relevant training. We developed an online HP education program for supporting and managing carer involvement (eTRIO). We aimed to assess whether HPs' self-efficacy in carer communication, knowledge, and decision-making preferences improve following eTRIO. Satisfaction and implementation potential were assessed. METHODS: This type 1 hybrid effectiveness-implementation study used a pre-post single arm intervention design. HPs completed baseline measures, the eTRIO online module, and measures at 1- and 12-weeks post-intervention. Measures included: self-efficacy in carer communication (13-items), applied knowledge (7-items), preference for carer involvement in decisions (1-item). Fifteen of participants completed feedback interviews which underwent thematic analysis. User analytics were collected and analysed. RESULTS: Fifty-six HPs completed baseline measures, 42 completed post- and follow-up measures. At baseline mean self-efficacy score was 88. HPs showed a statistically significant increase in self-efficacy post-intervention (mean = 105.8, CI [12.99, 20.47]), maintained at 12-weeks (mean = 101.1, CI [8.00, 15.72]). There were no changes in knowledge or decision-making preferences. Program engagement and satisfaction were high, 86.7% participants rated eTRIO as very/extremely helpful. CONCLUSIONS AND PRACTICE IMPLICATIONS: eTRIO provided HPs with confidence to effectively engage with carers and manage complex situations such as family dominance. These gains are noteworthy, as conflict with families/carers contributes to HP burnout.

Development and dissemination of structured hashtags for radiation oncology: Two-Year trends.

Purpose: For radiation oncology, social media is a favored communication platform, but it uses non-structured hashtags, which limits communication. In this work, we created a set of structured hashtags with key opinion leaders in radiation oncology, and we report on their use after two years post-deployment. Materials/Methods: Hashtags were created, voted on, and refined by crowdsourcing 38 international experts, including physicians, physicists, patients, and organizations from North America, Europe, and Australia. The finalized hashtag set was shared with the radiation oncology community in September 2019. The number of tweets for each hashtag was quantified via Symplur through December 2021. For the top five tweeted hashtags, we captured the number of yearly tweets in the pre-deployment and post-deployment periods from 09/01/2019 to 08/31/2021. Results: The initial 2019 list contained 39 hashtags organized into nine categories. The top five hashtags by total number of tweets were: #Radonc, #PallOnc, #MedPhys, #SurvOnc, and #SuppOnc. Six hashtags had less than 10 total tweets and were eliminated. Post-deployment, there was an increase in the yearly tweets, with the following number of tweets by the second year post-deployment: #RadOnc (98,189 tweets), #MedPhys (15,858 tweets), and #SurvOnc (6,361 tweets). Two popular radiation oncology-related hashtags were added because of increased use: #DEIinRO (1,603 tweets by year 2) and #WomenWhoCurie (7,212 tweets by year 2). Over the two years, hashtags were used mostly by physicians (131,625 tweets, 34.8%). Conclusion: We created and tracked structured social media hashtags in radiation oncology. These hashtags disseminate information among a diverse oncologic community. To maintain relevance, regular updates are needed.

Gender diversity and leadership in Radiation Oncology in Australia and New Zealand.

INTRODUCTION: There has been a groundswell of discussion and activism surrounding gender diversity. Given the growing importance of this issue, a working group was established under the Faculty of Radiation Oncology (FRO) of the Royal Australian and New Zealand College of Radiologists' (RANZCR) Economics and Workforce Committee (EWC) to review the current status of gender diversity within radiation oncology (RO) in Australia and New Zealand. METHODS: De-identified data were provided from two recent FRO workforce censuses conducted in 2014 and 2018 with permission from the EWC. Further data were provided via direct correspondence with staff at the RANZCR and the Trans-Tasman Radiation Oncology Group (TROG), the major RO research group in Australasia. The data were collated in February 2021. RESULTS: Our results showed that compared to females, male radiation oncologists were more likely to be engaged in full-time active clinical work, hold a postgraduate degree and obtain a consultant or fellowship position following graduation. Male fellows were more likely to have leadership positions within RANZCR and TROG and self-identify as holding any leadership position. The 2018 census revealed that within the trainee cohort, there was almost an equal number of male and female trainees as well as an equal number of male and female trainees holding a postgraduate degree. CONCLUSION: This review is an important first exploration into gender diversity across Australia and New Zealand's RO workforce. Whilst our study indicates that gender disparities exist, there are some indications that this may be equalizing out over time.

Dual-energy x-ray absorptiometry assessment of bone health in Australian men with prostate cancer commencing androgen deprivation therapy.

OBJECTIVE: To determine the prevalence in Australia of bone health assessment of men with prostate cancer by dual-energy x-ray absorptiometry (DXA), from six months before to twelve months after initiation of androgen deprivation therapy (ADT). DESIGN, SETTING: Cross-sectional national study; linkage of de-identified Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data. PARTICIPANTS: Men (18 years or older) first dispensed PBS-subsidised ADT during 1 May 2017 - 31 July 2020. MAIN OUTCOME MEASURES: Prevalence of MBS-subsidised DXA assessments undertaken from six months before to twelve months after first ADT prescription. RESULTS: Of 33 836 men with prostate cancer commencing ADT therapy during 2017-20, 6683 (19.8%) underwent DXA bone heath assessments between six months before and twelve months after commencing ADT; the mean time from first ADT dispensing to DXA scanning was +90 days (standard deviation, 134 days). The proportion of men aged 54 years or younger who had scans (66 of 639, 10%) was smaller than that of men aged 70-84 years (4528 of 19 378, 23.4%; adjusted odds ratio, 0.36; 95% CI, 0.28-0.47). CONCLUSIONS: For about 80% of men with prostate cancer commencing ADT in Australia, therapy initiation was not accompanied by DXA assessment of bone health. Given the excellent long term prognosis for men with prostate cancer and the availability of bone protective therapy, bone health monitoring should be a routine component of prostate cancer care for men receiving ADT.

The dosimetric error due to uncorrected tumor rotation during real-time adaptive prostate stereotactic body radiation therapy.

BACKGROUND: During prostate stereotactic body radiation therapy (SBRT), prostate tumor translational motion may deteriorate the planned dose distribution. Most of the major advances in motion management to date have focused on correcting this one aspect of the tumor motion, translation. However, large prostate rotation up to 30° has been measured. As the technological innovation evolves toward delivering increasingly precise radiotherapy, it is important to quantify the clinical benefit of translational and rotational motion correction over translational motion correction alone. PURPOSE: The purpose of this work was to quantify the dosimetric impact of intrafractional dynamic rotation of the prostate measured with a six degrees-of-freedom tumor motion monitoring technology. METHODS: The delivered dose was reconstructed including (a) translational and rotational motion and (b) only translational motion of the tumor for 32 prostate cancer patients recruited on a 5-fraction prostate SBRT clinical trial. Patients on the trial received 7.25 Gy in a treatment fraction. A 5 mm clinical target volume (CTV) to planning target volume (PTV) margin was applied in all directions except the posterior direction where a 3 mm expansion was used. Prostate intrafractional translational motion was managed using a gating strategy, and any translation above the gating threshold was corrected by applying an equivalent couch shift. The residual translational motion is denoted as T r e s $T_{res}$ . Prostate intrafractional rotational motion R u n c o r r $R_{uncorr}$ was recorded but not corrected. The dose differences from the planned dose due to T r e s $T_{res}$ + R u n c o r r $R_{uncorr}$ , ΔD( T r e s $T_{res}$ + R u n c o r r $R_{uncorr}$ ) and due to T r e s $T_{res}$ alone, ΔD( T r e s $T_{res}$ ), were then determined for CTV D98, PTV D95, bladder V6Gy, and rectum V6Gy. The residual dose error due to uncorrected rotation, R u n c o r r $R_{uncorr}$ was then quantified: Δ D R e s i d u a l $\Delta D_{Residual}$ = ΔD( T r e s $T_{res}$ + R u n c o r r $R_{uncorr}$ ) - ΔD( T res ${T}_{\textit{res}}$ ). RESULTS: Fractional data analysis shows that the dose differences from the plan (both ΔD( T r e s $T_{res}$ + R u n c o r r $R_{uncorr}$ ) and ΔD( T r e s $T_{res}$ )) for CTV D98 was less than 5% in all treatment fractions. ΔD( T r e s $T_{res}$ + R u n c o r r $R_{uncorr}$ ) was larger than 5% in one fraction for PTV D95, in one fraction for bladder V6Gy, and in five fractions for rectum V6Gy. Uncorrected rotation, R u n c o r r $R_{uncorr}$ induced residual dose error, Δ D R e s i d u a l $\Delta D_{Residual}$ , resulted in less dose to CTV and PTV in 43% and 59% treatment fractions, respectively, and more dose to bladder and rectum in 51% and 53% treatment fractions, respectively. The cumulative dose over five fractions, ∑D( T r e s $T_{res}$ + R u n c o r r $R_{uncorr}$ ) and ∑D( T r e s $T_{res}$ ), was always within 5% of the planned dose for all four structures for every patient. CONCLUSIONS: The dosimetric impact of tumor rotation on a large prostate cancer patient cohort was quantified in this study. These results suggest that the standard 3-5 mm CTV-PTV margin was sufficient to account for the intrafraction prostate rotation observed for this cohort of patients, provided an appropriate gating threshold was applied to correct for translational motion. Residual dose errors due to uncorrected prostate rotation were small in magnitude, which may be corrected using different treatment adaptation strategies to further improve the dosimetric accuracy.

A new wave of leaders: Early evaluation of the interdisciplinary Foundations of Leadership in Radiation Oncology (FLiRO) program.

Purpose: Effective leadership across all areas of radiation oncology (RO) is vital to fully realise the benefits of radiation therapy in cancer care. We report outcomes of a novel interdisciplinary leadership program designed for RO professionals under a global joint society initiative. Methods: The Foundations of Leadership in RO (FLiRO) program was designed for aspiring RO leaders. Initially delivered in a blended learning format, it was adapted to fully virtual in 2021. It comprised a webinar tutorial, on-line modules and homework followed by 'live' in-person/virtual workshops over an approximately 6-week period. Topics included personal awareness, effective teamwork, quality improvement skills, leading change and conflict management. An immediate post-program online survey was performed using Likert scales to measure self-reported educational value, interaction with others and the likely application of learning to practice. Open comments were invited. Results: 170 participants from 36 countries and 6 continents took part from 2018 to 2021 (99 doctors, 36 physicists, 32 radiation therapists/RTTs and 3 others). 141 (83%) participants responded to the post-program survey. Average weightings for responders' views on whether pre-determined learning objectives were met ranged from 4.30 to 4.61 on a 5-point scale (1 = 'not met at all' and 5 = completely met). For the question addressing potential value of learning for application to their workplace, 124 of 130 (95%) of responders indicated that FLIRO would be 'very useful' or 'extremely useful'. Conclusion: Initial evaluation of the FLiRO program supports its continuation and expansion with ongoing evolution based on emerging evidence around leadership education and participant feedback.

An International Expert Delphi Consensus to Develop Dedicated Geriatric Radiation Oncology Curriculum Learning Outcomes.

PURPOSE: The management of older adults with cancer is rapidly becoming a significant challenge in radiation oncology (RO) practice. The education of future radiation oncologists in geriatric oncology is fundamental to ensuring that older adults receive high-quality care. Currently RO trainees receive little training and education in geriatric oncology. The objective of this study was to define core geriatric RO curriculum learning outcomes relevant to RO trainees worldwide. METHODS AND MATERIALS: A 2-stage modified Delphi consensus was conducted. Stage 1 involved the formation of an expert reference panel (ERP) of multiprofessional experts in geriatric oncology and/or RO and the compilation of a potential geriatric RO learning outcomes set. Stage 2 involved 3 iterative rounds: round 1 and round 2 (both online surveys), and an intervening ERP round. These aimed at identifying and refining ideal geriatric RO learning outcomes. Invited participants for round 1 and 2 included oncology health care professionals with expertise across RO, geriatric oncology, and/or education and consumers. Predefined Delphi consensus definitions were applied to the results of rounds 1 and 2. RESULTS: An ERP of 11 experts in geriatric oncology and/or RO was formed. Seventy potential knowledge- and skill-based learning outcomes were identified. In round 1, 103 of 179 invited eligible Delphi participants completed the survey (58% response rate). The ERP round was conducted, resulting in the exclusion of 28 learning outcomes. In round 2, 54 of 103 completed the survey (52% response rate). This identified a final total of 33 geriatric RO learning outcomes. CONCLUSIONS: The geriatric RO learning outcomes described in this study form an international consensus that can inform RO training bodies worldwide. This represents the first fundamental step in developing a global educational framework aimed at improving RO trainee knowledge and skills in geriatric oncology.

Improving medical student education in radiation oncology: Integrating and evaluating an experiential interdisciplinary workshop into the medical student curriculum.

INTRODUCTION: To evaluate a novel interactive educational workshop designed to improve medical student knowledge and awareness of radiation oncology (RO). METHOD: A 2.5-h pilot workshop in RO was introduced in 2018 for one teaching hospital cohort of postgraduate medical students. Students participated in a voluntary interactive programme of learning 'stations' situated in the RO department, introducing students to practical aspects of RO planning, delivery and patient care. Students were surveyed before and immediately after the workshop to assess their perceptions of its educational value and the impact on RO knowledge and awareness. RESULTS: Forty-four of 51 students participated in the RO workshop with 44 students (100%) completing the preworkshop survey and 38 students completing postworkshop survey (86%). Twenty-three of 44 students had prior RO teaching, and 11/23 students (48%) had received between 30 and 60 min of teaching with only 4/44 (9%) confident in their knowledge of RO. Following the workshop, 22/38 (58%) felt their knowledge now met expectations for their level of training. Preworkshop, objective RO knowledge was low, regarding optimal use of RT (25%) and bone pain response (41%) and improved to 100% and 86% respectively. Overall, feedback around workshop value was highly positive with regard to enjoyment (97%) and students commented on the enthusiasm and multidisciplinarity of teachers. CONCLUSION: There remain large gaps in medical student knowledge and confidence in RO, and intervention is necessary to address these discrepancies. A novel interactive RO workshop for medical students has demonstrated improved awareness and knowledge with high levels of self-reported learner satisfaction.

Improving the Education of Radiation Oncology Professionals in Geriatric Oncology: Where Are We and Where Should We Be?

As the global population ages, the care of older adults with cancer is increasingly recognised as a growing challenge in oncology practice worldwide. At present, outcomes for older adults with cancer are worse than younger counterparts. The need for improved clinician education around geriatric oncology is internationally recognised as being fundamental to addressing this problem. Radiation therapy represents an excellent localised treatment modality for older adults due to its limited systemic toxicity, especially in circumstances in which surgery and chemotherapy are deemed inappropriate. Thus, the education of future radiation oncologists and other radiation oncology professionals (including radiation therapists, nurses, and physicists) in geriatric oncology is crucial to ensuring the complex needs of this patient population are met. However, evidence shows that within the specialty of radiation oncology, knowledge levels around key concepts in geriatric oncology are low and there is limited educational focus on the specific issues important for the care of older adults. An evidence-based, global approach to improving radiation oncology professionals' knowledge and clinical practice in geriatric oncology is needed to provide optimal care for older adults undergoing radiation therapy. This article provides an overview of the current status of geriatric oncology training and education in the specialty of radiation oncology and future directions to improve the knowledge and skills of radiation oncology professionals in caring for older adults.

Rapid Adaptation of Cancer Education in Response to the COVID-19 Pandemic: Evaluation of a Live Virtual Statistics and Research Skills Workshop for Oncology Trainees.

Due to COVID-19, an annual interactive statistics and research methodology workshop for radiation oncology trainees was adapted at short notice into a live virtual format. This study aimed to evaluate trainee opinions around the educational value of the workshop, logistical aspects and impact on interactivity. A post-course on-line survey was completed by 26/42 trainee attendees (response rate 62%). For five pre-specified learning outcomes (LO), 58 to 69% of trainees agreed that the LO was completely or largely met (Likert scores 6 and 7 on a scale 1 = not met at all; 7 = completely met). All trainees felt that logistical aspects of the workshop including organisation, accessibility to the platform and sound/image quality were good or excellent. With regard to opportunities for interaction and suitability for small-group 'break-out' sessions, the majority felt that interaction could be adequately maintained whilst just under a quarter felt the delivery method was not fit for the purpose. Networking/social engagement with peers and teachers was the factor most impaired using the live virtual delivery format. Over three-quarters of trainees replied they would favour the current event or other educational sessions being offered (at least as an option) in a virtual format in the future. Cost and convenience were given as the major non-COVID-19-related benefits of virtual on-line learning. These preliminary findings provide valuable feedback to help adapt or develop further on-line educational and training initiatives that will be necessary in the COVID-19 pandemic period and beyond.

Integrating Leadership Development Into Radiation Oncology Training: A Qualitative Analysis of Resident Interviews.

PURPOSE: Radiation oncologists need to have more than sound clinical and technical competencies. To optimize care for patients and advance all aspects of radiation oncology (RO), radiation oncologists must also be effective leaders. Embedding systematic leadership education into RO training programs is challenging. This study examined RO residents' perspectives and preferences relating to leadership education. Such data inform the integration of universal leadership learning into RO training in Australia and New Zealand and identify priority areas to facilitate successful leadership development initiatives in RO training programs worldwide. METHODS AND MATERIALS: Semistructured telephone interviews were conducted with 13 RO residents across 8 Australian training departments and all stages of training. Data from transcriptions of taped interviews were coded by at least 2 researchers and collected to saturation. Qualitative thematic analysis was conducted using an iterative inductive process to develop codes into themes and subthemes. Representative quotes were collated to illustrate subthemes. RESULTS: Four key themes related to leadership education were identified and labeled as follows: (1) recognition, credibility, and value of education; (2) logistics of formal learning; (3) real-world opportunities ("seeing and doing"); and (4) one size does not fit all. Residents unanimously reported that formal leadership education was important and that aspects of becoming a good leader could be learned. Organizational and cultural factors emerged as either barriers or facilitators to learning. There was strong support for interactive methods of learning, and role-modeling by senior colleagues was identified as having a major effect on junior learners. CONCLUSIONS: This study offers insight into RO residents' perspectives of and preferences for their own leadership development. The findings have practical implications for the design of effective RO leadership programs and bring the RO field one step closer to the ultimate goal of enhancing leadership capability for all RO professionals.

Patterns of care and outcomes of men with germ cell tumors in a high-volume Australian center.

AIM: To evaluate disease presentation, treatment practices, and outcomes of patients with germ cell tumor (GCT) treated in a high-volume cancer center in Australia. METHODS: This is a retrospective analysis of 609 patients diagnosed with GCT in the Sydney West Cancer Network between 1990 and 2013. Cause and date of death, and second malignancy information was sourced from The Centre for Health Record Linkage. RESULTS: The median age was 33 years (range, 14-85). Primary site was testis in 590 (96.9%), mediastinum in nine (1.5%), and retroperitoneum in nine (1.5%). History of undescended testis was present in 48 (7.9%). Pure seminoma was seen in 334 (54.8%), with 274 (82.0%) being stage I. There was a decline in use of adjuvant radiotherapy from 83% in 1990-1997 to 29% in 2006-2013. Nonseminoma GCT (NSGCT) was diagnosed in 275 (45.2%), with 162 (58.9%) being stage 1. Active surveillance has increased as the initial treatment, from 58% between 1990 and 1997 to 89% between 2006 and 2013. Metastatic disease at presentation was seen in 162 (26.6%): 55 (34.0%) seminoma and 107 (66.0%) NSGCT. With median of 15-year follow-up, 18 (3.0%) have died from GCT and 70 (11.5%) from all causes. Ten-year overall survival was 93% and GCT-specific survival was 97%. Forty patients developed a secondary malignancy, with 38 receiving chemotherapy, radiotherapy, or both. CONCLUSIONS: This large Australian series illustrates a changing pattern of care and outcomes and compares them favorably with other series. This serves as a basis for future comparison of outcomes for this malignancy.

An Expert Review on the Combination of Relugolix With Definitive Radiation Therapy for Prostate Cancer.

Androgen deprivation therapy (ADT) is an integral component in the management of prostate cancer across multiple disease states. Traditionally, luteinizing hormone-releasing hormone (LHRH) agonists constituted the backbone of ADT. However, gonadotropin-releasing hormone receptor hormone (GnRH) antagonists also are available, which offer faster testosterone suppression and reduced likelihood of ADT-related adverse effects compared with LHRH agonists, including the potential for fewer ADT-associated major cardiac events. Until recently, all forms of LHRH agonists and GnRH antagonist formulations were of parenteral administration. However, recently relugolix gained Food and Drug Administration approval as the first oral GnRH antagonist. Relugolix achieves faster and more complete testosterone suppression compared with an LHRH agonist. This translates to more rapid prostate-specific antigen response compared with LHRH agonists. After discontinuation of relugolix, testosterone recovers faster than after GnRH agonists or injectable GnRH antagonist therapy. Overall, these factors provide opportunities for more precisely defined ADT duration when combined with radiation therapy. The rapid onset and offset of testosterone suppression with relugolix may require physicians to rethink the mechanism and goals of ADT when prescribing. As an oral formulation, relugolix enables patients to avoid pain and injection site reactions, limit extra office visits for injections, and achieve a shorter duration of experiencing the side effects of castrate testosterone levels. This convenience and tolerability may enhance physicians' willingness to prescribe ADT and patients' feeling of control during their ADT course, but the potential advantages are accompanied by the risks of patients choosing to discontinue therapy to escape side effects of ADT. This article focuses on different aspects of what is known and unknown regarding the optimal use of ADT and radiation therapy, and how relugolix, due to its properties, fit into our current treatment paradigms for localized prostate cancer.

Evaluation of Hypofractionated Radiation Therapy Use and Patient-Reported Outcomes in Men With Nonmetastatic Prostate Cancer in Australia and New Zealand.

Importance: Randomized clinical trials in prostate cancer have reported noninferior outcomes for hypofractionated radiation therapy (HRT) compared with conventional RT (CRT); however, uptake of HRT across jurisdictions is variable. Objective: To evaluate the use of HRT vs CRT in men with nonmetastatic prostate cancer and compare patient-reported outcomes (PROs) at a population level. Design, Setting, and Participants: Registry-based cohort study from the Australian and New Zealand Prostate Cancer Outcomes Registry (PCOR-ANZ). Participants were men with nonmetastatic prostate cancer treated with primary RT (excluding brachytherapy) from January 2016 to December 2019. Data were analyzed in March 2021. Exposures: HRT defined as 2.5 to 3.3 Gy and CRT defined as 1.7 to 2.3 Gy per fraction. Main Outcomes and Measures: Temporal trends and institutional, clinicopathological, and sociodemographic factors associated with use of HRT were analyzed. PROs were assessed 12 months following RT using the Expanded Prostate Cancer Index Composite (EPIC)-26 Short Form questionnaire. Differences in PROs were analyzed by adjusting for age and National Comprehensive Cancer Network risk category. Results: Of 8305 men identified as receiving primary RT, 6368 met the inclusion criteria for CRT (n = 4482) and HRT (n = 1886). The median age was 73.1 years (IQR, 68.2-77.3 years), 2.6% (168) had low risk, 45.7% (2911) had intermediate risk, 44.5% (2836) had high-/very high-risk, and 7.1% (453) had regional nodal disease. Use of HRT increased from 2.1% (9 of 435) in the first half of 2016 to 52.7% (539 of 1023) in the second half of 2019, with lower uptake in the high-/very high-risk (1.9% [4 of 215] to 42.4% [181 of 427]) compared with the intermediate-risk group (2.2% [4 of 185] to 67.6% [325 of 481]) (odds ratio, 0.26; 95% CI, 0.15-0.45). Substantial variability in the use of HRT for intermediate-risk disease remained at the institutional level (median 53.3%; range, 0%-100%) and clinician level (median 57.9%; range, 0%-100%) in the last 2 years of the study period. There were no clinically significant differences across EPIC-26 urinary and bowel functional domains or bother scores. Conclusions and Relevance: In this cohort study, use of HRT for prostate cancer increased substantially from 2016. This population-level data demonstrated clinically equivalent PROs and supports the continued implementation of HRT into routine practice. The wide variation in practice observed at the jurisdictional, institutional, and clinician level provides stakeholders with information that may be useful in targeting implementation strategies and benchmarking services.

eTRIO trial: study protocol of a randomised controlled trial of online education modules to facilitate effective family caregiver involvement in oncology.

OBJECTIVE: Informal family caregivers play a crucial role in cancer care. Effective caregiver involvement in cancer care can improve both patient and caregiver outcomes. Despite this, interventions improving the caregiver involvement are sparse. This protocol describes a randomised controlled trial evaluating the combined effectiveness of novel online caregiver communication education modules for: (1) oncology clinicians (eTRIO) and (2) patients with cancer and caregivers (eTRIO-pc). METHODS AND ANALYSIS: Thirty medical/radiation/surgical oncology or haematology doctors and nurses will be randomly allocated to either intervention (eTRIO) or control (an Australian State Government Health website on caregivers) education conditions. Following completion of education, each clinician will recruit nine patient-caregiver pairs, who will be allocated to the same condition as their recruiting clinician. Eligibility includes any new adult patient diagnosed with any type/stage cancer attending consultations with a caregiver. Approximately 270 patient-caregiver pairs will be recruited. The primary outcome is caregiver self-efficacy in triadic (clinician-patient-caregiver) communication. Patient and clinician self-efficacy in triadic communication are secondary outcomes. Additional secondary outcomes for clinicians include preferences for caregiver involvement, perceived module usability/acceptability, analysis of module use, satisfaction with the module, knowledge of strategies and feedback interviews. Secondary outcomes for caregivers and patients include preferences for caregiver involvement, satisfaction with clinician communication, distress, quality of life, healthcare expenditure, perceived module usability/acceptability and analysis of module use. A subset of patients and caregivers will complete feedback interviews. Secondary outcomes for caregivers include preparedness for caregiving, patient-caregiver communication and caring experience. Assessments will be conducted at baseline, and 1 week, 12 weeks and 26 weeks post-intervention. ETHICS AND DISSEMINATION: Ethical approval has been received by the Sydney Local Health District Human Research Ethics Committee (REGIS project ID number: 2019/PID09787), with site-specific approval from each recruitment site. Protocol V.7 (dated 1 September 2020) is currently approved and reported in this manuscript. Findings will be disseminated via presentations and peer-reviewed publications. Engagement with clinicians, media, government, consumers and peak cancer groups will facilitate widespread dissemination and long-term availability of the educational modules. TRIAL REGISTRATION NUMBER: ACTRN12619001507178.

Earth System Model Analysis of How Astronomical Forcing Is Imprinted Onto the Marine Geological Record: The Role of the Inorganic (Carbonate) Carbon Cycle and Feedbacks.

Astronomical cycles are strongly expressed in marine geological records, providing important insights into Earth system dynamics and an invaluable means of constructing age models. However, how various astronomical periods are filtered by the Earth system and the mechanisms by which carbon reservoirs and climate components respond, particularly in absence of dynamic ice sheets, is unclear. Using an Earth system model that includes feedbacks between climate, ocean circulation, and inorganic (carbonate) carbon cycling relevant to geological timescales, we systematically explore the impact of astronomically modulated insolation forcing and its expression in model variables most comparable to key paleoceanographic proxies (temperature, the δ13C of inorganic carbon, and sedimentary carbonate content). Temperature predominately responds to short and long eccentricity and is little influenced by the modeled carbon cycle feedbacks. In contrast, the cycling of nutrients and carbon in the ocean generates significant precession power in atmospheric CO2, benthic ocean δ13C, and sedimentary wt% CaCO3, while inclusion of marine sedimentary and weathering processes shifts power to the long eccentricity period. Our simulations produce reduced pCO2 and dissolved inorganic carbon (DIC) δ13C at long eccentricity maxima and, contrary to early Cenozoic marine records, CaCO3 preservation in the model is enhanced during eccentricity-modulated warmth. Additionally, the magnitude of δ13C variability simulated in our model underestimates marine proxy records. These model-data discrepancies hint at the possibility that the Paleogene silicate weathering feedback was weaker than modeled here and that additional organic carbon cycle feedbacks are necessary to explain the full response of the Earth system to astronomical forcing.