Standardized template for clinical reporting of PSMA PET/CT scans.

PURPOSE: Accurate diagnosis and staging of prostate cancer are crucial to improving patient care. Prostate-specific membrane antigen (PSMA)-targeted positron emission tomography with computed tomography (PET/CT) imaging has demonstrated superiority for initial staging and restaging in patients with prostate cancer. Referring physicians and PET/CT readers must agree on a consistent communication method and application of information derived from this imaging modality. While several guidelines have been published, a single PSMA PET/CT reporting template has yet to be widely adopted. Based on the consensus from community and academic physicians, we developed a standardized PSMA PET/CT reporting template for radiologists and nuclear medicine physicians to report and relay key imaging findings to referring physicians. The aim was to improve the quality, clarity, and utility of imaging results reporting to facilitate patient management decisions. METHODS: Based on community and expert consensus, we developed a standardized PSMA PET/CT reporting template to deliver key imaging findings to referring clinicians. RESULTS: Core category components proposed include a summary of any prior treatment history; presence, location, and degree of PSMA radiopharmaceutical uptake in primary and/or metastatic tumor(s), lesions with no uptake, and incidentally found lesions with positive uptake on PET/CT. CONCLUSIONS: This article provides recommendations on best practices for standardized reporting of PSMA PET/CT imaging. The generated reporting template is a proposed supplement designed to educate and improve data communication between imaging experts and referring physicians.

Prostate Cancer Recurrence: Examining the Role of Salvage Radiotherapy Field and Risk Factors for Regional Disease Recurrence Captured on 18F-DCFPyL PET/CT.

PURPOSE: The role of elective pelvic nodal irradiation in salvage radiotherapy (sRT) remains controversial. Utilizing 18F-DCFPyL PET/CT, this study aimed to investigate differences in disease distribution after whole pelvic (WPRT) or prostate bed (PBRT) radiotherapy and to identify risk factors for pelvic lymph node (LN) relapse. METHODS: This retrospective study included patients with PSA > 0.1 ng/mL post-radical prostatectomy (RP) or post-RP and sRT who underwent 18F-DCFPyL PET/CT. Disease distribution on 18F-DCFPyL PET/CT after sRT was compared using Chi-square tests. Risk factors were tested for association with pelvic LN relapse after RP and salvage PBRT using logistic regression. RESULTS: 979 18F-DCFPyL PET/CTs performed at our institution between 1/1/2022 - 3/24/2023 were analyzed. There were 246 patients meeting criteria, of which 84 received salvage RT after RP (post-salvage RT group) and 162 received only RP (post-RP group). Salvage PBRT patients (n = 58) had frequent pelvic nodal (53.6%) and nodal-only (42.6%) relapse. Salvage WPRT patients (n = 26) had comparatively lower rates of pelvic nodal (16.7%, p = 0.002) and nodal-only (19.2%, p = 0.04) relapse. The proportion of distant metastases did not differ between the two groups. Multiple patient characteristics, including ISUP grade and seminal vesicle invasion, were associated with pelvic LN disease in the post-RP group. CONCLUSION: At PSA persistence or progression, salvage WPRT resulted in lower rates of nodal involvement than salvage PBRT, but did not reduce distant metastases. Certain risk factors increase the likelihood of pelvic LN relapse after RP and can help inform salvage RT field selection.

Pilot Study Assessing Student Interest in Combined Residency Training Pathways With Radiation Oncology.

Purpose: Most medical students have limited exposure to radiation oncology (RO) before deciding which specialty to choose for residency. This may limit the number and diversity of RO applicants. The purpose of this study was to determine students' views on a combined pathway program of RO with internal medicine (IM), as well as other related medical specialties, as a potential means of overcoming barriers to interest in RO and the early decision point to solo training in a highly specialized field. Methods and Materials: In July to August 2022, all 299 United States student and postgraduate year 1 members of the American Society for Radiation Oncology were sent an electronic survey assessing their views on advantages and disadvantages of a combined IM/RO training pathway, and interest in several options of combined pathway programs. Results: Eighty participants completed the survey (response rate 27%). Thirty-four (43%) were very or extremely interested in IM/RO residency (median Likert-type rating 3, IQR 2-4). The most important potential advantages of an IM/RO pathway included greater flexibility in employment options (n = 51, 64%), enhanced general medical knowledge to facilitate ambitions in other career pathways (n = 46, 58%), improved patient care (n = 43, 54%), and having a pathway for combined hematologic/oncology and RO board certification (n = 46, 58%). In comparison to IM/RO, participants were significantly more interested in a combined RO and hematology/oncology program (median Likert-type rating 5, IQR 5-5, P = .005). Among the subgroup of 26 survey participants who believed it less likely they would apply for RO residency, 18 (69%) thought an IM/RO pathway would increase their interest in RO (median Likert-type rating 4, IQR 3-5). Interest in IM/RO did not differ by gender, race, or ethnicity. Conclusions: Combined training pathways involving RO were viewed positively by survey respondents, and may be particularly appealing to those less committed to a career in RO. Further research will help guide recommendations for the creation of these programs.

Recent Trends in "Manels" and Gender Representation Among Panelists at North American Annual Radiation Oncology Meetings.

PURPOSE: Achieving gender equity in radiation oncology is an important goal, as a smaller proportion of women enter radiation oncology residency compared with those graduating from medical school. As invited speaking opportunities at academic medical conferences are vital for promotion/tenure, we investigated the prevalence of all-men panels ("manels") at American Society for Radiation Oncology (ASTRO) and Canadian Society of Radiation Oncology (CARO) annual meetings. METHODS AND MATERIALS: Using ASTRO and CARO online meeting programs, 2018 to 2021 faculty information was obtained, including gender, panel role (chair vs nonchair), type of session, and topic. Primary outcomes included percentage of manels and proportion of female panelists over time. Representation of women among chairs was also evaluated. RESULTS: Over the 4-year study period across both conferences, a total of 765 panel sessions were held with 2973 faculty members, of whom 1287 (43.3%) were women. Of these sessions, 127 of 765 (16.6%) were manels. ASTRO meetings had 1169 of 2742 (42.6%) female faculty members and held 107 of 680 (15.7%) manels, whereas CARO meetings had 118 of 231 (51.1%) female faculty and held 20 of 85 manels (23.5%). From 2018 to 2021, the proportion of manels decreased at ASTRO and CARO meetings from 25.6% to 8.2% (P < .001) and from 29.6% to 15.0% (P = .130), respectively. The role of chair was majority male in every year from 2018 to 2021 at ASTRO meetings (58.6% overall), but more balanced at CARO meetings (48.0% overall). Among session types, the highest proportion of manels was observed for scientific sessions (19.1%, P = .011) at ASTRO meetings and leadership sessions (29.4%, P = .533) at CARO meetings. The lowest proportion of female panelists was on genitourinary cancer topics at ASTRO meetings (31.9%, P = .018) and physics topics at CARO meetings (40.4%, P = .085). CONCLUSIONS: During the study period, the proportion of female panelists increased with a corresponding decrease in manels. ASTRO and CARO should strive for further involvement of women and the elimination of manels whenever possible.

Evaluating an Academic Radiation Oncology Position.

What are the factors that physicians could consider in an academic radiation oncology practice job offer? In this minireview, we discuss how prospective academic faculty could evaluate the "big 3" domains: (1) the compensation, including the direct and indirect payments; (2) the daily job, including aspects of the clinic, research, and education; and (3) the location, including geography, atmosphere, environment, and culture. If a prospective academic radiation oncologist believes that the academic practice is "great" in at least 2 of the 3 and "good" in the remaining 1, then they should likely sign the contract.

Approach to Patients with High-Risk Localized Prostate Cancer: Radiation Oncology Perspective.

OPINION STATEMENT: High-risk localized prostate cancer is a challenging clinical entity to treat, with heterogeneous responses to an evolving array of multidisciplinary treatment approaches. In addition, this disease state is growing in incidence due to a variety of factors, including shifting recommendations that discouraged routine prostate cancer screening. Current guidelines now incorporate an informed decision-making process for prostate cancer screening and evaluation. More work is underway to improve targeted screening for certain at-risk populations and to implement greater personalization in the use of diagnostic tools. Once diagnosed with high-risk localized disease, a multimodality treatment paradigm is warranted. Radiation-in its various forms and combinations-plays a large and continually evolving role in the management of high-risk prostate cancer, yet treatment outcomes are still suboptimal. There is a growing need to improve upon current treatment approaches, and better personalize a particular treatment recommendation based on both tumor and patient characteristics, as well as patient preference and goals of therapy. Given that treatment generally requires more than one therapy, there are notable implications on long-term quality of life, especially with respect to overlapping and cumulative side effects of local and systemic therapies, respectively. The desire for aggressive therapy to optimize cancer control outcomes must be weighed against the risk of morbidities and overtreatment and discussed with each patient so that an informed decision about treatment and care can be determined. High-level evidence to support treatment recommendations, where available, is critical for a data-driven and tailored approach to address all goals of care.

Radiation Therapy Summary of the AUA/ASTRO Guideline on Clinically Localized Prostate Cancer.

PURPOSE: Our purpose was to develop a summary of recommendations regarding the management of patients with clinically localized prostate cancer based on the American Urologic Association/ ASTRO Guideline on Clinically Localized Prostate Cancer. METHODS: The American Urologic Association and ASTRO convened a multidisciplinary, expert panel to develop recommendations based on a systematic literature review using an a priori defined consensus-building methodology. The topics covered were risk assessment, staging, risk-based management, principles of management including active surveillance, surgery, radiation, and follow-up after treatment. Presented are recommendations from the guideline most pertinent to radiation oncologists with an additional statement on health equity, diversity, and inclusion related to guideline panel composition and the topic of clinically localized prostate cancer. SUMMARY: Staging, risk assessment, and management options in prostate cancer have advanced over the last decade and significantly affect shared decision-making for treatment management. Current advancements and controversies discussed to guide staging, risk assessment, and treatment recommendations include the use of advanced imaging and tumor genomic profiling. An essential active surveillance strategy includes prostate-specific antigen monitoring and periodic digital rectal examination with changes triggering magnetic resonance imaging and possible biopsy thereafter and histologic progression or greater tumor volume prompting consideration of definitive local treatment. The panel recommends against routine use of adjuvant radiation therapy (RT) for patients with prostate cancer after prostatectomy with negative nodes and an undetectable prostate-specific antigen, while acknowledging that patients at highest risk of recurrence were relatively poorly represented in the 3 largest randomized trials comparing adjuvant RT to early salvage and that a role may exist for adjuvant RT in selected patients at highest risk. RT for clinically localized prostate cancer has evolved rapidly, with new trial results, therapeutic combinations, and technological advances. The recommendation of moderately hypofractionated RT has not changed, and the updated guideline incorporates a conditional recommendation for the use of ultrahypofractionated treatment. Health disparities and inequities exist in the management of clinically localized prostate cancer across the continuum of care that can influence guideline concordance.

Trajectories and predictors of high-occurrence pain flares in ambulatory cancer patients on opioids.

BACKGROUND: Pain flares have a substantive impact on the quality of life and well-being of patients with cancer. We identified longitudinal trajectories (clusters) of cancer pain flares in ambulatory patients and sociodemographic and clinical predictors of these trajectories. METHODS: In a prospective cohort study using ecological momentary assessment (mEMA), we collected patient-reported daily pain flare ratings data over 5 months and identified predictors and correlates using validated measures. RESULTS: The mean age of the sample (N = 270) was 60.9 years (SD = 11.2), 64.8% were female, and 32.6% self-identified as African American. Four pain flare clusters were identified. The "high-occurrence" cluster (23% of patients) experienced 5.5 (SD = 5.47) daily flares, whereas low-moderate clusters (77%) reported 2.4 (SD = 2.74) daily flares (P < .000). Those in the high-occurrence cluster reported higher pain scores (P = .000), increased pain-related interference (P = .000), depressive symptoms (P = .023), lower quality of life (P = .001), and reduced pain self-efficacy (P = .006). Notably, 67.2% of those prescribed opioids as needed (PRN only) were in the high-occurrence pain flare cluster, compared with 27.9% with PRN and around-the-clock opioid prescriptions (P = .024). Individual predictors of high-occurrence pain flares were income below $30 000, unemployment, being African American, lower education level, Medicaid insurance, current opioid misuse (COMM), baseline inpatient hospital stay duration, and PRN-only opioid regimen. In the multiple predictor model, lower education level, unemployment, COMM score, extended inpatient duration, and PRN-only opioid regimen remained significant. CONCLUSION: In ambulatory patients with cancer, high occurrence of pain flares may be mitigated by attention to opioid prescription factors and addressing social determinants of health needs of underserved patients.

ACR-ACNM-ARS-ASTRO-SNMMI Practice Parameter for the Performance of Therapy With Radiopharmaceuticals.

OBJECTIVES: This practice parameter was revised collaboratively by the American College of Radiology (ACR), the American College of Nuclear Medicine, the American Radium Society, the American Society for Radiation Oncology, and the Society of Nuclear Medicine and Molecular Imaging. The document is intended to serve as a resource for appropriately trained and licensed physicians who perform therapeutic procedures with unsealed sources, referred to in the document using the more inclusive terminology of radiopharmaceuticals, for which a written directive is required for authorized users under NRC 10 CFR 35.300. METHODS: This practice parameter was developed according to the process described under the heading The Process for Developing ACR Practice Parameters and Technical Standards on the ACR website ( https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards ) by the Committee on Practice Parameters-Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with the American Radium Society. RESULTS: This practice parameter addresses the overall role of the applicable physician-authorized user, Qualified Medical Physicist, and other specialized personnel involved in the delivery of radiopharmaceutical therapy. Therapeutic radiopharmaceuticals include those administered as elemental radioactive isotopes (radionuclides) or the radioactive element incorporated into a targeting molecule (ligand) by one or more chemical bonds. This document provides guidance regarding general principles of radionuclide therapies and indications of various alpha, beta, gamma, and mixed emission agents with references to several recent practice parameters on new and commonly performed radiopharmaceutical therapies. CONCLUSION: This document addresses clinical circumstances, elements of available agents, and the qualifications and responsibilities of various members of the radiation care team, specifications of consultation and other clinical documentation, post-therapy follow-up, radiation safety precautions, elements of quality control and improvement programs, infection control, and patient education to ensure optimal patient care and safety when utilizing radiopharmaceuticals.

A pooled patient-reported outcomes analysis of moderately hypofractionated proton beam therapy and photon-based intensity modulated radiation therapy for low- or intermediate-risk prostate cancer.

BACKGROUND: We sought to characterize and compare late patient-reported outcomes (PROs) after moderately hypofractionated intensity modulated radiation therapy (IMRT) and proton beam therapy (PBT) for localized prostate cancer (PC). METHODS: This multi-institutional analysis included low- or intermediate-risk group PC patients treated with moderately hypofractionated radiation to an intact prostate stratified by treatment modality: IMRT or PBT. The primary outcomes were prospectively collected patient-reported late gastrointestinal (GI) and genitourinary (GU) toxicity assessed by International Prostate Symptom Score (IPSS) and Expanded PC Index Composite (EPIC). Multivariable regression analysis (MVA) controlling for age, race, and risk group tested the effect of time, treatment, and their interaction. RESULTS: 287 IMRT and 485 PBT patients were included. Intermediate risk group (81.2 vs. 68.2%; p < 0.001) and median age at diagnosis (70 vs. 67 years; p < 0.001) were higher in the IMRT group. On MVA, there was no significant difference between modalities. PBT IPSS did not differ from IMRT IPSS at 12 months (odds ratio [OR], 1.19; p = 0.08) or 24 months (OR, 0.99; p = 0.94). PBT EPIC overall GI function at 12 months (OR, 3.68; p = 0.085) and 24 months (OR 2.78; p = 0.26) did not differ from IMRT EPIC overall GI function. At 24 months, urinary frequency was no different between PBT and IMRT groups (OR 0.35; p = 0.096). CONCLUSIONS: This multi-institutional analysis of low- or intermediate-risk PC treated with moderately hypofractionated PBT and IMRT demonstrated low rates of late patient-reported GI and GU toxicities. After covariate adjustment, late GI and GU PROs were not significantly different between PBT or IMRT cohorts.

Association of applicant demographic factors with medical school acceptance.

BACKGROUND: Medical school acceptance rates in the United States (US) have been lower for applicants who identify as Underrepresented-in-Medicine (UiM) compared to non-UiM applicants. The gap between UiM and no-UiM groups is narrowing in recent years. Less well-studied are associations of acceptance decisions with family income and parental education. This study's purpose is to evaluate the relationships between medical school acceptance and family income, parental education status, racial/ethnic background, Grade Point Average (GPA), Medical College Admission Test (MCAT) score, and participation in extracurricular activities. METHODS: This is a cross-sectional study of first-time US medical school applicants between 2017 and 2020. Acceptance rates for first-time applicants were calculated for first-generation (FG), low-income (LI), and UiM applicants. Associations of these attributes with MCAT scores, science GPAs, and seven categories of extracurricular activities were evaluated. Regression analyses estimated associations between acceptance to medical school with all variables with and without interaction terms (FG*URM, LI*URM, FG*LI). RESULTS: The overall acceptance rate for first-time applicants from 2017-2020 was 45.3%. The acceptance rates among FG, LI and UiM applicants were 37.9%, 39.6% and 44.2%, respectively. In univariable logistic regression analyses, acceptance was negatively associated with being FG (OR: 0.68, CI: 0.67-0.70), LI (OR: 0.70, CI: 0.69-0.72), and UiM (OR: 0.95, CI: 0.93-0.97). In multivariable regression, acceptance was most strongly associated with science GPA (OR: 7.15, CI: 6.78-7.54 for the highest quintile) and UiM (OR: 5.56, CI: 5.48-5.93) status and MCAT score (OR: 1.19, CI: 1.18-1.19), FG (OR: 1.14, CI: 1.10-1.18), and most extracurricular activities. Including interaction terms revealed a negative association between acceptance and LI (OR:0.90, CI: 0.87-0.94) and FG was no longer significant (OR:1.10, CI:0.96-1.08). CONCLUSIONS: Collectively these results suggest medical school admissions committees may be relying on holistic admission practices. While MCAT and GPA scores continue to predict acceptance, individuals from racially and ethnically UiM backgrounds have favorable odds of acceptance when controlling for MCAT and GPA. However, these positive associations were not seen for low-income and first-generation applicants. Additional preparation for college and the MCAT for these latter groups may help further diversify the medical profession.