RENORT: a project to analyze patterns of care in radiation oncology in Spain.

PURPOSE: RENORT is an application (app) developed to assess the role of radiotherapy in the treatment of cancer using the oncology information systems (OIS). METHODS/PATIENTS: The RENORT app was used to analyze the data for all patients seen and/or treated at six radiation oncology departments in Spain in 2019. This app can be used to extract the demographic data, treatment sequence, disease status, and radiotherapy treatments from the ARIA and Mosaiq OIS. RESULTS: A total of 6564 treatments were performed at these six centers in 2019. Most patients (56.9%) were males (females 43.1%). The mean patient age was 64.9 years. The most common treatment types and sites were as follows: metastases/palliative care (25.9%), followed by breast (19.0%), genitourinary (13.7%), lung (10.1%), head and neck (6.0%), rectal (6.0%), gynecological (4.9%), and other (< 4%) cancers. Distribution by disease stage was as follows: breast cancer: 75.5% early stage (stages 0, I, and II); lung: 63.1% advanced stage (III and IV); and head and neck: 72.1% advanced. Treatment intent was curative in 76.5% of cases and palliative in 23.5%. The most common techniques were intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) (41.4%), followed by three-dimensional conformal radiation therapy (3D-CRT) (39.2%); stereotactic body radiotherapy (SBRT) (8.1%); brachytherapy (5.5%); radiosurgery (2.1%); fractionated stereotactic radiotherapy to the brain (1.4%); and intraoperative radiotherapy (1.4%). Hypofractionation was used in 62.3% of curative treatments (mean number of fractions = 16.5). CONCLUSIONS: RENORT is a free app that is available for the two main oncology information systems used in most radiation oncology departments. This app has demonstrated the capacity to extract data from these systems, which in turns allows for a comprehensive analysis and better understanding of the role of radiotherapy in the treatment of cancer.

Surface-guided radiation therapy for breast cancer: more precise positioning.

INTRODUCTION: Hypofractionated radiation therapy for breast cancer requires highly precise delivery through the use of image-guided radiotherapy (IGRT). Surface-guided radiation therapy (SGRT) is being increasingly used for patient positioning in breast radiotherapy. We aimed to assess the role of SGRT for verification of breast radiotherapy and the tumour bed. MATERIALS AND METHODS: Prospective study of 252 patients with early stage breast cancer. A total of 1170 determinations of daily positioning were performed. Breast surface positioning was determined with SGRT (AlignRT) and correlated with the surgical clips in the tumour bed, verified by IGRT (ExacTrac). RESULTS: SGRT improved surface matching by a mean of 5.3 points compared to conventional skin markers (98.0 vs. 92.7), a statistically significant difference (p < 0.01, Wilcoxon Test). For surface matching values > 95%, ≥ 3 clips coincided in 99.7% of the determinations and all markers coincided in 92.5%. For surface matching rates > 90%, the location of ≥ 3 clips coincided in 99.55% of determinations. CONCLUSIONS: SGRT improves patient positioning accuracy compared to skin markers. Optimal breast SGRT can accurately verify the localisation of the tumour bed, ensuring matching with ≥ 3 surgical clips. SGRT can eliminate unwanted radiation from IGRT verification systems.

SEOR SBRT-SG survey on SRS/SBRT dose prescription criteria in Spain.

AIM: Stereotactic body radiotherapy (SBRT) and stereotactic radiosurgery (SRS) are essential tools in radiation oncology. In Spain, the use of these techniques continues to grow as older linear accelerators (linacs) are replaced with modern equipment. However, little is known about inter-centre variability in prescription and dose heterogeneity limits. Consequently, the SBRT-Spanish Task Group (SBRT-SG) of the Spanish Society of Radiation Oncology (SEOR) has undertaken an initiative to assess prescription and homogeneity in SRS/SBRT treatment. In the present study, we surveyed radiation oncology (RO) departments to obtain a realistic overview of prescription methods used for SBRT and SRS treatment in Spain. METHODS: A brief survey was developed and sent to 34 RO departments in Spain, mostly those who are members of the SEOR SBRT-SG. The survey contained seven questions about the specific prescription mode, dose distribution heterogeneity limits, prescription strategies according to SRS/SBRT type, and the use of IMRT-VMAT (Intensity Modulated Radiation Therapy-Volumetric Modulated Arc Therapy). RESULTS: Responses were received from 29 centres. Most centres (59%) used the prescription criteria D95% ≥ 100%. Accepted dose heterogeneity was wide, ranging from 107 to 200%. Most centres used IMRT-VMAT (93%). CONCLUSIONS: This survey about SRS/SBRT prescription and dose heterogeneity has evidenced substantial inter-centre variability in prescription criteria, particularly for intended and accepted dose heterogeneity. These differences could potentially influence the mean planning target volume dose and its correlation with treatment outcomes. The findings presented here will be used by the SEOR SBRT-SG to develop recommendations for SRS/SBRT dose prescription and heterogeneity.

Pattern of care in radiotherapy at a University Hospital in Spain: the RENORT project.

PURPOSE: RENORT is a novel data mining application developed to extract relevant clinical data from oncology information systems (OIS; ARIA and Mosaiq) used in radiation oncology (RO). METHODS/PATIENTS: We used RENORT to extract demographic and clinical data from the OIS of all patients treated at the RO Department at the General Hospital of Valencia during the year 2019. RESULTS: A total of 1158 treatments were performed. The female/male ratio was 39.3%/60.7%, with a mean age of 66 years. The mean waiting time between the treatment decision/proposal to the first visit was 10.1 days. Mean duration of the treatment preparation process was 21 days. Most patients (90.4%) completed treatment within the prescribed time ± 7 days. The most common sites/treatment types were: metastatic/palliative treatments (n = 300; 25.9%), breast (209; 18.0%), genitourinary (195; 16.8%), digestive (116; 10.0%), thoracic (104; 9.0%), head and neck (62; 5.4%), and skin cancer (51; 4.4%). The distribution according to treatment intent was as follows: palliative (n = 266; 23.0%), adjuvant curative (335; 28.9%), radical without adjuvant treatment (229; 19.8%), radical with concomitant treatment (188; 16.2%), curative neoadjuvant (70; 6.0%), salvage radiotherapy (61; 5.3%); and reirradiation (9; 0.8%). The most common treatment techniques were IMRT/VMAT with IGRT (n = 468; 40.4%), 3D-CRT with IGRT (421; 36.4%), SBRT (127; 11.0%), 2DRT (57; 4.9%), and SFRT (56; 4.8%). A mean of 15.9 fractions were administered per treatment. Hypofractionated schemes were used in 100% of radical intent breast and prostate cancer treatments. CONCLUSIONS: The RENORT application facilitates data retrieval from oncology information systems to allow for a comprehensive determination of the real role of radiotherapy in the treatment of cancer patients. This application is valuable to identify patterns of care and to assess treatment efficacy.

Patterns of treatment failure in patients with prostate cancer treated with 76-80 Gy radiotherapy to the prostate and seminal vesicles ± hormonotherapy.

PURPOSE: To assess the pattern of treatment failure in patients with prostate cancer (PCa) treated with radiotherapy (76-80 Gy) ± hormone therapy (HT). We also evaluated the influence of treatment failure on survival outcomes. METHODS: Retrospective study of patients with PCa (n = 302) treated with radiotherapy (RT) ± HT at our centre between November 1999 and July 2007. The mean patient age was 70.2 years (range 51-87). Distribution by NCCN risk group was low (n = 80, 26.5%), intermediate (n = 86, 28.5%), high (n = 77, 25.5%), and very high (n = 49, 16.2%). Most patients (n = 273, 90.4%) received IMRT at a dose of 76-80 Gy. HT was administered in 237 patients (78.5%), in most cases (n = 167, 55.3%) for < 7 months RESULTS: Survival rates at 10 years were: overall survival (OS), 64.3%; biochemical disease-free survival, 83.9%; disease-free survival, 92.5%; and metastasis-free survival (MFS), 94.3%. Biochemical failure (BF) was observed in 55 cases (18.2%), 32 of whom subsequently developed clinical recurrence: metastasis (n = 17, 5.6%), local failure (n = 11, 3.6%), and regional failure (n = 4, 1.3%). The cause of death (n = 159) was intercurrent disease in 115 cases (72.3%), second cancer in 27 (17.0%), and PCa in 17 (10.7%). Biochemical failure-free survival ≤ 24 months was significantly associated with worse OS and MFS (p = 0.0001). Late genitourinary and gastrointestinal toxicity grade ≥ 3 (RTOG) was observed in 18 (6.0%) and 7 (2.3%) patients, respectively. CONCLUSIONS: The main type of treatment failure after 76-80 Gy of radiotherapy ± HT is local or metastatic. In all cases, biochemical failure occurred prior to treatment failure. BF within 24 months of treatment completion was significantly associated with worse OS and MFS.

Salvage I-125 brachytherapy for locally-recurrent prostate cancer after radiotherapy.

PURPOSE: Retrospective, single-institution analysis of clinical outcomes and treatment-related toxicity in patients treated with salvage I-125 low-dose rate (LDR) brachytherapy (BT) for locally-recurrent prostate cancer after radiotherapy. MATERIALS AND METHODS: Between 2008 and 2018, 30 patients with biopsy-confirmed prostate cancer recurrence underwent salvage treatment with I-125 LDR-BT. Of these 30 patients, 14 were previously treated with primary external beam radiotherapy (EBRT; median dose, 73 Gy) and 16 with primary I-125 LDR-BT (145 Gy and 160 Gy in 14 and 2 cases, respectively). At seed implantation, the mean age was 75.8 years, with a median Gleason score of 7 and pre-salvage PSA of <10 ng/mL. Six patients received androgen deprivation therapy for six months after relapse diagnosis. The prescribed salvage I-125 BT dose to the gland was 120-130 Gy, with dose restrictions of Dmax <135% (urethra) and <100% (rectum). Toxicity was evaluated according to the CTCAE scale (v4.0). RESULTS: At a median follow-up of 45 months, the biochemical recurrence-free survival rates at 1, 3 and 5 years were 86.7%, 56.7% and 53.3%, respectively. Overall survival at 5 years was 87%. On the multivariate analysis, two variables were significant predictors of recurrence: PSA at relapse and nadir PSA post-salvage. Grade 3 genitourinary toxicity was observed in 5 patients (radiation-induced cystitis in 3 cases and urethral stenosis in 2) and G3 gastrointestinal toxicity in 3 patients (rectal bleeding). CONCLUSION: Salvage therapy with I-125 brachytherapy is a safe and effective treatment option for locally-recurrent prostate cancer in previously-irradiated patients. High pre-salvage PSA and post-salvage nadir PSA values were significantly associated with a worse disease control after salvage I-125 LDR-BT. In well-selected patients, I-125 LDR-BT is comparable to other salvage therapies in terms of disease control and toxicity. However, more research is needed to determine the optimal management of locally-recurrent prostate cancer.

Impact of real-time, dose-escalated permanent seed implant brachytherapy in intermediate-risk prostate cancer.

PURPOSE: To retrospectively evaluate biochemical control and toxicity in patients who underwent 125I seed brachytherapy (BT) for intermediate-risk prostate cancer (PCa). MATERIALS AND METHODS: Between January 2004-December 2014, 395 patients with intermediate-risk PCa underwent 125I BT. Of these, 117 underwent preoperative planning (PP; 145 Gy) and 278 real-time intraoperative preplanning (IoP; 160 Gy). All patients were followed for ≥ 6 months (> 5 years in 48% of patients and > 7 years in 13%). Median follow-up was 59 months. RESULTS: Biochemical relapse-free survival (BRFS) rates at 5 and 8 years were, respectively, 91.7% and 82.1%. By treatment group, the corresponding BRFS rates were 93.5% and 90% for IoP and 89% and 76.8% for PP. The maximum dose to the urethra remained unchanged (217 Gy) despite the dose escalation (from 145 to 160 Gy), without any significant increase in treatment-related toxicity (p = 0.13). Overall toxicity outcomes in the series were excellent, with only 3 cases (0.76%) of grade 3 genitourinary toxicity. CONCLUSION: The real-time intraoperative planning technique at 160 Gy yields better biochemical controls than the preoperative planning technique at 145 Gy. Dose escalation did not increase urinary toxicity. The excellent results obtained with the IoP BT technique support its use as the first treatment option in this patient population.

Are there enough radiation oncologists to lead the new Spanish radiotherapy?

AIM: Radiation oncology services in Spain are undergoing a process of technical modernization, but-in a context of increasing demand by an ageing population-it is unclear whether there are enough radiation oncologists to staff the newly equipped units. This study aims to assess the number of specialists working in radiation oncology services in Spain relative to current and future needs. MATERIALS AND METHODS: In the second half of 2017, the Commission on Infrastructures of the Spanish Society for Radiation Oncology (SEOR) sent a questionnaire on radiation oncology staff to the heads of all 122 public (n = 76, 62%) and private (n = 46, 38%) radiation oncology services in Spain. Data collected were the number of professionals, their position, and their year of birth for specialists and residents in each service. In the descriptive analysis, for continuous variables we calculated means, standard deviations and ranges for each Spanish region and work post. For qualitative variables, we constructed frequency tables. All analyses were performed with R statistical software, version 3.5.1. RESULTS: The survey response rate was 100% among service heads across all 122 centers. The total number of radiation oncologists working in these centers is 721, or 15.4 per million population, with considerable variations between regions. Given the national recommendations to have 20 radiation oncologists per million population, there is currently a deficit of 204 specialists. If the 163 upcoming retirements are also taken into account, there will be 367 fewer radiation oncologists than required to meet the 25% increase in indications for radiotherapy projected for 2025. CONCLUSIONS: The classic model for calculating staff needs based on the number of treatments is outdated, and recommendations should be revised to reflect the current reality. A new model should integrate the most complex technological advances and emerging plans in radiotherapy, without neglecting the other activities carried out in radiation oncology services that are not directly linked to patient care.

Survival after biochemical failure in prostate cancer treated with radiotherapy: Spanish Registry of Prostate Cancer (RECAP) database outcomes.

INTRODUCTION: The clinical course in patients with prostate cancer (PCa) after biochemical failure (BF) has received limited attention. This study analyzes survival time from recurrence, patterns of progression, and the efficacy of salvage therapies in patients treated with radical or postoperative radiotherapy (RT). METHODS: This is a multicenter retrospective comparative study of 1135 patients diagnosed with BF and treated with either radical (882) or postoperative (253) RT. Data correspond to the RECAP database. Clinical, tumor, and therapeutic characteristics were collected. Descriptive statistics, survival estimates, and comparisons of survival rates were calculated. RESULTS: Time to BF from initial treatment (RT or surgery) was higher in irradiated patients (51 vs 37 months). At a median follow-up of 102 months (14-254), the 8-year cause-specific survival (CSS) was 80.5%, without significant differences between the radical (80.1%) and postoperative (83.4%) RT groups. The 8-year metastasis-free survival rate was 57%. 173 patients (15%) died of PCa and 29 (2.5%) of a second cancer. No salvage therapy was given in 15% of pts. Only 5.5% of pts who underwent radical RT had local salvage treatment and 71% received androgen deprivation (AD) ± chemotherapy. The worst outcomes were in patients who developed metastases after BF (302 pts; 26.5%) and in cases with a Gleason > 7. CONCLUSIONS: In PCa treated with radiotherapy, median survival after BF is relatively long. In this sample, no differences in survival rates at 8-years have been found, regardless of the time of radiotherapy administered. AD was the most common treatment after BF. Metastases and high Gleason score are adverse variables. To our knowledge, this is the first study to compare outcomes after BF among patients treated with primary RT vs. those treated with postoperative RT and to evaluate recurrence patterns, treatments administered, and causes of death. The results allow avoiding overtreatment, improving quality of life, without negatively affecting survival.

Quality indicators in radiation oncology: proposal of the Spanish Society of Radiation Oncology (SEOR) for a continuous improvement of the quality of care in oncology.

PURPOSE: Current cancer treatment options include surgical intervention, radiotherapy, and chemotherapy. The quality of the provision of each of them and their effective coordination determines the results in terms of benefit/risk. Regarding the radiation oncology treatments, there are not stabilised quality indicators to be used to perform control and continuous improvement processes for healthcare services. Therefore, the Spanish Society of Radiation Oncology has undertaken a comprehensive project to establish quality indicators for use with the information systems available in most Spanish healthcare services. METHODS: A two-round Delphi study examines consensus of several possible quality indicators (n = 28) in daily practice. These indicators were defined after a bibliographic search and the assessment by radiation oncology specialists (n = 8). They included aspects regarding treatment equipment, patient preparation, treatment, and follow-up processes and were divided in structure, process, and outcome indicators. RESULTS: After the evaluation of the defined quality indicators (n = 28) by an expert panel (38 radiation oncologist), 26 indicators achieved consensus in terms of agreement with the statement. Two quality indicators did not achieve consensus. CONCLUSIONS: There is a high degree of consensus in Spanish Radiation Oncology specialists on which indicators in routine clinical practice can best measure quality. These indicators can be used to classify services based on several parameters (patients, equipments, complexity of the techniques used, and scientific research). Furthermore, these indicators allow assess our current situation and set improvements' objectives.

Infrastructure and equipment for radiation oncology in the Spanish National Health System: analysis of external beam radiotherapy 2015-2020.

PURPOSE: Planning for radiation oncology requires reliable estimates of both demand for radiotherapy and availability of technological resources. This study compares radiotherapy resources in the 17 regions of the decentralised Spanish National Health System (SNHS). MATERIALS AND METHODS: The Sociedad Española de Oncología Radioterápica (SEOR) performed a cross-sectional survey of all Spanish radiation oncology services (ROS) in 2015. We collected data on SNHS radiotherapy units, recording the year of installation, specific features of linear accelerators (LINACs) and other treatment units, and radiotherapeutic techniques implemented by region. Any machine over 10 years old or lacking a multileaf collimator or portal imaging system was considered obsolete. We performed a k-means clustering analysis using the Hartigan-Wong method to test associations between the gross domestic regional product (GDRP), the number of LINACs per million population and the percentage of LINACs over 10 years old. RESULTS: The SNHS controls 72 (61%) of the 118 Spanish ROS and has 180 LINACs, or 72.5% of the total public and private resources. The mean rate of LINACs per million population is 3.9 for public ROS, and 42% (n = 75) of the public accelerators were obsolete in 2015: 61 due to age and 14 due to technological capability. There was considerable regional variation in terms of the number and technological capacity of radiotherapy units; correlation between GRDP and resource availability was moderate. CONCLUSION: Despite improvements, new investments are still needed to replace obsolete units and increase access to modern radiotherapy. Regular analysis of ROS in each Spanish region is the only strategy for monitoring progress in radiotherapy capacity.

Failure modes and effects analysis of total skin electron irradiation technique.

PURPOSE: Total skin electron irradiation (TSEI) is a radiotherapy technique which consists of an homogeneous body surface irradiation by electrons. This treatment requires very strict technical and dosimetric conditions, requiring the implementation of multiple controls. Recently, the Task Group 100 report of the AAPM has recommended adapting the quality assurance program of the facility to the risks of their processes. MATERIALS AND METHODS: A multidisciplinary team evaluated the potential failure modes (FMs) of every process step, regardless of the management tools applied in the installation. For every FM, occurrence (O), severity (S) and detectability (D) by consensus was evaluated, which resulted in the risk priority number (RPN), which permitted the ranking of the FMs. Subsequently, all the management tools used, related to the TSEI process, were examined and the FMs were reevaluated, to analyze the effectiveness of these tools and to propose new management tools to cover the greater risk FMs. RESULTS: 361 FMs were identified, 103 of which had RPN ≥80, initially, and 41 had S ≥ 8. Taking this into account the quality management tools FMs were reevaluated and only 30 FMs had RPN ≥80. The study of these 30 FMs emphasized that the FMs that involved greater risk were related to the diffuser screen placement and the patient's position during treatment. CONCLUSIONS: The quality assurance program of the facility has been adapted to the risk of this treatment process, following the guidelines proposed by the TG-100. However, clinical experience continually reveals new FMs, so the need for periodic risk analysis is required.

Consensus statement on definition, diagnosis, and management of high-risk prostate cancer patients on behalf of the Spanish Groups of Uro-Oncology Societies URONCOR, GUO, and SOGUG.

PURPOSE: Prostate cancer (PCa) is the most prevalent malignancy in men and the second cause of mortality in industrialized countries. METHODS: Based on Spanish Register of PCa, the incidence of high-risk PCa is 29%, approximately. In spite of the evidence-based beneficial effect of radiotherapy and androgen deprivation therapy in high-risk PCa, these patients (pts) are still a therapeutic challenge for all specialists involved, in part due to the absence of comparative studies to establish which of the present disposable treatments offer better results. RESULTS: Nowadays, high-risk PCa definition is not well consensual through the published oncology guides. Clinical stage, tumour grade, and number of risk factors are relevant to be considered on PCa prognosis. However, these factors are susceptible to change depending on when surgical or radiation therapy is considered to be the treatment of choice. Other factors, such as reference pathologist, different diagnosis biopsy schedules, surgical or radiotherapy techniques, adjuvant treatments, biochemical failures, and follow-up, make it difficult to compare the results between different therapeutic options. CONCLUSIONS: This article reviews important issues concerning high-risk PCa. URONCOR, GUO, and SOGUG on behalf of the Spanish Groups of Uro-Oncology Societies have reached a consensus addressing a practical recommendation on definition, diagnosis, and management of high-risk PCa.

Demand for radiotherapy in Spain.

AIM: Assessing the demand for radiotherapy in Spain based on existing evidence to estimate the human resources and equipment needed so that every person in Spain has access to high-quality radiotherapy when they need it. MATERIAL AND METHODS: We used data from the European Cancer Observatory on the estimated incidence of cancer in Spain in 2012, along with the evidence-based indications for radiotherapy developed by the Australian CCORE project, to obtain an optimal radiotherapy utilisation proportion (OUP) for each tumour. RESULTS: About 50.5 % of new cancers in Spain require radiotherapy at least once over the course of the disease. Additional demand for these services comes from reradiation therapy and non-melanoma skin cancer. Approximately, 25-30 % of cancer patients with an indication for radiotherapy do not receive it due to factors that include access, patient preference, familiarity with the treatment among physicians, and especially resource shortages, all of which contribute to its underutilisation. CONCLUSIONS: Radiotherapy is underused in Spain. The increasing incidence of cancer expected over the next decade and the greater frequency of reradiations necessitate the incorporation of radiotherapy demand into need-based calculations for cancer services planning.

Management of prostate cancer patients following radiation therapy after radical surgery referred from urology to radiation oncology departments in Spain.

PURPOSE: To define usual clinical management of prostate cancer (PCa) patients following postoperative radiation therapy (RT) (adjuvant or salvage) and its evolution over time in radiation oncology (RO) departments in Spain. METHODS: An epidemiological, cross-sectional, multicentre study was conducted. 567 PCa patients that had undergone radical prostatectomy (RP) and received postoperative RT between February and December of both 2006 and 2011 participated in the study. In patients from 2006, health-related quality of life (HRQoL) was assessed using the EPIC questionnaire. Investigators completed a specific survey on two clinical cases of adjuvant and salvage RT. RESULTS: 70.6 % of patients received salvage RT versus 29.4 % who received adjuvant RT; no significant differences were found in terms of frequency for each procedure between both the years. Regarding the survey, a positive surgical margin was the main criteria used in adjuvant RT decision making. In terms of salvage RT scenario, 85.7 % of the investigators stated that adjuvant RT should have been offered instead, 81.4 % of the investigators agreed on a PSA score >0.2 ng/mL as the main criteria for identifying biochemical recurrence after RP, and 67.4 % of investigators did not consider any PSA score for ruling out salvage RT treatment. CONCLUSIONS: Most patients are referred to RO departments to receive salvage RT. Despite the publication of three IA evidence level randomized clinical trials, the patterns for using adjuvant and salvage RT did not change from 2006 to 2011, although patients' profile did. A consensus regarding postoperative RT indications should be reached in order to correct this controversial situation.

Spanish Society of Radiation Oncology clinical guidelines for stereotactic body radiation therapy in lymph node oligometastases.

Data in the literature support the existence of a state of limited metastases or oligometastases. Favorable outcomes have been observed in selected patients with such oligometastases that are treated with local ablative therapies, which include surgical extirpation, stereotactic body radiation therapy (SBRT), and radiofrequency ablation. The role of SBRT in the setting of lymph node oligometastases is still emerging but the early results for local control are promising. However, the biggest challenge is to identify patients who will benefit from treatment of their oligometastatic disease with local aggressive therapy. Patients are initially categorized based upon examination of the initial biopsy, location, stage, and previous treatments received. Appropriate patient management with SBRT requires an understanding of several clinicopathological features that help to identify several subsets of patients with more responsive tumors and a good tolerance to SBRT. In an effort to incorporate the most recent evidence, here the Spanish Society of Radiation Oncology presents guidelines for using SBRT in lymph node oligometastases.

Androgen deprivation and radiotherapy in patients with prostate cancer and cardiovascular risk factors: clinical controversies.

INTRODUCTION: Recent reports of an association between androgen deprivation treatment (ADT) and increased risk of cardiovascular (CV) events have generated debate on the use of ADT in patients with prostate cancer (PCa) and CV comorbidities. This study aims to describe the recommendations of radiation oncologists in the most controversial aspects of treating such patients. MATERIALS AND METHODS: The project involved 61 oncologists and comprised 4 phases: (1) selection of the most controversial aspects in the administration of ADT in patients with a history of CV disease and PCa, (2) selection of the most relevant published evidence, (3) preparation of case reports, (4) critical reading and discussion. Therapeutic procedures were classified as "highly recommendable", "recommendable in some cases", or "not recommendable/not applicable". For each item assessed, the mode of the scores given, and the percentage of experts who selected each score were calculated. RESULTS: The panel recommended that patients with high/very high-risk PCa and a history of CV disease should receive gonadotropin-releasing hormone agonists (GnRHa). ADT with GnRHa for 24-36 months + radiotherapy (RT) was also considered highly recommendable. In intermediate-risk PCa and a history of CV, ADT with GnRHa for 6-8 months + RT, and not administering ADT were considered highly recommendable. CONCLUSIONS: Studies are necessary to investigate the impact of ADT on CV mortality in patients who benefit most from adjuvant ADT in terms of survival. In the meantime, the experts believe that clinical evidence on the proven therapeutic benefits of ADT should override concerns about potential cardiac toxicity.

Infrastructures, treatment modalities, and workload of radiation oncology departments in Spain with special attention to prostate cancer.

AIM: The purpose of the study was to describe infrastructures, treatment modalities, and workload in radiation oncology (RO) in Spain, referred particularly to prostate cancer (PC). METHODS: An epidemiologic, cross-sectional study was performed during 2008-2009. A study-specific questionnaire was sent to the 108 RO-registered departments. RESULTS: One hundred and two departments answered the survey, and six were contacted by telephone. Centers operated 236 treatment units: 23 (9.7 %) cobalt machines, 37 (15.7 %) mono-energetic linear accelerators, and 176 (74.6 %) multi-energy linear accelerators. Sixty-one (56.4 %) and 33 (30.5 %) departments, respectively, reported intensity-modulated radiation therapy (IMRT) and image-guided RT (IGRT) capabilities; three-dimensional-conformal RT was used in 75.8 % of patients. Virtual simulators were present in 95 departments (88.0 %), 35 use conventional simulators. Fifty-one departments (47.2 %) have brachytherapy units, 38 (35.2 %) perform prostatic implants. Departments saw a mean of 24.9 new patients/week; the number of patients treated annually was 102,054, corresponding to 88.4 % of patients with a RT indication. In 56.5 % of the hospitals, multidisciplinary teams were available to treat PC. CONCLUSIONS: Results provide an accurate picture of current situation of RO in Spain, showing a trend toward the progressive introduction of new technologies (IMRT, IGRT, brachytherapy).

Looking for complementary alternatives to CTCAE for skin toxicity in radiotherapy: quantitative determinations.

INTRODUCTION: Radiotherapy (RT) is an essential part of the patient's treatment diagnosed with cancer. Determination of the most common RT secondary effect, the cutaneous toxicity, is usually based on visual rating scales, like Common Terminology Criteria for Adverse Events with an inherent subjectivity. The aim of this work is to perform an objective method to evaluate the radiodermatitis using a non-invasive imaging technique based on laser Doppler flowmetry (LDF). MATERIALS AND METHODS: A prospective study was performed analysing 1,824 measurements. A LDF was used to measure the cutaneous microcirculation in real time. A basal measurement was taken prior to radiotherapy treatment. To be able to observe the microcirculation changes related to the delivered dose, several sets of measurements were taken in the irradiated area along the RT treatment and in the contralateral non-irradiated area. RESULTS: A relative increase in blood flow at all measured points was found in the irradiated area. This relative increase in blood flow increases with the dose administered. In the non-irradiated contralateral area, the relative increase in blood flow is not significant and is independent of the dose administered. After treatment, a decrease in blood flow was detected with a trend towards returning to the baseline measurements. CONCLUSIONS: LDF is an objective technique that assesses early radiodermatitis. This method is useful to develop strategies to prevent onset of radiation dermatitis in patients irradiated, such as the modification and individualization of fractionation parameters of the RT. This allows the reduction of radiation morbidities and maintains patient quality of life.