Implementing an online radiotherapy quality assurance programme with supporting continuous medical education - report from the EMBRACE-II evaluation of cervix cancer IMRT contouring.

BACKGROUND AND PURPOSE: EMBRACE-II is an international prospective study of IMRT and MRI-guided adaptive brachytherapy (IGABT) in locally advanced cervix cancer. An online radiotherapy quality assurance (RTQA) programme with minimal data transfer and supporting continuing medical education (CME) was implemented for IMRT contouring. MATERIALS AND METHODS: Participant contours for six volumes-of-interest (VOIs) on one benchmark case were scored (2 = excellent, 1 = fair, 0 = revision required) against a consensus reference contour. For contours receiving a 0 or 1 score, additional qualitative comments were provided. The Jaccard conformity index (JCI) was retrospectively calculated. User interaction with CME content (pre-accreditation questionnaire, contouring atlas, practice cases, quizzes, internal target volume (ITV-T) guide) was analysed. RESULTS: 78 clinicians submitted contours for evaluation. 41% passed at the first attempt, 44% after one revision and 6% after two or more revisions. 9% did not re-submit after failing. The lowest mean scores were for the elective nodal CTV (CTV-E) (1.01/2) and ITV-T (1.06/2). 60 different errors across the six VOIs were identified; five potentially had high impact on loco-regional control. A JCI cut-off of 0.7 would have identified 87% contours that failed expert assessment, but also excluded 54% of passing contours. 39 clinicians responded to the pre-accreditation questionnaire - 36% anticipated difficulties with the ITV-T and 13% with the CTV-E. 35% clinicians contoured on the practice cases, 17% answered a quiz, 96% used the atlas and 38% the ITV-T guide. CONCLUSION: Expert evaluation with qualitative feedback improved contouring compliance. The JCI is not a reliable alternative to expert assessment. Moderate uptake of optional CME content limited evaluation.

Migrate your mind: the role of palliative care in transcultural cancer treatment : A qualitative analysis.

BACKGROUND: In increasingly multi-ethnic societies fostering cultural awareness and integration of immigrants is not only a political duty but also an obligation for social and healthcare systems. Importantly, cultural beliefs and needs strongly impact on the quality of life of cancer patients and may become even more crucial at the end of life. However, to date, ethnic and cultural aspects of palliative care are insufficiently researched. METHODS: This qualitative study at the Medical University of Vienna included 21 staff members from different disciplines in oncology and palliative care working with patients with various cultural backgrounds at the end of life. Semi-structured interviews were performed to gain insights into specific aspects of palliative care that are important in the clinical encounter with terminally ill cancer patients with migrant backgrounds and their relatives. RESULTS: Interviews revealed specific aspects of palliative care, which fell into four fundamental categories and were all perceived as beneficial in the clinical encounter with migrant clients: (A) structural and (B) personal conditions of the palliative care setting, (C) specific care and treatment intentions and (D) personnel requirements and attitudes. CONCLUSION: This study revealed first insights into possibilities and prospects of transcultural palliative care for migrants and their relatives. The results might have important implications for the end of life care in this growing population.

Importance of training in external beam treatment planning for locally advanced cervix cancer: Report from the EMBRACE II dummy run.

BACKGROUND AND PURPOSE: The EMBRACE II study combines state-of-the-art Image-Guided Adaptive Brachytherapy in cervix cancer with an advanced protocol for external beam radiotherapy (EBRT) which specifies target volume selection, contouring and treatment planning. In EMBRACE II, well-defined EBRT is an integral part of the overall treatment strategy with the primary aim of improving nodal control and reducing morbidity. The EMBRACE II EBRT planning concept is based on improved conformality through relaxed coverage criteria for all target volumes. For boosting of lymph nodes, a simultaneous integrated boost and coverage probability planning is applied. Before entering EMBRACE II, institutes had to go through accreditation. MATERIAL AND METHODS: As part of accreditation, a treatment planning dummy-run included educational blocks and submission of an examination case provided by the study coordinators. Seventy-one centers submitted 123 EBRT dose distributions. Replanning was required if hard constraints were violated or planning concepts were not fully accomplished. Dosimetric parameters of original and revised plans were compared. RESULTS: Only 11 plans violated hard constraints. Twenty-seven centers passed after first submission. 27 needed one and 13 centers needed more revisions. The most common reasons for revisions were low conformality, relatively high OAR doses or insufficient lymph node coverage reduction. Individual feedback on planning concepts improved plan quality considerably, resulting in a median body V43Gy reduction of 158 cm3 from first plan submission to approved plan. CONCLUSION: A dummy-run as applied in EMBRACE II, consisting of training and examination cases enabled us to test institutes' treatment planning capabilities, and improve plan quality.

Attitude Towards End of Life Communication of Austrian Medical Students.

Medical students have to acquire theoretical knowledge, practical skills, and a personal attitude to meet the emerging needs of palliative care. The present study aimed to assess the personal attitude of Austrian medical students towards end of life communication (EOLC), as key part of palliative care. This cross-sectional, mono-institutional assessment invited all medical students at the Medical University of Vienna in 2015. The assessment was conducted web-based via questionnaire about attitudes towards EOLC. Additional socio-demographic and medical education-related parameters were collected. Overall, 743 medical students participated in the present report. Differences regarding the agreement or disagreement to several statements concerning the satisfaction of working with chronically ill patients, palliative care, and health care costs, as well as the extent of information about palliative disease, were found for age, gender, and academic years. The overall attitude towards EOLC in the present sample can be regarded as quite balanced. Nevertheless, a considerable number of medical students are still reluctant to inform patients about their incurable disease. Reservations towards palliative care as part of the health care system seem to exist. The influence of the curriculum as well as practical experiences seems to be important but needs further investigation.

Are hypothyroidism and hypogonadism clinically relevant in patients with malignant gliomas? A longitudinal trial in patients with glioma.

BACKGROUND: So far, the development and course of therapy-induced deficiencies in hypothalamic-pituitary hormones in adult patients with malignant gliomas has not received much attention. However, such deficiencies may impact patient's quality of life substantially. METHODS: In this monocentric longitudinal trial, we examined hormonal levels of TSH, T3, T4, fT3, fT4, FSH, LH, testosterone, estradiol and prolactin in patients with malignant high grade gliomas before the start of radiochemotherapy (RCT), at the end of RCT and then every three months for newly diagnosed patients and every six months in patients diagnosed more than two years before study inclusion. Growth hormone was not measured in this trial. RESULTS: 436 patients (198 female, 238 male) with high-grade gliomas, aged 19-83 years (median 50 years), were included in this study. Low levels of thyroid hormones were observed in around 10% of patients within the first six months of follow up and increasingly after 36 months. Half of premenopausal women at study entry developed premature menopause, 35% showed hyperprolactinemia. Low testosterone levels were measured in 37% of men aged less than 50 years and in 35/63 (55%) of men aged 50 years or older. DISCUSSION: The results of this study show that a significant percentage of patients with malignant gliomas develop hormonal deficiencies mandating regular clinical follow up, state of the art counseling and if clinically necessary substitution therapy.

[Beliefs and distress related to hearing voices: the German version of the Beliefs About Voices Questionnaire-Revised (BAVQ-R)]. / Überzeugungen und Belastungen durch Stimmenhören: die deutsche Version des Beliefs About Voices Questionnaire ­ Revised (BAVQ-R).

BACKGROUND: Beliefs about voices are a determining factor with regards to distress, coping and therapeutic interventions in verbal auditory hallucinations. Aim of the present study was to use and validate the internationally well established Beliefs About Voices Questionnaire-Revised (BAVQ-R) in a German translation with people suffering from schizophrenic psychoses. METHODS: 93 participants with a diagnosis of schizophrenia and current verbal auditory hallucinations completed the BAVQ-R autonomously for their dominant voice. Sociodemographic and clinical data as well as data concerning the severity of illness (CGI-Sch) and symptom specific dimensions of voice-hearing (PSYRATS-AH) were collected. Construct validity, reliability and test-retest-reliability were calculated. RESULTS: Each of the subscales (malevolence, benevolence, resistance, engagement) with the exception of the subscale omnipotence showed satisfying internal consistency. Good test-retest-reliability was shown for the belief-subscales but not for emotion and behaviour in resistance and engagement. Significant correlations between the subscales showed the expected results, comparable to the results of the original BAVQ-R study. No correlations with severity of the illness, but with amount and intensity of distress through voices and their negative contents correlations were found. CONCLUSIONS FOR PRACTICE: The BAVQ-R is a feasible instrument to collect data about beliefs about voices in a valid and reliable way in people with a diagnosis of schizophrenia. From a therapeutic as well as from a scientific point of view, the question about the conceptualization of the relationship between cognition, emotion and behaviour stays relevant.

The EMBRACE II study: The outcome and prospect of two decades of evolution within the GEC-ESTRO GYN working group and the EMBRACE studies.

The publication of the GEC-ESTRO recommendations one decade ago was a significant step forward for reaching international consensus on adaptive target definition and dose reporting in image guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer. Since then, IGABT has been spreading, particularly in Europe, North America and Asia, and the guidelines have proved their broad acceptance and applicability in clinical practice. However, a unified approach to volume contouring and reporting does not imply a unified administration of treatment, and currently both external beam radiotherapy (EBRT) and IGABT are delivered using a large variety of techniques and prescription/fractionation schedules. With IGABT, local control is excellent in limited and well-responding tumours. The major challenges are currently loco-regional control in advanced tumours, treatment-related morbidity, and distant metastatic disease. Emerging evidence from the RetroEMBRACE and EMBRACE I studies has demonstrated that clinical outcome is related to dose prescription and technique. The next logical step is to demonstrate excellent clinical outcome with the most advanced EBRT and brachytherapy techniques based on an evidence-based prospective dose and volume prescription protocol. The EMBRACE II study is an interventional and observational multicentre study which aims to benchmark a high level of local, nodal and systemic control while limiting morbidity, using state of the art treatment including an advanced target volume selection and contouring protocol for EBRT and brachytherapy, a multi-parametric brachytherapy dose prescription protocol (clinical validation of dose constraints), and use of advanced EBRT (IMRT and IGRT) and brachytherapy (IC/IS) techniques (clinical validation). The study also incorporates translational research including imaging and tissue biomarkers.

Pushing boundaries-culture-sensitive care in oncology and palliative care: a qualitative study.

OBJECTIVE: In increasingly globalized societies, patient-centered cancer care requires culture-sensitive approaches in order to ensure patients well-being. While migrant patients' needs are frequently reported in the literature, staff members' perception of work with migrant patients, associated challenges, or individual work approaches are largely unknown. This study addresses this research gap through qualitative exploration of experiences of multicultural health care professionals in supportive oncology and palliative care, working with patients from different cultural backgrounds. This study aims to understand staff experience of the impact of culture on cancer care. METHODS: This study was conducted at the Medical University of Vienna, including staff from different settings of oncology and palliative care, in different professional positions, and with a range of individual migration backgrounds. Semistructured interviews were conducted with 21 staff members working with patients from different cultural backgrounds. Interviews explored views on the impact of culture on care were audio-taped, transcribed, and analyzed using a rigorous method of thematic analysis, enhanced with grounded theory techniques. RESULTS: Interviews revealed 4 key topics: culture-specific differences, assumed reasons for differences, consequences of multicultural care, and tools for culture-sensitive care. Strategies to better deal with migrant patients and their families were suggested to improve work satisfaction amongst staff. CONCLUSIONS: This study identifies relevant staff challenges in work with migrant patients. Concrete suggestions for improvement include measures on an organizational level, team level, and personal tools. The suggested measures are applicable to improve work satisfaction and culture-sensitive care not only in cancer care but also in other areas of medicine.

Parenthood among patients with psychotic disorders: gender differences in a non-selective clinical sample.

A large proportion of people with psychotic disorders have children and also live with them. However, research has rarely studied this in clinical populations and included male patients. This exploratory study used routine data of all 709 patients with a psychotic disorder treated in a psychiatric inpatient service in Austria between 2012 and 2015. Socio-demographic and clinical characteristics, number and age of children, and living arrangements were assessed and analysed. More female patients than male patients had children in the total sample (56% vs. 30%), and in diagnostic subgroups with bipolar disorder (71%, 53%), schizoaffective disorder (65%, 24%), and schizophrenia (45%, 21%). Being female, higher age, and living with a partner were associated with having children. Unlike female patients, most male patients with underage children (≤18 years) did not live with them, especially when patients had a diagnosis of schizophrenia. The gender specific differences in parenthood and custody arrangements identified in this study indicate different support needs of mothers and fathers with psychotic disorders. Not living with a child and having limited access might come with feelings of guilt and loss, which should be addressed in research and practice.

What Makes a Good Palliative Care Physician? A Qualitative Study about the Patient's Expectations and Needs when Being Admitted to a Palliative Care Unit.

OBJECTIVE: The aims of the study were to examine a) patients' knowledge of palliative care, b) patients' expectations and needs when being admitted to a palliative care unit, and c) patient's concept of a good palliative care physician. METHODS: The study was based on a qualitative methodology, comprising 32 semistructured interviews with advanced cancer patients admitted to the palliative care unit of the Medical University of Vienna. Interviews were conducted with 20 patients during the first three days after admission to the unit and after one week, recorded digitally, and transcribed verbatim. Data were analyzed using NVivo 10 software, based on thematic analysis enhanced with grounded theory techniques. RESULTS: The results revealed four themes: (1) information about palliative care, (2) supportive care needs, (3) being treated in a palliative care unit, and (4) qualities required of palliative care physicians. The data showed that patients lack information about palliative care, that help in social concerns plays a central role in palliative care, and attentiveness as well as symptom management are important to patients. Patients desire a personal patient-physician relationship. The qualities of a good palliative care physician were honesty, the ability to listen, taking time, being experienced in their field, speaking the patient's language, being human, and being gentle. Patients experienced relief when being treated in a palliative care unit, perceived their care as an interdisciplinary activity, and felt that their burdensome symptoms were being attended to with emotional care. Negative perceptions included the overtly intense treatment. CONCLUSIONS: The results of the present study offer an insight into what patients expect from palliative care teams. Being aware of patient's needs will enable medical teams to improve professional and individualized care.

Information preferences regarding cure rates and prognosis of Austrian patients with advanced lung cancer.

INTRODUCTION: Due to concerns about patients' wellbeing, open end-of-life communication is associated with reservation. Furthermore, sociocultural differences must be considered. The objective of this pilot study was therefore to investigate the information preferences of Austrian patients regarding cure rates and prognosis. PATIENTS AND METHODS: The information preferences of 50 advanced lung cancer patients were assessed at their first visit to the Department of Radiation Oncology, Medical University of Vienna. Preferences in terms of content (cure rates and/or prognosis) and depth of the information (additional quantitative estimates) were addressed. After the individually adapted medical consultation, patients' satisfaction with the consultation and the emotional responses to the information were evaluated. RESULTS: The majority of patients (76 %) requested information about cure rates and/or prognosis; nearly half of these (47 %) wanted additional quantitative estimates. Neither sociodemographic variables, disease characteristics, nor time since diagnosis had an impact on the information preferences. The individually adapted medical information showed no overall negative influence on the emotional responses; only patients receiving prognostic information had significantly higher distress scores after the consultation. High satisfaction with the individually adapted medical consultation was reported by 92 % of patients. CONCLUSION: Austrian physicians may offer end-of-life communication and directly ask patients about their information preferences, since patients seem able to decide whether or not prognostic information would overwhelm their emotional capacity and therefore to accept or reject the invitation. The disclosure of cure rates and/or prognosis with or without quantitative estimates-according to the patients' preferences-shows overall no negative impact on emotional reactions. The individually adapted consultation results in high patient satisfaction. Nevertheless, prognostic information may lead to higher distress.