Six-Month Prostate Cancer Empowerment Program (PC-PEP) Improves Urinary Function: A Randomized Trial.

Purpose: This is a secondary analysis examining a six-month home-based Prostate Cancer-Patient Empowerment Program (PC-PEP) on patient-reported urinary, bowel, sexual, and hormonal function in men with curative prostate cancer (PC) against standard of care. Methods: In a crossover clinical trial, 128 men scheduled for PC surgery (n = 62) or radiotherapy with/without hormones (n = 66) were randomized to PC-PEP (n = 66) or waitlist-control and received the standard of care for 6 months, and then PC-PEP to the end of the year. PC-PEP included daily emails with video instructions, aerobic and strength training, dietary guidance, stress management, and social support, with an initial PFMT nurse consultation. Over 6 months, participants in the PC-PEP received optional text alerts (up to three times daily) reminding them to follow the PFMT video program, encompassing relaxation, quick-twitch, and endurance exercises; compliance was assessed weekly. Participants completed baseline, 6, and 12-month International Prostate Symptom Score (IPSS) and Expanded Prostate Cancer Index Composite (EPIC) questionnaires. Results: At 6 months, men in the PC-PEP reported improved urinary bother (IPSS, p = 0.004), continence (EPIC, p < 0.001), and irritation/obstruction function (p = 0.008) compared to controls, with sustained urinary continence benefits at 12 months (p = 0.002). Surgery patients in the waitlist-control group had 3.5 (95% CI: 1.2, 10, p = 0.024) times and 2.3 (95% CI: 0.82, 6.7, p = 0.11) times higher odds of moderate to severe urinary problems compared to PC-PEP at 6 and 12 months, respectively. Conclusions: PC-PEP significantly improves lower urinary tract symptoms, affirming its suitability for clinical integration alongside established mental health benefits in men with curative prostate cancer.

PC-PEP, a Comprehensive Daily Six-Month Home-Based Patient Empowerment Program Leads to Weight Loss in Men with Prostate Cancer: A Secondary Analysis of a Clinical Trial.

Background: The Prostate Cancer-Patient Empowerment Program (PC-PEP) is a six-month daily home-based program shown to improve mental health and urinary function. This secondary analysis explores weight loss in male PC-PEP participants. Methods: In a randomized clinical trial with 128 men undergoing curative prostate cancer (PC) treatment, 66 received 'early' PC-PEP, while 62 were assigned to the 'late' waitlist-control group, receiving 6 months of standard-of-care treatment followed by 6 months of PC-PEP. PC-PEP comprised 182 daily emails with video-based exercise and dietary (predominantly plant-based) education, live online events, and 30 min strength training routines (using body weight and elastic bands). Weight and height data were collected via online surveys (baseline, 6 months, and 12 months) including medical chart reviews. Adherence was tracked weekly. Results: No attrition or adverse events were reported. At 6 months, the early PC-PEP group experienced significant weight loss, averaging 2.7 kg (p < 0.001) compared to the waitlist-control group. Weight loss was noted in the late intervention group of PC-PEP, albeit less pronounced than in the early group. Early PC-PEP surgery patients lost on average 1.4 kg (SE = 0.65) from the trial's start to surgery day. High adherence to exercise and dietary recommendations was noted. Conclusions: PC-PEP led to significant weight loss in men undergoing curative prostate cancer treatment compared to standard-of-care.

Addressing medical resident mistreatment: A resident-centred approach.

INTRODUCTION: Mistreatment negatively impacts the wellbeing of medical learners and is related to worse patient outcomes and team functioning. Resident perspectives on improving mistreatment reporting structures and investigations have not been explored. We aimed to understand residents' views on safe reporting structures, investigations, and resolution processes. METHOD: We conducted an exploratory sequential mixed method study beginning with a series of qualitative interviews to inform an anonymous online survey to all Dalhousie University residents (N = 645). RESULTS: When interviewed, residents (N = 10) discussed personal experiences with mistreatment, barriers to reporting, and how these processes could better serve them. Themes from the interviews were imbedded in an anonymous online survey to explore their prevalence among a larger group. Residents (N = 120; 19%) completed the online survey and revealed that mistreatment was very common yet underreported. Barriers to reporting included confidentiality concerns, perceptions that reporting would not change anything, and fear of retaliation. Desired outcomes for perpetrators depended on the perpetrator's position and incident severity, and most prefer a remedial approach. CONCLUSION: Resident mistreatment remains prevalent and current processes of dealing with reports may be inadequate. Residents have thoughtful insights for improving institutional policies and procedures and should be meaningfully engaged.

Assessing the Efficacy of a 28-Day Comprehensive Online Prostate Cancer Patient Empowerment Program (PC-PEP) in Facilitating Engagement of Prostate Cancer Patients in Their Survivorship Care: A Qualitative Study.

A 28-day Prostate Cancer-Patient Empowerment Program (PC-PEP) developed through patient engagement was successful at promoting mental and physical health. Thirty prostate cancer patients from Halifax, Canada participated in the 28-day PC-PEP intervention in early 2019. PC-PEP encompassed daily patient education and empowerment videos, prescribed physical activities (including pelvic floor exercises), a mostly plant-based diet, stress reduction techniques, intimacy education, social connection, and support. Quantitative exit surveys and semi-structured interviews (conducted in focus groups of ten) were used to assess perceived factors that facilitated or impeded adherence to the program. The program received high praise from the patients and was deemed extremely useful by the participating men, who rated it 9 out of 10. Patients expressed that the multifaceted, online, home-based nature of the program helped them adhere to it better than they would have had to a single or less comprehensive intervention. Feedback from the participants indicated that the program, when viewed as a whole, was perceived as greater than the sum of its individual parts. Furthermore, the program addressed various issues, including emotional vulnerability and distress, physical fitness, urinary incontinence, challenges in expressing emotions, perceived lack of control over healthcare decisions, emotional fragility, and hesitancy to discuss prostate cancer-related matters in social settings. Patients highly (9.6/10) endorsed integrating the program into the standard care regimen from the very beginning of diagnosis. However, challenges such as work commitments were noted. Patients' high endorsement of PC-PEP suggests that its implementation into the standard of care from day one of diagnosis may be warranted.

Development and implementation of a postgraduate medical education-wide initiative in quality improvement and patient safety.

BACKGROUND: Quality improvement and patient safety (QIPS) have been assigned a higher profile in CanMEDS 2015, CanMEDS-Family Medicine 2017 and new accreditation standards, prompting an initiative at Dalhousie University to create a vision for integrating QIPS into postgraduate medical education. OBJECTIVE: The purpose of this study is to describe the implementation of a QIPS strategy across residency education at Dalhousie University. METHODS: A QIPS task force was formed, and a literature review and needs assessment survey were completed. A needs assessment survey was distributed to all Dalhousie residency programme directors. 12 programme directors were interviewed individually to collect additional feedback. The results were used to develop a 'road map' of recommendations with a graduated timeline. RESULTS: A task force report was released in February 2018. 46 recommendations were developed with a timeframe and responsible party identified for each. Implementation of the QIPS strategy is underway, and evaluation and challenges faced will be described. CONCLUSIONS: We have developed a multiyear strategy that is available to provide guidance and support to all programmes in QIPS. The development and implementation of this QIPS framework may serve as a template for other institutions who seek to integrate these competencies into residency training.

A Comprehensive 6-mo Prostate Cancer Patient Empowerment Program Decreases Psychological Distress Among Men Undergoing Curative Prostate Cancer Treatment: A Randomized Clinical Trial.

BACKGROUND: Although survival rates for newly diagnosed prostate cancer patients are very high, most of them will likely suffer significant treatment-related side effects, depression, or anxiety, affecting their quality of life. OBJECTIVE: The aim of this study was to examine the effects of a 6-mo online home-based physical, mental, and social support intervention, the Prostate Cancer Patient Empowerment Program (PC-PEP), on preventing psychological distress among men undergoing curative prostate cancer treatment. DESIGN, SETTING, AND PARTICIPANTS: In a crossover randomized clinical trial of 128 men aged 50-82 yr scheduled for curative prostate cancer surgery or radiotherapy (± hormone treatment), 66 received the 6-mo PC-PEP intervention and 62 were randomized to a waitlist-control arm and received the standard of care for 6 mo, and then PC-PEP to the end of the year. The PC-PEP intervention consisted of daily e-mails with video instructions providing education, patient activation, and empowerment on healthy living including physical and mental health, dietary recommendations, social support, physical and pelvic floor fitness, stress reduction using a biofeedback device, social connection and intimacy, and social support. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was nonspecific psychological distress (clinical cutoff ≥20) measured at baseline, and at 6 and 12 mo using the Kessler Psychological Distress Scale (K10). RESULTS AND LIMITATIONS: At 6 mo, patients in the waitlist-control group had 3.59 (95% confidence interval: 1.12-11.51) times higher odds for nonspecific psychological distress and need for psychological treatment than men who received the PC-PEP intervention. At 12 mo, the wait-list control group that received the intervention at 6 mo had higher psychological distress than the early group. CONCLUSIONS: PC-PEP delivered early following diagnosis significantly prevented the burden of psychological distress in men undergoing curative prostate cancer treatment compared with standard of care, or late (6 mo later) intervention. PATIENT SUMMARY: In this report, we looked at the effectiveness of a program (Prostate Cancer Patient Empowerment Program: PC-PEP) developed with patients' engagement on the mental distress of patients awaiting curative treatment for their prostate cancer. The PC-PEP program lasted for 6 mo, and it prescribed, described, and demonstrated daily aerobic and strength training, kegels (pelvic floor training to help with urinary and sexual function), dietary changes that have been shown to be helpful in the prevention of prostate cancer and prostate cancer progression, stress reduction using a biofeedback device, as well as social and emotional support. All patients in the PC-PEP program were invited to a monthly video conference with the leads of the program who appeared in the 6 mo of daily videos prescribing the activities the patients were asked to watch and follow. The leads were a prostate cancer oncologist and a scientist in prostate cancer quality of life research. Half of the patients in this study received PC-PEP daily for the first 6 mo and were re-assessed at the end of the year. The other half received standard of care for 6 month and then received the intervention to the end of the year. The results of the study show that, at 6 mo, this intervention was effective at reducing the mental distress that accompanies a prostate cancer diagnosis and treatment compared with the standard of care. Mental distress was significantly reduced when the intervention was received early, compared with that received late (6 mo after scheduled curative treatment). We conclude that multi-faceted patient education and empowerment programming of this kind that is developed with patient engagement from the start is crucial to the care of patients diagnosed with prostate cancer and should be implemented in the standard of care. While treatment for prostate cancer is highly successful, side effects that accompany most treatments significantly affect the quality of life of patients. Here, we describe PC-PEP, a patient education and activation program that is cost effective, highly enforced by patients, and successful at reducing the impact of prostate cancer active treatment-related side effects on their psychological state. To learn more about this project, please visit www.pcpep.org. The program is now being tested in a phase 4 implementation trial throughout Canada and internationally (New Zealand), and is being expanded and tested for other types of cancer.

The Impact of Parent and Family Caregiver Roles Among Canadian Radiation Oncologists.

PURPOSE: Working parents, and a rising number of adults delivering care for aging relatives, experience numerous challenges in their personal, family, professional, and financial lives owing to multiple responsibilities. This study describes the experiences of Canadian radiation oncologist (RO) parents and family caregivers, reporting challenges that may exist in providing family care with clinical and academic work commitments. METHODS AND MATERIALS: Canadian ROs, via RO heads of departments in cancer centers across Canada, and physician members of the Canadian Association of Radiation Oncology were invited to participate in an anonymous online survey between November 2021 and January 2022. The survey focused on demographics, experiences of pregnancy and leave, parenting and adult caregiving responsibilities, and self-care. RESULTS: A total of 103 staff ROs (38%) completed the survey and 78 (75.7%) identified as having a parental (76 [89.7%]) and/or other family caregiver (8 [10.3%]) role; 41% were female and 59% were male, with no difference between genders in the number of children (median, 2; interquartile range, 1-3; P = .17). More female respondents took parental leave for their first child compared with male respondents (mean, 29 vs 6 weeks; P < .001). Of male respondents who started caring for their first child during residency, 27% took parental leave, compared with 77% who started caring for their first child as a staff member (P = .003). The majority of respondents described "always/usually" having collegial support for each pregnancy and parental leave. Both genders described parental responsibilities as negatively affecting attendance at conferences (male, 65%; female, 77%; P = .31) and early or late work-related meetings (male, 76%; female, 79%; P = 1.0). More female respondents described parental responsibilities as negatively affecting their career (50% vs 29%; P = .085). Of female respondents, 52% (vs 26% of male respondents; P = .044) identified a physician mentor or positive role model around parenting issues. CONCLUSIONS: Parental and other family caregiving responsibilities are not gender unique in Canadian ROs, but competing work and family roles may affect genders differently.

Palliative Radiation for Advanced Central Lung Tumors With Intentional Avoidance of the Esophagus (PROACTIVE): A Phase 3 Randomized Clinical Trial.

IMPORTANCE: Palliative thoracic radiotherapy (RT) can alleviate local symptoms associated with advanced non-small cell lung cancer (NSCLC), but esophagitis is a common treatment-related adverse event. Whether esophageal-sparing intensity-modulated RT (ES-IMRT) achieves a clinically relevant reduction in esophageal symptoms remains unclear. OBJECTIVE: To examine whether ES-IMRT achieves a clinically relevant reduction in esophageal symptoms compared with standard RT. DESIGN, SETTING, AND PARTICIPANTS: Palliative Radiation for Advanced Central Lung Tumors With Intentional Avoidance of the Esophagus (PROACTIVE) is a multicenter phase 3 randomized clinical trial that enrolled patients between June 24, 2016, and March 6, 2019. Data analysis was conducted from January 23, 2020, to October 22, 2021. Patients had up to 1 year of follow-up. Ninety patients at 6 tertiary academic cancer centers who had stage III/IV NSCLC and were eligible for palliative thoracic RT (20 Gy in 5 fractions or 30 Gy in 10 fractions) were included. INTERVENTIONS: Patients were randomized (1:1) to standard RT (control arm) or ES-IMRT. Target coverage was compromised to ensure the maximum esophagus dose was no more than 80% of the RT prescription dose. MAIN OUTCOMES AND MEASURES: The primary outcome was esophageal quality of life (QOL) 2 weeks post-RT, measured by the esophageal cancer subscale (ECS) of the Functional Assessment of Cancer Therapy: Esophagus questionnaire. Higher esophageal cancer subscale scores correspond with improved QOL, with a 2- to 3-point change considered clinically meaningful. Secondary outcomes included overall survival, toxic events, and other QOL metrics. Intention-to-treat analysis was used. RESULTS: Between June 24, 2016, and March 6, 2019, 90 patients were randomized to standard RT or ES-IMRT (median age at randomization, 72.0 years [IQR, 65.6-80.3]; 50 [56%] were female). Thirty-six patients (40%) received 20 Gy and 54 (60%) received 30 Gy. For the primary end point, the mean (SD) 2-week ECS score was 50.5 (10.2) in the control arm (95% CI, 47.2-53.8) and 54.3 (7.6) in the ES-IMRT arm (95% CI, 51.9-56.7) (P = .06). Symptomatic RT-associated esophagitis occurred in 24% (n = 11) of patients in the control arm vs 2% (n = 1) in the ES-IMRT arm (P = .002). In a post hoc subgroup analysis based on the stratification factor, reduction in esophagitis was most evident in patients receiving 30 Gy (30% [n = 8] vs 0%; P = .004). Overall survival was similar with standard RT (median, 8.6; 95% CI, 5.7-15.6 months) and ES-IMRT (median, 8.7; 95% CI, 5.1-10.2 months) (P = .62). CONCLUSIONS AND RELEVANCE: In this phase 3 randomized clinical trial, ES-IMRT did not significantly improve esophageal QOL but significantly reduced the incidence of symptomatic esophagitis. Because post hoc analysis found that reduced esophagitis was most evident in patients receiving 30 Gy of RT, these findings suggest that ES-IMRT may be most beneficial when the prescription dose is higher (30 Gy). TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02752126.

Determining Planning Priorities for SABR for Oligometastatic Disease: A Secondary Analysis of the SABR-COMET Phase II Randomized Trial.

PURPOSE: SABR may improve survival in patients with oligometastases, but for some lesions, safe delivery of SABR may require a reduction in delivered dose or target coverage. This study assessed the association between target coverage compromise and oncologic and survival outcomes. METHODS AND MATERIALS: Patients with a controlled primary malignancy and 1 to 5 oligometastases were randomized (1:2) between standard of care (SOC) treatment and SOC plus SABR. In patients receiving SABR, the target dose coverage was reduced to meet organ at risk (OAR) constraints, if necessary. The D99 value (minimum dose received by the hottest 99% of the planning target volume [PTV]) was used as a measure of PTV coverage for each treatment plan, and the relationship between the coverage compromise index (CCI, defined as D99/prescription dose) and patient outcomes was assessed. RESULTS: Sixty-two patients in the SABR arm had dosimetric information available and a total of 109 lesions were evaluated. The mean CCI per lesion was 0.96 (95% CI, 0.56-1.61). Of the 109 lesions evaluated, 29.4% (n = 32) required coverage compromise (CCI <0.9). Adrenal metastases required coverage compromise in 100% of analyzed lesions (n = 7). CCI was not significantly associated with lesional control, adverse events, overall survival (OS), or progression-free survival (PFS). CONCLUSIONS: Target compromise was required in a substantial minority of cases, but PTV coverage was not associated with OS, progression-free survival, or lesional control. This suggests that OAR constraints used for SABR treatments in the oligometastatic setting should continue to be prioritized during planning.

Personality Traits and Urinary Symptoms Are Associated with Mental Health Distress in Patients with a Diagnosis of Prostate Cancer.

OBJECTIVE: With a prolonged natural history compared with many other cancers, prostate cancer patients have high rates of mental illness over the duration of their treatment. Here, we examine the relationship between personality and mental health distress in a sample of prostate cancer patients. METHODS: This study was conducted in the Canadian Maritime provinces, where a cohort of 189 men with prostate cancer were invited to complete a quality-of-life online survey between May 2017 and December 2019. The presence or absence of screening positive for mental health illness was the primary outcome and was assessed using Kessler's 10-item scale (K10). Urinary symptoms were assessed using the International Prostate Symptom Score (IPSS). The ten-item personality inventory (TIPI) assessed extraversion, agreeableness, conscientiousness, emotional stability (or neuroticism), and openness to experiences. A multivariate logistic regression model was created to examine the association between personality, urinary symptoms, and mental health distress, while controlling for time from diagnosis, treatment type, age, and multimorbidity. RESULTS: Screening positive for mental illness (18.0%) was associated with personality traits of low levels of emotional stability (OR = 0.07, 95% CI: 0.03-0.20) and moderate to severe urinary problems (OR = 5.21, 95% CI: 1.94-14.05)). There was no identified association between treatment received for prostate cancer and personality type. CONCLUSION: Screening for mental health illness in this population may help reduce morbidity associated with cancer treatment, as well as identify patients who may be at risk of mental health distress and could benefit from individualized mental health support services. These findings suggest that multidisciplinary care is essential for the management of these patients.

Sequence Inversion to Facilitate Concurrent Radiotherapy and Systemic Therapy. A Proof of Principle Study in the Setting of a Phase II Randomized Trial in Prostate Cancer.

Background: Concomitant chemo-radiation for pelvic cancers remains challenging to be delivered at full doses. We hypothesized that fewer delays in chemotherapy would occur if the sequence of radiotherapy would be reversed, starting with the boost volume followed by the elective nodal volume. We report the result of a Phase II randomized study for high risk prostate cancer. Patients and Method: The study was a double-blinded phase II randomized trial. Patients were eligible if they had non-metastatic high-risk prostate cancer. All patients received 2.5 years of hormonal therapy and 46.5 Gy in 25 fractions to the pelvic lymph nodes. Patients received a radiation boost to the prostate, either before or after whole pelvic irradiation. Concurrent (20 mg/m2) Docetaxel was given on the first day of radiotherapy and weekly thereafter for a total of eight treatments until predefined toxicity stopping rules. Results: Ninety patients were included and randomized. Four were ineligible for the analysis. In total, 42 patients were randomized to the standard sequence, 44 patients to the experimental sequence. There were statistically fewer GI or GU toxicities leading to a docetaxel dose reduction or omission in the experimental sequence compared to the standard sequence, 5 vs. 15 events (p = 0.027). There was no difference in overall survival, cause-specific survival, or biochemical-relapse free survival between the two sequences. Conclusions: This is the first study to test sequence inversion for pelvic radio-chemotherapy in a randomized double-blind trial. Less chemotherapy interruptions or dose reductions occurred by inverting the radiation sequence of the large field and the boost. The trial was registered with Clinicaltrials.gov: NCT00452556.

Current Mental Distress Among Men With a History of Radical Prostatectomy and Related Adverse Correlates.

Recent reviews and observational studies have reported that patients with prostate cancer (PCa) are at increased risk of mental health issues, which in turn negatively affects oncological outcomes. Here, we examine possible explanatory variables of mental distress in a population-based cohort of men who have undergone radical prostatectomy (RP). Data were derived from a Maritimes-Canada online survey assessing patient-reported quality of life outcomes between 2017 and 2019 administered to 136 men (47-88 years old, currently in a relationship) who have undergone RP for their PCa diagnosis. The primary outcome was a validated assessment of mental distress, the Kessler Psychological Distress Scale (K10). Urinary function was assessed using the International Prostate Symptom Score, and relationship satisfaction was assessed using the Dyadic Assessment Scale. A multivariate logistic regression assessed the contribution of urinary function, relationship satisfaction, age, multimorbidity, additional treatments, medication for depression and/or anxiety, and survivorship time. A total of 16.2% men in this sample screened positive for mental distress. The severity of urinary problems was positively associated with increased mental distress (OR = 4.79, 95% CI [1.04, 22.03]), while increased age (OR = 0.87, 95% CI [0.78, 0.97]), relationship satisfaction (OR = 0.14, 95% CI [0.3, .077]), and current medication for anxiety, depression, or both (OR = 0.09, 95% CI [0.02, 0.62]) were protective factors. Survivorship time, the presence of additional comorbidities, or PCa treatments were not identified to be statistically significant contributions to the fitted model. Here, we report that RP survivors are prone to presenting with increased mental distress long after treatment. Screening for mental distress during RP survivorship is recommended.

The Impact of a Rotating Elective on Medical Students' Perception of Radiation Oncology.

Background As Radiation Oncology (RO) is a field with limited exposure in undergraduate medical education curricula, the information sources used to form students' perception of the field can have a substantial impact on whether students decide to pursue experiences in RO. Furthermore, the effects of a single elective experience in RO can strongly influence career decisions as it may serve as the only experience for students to gain an understanding of RO as a specialty. This study analyzes which information sources students use and most strongly value when forming their perception of RO both before and after participating in the program, while also analyzing changes in the perception of various speciality-related factors associated with RO. Methods To address underrepresented specialties, the Pre-clerkship Residency Exploration Program (PREP) was developed to provide students exposure to RO and 13 other specialties through half-day clinical rotations, simulations, skills sessions, and panel discussions. A total of 37 participants completed both "Pre-program" and "Post-program" surveys to evaluate which information sources they use and value most when forming their perception of RO, and student perception of career factors associated with RO was assessed. Results Students reported that Pre-program information sources of RO were based on Lectures (35 students, 94.6%) and Preceptors (18 students, 48.7%). Post-program responses indicated that the greatest sources of information used were from Preceptors (36 students, 97.3%) and Residents (34 students, 91.9%), with the greatest increase being found in interactions with Residents for gaining specialty information (78% increase). Students most highly valued Preceptors, Residents, and Lectures as information sources when forming their perception of RO. Pre-program, students had the greatest positive perception of RO with respect to Income Potential (mean: 3.76/5.00 ± 0.87), Intellectual Challenge (mean: 3.90/5.00 ± 0.94), and Research Opportunities (mean: 3.86/5.00 ± 0.83) while most negatively assessing the factors of Flexibility (mean: 2.69/5.00 ± 0.93) and Level of Stress (mean: 2.93/5.00 ± 0.94). Conclusions Student perception of a medical specialty is a factor that may influence student elective choice and career decisions. Through participating in PREP, significant positive increases were found in students' perception of RO in the areas of Flexibility, Patient Population, Competitiveness of the Specialty, Quality of the Working Environment, and Levels of Stress. This study highlights which information sources students value the most when forming their perception of RO and the impact a single elective experience has on improving student perception of the field. RO-based programs and lectures can be better designed using this information to introduce students to this specialty.

Pituitary Metastasis of Pulmonary Large Cell Neuroendocrine Carcinoma: A Case Report.

The pituitary gland is an uncommon site of tumor metastasis in the brain, comprising only 1% of all intracranial metastasis. Large cell neuroendocrine carcinoma (LCNEC) is similarly rare, accounting for only 3% of all lung malignancies in adults. We describe a case of LCNEC of lung origin that metastasized to the pituitary gland. The pituitary lesion was found during the workup for a metastatic LCNEC of lung origin in the ovary. Initially thought to be a pituitary adenoma, interval growth of the lesion during imaging follow-up raised clinical suspicion of a second metastatic site. The patient underwent endoscopic resection and pathological examination confirmed the pituitary lesion to be from the lung primary. Post-operatively, the patient developed signs and symptoms of diabetes insipidus that was adequately treated with DDAVP. The patient underwent postoperative radiotherapy one month after the surgery and a repeat MRI at the 12-month follow-up demonstrates no progression of the pituitary lesion.

Attitudes Towards Research During Residency Training: a Survey of Canadian Radiation Oncology Residents and Program Directors.

Radiation oncologists require clinical appraisal and research methodology skills, yet it is unclear how to develop these competencies during residency. We sought to attain a deeper understanding of the barriers that limit, as well as the factors that promote, engaging in research/scholarly activity during radiation oncology residency training in Canada. Following ethics approval, online surveys were circulated to all Canadian Radiation Oncology program directors and residents. Unidentifiable demographics, prior research experience, and descriptions of current research environment and barriers to engaging in research and scholarly activities were collected. Thirty-three percent (35/105) of residents and 71% (10/14) of program directors responded. Ninety-seven percent of residents, and 90% of program directors, agreed or strongly agreed that research/scholarly activity was an important part of residency training. While 66% of residents felt that there was a lack of protected time for research/scholarly activity, only 20% of program directors agreed this was a barrier (p = 0.011). While 94% of residents thought mentorship was important to completing high-quality research/scholarly activity, only 48% of respondents had a mentor. The highest barriers to completing research/scholarly activity projects were lack of protected time (for both residents and faculty), high resident clinical workload, and lack of experience in research skills. Canadian Radiation Oncology residents expressed strong enthusiasm to participate in research/scholarly activity, yet lack of protected time and competing demands were identified as major barriers. We suggest programs offer more protected time for research/scholarly activity, provide optional research methodology training, and support meaningful mentorship relationships.

Medical Student Exposure to Radiation Oncology Through the Pre-clerkship Residency Exploration Program (PREP): Effect on Career Interest and Understanding of Radiation Oncology.

Medical students receive little exposure to Radiation Oncology (RO) during pre-clinical training and clerkship. Pre-clerkship Residency Exploration Program (PREP) was developed by medical students at our institution to provide students with exposure to disciplines like RO with which they may not have had previous exposure, with the goal of helping with career decision making. The purpose of this study was to review how PREP affected self-reported interest in RO. PREP is a 2-week intensive elective developed by students at Dalhousie University that provides exposure to 12 specialties, including RO. PREP includes five components: half day clinical rotations, skills sessions, simulations, specialty-specific workshops, and lunchtime panel discussions. PREP participants completed questionnaires pre- and post-participation to assess career interest and understanding of Radiation Oncology. Forty participants took part in PREP. Thirty-six responded to pre-PREP questionnaires and 37 to the post-PREP questionnaire. Participants reported increasing interest in RO (24 students, 64.8%) and an increase in the understanding of the role and responsibilities of a radiation oncologist such that they felt comfortable making a career decision about RO. In pre-PREP, five (13.8%) participants listed RO as a top 3 career choice. Post-program, this number increased to nine (25.0%) of the same surveyed participants. PREP has demonstrated early exposure to RO can increase interest in RO as a career choice. Early clinical exposure experiences like we describe here may be useful for specialties such as RO, which is having difficulty filling residency positions in Canada despite an optimistic job forecast for trainees.

An Examination of the Relationship between Mental Distress, Functional and Psychosocial Quality of Life Indicators in a Population Based Sample of Prostate Cancer Survivors Who Received Curative Treatment.

INTRODUCTION: Although survival rates are highest among prostate cancer survivors compared to any other forms of cancer, nearly 60% suffer from mental distress. Here we examine urinary function and psychosocial stressors and their association with poor mental health in a younger group of prostate cancer survivors who have undergone curative treatment. METHODS: The study includes 128 men (47 to 70 years old) who received active treatment for prostate cancer, and completed a survivorship online survey between 2017 and 2018. Psychological distress was assessed with Kessler Psychological Distress Scale. International Prostate Symptom Score subscales (incomplete urinary emptying, frequency, intermittency, urgency, weak stream, straining and nocturia) and number of current prostate cancer survivorship stressors were predictors. Multivariate logistic regression was used to fit the model while controlling for months of survivorship since diagnosis, the presence or absence of surgery, radiation or hormone therapy treatment, current medication for depression and demographics. RESULTS: A total of 19.5% of men scored positive for current mental health issues. Prostate cancer survivors who reported increased number of current survivorship stressors (OR 1.48, 95% CI 1.09-2.01), had higher frequency of urination (OR 2.05, 95% CI 1.15-3.64), history of radiation treatment (OR 7.15, 95% CI 1.02-50.35) and were currently on prescribed medication for depression (OR 33.47, 95% CI 3.80-294.87) had higher odds for screening positive for psychological distress compared with their counterparts. CONCLUSIONS: These results corroborate recent findings showing an intersection between urological oncology and poor mental health during survivorship, and warrant the development of multidisciplinary teams in addressing survivorship issues in this population.

Individualized Dose-Escalation of HDR Prostate Brachytherapy Implant to Decrease Required External Beam Radiation Dose: A Retrospective Feasibility Study.

PURPOSE: High-dose-rate brachytherapy (HDR-BT) is commonly combined with external beam radiation therapy (EBRT) for the treatment of localized prostate cancer. Escalating the HDR-BT dose as far as organ-at-risk (OAR) constraints allow, on a personalized basis, would allow for a reduction in EBRT dose while achieving similar total biologic equivalence. The primary objective of this study was to determine the dosimetric feasibility of escalating the HDR-BT dose from 15 Gy to 16 or 17 Gy while continuing to meet OAR constraints from the original 15 Gy plan on an individualized basis. METHODS AND MATERIALS: A total of 53 consecutive HDR-BT plans were retrospectively assessed to determine what percentage of plans could be reoptimized to deliver a dose of 16 Gy or 17 Gy, while meeting defined 15-Gy OAR constraints. Factors independently associated with dose escalation were examined. RESULTS: Thirty-nine plans (74%) and 2 plans (4%) were successfully escalated to a dose of 16 Gy and 17 Gy, respectively. Rectum V80 and urethra Dmax were independently predictive of the ability to dose escalate to 16 Gy. CONCLUSIONS: Individualized HDR-BT dose escalation beyond 15 Gy without compromising OAR constraints is dosimetrically feasible. This approach could allow for a corresponding reduction of EBRT fractions (ie, from 15 to 12 fractions) and would be beneficial in terms of resource savings for departments, convenience for patients, and potentially better tolerance of treatment with the expected reduction in biologically equivalent doses to OARs. A clinical trial is being developed to investigate the efficacy and tolerance of personalized HDR-BT/EBRT dose fractionation for localized intracapsular prostate cancer.

MRI-based interstitial brachytherapy for vaginal tumors: A multi-institutional study on practice patterns, contouring, and consensus definitions of target volumes.

PURPOSE: Interstitial brachytherapy (ISBT) can be effective for vaginal tumors due to its ability to deliver conformal treatment with 3D planning. As there is no consensus for 3D vaginal brachytherapy (BT) contouring, the goals of this study are to evaluate the variability in practices and contouring, and to develop consensus concepts on target definitions. METHODS: A survey/contouring study was conducted with 16 radiation oncologists from 10 Canadian academic centers. The study included three vaginal ISBT cases. Participants were provided staging, prebrachytherapy (pre-BT), and BT MRIs. Participants responded to a questionnaire and contoured on the provided images. Agreement between contours was analyzed. A meeting was held to develop consensus definitions of targets. RESULTS: Median ISBT experience was 3.5 years. All 16 participants regularly contour with MRI, whereas three also plan on MRI. For the three cases, there was variation into how CTVHR and CTVIR was defined. Kappa statistics showed higher agreement with bulky tumors (mean 0.59) as compared with small residual tumors (mean 0.29). For all cases, kappa was highest in pre-BT GTVres as compared with BT GTVres (mean 0.58, 0.46). Consensus concepts to define targets were developed. CONCLUSIONS: Variations exist in how ISBT targets are defined for vaginal tumors. Highest contouring variability was seen with small residual at BT. Contouring is more consistent on pre-BT MRI as compared with BT MRI suggesting a needle distortion effect. Consensus CTVHR and CTVIR definitions have been developed and further work is warranted to establish international standards.