Biological effective dose in analysis of rectal dose in prostate cancer patients who underwent a combination therapy of VMAT and LDR with hydrogel spacer insertion.

This study aimed to evaluate rectal dose reduction in prostate cancer patients who underwent a combination of volumetric modulated arc therapy (VMAT) and low-dose-rate (LDR) brachytherapy with insertion of hydrogel spacer (SpaceOAR). For this study, 35 patients receiving hydrogel spacer and 30 patients receiving no spacer were retrospectively enrolled. Patient was treated to doses of 45 Gy to the primary tumor site and nodal regions over 25 fractions using VMAT and 100 Gy to the prostate using prostate seed implant (PSI). In VMAT plans of patients with no spacer, mean doses of rectal wall were 43.6, 42.4, 40.1, and 28.8 Gy to the volume of 0.5, 1, 2, and 5 cm3 , respectively. In patients with SpaceOAR, average rectal wall doses decreased to 39.0, 36.9, 33.5, and 23.9 Gy to the volume of 0.5, 1, 2, and 5 cm3 , respectively (p < 0.01). In PSI plans, rectal wall doses were on average 78.5, 60.9, 41.8, and 14.8 Gy to the volume of 0.5, 1, 2, and 5 cm3 , respectively, in patients without spacer. In contrast, the doses decreased to 34.5, 28.4, 20.6 (p < 0.01), and 8.5 Gy (p < 0.05) to rectal wall volume of 0.5, 1, 2, and 5 cm3 , respectively, in patient with SpaceOAR. To demonstrate rectal sum dose sparing, dose-biological effective dose (BED) calculation was accomplished in those patients who showed >60% overlap of rectal volumetric doses between VMAT and PSI. In patients with SpaceOAR, average BEDsum was decreased up to 34%, which was 90.1, 78.9, 65.9, and 40.8 Gy to rectal volume of 0.5, 1, 2, and 5 cm3 , respectively, in comparison to 137.4, 116.7, 93.0, and 50.2 Gy to the volume of 0.5, 1, 2, and 5 cm3 , respectively, in those with no spacer. Our result suggested a significant reduction of rectal doses in those patients who underwent a combination of VMAT and LDR with hydrogel spacer placement.

Assessing initial plan check efficacy using TG 275 failure modes and incident reporting.

Plan checks are important components of a robust quality assurance (QA) program. Recently, the American Association of Physicists in Medicine (AAPM) published two reports concerning plan and chart checking, Task Group (TG) 275 and Medical Physics Practice Guideline (MPPG) 11.A. The purpose of the current study was to crosswalk initial plan check failure modes revealed in TG 275 against our institutional QA program and local incident reporting data. Ten physicists reviewed 46 high-risk failure modes reported in Table S1.A.i of the TG 275 report. The committee identified steps in our planning process which sufficiently checked each failure mode. Failure modes that were not covered were noted for follow-up. A multidisciplinary committee reviewed the narratives of 1599 locally-reported incidents in our Radiation Oncology Incident Learning System (ROILS) database and categorized each into the high-risk TG 275 failure modes. We found that over half of the 46 high-risk failure modes, six of which were top-ten failure modes, were covered in part by daily contouring peer-review rounds, upstream of the traditional initial plan check. Five failure modes were not adequately covered, three of which concerned pregnancy, pacemakers, and prior dose. Of the 1599 incidents analyzed, 710 were germane to the initial plan check, 23.4% of which concerned missing pregnancy attestations. Most, however, were caught prior to CT simulation (98.8%). Physics review and initial plan check were the least efficacious checks, with error detection rates of 31.8% and 31.3%, respectively, for some failure modes. Our QA process that includes daily contouring rounds resulted in increased upstream error detection. This work has led to several initiatives in the department, including increased automation and enhancement of several policies and procedures. With TG 275 and MPPG 11.A as a guide, we strongly recommend that departments consider an internal chart checking policy and procedure review.

Guidelines for Palliative Treatment of Spinal Metastases: Choosing Between Stereotactic Body Radiation Therapy and Conventional Fractionation.

Symptomatic spinal metastasis is a frequent complication of cancer that had been treated, until relatively recently, with primitive techniques to modest radiation dose levels, with a baseline assumption of limited survival and poor patient performance in that setting. In the era of targeted and personalized therapies, many patients are living longer and more functionally and are able to manage their disease on the model of chronic illness. Given these developments, an attractive option is the use of stereotactic body radiation therapy (SBRT) to deliver high biologically effective doses of radiation conformally to maximize the palliative gains of treatment. However, randomized data to guide practice are scarce. We review the extant literature and present an algorithmic approach to selecting patients with metastatic disease for palliative spinal SBRT favoring the results of available randomized studies and remaining within the safety constraints supported by evidence from randomized trials.

Development and execution of a pandemic preparedness plan: Therapeutic medical physics and radiation dosimetry during the COVID-19 crisis.

The SARS-CoV-2 coronavirus pandemic has spread around the world including the United States. New York State has been hardest hit by the virus with over 380 000 citizens with confirmed COVID-19, the illness associated with the SARS-CoV-2 virus. At our institution, the medical physics and dosimetry group developed a pandemic preparedness plan to ensure continued operation of our service. Actions taken included launching remote access to clinical systems for all dosimetrists and physicists, establishing lines of communication among staff members, and altering coverage schedules to limit on-site presence and decrease risk of infection. The preparedness plan was activated March 23, 2020, and data were collected on treatment planning and chart checking efficiency for 6 weeks. External beam patient load decreased by 25% during the COVID-19 crisis, and special procedures were almost entirely eliminated excepting urgent stereotactic radiosurgery or brachytherapy. Efficiency of treatment planning and chart checking was slightly better than a comparable 6-week interval in 2019. This is most likely due to decreased patient load: Fewer plans to generate and more physicists available for checking without special procedure coverage. Physicists and dosimetrists completed a survey about their experience during the crisis and responded positively about the preparedness plan and their altered work arrangements, though technical problems and connectivity issues made the transition to remote work difficult. Overall, the medical physics and dosimetry group successfully maintained high-quality, efficient care while minimizing risk to the staff by minimizing on-site presence. Currently, the number of COVID-19 cases in our area is decreasing, but the preparedness plan has demonstrated efficacy, and we will be ready to activate the plan should COVID-19 return or an unknown virus manifest in the future.

Deformable image registration and interobserver variation in contour propagation for radiation therapy planning.

Deformable image registration (DIR) and interobserver variation inevitably intro-duce uncertainty into the treatment planning process. The purpose of the current work was to measure deformable image registration (DIR) errors and interobserver variability for regions of interest (ROIs) in the head and neck and pelvic regions. Measured uncertainties were combined to examine planning margin adequacy for contours propagated for adaptive therapy and to assess the trade-off of DIR and interobserver uncertainty in atlas-based automatic segmentation. Two experi-enced dosimetrists retrospectively contoured brainstem, spinal cord, anterior oral cavity, larynx, right and left parotids, optic nerves, and eyes on the planning CT (CT1) and attenuation-correction CT of diagnostic PET/CT (CT2) for 30 patients who received radiation therapy for head and neck cancer. Two senior radiation oncology residents retrospectively contoured prostate, bladder, and rectum on the postseed-implant CT (CT1) and planning CT (CT2) for 20 patients who received radiation therapy for prostate cancer. Interobserver variation was measured by calculating mean Hausdorff distances between the two observers' contours. CT2 was deformably registered to CT1 via commercially available multipass B-spline DIR. CT2 contours were propagated and compared with CT1 contours via mean Hausdorff distances. These values were summed in quadrature with interobserver variation for margin analysis and compared with interobserver variation for sta-tistical significance using two-tailed t-tests for independent samples (α = 0.05). Combined uncertainty ranged from 1.5-5.8 mm for head and neck structures and 3.1-3.7 mm for pelvic structures. Conventional 5 mm margins may not be adequate to cover this additional uncertainty. DIR uncertainty was significantly less than interobserver variation for four head and neck and one pelvic ROI. DIR uncertainty was not significantly different than interobserver variation for four head and neck and one pelvic ROI. DIR uncertainty was significantly greater than interobserver variation for two head and neck and one pelvic ROI. The introduction of DIR errors may offset any reduction in interobserver variation by using atlas-based automatic segmentation.

Radiation Therapy Practice Patterns for Treatment of Curative Breast Cancer in a Large Tertiary Health Care System.

Purpose: Disparities have been reported in women treated for breast cancer (BrCa). This study examines potential disparities in BrCa treatment offered based on race and age from a multicenter radiation department. Methods and Materials: We identified 901 patients with early stage BrCa who received curative intent radiation therapy (RT) between 2004 and 2018. Data extracted included age, race, disease stage, treatment technique, treatment dates, and fractionation. Patient race was recorded as Asian, Black, Hispanic, and White. RT technique delivered was classified as a type of external beam radiation therapy or brachytherapy/intraoperative radiation therapy. Fractionation schema were defined as 1) standard fractionation, 1.8-2 Gy; 2) hypofractionation, 2.5-2.67 Gy; 3) accelerated partial breast irradiation (APBI), 3.4 Gy - 4.25 Gy, and 4) intraoperative radiation therapy, single dose of 20 Gy. Stage was recorded using TNM staging. The χ2 test and a multivariable multinomial logistic regression model were used to assess whether patient characteristics, such as age, race, or stage influenced fractionation schemes. Results with 2-sided P values < .05 were considered statistically significant. Results: Racial composition of the study was 13.8% Asian, 22% Black, 29%, White, and 35.1% Hispanic. Mean age was 61 and was divided into 4 age range groups: 30 to 49 (n = 160), 50 to 59 (n = 231), 60 to 69 (n = 294), and ≥70 years (n = 216). In addition, 501 patients (56%) received hypofractionation, 342 (38.8%) received standard fractionation, and 58 (7.1%) received APBI, respectively. For all groups, hypofractionation became more common over time. Age ≥70 years was associated with 9 times higher odds of APBI and 14 times higher odds of hypofractionation, compared with age 30 to 49 years. After adjusting for the other predictors in a multivariable multinomial logistic regression model, the race distribution differed among the 3 groups (P = .03), with a smaller percentage of Hispanics and higher percentage of blacks in the standard group. Conclusions: This study of a diverse cohort of patients with breast cancer failed to identify treatment differences associated by race. The study found an association between age and hypofractionation.

Treatment Terminations During Radiation Therapy: A Ten-Year Experience.

PURPOSE: Patients undergoing radiation therapy may terminate treatment for any number of reasons. The incidence of treatment termination (TT) during radiation therapy has not been studied. Herein we present a cohort of TT at a large multi-center radiation oncology department over 10 years. METHODS AND MATERIALS: TTs between 1/2013 and 1/2023 were prospectively analyzed as part of an ongoing departmental quality and safety program. TT was defined as any premature discontinuation of therapy after initiating radiation planning. The rate of TT was calculated as a percentage of all patients starting radiation planning. All cases were presented at monthly morbidity and mortality (MM) conferences with a root cause reviewed (RCA). RESULTS: A total of 1,448 TTs were identified out of 31,199 planned courses of care (4.6%). Six hundred eighty-six (47.4%) involved patients treated with curative intent, while 753 (52.0%) with palliative intent, and 9 (0.6%) for benign disease. The rate of TT decreased from 8.49% in 2013 to 3.02% in 2022 with rates decreasing yearly. The most common disease sites for TT were CNS (21.7%), H&N (19.3%), Thorax (17.5%), and Bone (14.2%). The most common causes of TT were hospice and/or patient expiration (35.9%), patient choice unrelated to toxicity (35.2%), and clinician choice unrelated to toxicity (11.5%). CONCLUSION: This 10-year prospective review of TTs identified a year-over-year decrease in TTs as a percentage of planned patients. This decrease may be associated with the addition of RCA for TTs and discussion monthly at MM rounds, coupled with departmental upstream quality initiatives implemented over time. Understanding the reasons behind TTs may help to decrease preventable TTs. While some TTs may be unavoidable, open discourse and quality improvement changes effectively reduce TT incidents over time.

Noninferiority of Hypofractionated vs Conventional Postprostatectomy Radiotherapy for Genitourinary and Gastrointestinal Symptoms: The NRG-GU003 Phase 3 Randomized Clinical Trial.

Importance: No prior trial has compared hypofractionated postprostatectomy radiotherapy (HYPORT) to conventionally fractionated postprostatectomy (COPORT) in patients primarily treated with prostatectomy. Objective: To determine if HYPORT is noninferior to COPORT for patient-reported genitourinary (GU) and gastrointestinal (GI) symptoms at 2 years. Design, Setting, and Participants: In this phase 3 randomized clinical trial, patients with a detectable prostate-specific antigen (PSA; ≥0.1 ng/mL) postprostatectomy with pT2/3pNX/0 disease or an undetectable PSA (<0.1 ng/mL) with either pT3 disease or pT2 disease with a positive surgical margin were recruited from 93 academic, community-based, and tertiary medical sites in the US and Canada. Between June 2017 and July 2018, a total of 296 patients were randomized. Data were analyzed in December 2020, with additional analyses occurring after as needed. Intervention: Patients were randomized to receive 62.5 Gy in 25 fractions (HYPORT) or 66.6 Gy in 37 fractions (COPORT). Main Outcomes and Measures: The coprimary end points were the 2-year change in score from baseline for the bowel and urinary domains of the Expanded Prostate Cancer Composite Index questionnaire. Secondary objectives were to compare between arms freedom from biochemical failure, time to progression, local failure, regional failure, salvage therapy, distant metastasis, prostate cancer-specific survival, overall survival, and adverse events. Results: Of the 296 patients randomized (median [range] age, 65 [44-81] years; 100% male), 144 received HYPORT and 152 received COPORT. At the end of RT, the mean GU change scores among those in the HYPORT and COPORT arms were neither clinically significant nor different in statistical significance and remained so at 6 and 12 months. The mean (SD) GI change scores for HYPORT and COPORT were both clinically significant and different in statistical significance at the end of RT (-15.52 [18.43] and -7.06 [12.78], respectively; P < .001). However, the clinically and statistically significant differences in HYPORT and COPORT mean GI change scores were resolved at 6 and 12 months. The 24-month differences in mean GU and GI change scores for HYPORT were noninferior to COPORT using noninferiority margins of -5 and -6, respectively, rejecting the null hypothesis of inferiority (mean [SD] GU score: HYPORT, -5.01 [15.10] and COPORT, -4.07 [14.67]; P = .005; mean [SD] GI score: HYPORT, -4.17 [10.97] and COPORT, -1.41 [8.32]; P = .02). With a median follow-up for censored patients of 2.1 years, there was no difference between HYPORT vs COPORT for biochemical failure, defined as a PSA of 0.4 ng/mL or higher and rising (2-year rate, 12% vs 8%; P = .28). Conclusions and Relevance: In this randomized clinical trial, HYPORT was associated with greater patient-reported GI toxic effects compared with COPORT at the completion of RT, but both groups recovered to baseline levels within 6 months. At 2 years, HYPORT was noninferior to COPORT in terms of patient-reported GU or GI toxic effects. HYPORT is a new acceptable practice standard for patients receiving postprostatectomy radiotherapy. Trial Registration: ClinicalTrials.gov Identifier: NCT03274687.

A Decade of Prospective Peer Review: Impact on Safety Culture and Lessons Learned in a Multicenter Radiation Medicine Department.

PURPOSE: Quality assurance (QA) is critical to the success of radiation therapy (RT) for patients with cancer and affects clinical outcomes. We report longitudinal findings of a prospective peer review evaluation system implemented at a major academic health system as part of RT QA during a 10-year period. METHODS AND MATERIALS: All cases treated within our department undergo prospective multidisciplinary peer review and are assigned a grade (A, B, or C). "A" cases require no changes, "B" cases require minor modification, and "C" cases require major modification before treatment planning. The z-ratio test for the significance of the difference between the 5-year baseline (2012-2016) and follow-up (2017-2021) period was used to compare grades between the 2 periods. A 2-tailed P value <.05 was considered significant. RESULTS: Of the 20,069 cases, 15,659 (78%) were curative and were analyzed. The fraction of A cases decreased from 74.8% (baseline) to 64.5% (follow-up), whereas B cases increased from 19.4% to 35.4% and C cases decreased from 5.8% to 0.1%. Of the 9 treatment locations, the main hospital site had a higher percentage of A grades relative to community locations in the baseline (78.6% vs 67.8%; P < .002) and follow-up (66.9% vs 62.3%; P < .002) periods. There was a decrease in the percentage of A cases from the baseline to the follow-up period regardless of plan type (complex vs intermediate vs simple). There was a decrease in the percentage of A cases among specialists from baseline to follow-up (78.2% to 67.7%; P < .002) and among generalists from baseline to follow-up (69.7% to 61.7%; P < .002). CONCLUSIONS: Our 10-year experience in contour peer review identified increased opportunities in improving treatment plan quality over time. The drop in A scores and rise in B scores suggests increased scrutiny and findings-based improvements over time, whereas the drop in C scores indicates amelioration of "major failures" addressed in the startup years. Peer review rounds upstream of treatment planning provide valuable RT QA and should be considered by other departments to enhance the quality and consistency of RT.

Efficacy of ketamine mouthwash in the management of oral and pharyngeal toxicity associated with head and neck chemoradiotherapy: protocol for a phase II, Simon's two-stage trial.

INTRODUCTION: Curative intent treatment of head and neck cancer (HNC) is frequently radiation therapy over 7 weeks with concurrent chemotherapy. This regimen is effective but carries a burden of toxicity leading to severe pain and treatment breaks portending inferior outcomes. Conventional palliation methods include opioids, anticonvulsants and local anaesthetics. Breakthrough toxicities are nevertheless ubiquitous and present an urgent unmet need. Ketamine is an inexpensive drug with mechanisms of analgesia outside the opioid pathway including N-methyl-D-aspartate (NMDA) receptor antagonism and a pharmacologically unique property of opioid desensitisation. Systemic ketamine is validated in randomised controlled trials for efficacy in reducing pain and/or opioid burden in the oncologic setting. Literature supports peripherally administered ketamine for pain control without systemic toxicity. These data support our rationale of using ketamine mouthwash to decrease acute toxicity of curative treatment of HNC, the efficacy of which is our aim to elucidate. METHODS AND ANALYSIS: This is a phase II, Simon's two-stage trial. Patients have pathologically confirmed HNC and an intended regimen of 70 Gy of radiation with concurrent cisplatin. The protocol is initiated on diagnosis of grade 3 mucositis and consists of 2 weeks of 4 times daily (QID) ketamine mouthwash use. The primary endpoint is pain response defined as a combination of pain score and opioid use. 23 subjects will be enrolled in stage 1. If statistical criteria are met, 33 subjects will be enrolled in stage 2. Secondary endpoints include daily pain, daily opioid use, dysphagia at baseline and completion, nightly sleep quality, feeding tube placement and any unscheduled treatment breaks. ETHICS AND DISSEMINATION: All trial data will be stored in an Institutional Review Board (IRB) approved database. The protocol is registered under Northwell IRB registration number #22-0292 and U.S. Food and Drug Administration (FDA) Investigational New Drug (IND) approval has been granted under IND number 161609. Results are intended to be published in an open-source journal and further data, statistics and source documents are available on request. TRIAL REGISTRATION NUMBER: NCT05331131.

Determining Combined Modality Dosimetric Constraints by Integration of IMRT and LDR Prostate Brachytherapy Dosimetry and Correlation with Toxicity.

Purpose: Intermediate- and high-risk prostate cancer patients undergoing combination external beam radiation therapy (EBRT) and low dose rate (LDR) brachytherapy have demonstrated increased genitourinary (GU) toxicity. We have previously demonstrated a method to combine EBRT and LDR dosimetry. In this work, we use this technique for a sample of patients with intermediate- and high-risk prostate cancer, correlate with clinical toxicity, and suggest preliminary summed organ-at-risk constraints for future investigation. Methods and Materials: Intensity modulated EBRT and 103Pd-based LDR treatment plans were combined for 138 patients using biological effective dose (BED) and deformable image registration. GU and gastrointestinal (GI) toxicity were compared with combined dosimetry for the urethra, bladder, and rectum. Differences between doses in each toxicity grade were assessed by analysis of variance (α = 0.05). Combined dosimetric constraints are proposed using the mean organ-at-risk dose, subtracting 1 standard deviation for a conservative recommendation. Results: The majority of our 138-patient cohort experienced grade 0 to 2 GU or GI toxicity. Six grade 3 toxicities were noted. Mean prostate BED D90 (± 1 standard deviation) was 165.5±11.1 Gy. Mean urethra BED D10 was 230.3±33.9 Gy. Mean bladder BED was 35.2±11.0 Gy. Mean rectum BED D2cc was 85.6±24.3 Gy. Significant dosimetric differences between toxicity grades were found for mean bladder BED, bladder D15, and rectum D50, but differences between individual means were not statistically significant. Given the low incidence of grade 3 GU and GI toxicity, we propose urethra D10 <200 Gy, rectum D2cc <60 Gy, and bladder D15 <45 Gy as preliminary dose constraints for combined modality therapy. Conclusions: We successfully applied our dose integration technique to a sample of patients with intermediate- and high-risk prostate cancer. Incidence of grade 3 toxicity was low, suggesting that combined doses observed in this study were safe. We suggest preliminary dose constraints as a conservative starting point to investigate and escalate prospectively in a future study.

Patient Experience Performance at a Primary Cancer Center Versus Affiliated Community Facilities.

Purpose: Patient experience tools are used throughout health care to evaluate physician and departmental performance. In radiation medicine, these tools are important in evaluating patient-specific metrics throughout their care journey. This study compared patient experience outcomes from a central tertiary cancer program with network clinics in a health care network. Methods and Materials: Radiation medicine patient experience surveys (Press Ganey, LLC) were collected from a central facility and 5 network locations from January 2017 through June 2021. Surveys were distributed to patients after treatment completion. The study cohort was divided into the central facility and satellites. Questions were converted to a 0 to 100 scale from the Likert scale (1-5). To compare scores between site types, 2-way analysis of variance tests for the significance of sites adjusted for years of operations and adjustments for multiple comparisons (Dunnett's test) were completed on each question. Results: The number of consecutively returned surveys analyzed was 3777; a response rate of 33.3% was observed. The central site conducted 117,583 linear accelerator, 1425 Gamma Knife, 273 stereotactic radiosurgery, and 830 stereotactic body radiation therapy procedures. All satellites combined conducted 76,788 linear accelerator, 131 Gamma Knife, 95 stereotactic radiosurgery, and 355 stereotactic body radiation therapy procedures. The central facility fared better than the satellites on "Convenience of parking" (95.9 vs 87.9; P = .0001) but worse in other domains of care. Conclusions: All sites yielded exemplary patient experience rates. Community clinics scored higher than the main campus. The higher scores at the network sites require a deeper analysis of factors influencing the central facility, as the survey did not account for varying patient volumes and disparities in care complexity across sites. Attributes to satellites include lower patient volumes and easily navigable layouts. These results counter the impression that increased resources at the main campus create a better patient experience relative to network clinics and suggest that high-volume tertiary facilities will require unique initiatives to improve the patient experience.

Assessment of Differences in Academic Rank and Compensation by Gender and Race/Ethnicity Among Academic Radiation Oncologists in the United States.

Purpose: Advancing equity, diversity, and inclusion in the physician workforce is essential to providing high-quality and culturally responsive patient care and has been shown to improve patient outcomes. To better characterize equity in the field of radiation oncology, we sought to describe the current academic radiation oncology workforce, including any contemporary differences in compensation and rank by gender and race/ethnicity. Methods and Materials: We conducted a retrospective cohort study using data from the Society of Chairs of Academic Radiation Oncology Programs (SCAROP) 2018 Financial Survey. Multivariable logistic regression models were used to identify factors associated with associate or full professor rank. Compensation was compared by gender and race/ethnicity overall and stratified by rank and was further analyzed using multivariable linear regression models. Results: Of the 858 academic radiation oncologists from 63 departments in the United States in the sample, 33.2% were female, 65.2% were White, 27.2% were Asian, and 7.6% were underrepresented in medicine (URiM). There were 44.0% assistant professors, 32.0% associate professors, and 22.8% full professors. Multivariable logistic regression analysis for factors associated with associate or full professor rank did not reveal statistically significant associations between gender or race/ethnicity with academic rank (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.56-1.32; P = .48 for gender; OR, 0.81; 95% CI, 0.5-1.30; P = .37 for Asian vs White; and OR, 0.69; 95% CI, 0.31-1.55; P = .37 for URiM vs White), but CIs were wide due to sample size, and point estimates were <1. Similarly, multivariable linear regression analysis modeling the log relative total compensation did not detect statistically significant differences between radiation oncologists by gender (-1.7%; 95% CI, -6.8% to 3.4%; P = .51 for female vs male) or race/ethnicity (-1.6%; 95% CI, -7.3% to 4.0%; P = .57 for Asian vs White and -3.0%; 95% CI, -12.1% to 6.0%; P = .51 for URiM vs White). Conclusions: The low numbers of women and faculty with URiM race/ethnicity in this radiation oncology faculty sample limits the ability to compare career trajectory and compensation by those characteristics. Given that point estimates were <1, our findings do not contradict larger multispecialty studies that suggest an ongoing need to monitor equity.

Consensus Quality Measures and Dose Constraints for Prostate Cancer From the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Expert Panel.

PURPOSE: There are no agreed upon measures to comprehensively determine the quality of radiation oncology (RO) care delivered for prostate cancer. Consequently, it is difficult to assess the implementation of scientific advances and adherence to best practices in routine clinical practice. To address this need, the US Department of Veterans Affairs (VA) National Radiation Oncology Program established the VA Radiation Oncology Quality Surveillance (VA ROQS) Program to develop clinical quality measures to assess the quality of RO care delivered to Veterans with cancer. This article reports the prostate cancer consensus measures. METHODS AND MATERIALS: The VA ROQS Program contracted with the American Society for Radiation Oncology to commission a Blue Ribbon Panel of prostate cancer experts to develop a set of evidence-based measures and performance expectations. From February to June 2021, the panel developed quality, aspirational, and surveillance measures for (1) initial consultation and workup, (2) simulation, treatment planning, and delivery, and (3) follow-up. Dose-volume histogram (DVH) constraints to be used as quality measures for definitive and post-prostatectomy radiation therapy were selected. The panel also identified the optimal Common Terminology Criteria for Adverse Events, version 5.0 (CTCAE V5.0), toxicity terms to assess in follow-up. RESULTS: Eighteen prostate-specific measures were developed (13 quality, 2 aspirational, and 3 surveillance). DVH metrics tailored to conventional, moderately hypofractionated, and ultrahypofractionated regimens were identified. Decision trees to determine performance for each measure were developed. Eighteen CTCAE V5.0 terms were selected in the sexual, urinary, and gastrointestinal domains as highest priority for assessment during follow-up. CONCLUSIONS: This set of measures and DVH constraints serves as a tool for assessing the comprehensive quality of RO care for prostate cancer. These measures will be used for ongoing quality surveillance and improvement among veterans receiving care across VA and community sites. These measures can also be applied to clinical settings outside of those serving veterans.

Salvage prostate brachytherapy in radiorecurrent prostate cancer: An international Delphi consensus study.

BACKGROUND AND PURPOSE: Local recurrences after previous radiotherapy (RT) are increasingly being identified in biochemically recurrent prostate cancer. Salvage prostate brachytherapy (BT) is an effective and well tolerated treatment option. We sought to generate international consensus statements on the use and preferred technical considerations for salvage prostate BT. MATERIALS AND METHODS: International experts in salvage prostate BT were invited (n = 34) to participate. A three-round modified Delphi technique was utilized, with questions focused on patient- and cancer-specific criteria, type and technique of BT, and follow-up. An a priori threshold for consensus of ≥ 75% was set, with a majority opinion being ≥ 50%. RESULTS: Thirty international experts agreed to participate. Consensus was achieved for 56% (18/32) of statements. Consensus was achieved in several areas of patient selection: 1) A minimum of 2-3 years from initial RT to salvage BT; 2) MRI and PSMA PET should be obtained; and 3) Both targeted and systematic biopsies should be performed. Several areas did not reach consensus: 1) Maximum T stage/PSA at time of salvage; 2) Utilization/duration of ADT; 3) Appropriateness of combining local salvage with SABR for oligometastatic disease and 4) Repeating a second course of salvage BT. A majority opinion preferred High Dose-Rate salvage BT, and indicated that both focal and whole gland techniques could be appropriate. There was no single preferred dose/fractionation. CONCLUSION: Areas of consensus within our Delphi study may serve as practical advice for salvage prostate BT. Future research in salvage BT should address areas of controversy identified in our study.

Posttraumatic Growth in Radiation Medicine During the COVID-19 Outbreak.

Purpose: It has been reported that adversarial growth during traumatic events potentially enhances coping with sequelae. The purpose of this work was to assess posttraumatic growth (PTG) among radiation medicine staff members at the individual level as well as changes in perceptions of departmental culture after the COVID-19 pandemic. Methods and Materials: An anonymous PTG inventory (PTGI) survey comprising 21 indicators was disseminated to all 213 members of our multicenter radiation department to measure perceptions of change in personal, interpersonal-relationship, and philosophy of life factors using principal-factor analysis. Additionally, 8 department safety-culture indicators from the National Hospital Patient Safety Culture Survey developed by the Agency for Healthcare Research and Quality were included to assess changes in department safety-culture perceptions verses a prepandemic survey. The survey was repeated 15 months later to assess longitudinal trends. Results: With a 56.3% survey-response rate, PTGI factor analysis yielded Cronbach's alpha values exceeding 0.90 for the 3 aforementioned PTG factors. The average growth per indicator was 2.3 (out of 5.0), which fell between small and moderate. The values were 2.4 (personal), 2.1 (interpersonal), and 1.6 (philosophy) for the 3 factors. The total PTGI score (47.7 ± 28.3 out of 105 points) was lower for masked, patient-facing, frontline workers members (41.8 ± 28.4) compared with others (53.1 ± 27.3, P value .001). For the Agency for Healthcare Research and Quality survey there was an improvement of 15% in perceptions of department safety culture, and 7 of the 8 indicators showed improvements compared with baseline. The follow-up survey demonstrated overall sustained findings, albeit with a trend toward declining PTG scores for nonfrontline workers, notably in interpersonal relationships (47.4 ± 27.0, P value .05). Conclusions: A fair-to-moderate degree of PTG was observed in personal and interpersonal relationship factors whereas least growth was noted in spiritual and religious beliefs. Perceptions of department patient-safety culture improved substantially. Sustained improvements were thus perceived at the individual and department levels.

Burnout in Radiation Oncology Physician Workforce: The Effect of Mindfulness and Fulfillment.

Purpose: Mindfulness, defined as awareness of the moment while acknowledging and accepting one's feelings, thoughts, and sensations, is the aim of mindfulness meditation. Our objective was to investigate the relationship between burnout, mindfulness, fulfillment, and other personal characteristics in radiation oncology (RO) residents/attendings compared with other specialties. Methods and Materials: From December 2019 to February 2020, residents and attendings in multiple specialties at a single tertiary care academic institution were sent surveys, including the mindfulness attention awareness scale, Stanford professional fulfillment index, and a personal questionnaire. A Pearson correlation was conducted on the relationship between mindfulness, fulfillment, disengagement, and exhaustion. To determine risk factors for burnout (overall burnout ≥ 1.33), a univariate analysis was conducted to yield odds ratios (ORs) on debt, specialty, income, sleep, exercise, marital status, number of children, work hours, mindfulness (mindfulness attention awareness scale ≥ 4), fulfillment (professional fulfillment ≥ 3), and time with family/friends. Significant factors on univariate analysis were entered into multivariate analysis. Results: There were 180 surveys completed by 60 residents and attendings across 17 specialties. Eighteen (30%) respondents were in RO. Mindfulness positively correlated with fulfillment (P < .001, r = 0.534), negatively correlated with exhaustion (P < .001, r = -0.578), and negatively correlated with disengagement (P < .001, r = -0.483). Univariate analysis for factors associated with burnout was significant for mindfulness (OR = 0.065, P < .001), RO versus other specialty (OR = 0.024, P = .044), working >60 h/wk (OR = 5.091, P = .018), spending >10 h/wk with family or friends (OR = 0.120, P = .001), and fulfillment (OR = 0.103, P < .001). Multivariate analysis showed mindfulness and fulfillment to significantly decrease odds of burnout. Conclusions: RO physicians experienced less burnout than physicians in other specialties at our institution. Mindfulness, professional fulfillment, moderate work hours, and spending time with loved ones protected against burnout. Further study of interventions to promote mindfulness and fulfillment may help us understand how best to improve the mental and emotional health of RO physicians.

Implementation of External Beam Five-Fraction Adjuvant Breast Irradiation in a US Center.

Five-fraction adjuvant whole breast radiation has been shown to be a safe and effective alternative to longer fractionation regimens. Given the lack of international consensus on patient selection for the protocol, we developed a consensus protocol to guide patient selection and facilitate safe and efficient five-fraction radiation in our radiation medicine department. In developing the directive, we surveyed departmental physicians about their choice of adjuvant breast regimen for various clinical scenarios. Patient travel burden was the factor most strongly impacting radiation oncologists' decision-making when considering prescribing a five-fraction course of adjuvant breast radiation; the length of clinical trial follow-up data and acute and late normal tissue effects also impacted it, along with personal clinical experience and experience of dosimetry and physics personnel. Relative value unit (RVU) reimbursement and financial toxicity to the patient were reported to be less important in decision-making. Physicians were most comfortable using five-fraction radiation in women >50 years of age with low-risk cancer and for patients unable to attend for longer treatment courses. Eight months after implementation, the protocol accounts for 4.7% of breast irradiation delivered in our department.

A Retrospective Analysis of Three Focused Attention Meditation Techniques: Mantra, Breath, and External-Point Meditation.

Objective The goal of this study is to compare the effectiveness of three different meditation techniques (two internal focus techniques and one external focus technique) using a low-cost portable electroencephalography (EEG) device, namely, MUSE, for an objective comparison. Methods This is an IRB-approved retrospective study. All participants in the study were healthy adults. Each study participant (n = 34) was instructed to participate in three meditation sessions: mantra (internal), breath (internal), and external point. The MUSE brain-sensing headband (EEG) was used to document the "total time spent in the calm state" and the "total time spent in the calm or neutral state" (outcomes) in each three-minute session to conduct separate analyses for the meditation type. Separate generalized linear models (GLM) with unstructured covariance structures were used to examine the association between each outcome and the explanatory variable (meditation type). For all models, if there was a significant association between the outcome and the explanatory variable, pairwise comparisons were carried out using the Tukey-Kramer correction. Results The median time (in seconds) spent in the calm state while practicing mantra meditation was 131.5 (IQR: 94-168), while practicing breath meditation was 150 (IQR: 113-164), and while practicing external-point meditation was 100 (IQR: 62-126). Upon analysis, there was a significant association between the meditation type and the time spent in the calm state (p-value = 0.0006). Conclusion This is the first study comparing "internal" versus "external" meditation techniques using an objective measure. Our study shows the breath and mantra technique as superior to the external-point technique as regards time spent in the calm state. Additional research is needed using a combination of "EEG" and patient-reported surveys to compare various meditative practices. The findings from this study can help incorporate specific meditation practices in future mindfulness-based studies that are focused on healthcare settings and on impacting clinical outcomes, such as survival or disease outcomes.