Evolution of the prevalence of pre-residency peer-reviewed publications among incoming junior residents.

Pre-residency peer-reviewed publications (PRP) have been associated with subsequent resident choice of academic versus private practice career. The evolution of PRP prevalence among radiation oncology resident classes has yet to be examined. A list of radiation oncology residents from the graduating classes of 2016 and 2022 were obtained, and PRP was compiled as the number of publications a resident had listed in PubMed as of the end of the calendar year of residency application. Statistical analysis was conducted using Fisher's exact test. Analysis of 163 residents from the 2016 class compared with 195 from the 2022 class revealed that the proportion of residents with zero PRP decreased from 46.6% to 23.6% between the 2016 to 2022 classes (p<0.0001), while that of residents with one PRP increased from 17.8% to 19.0% (p>0.05) and with at least two PRP increased from 35.6% to 57.4% (p<0.0001). Residents with a PhD were more likely to have at least two PRP in each class (p<0.0001). As with the class of 2016, there remained no significant difference in PRP by gender for the class of 2022. Over the past six years, PRP has become more prevalent among incoming radiation oncology residents. Residents in the class of 2016 were 180% less likely than the class of 2022 to have at least one PRP, and 60% less likely to have at least two PRP. These findings are indicative of the increasing pressure on medical students to enter residency with a publication background.

Demographic factors associated with missed follow-up among solid tumor patients treated at a large multi-site academic institution.

Aim: To identify demographic predictors of patients who miss oncology follow-up, considering that missed follow-up has not been well studies in cancer patients. Methods: Patients with solid tumors diagnosed from 2007 to 2016 were analyzed (n = 16,080). Univariate and multivariable logistic regression models were constructed to examine predictors of missed follow-up. Results: Our study revealed that 21.2% of patients missed ≥1 follow-up appointment. African-American race (odds ratio [OR] 1.33; 95% CI: 1.17-1.51), Medicaid insurance (OR 1.59; 1.36-1.87), no insurance (OR 1.66; 1.32-2.10) and rural residence (OR 1.78; 1.49-2.13) were associated with missed follow-up. Conclusion: Many cancer patients miss follow-up, and inadequate follow-up may influence cancer outcomes. Further research is needed on how to address disparities in follow-up care in high-risk patients.

Baseline Karnofsky performance status is independently predictive of death within 30 days of intracranial radiation therapy completion for metastatic disease.

INTRODUCTION: For patients with brain metastases, palliative radiation therapy (RT) has long been a standard of care for improving quality of life and optimizing intracranial disease control. The duration of time between completion of palliative RT and patient death has rarely been evaluated. METHODS: A compilation of two prospective institutional databases encompassing April 2015 through December 2018 was used to identify patients who received palliative intracranial radiation therapy. A multivariate logistic regression model characterized patients adjusting for age, sex, admission status (inpatient versus outpatient), Karnofsky Performance Status (KPS), and radiation therapy indication. RESULTS: 136 consecutive patients received intracranial palliative radiation therapy. Patients with baseline KPS <70 (OR = 2.2; 95%CI = 1.6-3.1; p < 0.0001) were significantly more likely to die within 30 days of treatment. Intracranial palliative radiation therapy was most commonly delivered to provide local control (66% of patients) or alleviate neurologic symptoms (32% of patients), and was most commonly delivered via whole brain radiation therapy in 10 fractions to 30 Gy (38% of patients). Of the 42 patients who died within 30 days of RT, 31 (74%) received at least 10 fractions. CONCLUSIONS: Our findings indicate that baseline KPS <70 is independently predictive of death within 30 days of palliative intracranial RT, and that a large majority of patients who died within 30 days received at least 10 fractions. These results indicate that for poor performance status patients requiring palliative intracranial radiation, hypofractionated RT courses should be strongly considered.

Analysis of pre-residency research productivity, dual degree status, and gender distribution of underrepresented minorities among a current United States radiation oncology junior resident class.

BACKGROUND: Among the most competitive medical subspecialties, representation of underrepresented minorities (African-American race and/or Hispanic ethnicity) among resident trainees has historically been low compared to their United States Census general population representation. Research productivity and dual degree status may impact residency applicant competitiveness. To date, such an analysis has yet to be performed in Radiation Oncology. METHODS: A list of radiation oncology residents from the graduating class of 2022 was obtained through internet searches. Demographics included were gender and dual degree status. Research productivity was calculated using the number of pre-residency peer-reviewed publications (PRP). Fisher's exact test was used for statistical analysis. RESULTS: Of the 179 residents evaluated from the 2022 class, eleven (6.1%) were underrepresented minorities. Compared to the remainder of the class, underrepresented minorities had a lower proportion of men (63.6% versus 69.3%), a higher proportion of dual degrees (45.5% versus 28.6%), and a lower proportion of MD-PhD degrees (9.1% versus 17.2%). Underrepresented minorities had a higher proportion of residents with at least two PRP (72.7% versus 57.1%) and a lower proportion of residents with no PRP (18.2% versus 24.4%). None of these differences reached statistical significance (p > 0.05). CONCLUSION: Underrepresented minorities were comparable to the remainder of their Radiation Oncology resident class regarding gender distribution, dual degrees status, and likelihood of having at least two peer-reviewed publications cited in PubMed during the calendar year of residency application. Further studies will be needed to determine how these findings translate into future scholarly activity and post-graduate career choice.

Early cardiac perfusion defects after left-sided radiation therapy for breast cancer: is there a volume response?

PURPOSE: Cardiac single-photon emission computed tomography (SPECT) is often used to identify defects in myocardial perfusion due to atherosclerotic coronary artery disease. It was also used in studies to evaluate radiation therapy (RT)-associated cardiac abnormalities. In the current review, we aim to evaluate the rates of post-RT cardiac SPECT early perfusion abnormalities and relate this to the irradiated left ventricular volume. METHODS: The studies cited in this systematic review were identified using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. RESULTS: Six studies between 1996 and 2016 fulfilled the inclusion criteria. The reported perfusion defects in these studies were seen in the apical and anterolateral aspects of the left ventricle. Three studies show correlation between the percent of the left ventricle within the RT-field and percent of patients with early perfusion defects on cardiac SPECT. In two studies that used cardiac sparing techniques (such as deep inspiration), that resulted in a low mean heart dose, no perfusion defects were noted. CONCLUSIONS: Data suggest that incidental irradiation of the heart in cases of left breast/chest wall RT can result in early post-RT perfusion defects on cardiac SPECT. There appears to be strong dose/volume dependence to the risk, and hence techniques to reduce cardiac exposure are recommended.

Breast cancer version 3.2014.

Breast cancer is the most common malignancy in women in the United States and is second only to lung cancer as a cause of cancer death. The overall management of breast cancer includes the treatment of local disease with surgery, radiation therapy, or both, and the treatment of systemic disease with cytotoxic chemotherapy, endocrine therapy, biologic therapy, or combinations of these. The NCCN Guidelines specific to management of large clinical stage II and III tumors are discussed in this article. These guidelines are the work of the members of the NCCN Breast Cancer Panel. Expert medical clinical judgment is required to apply these guidelines in the context of an individual patient to provide optimal care. Although not stated at every decision point of the guidelines, patient participation in prospective clinical trials is the preferred option of treatment for all stages of breast cancer.

Missed Follow-up is associated with worse survival in stage I lung cancer: results from a large multi-site academic hospital system.

The purpose of this study is to examine the effect of early incomplete follow-up on overall survival among stage I lung cancer patients. Patients with clinical stage I lung cancer at our institution between 2007 and 2016 were identified (N = 1111). Exclusions included < 18 years of age (N = 2), missing stage or demographics (N = 56), incomplete appointment data or had only one scheduled appointment (N = 351), or did not survive for at least 1 year after diagnosis (N = 120). Missed appointments were defined as unattended follow-up appointments within the first year of diagnosis without an attended appointment in the subsequent 60 days. The primary outcome was the hazard ratio (HR) for death associated per 10% increase in missed oncology follow-up appointments. Univariable and descriptive statistics were performed, and a multivariable landmark Cox regression model was created to examine the effect of missed oncology follow-up on survival. A total of 582 patients were analyzed with median follow-up of 3.2 years and median age of 69 years. On multivariable analysis controlling for age, sex, race, insurance status, and definitive treatment type the HR for death was 1.44 (95% CI 1.05-1.97) for every 10% increase in missed appointments. Incomplete oncologic follow-up may negatively impact overall survival among survivors of early-stage lung cancer.

Analysis of Retrospective Versus Prospective Peer Review in a Multisite Academic Radiation Department.

Purpose: Our multisite academic radiation department reviewed our experience with transitioning from weekly primarily retrospective to daily primarily prospective peer review to improve plan quality and decrease the rate of plan revisions after treatment start. Methods and Materials: This study was an institutional review board-approved prospective comparison of radiation treatment plan review outcomes of plans reviewed weekly (majority within 1 week after treatment start) versus plans reviewed daily (majority before treatment start, except brachytherapy, frame-based radiosurgery, and some emergent plans). Deviations were based on peer comments and considered major if plan revisions were recommended before the next fraction and minor if modifications were suggested but not required. Categorical variables were compared using χ2 distribution tests of independence; means were compared using independent t tests. Results: In all, 798 patients with 1124 plans were reviewed: 611 plans weekly and 513 plans daily. Overall, 76 deviations (6.8%) were noted. Rates of any deviation were increased in the daily era (8.6% vs 5.2%; P = .026), with higher rates of major deviations in the daily era (4.1% vs 1.6%; P = .012). Median working days between initial simulation and treatment was the same across eras (8 days). Deviations led to a plan revision at a higher rate in the daily era (84.1% vs 31.3%; P < .001). Conclusions: Daily prospective peer review is feasible in a multisite academic setting. Daily peer review with emphasis on prospective plan evaluation increased constructive plan feedback, plan revisions, and plan revisions being implemented before treatment start.

Breast cancer, version 3.2013: featured updates to the NCCN guidelines.

These NCCN Guidelines Insights highlight the important updates specific to the management of HER2-positive metastatic breast cancer in the 2013 version of the NCCN Clinical Practice Guidelines in Oncology for Breast Cancer. These include new first-line and subsequent therapy options for patients with HER2-positive metastatic breast cancer.

Concurrent chemotherapy with partial breast irradiation in triple negative breast cancer patients may improve disease control compared with sequential therapy.

Purpose: To report outcomes on a subset of patients with triple negative breast cancer (TNBC) treated on prospective trials with post-lumpectomy partial breast irradiation and concurrent chemotherapy (PBICC) and compare them to a retrospectively assessed similar cohort treated with whole breast irradiation after adjuvant chemotherapy (WBIaC). Methods and materials: Women with T1-2, N0-1 invasive breast cancer with ≥ 2mm lumpectomy margins were offered therapy on one of two PBICC trials. PBI consisted of 40.5 Gy in 15 daily 2.7 Gy fractions delivered concurrently with the first 2 cycles of adjuvant chemotherapy. The comparison cohort received WBI to a median dose of 60.7 Gy, (including boost, range 42.5 - 66 Gy), after completion of non-concurrent, adjuvant chemotherapy. We evaluated disease-free survival (DFS), and local/loco-regional/distant recurrence-free survival (RFS). We compared survival rates using Kaplan-Meier curves and log-rank test of statistical significance. Results: Nineteen patients with TNBC were treated with PBICC on prospective protocol, and 49 received WBIaC. At a median follow-up of 35.5 months (range 4.8-71.9), we observed no deaths in the PBICC cohort and 2 deaths in the WBIaC cohort (one from disease recurrence). With a median time of 23.4 (range 4.8 to 47) months, there were 7 recurrences (1 nodal, 4 local, 4 distant), all in the WBIaC group. At 5 years, there was a trend towards increased local RFS (100% vs. 85.4%, p=0.17) and loco-regional RFS (100% vs. 83.5, p=0.13) favoring the PBICC cohort. There was no significant difference in distant RFS between the two groups (100% vs. 94.4%, p=0.36). Five-year DFS was 100% with PBICC vs.78.9% (95% CI: 63.2 to 94.6%, p=0.08) with WBIaC. Conclusion: This study suggests that PBICC may offer similar and possibly better outcomes in patients with TNBC compared to a retrospective cohort treated with WBIaC. This observation is hypothesis-generating for prospective trials.

Patient characteristics and clinical factors affecting lumpectomy cavity volume: implications for partial breast irradiation.

Introduction: Partial breast irradiation (PBI) has increased in utilization, with the postoperative lumpectomy cavity and clips used to guide target volumes. The ideal timing to perform computed tomography (CT)-based treatment planning for this technique is unclear. Prior studies have examined change in volume over time from surgery but not the effect of patient characteristics on lumpectomy cavity volume. We sought to investigate patient and clinical factors that may contribute to larger postsurgical lumpectomy cavities and therefore predict for larger PBI volumes. Methods: A total of 351 consecutive women with invasive or in situ breast cancer underwent planning CT after breast-conserving surgery at a single institution during 2019 and 2020. Lumpectomy cavities were contoured, and volume was retrospectively computed using the treatment planning system. Univariate and multivariate analyses were performed to evaluate the associations between lumpectomy cavity volume and patient and clinical factors. Results: Median age was 61.0 years (range, 30-91), 23.9% of patients were Black people, 52.1% had hypertension, the median body mass index (BMI) was 30.4 kg/m², 11.4% received neoadjuvant chemotherapy, 32.5% were treated prone, mean interval from surgery to CT simulation was 54.1 days ± 45.9, and mean lumpectomy cavity volume was 42.2 cm3 ± 52.0. Longer interval from surgery was significantly associated with smaller lumpectomy cavity volume on univariate analysis, p = 0.048. Race, hypertension, BMI, the receipt of neoadjuvant chemotherapy, and prone position remained significant on multivariate analysis (p < 0.05 for all). Prone position vs. supine, higher BMI, the receipt of neoadjuvant chemotherapy, the presence of hypertension, and race (Black people vs. White people) were associated with larger mean lumpectomy cavity volume. Discussion: These data may be used to select patients for which longer time to simulation may result in smaller lumpectomy cavity volumes and therefore smaller PBI target volumes. Racial disparity in cavity size is not explained by known confounders and may reflect unmeasured systemic determinants of health. Larger datasets and prospective evaluation would be ideal to confirm these hypotheses.

Metastatic breast cancer, version 1.2012: featured updates to the NCCN guidelines.

These NCCN Guidelines Insights highlight the important updates/changes specific to the management of metastatic breast cancer in the 2012 version of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Breast Cancer. These changes/updates include the issue of retesting of biomarkers (estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2) on recurrent disease, new information regarding first-line combination endocrine therapy for metastatic disease, a new section on monitoring of patients with metastatic disease, and new information on endocrine therapy combined with an mTOR inhibitor as a subsequent therapeutic option.

Progression of citation-based scholarly activity from postgraduate year one to postgraduate year two in a current resident class.

BACKGROUND: Recent work has demonstrated multiple measures of citation-based scholarly activity. Measures including Hirsch index (h-index), h-index limited to first author manuscripts (hf), h-index limited to first or second author only manuscripts (hs), and g-index have been associated with radiation oncology resident choice of academic versus private practice career. To date, there has been no evaluation of the progression of citation-based scholarly activity during residency. METHODS: A list of United States radiation oncology residents from the graduating class of 2022 [postgraduate year two (PGY-2) academic year of 2018-2019] was obtained through internet investigation. Citation-based scholarly activity was collected and calculated from searches of the Scopus bibliometric citation database for h-index, hf, hs, and g-index for each resident as previously described. Calculations were derived in June 2018 for the postgraduate year one (PGY-1) year, and in June 2019 for the PGY-2 year. Fisher's exact test was used for statistical analysis. RESULTS: Analysis of 195 residents from the 2022 class revealed that the citation-based scholarly activity significantly increased from PGY-1 to PGY-2 for h-index (2.6 to 3.2; P=0.047) and g-index (4.0 to 5.1; P=0.045), but not for hf (1.0 to 1.3; P=0.170) or hs (1.5 to 1.9; P=0.065). Underrepresented minority race/ethnicity (African-American/Hispanic) did not impact the significance of the h-index and g-index findings. CONCLUSIONS: From the PGY-1 to PGY-2 academic year, residents significantly increased in citation-based academic productivity, with an increase in the proportion of residents with a cited first-or-second author manuscript. Further study is necessary to determine how this trend persists in future years.

Composition of the Current Academic Radiation Oncology Workforce in Comprehensive Cancer Centers.

PURPOSE: The landscape of the profession of academic radiation oncology is constantly changing. We sought to determine the demographic makeup of the current academic radiation oncology workforce. MATERIALS AND METHODS: Internet web site searches of the 51 National Cancer Institute-designated Comprehensive Cancer Centers (CCCs) were conducted in September 2019. The Scopus database was subsequently searched in December 2019 to ascertain the h-index for each radiation oncologist. Geographic location was economically stratified (New York, California, Massachusetts, Illinois, and Washington DC) as previously reported. Race and binary sex were attributed by authors using publicly available information. Univariate analysis involved the chi-square test; a multivariable model considered several factors including rank and sex. RESULTS: Of 993 radiation oncologists at CCCs, 53.6% are junior faculty, 24.8% associate professors, and 21.7% full professors. The average radiation oncologist at a CCC has been a physician for 19.7 (standard deviation = 11.3) years; 4.7% (47/993) are under-represented minorities. 24.6% of men and 15.5% of women were full professors, a statistically significant difference (P = .001). Of the 51 department chairs, 11.8% are women and 5.6% are under-represented minorities. There are fewer female than male program directors in the most economically stratified locations (P = .02). The mean h-index for all faculty is 17.6 (standard deviation = 16.9), and significantly differs between junior faculty (8.21), associate professors (18.46), and full professors (40.05; P < .0001). It also differs between men (19.35) and women (14.11). On multivariable analysis, sex, academic rank, and a secondary advanced degree were independently significant correlates of h-index. CONCLUSION: Among academic radiation oncologists at CCCs, under 5% are under-represented minorities, men are significantly over-represented among senior faculty, and women have significantly lower h-indices than men.

Gender-based analysis of pre-residency research productivity among a current United States radiation oncology resident class.

BACKGROUND: The increasing proportion of women in medicine has not been adequately reflected in the gender distribution of radiation oncology residents. The presence of at least one pre-residency peer-reviewed publication (PRP) has been associated with radiation oncology resident choice of academic over private practice career, with no significant gender difference in the likelihood of having a PRP (McClelland et al., 2017). We sought to pursue a gender-based analysis of PRP productivity in a current junior resident class. METHODS: A list of radiation oncology residents from the graduating class of 2022 (PGY-2 academic year of 2018-2019) was obtained through internet investigation. Research productivity was calculated using PRP number, defined as the number of a resident's publications listed in PubMed (pubmed.gov) through the calendar year of residency application (2016 for this class). RESULTS: Of 195 residents examined from the 2022 class, 61 (31%) were women, representing a nine percent increase from the resident class of 2016. Four-fifths of women had 1+ PRP, 31% had dual degrees, and 18% had a PhD. These percentages were comparable to their male counterparts, 73% with 1+ PRP, 28% with dual degrees, and 15% with a PhD. There were no statistically significant differences by gender in any of these benchmarks. CONCLUSIONS: While slower than the overall trend of increased female representation in medicine, the proportion of women in radiation oncology residency has increased by 0.9-1.5% annually over a recent six-year span. There remain no significant differences in PRP productivity, dual degree status, or PhD status by gender.