Transformative Peer Connections: Early Experiences From the ASCO Palliative Care Community of Practice.

The integration of palliative care into routine oncology practice is the standard of care by most leading cancer organizations. Palliative medicine helps to deliver higher quality of care at a lower cost. However, there are barriers to implementing palliative oncology at many institutions for myriad reasons. In this article, we discuss an innovative strategy that ASCO implemented called the Communities of Practice (CoP). We share our experiences as the Palliative Care CoP and how our group seeks to develop processes and structures to collectively promote systemic change and enhance palliative care delivery for people with cancer. Our Palliative Care CoP engages with senior leaders, administrators, and those in power to achieve a shared vision of delivering holistic health care for people with serious illness. We continue to evolve to meet our members' growing needs by addressing eight main domains: (1) increasing palliative care education and resources; (2) creating opportunities for global palliative care research; (3) providing peer mentorship and community building; (4) engaging with patient advocates; (5) supporting and developing interdisciplinary teams; (6) assisting with professional development and identity formation, especially for trainees and early career faculty; (7) extending our outreach through social media; and (8) enhancing the clinical practice of palliative oncology. The ASCO CoP has been a vital forum to realize ASCO's mission of conquering cancer and advancing the Art and Science of Cancer Care: From Comfort to Cure.

Stereotactic body radiation therapy (SBRT) for the treatment of primary breast cancer in patients not undergoing surgery.

PURPOSE: The purpose was to explore the role of stereotactic body radiation therapy (SBRT) in providing local control (LC) for primary breast cancer in patients unable to undergo surgery. MATERIALS/METHODS: Between 2015 and 2019, 13 non-surgical candidates with 14 lesions were treated with SBRT for primary breast cancer. In 4 cases, SBRT was used after whole breast radiation therapy (WBRT; 40-50 Gy/20-25 fractions). SBRT dose was 30-40 â€‹Gy in 5 fractions for patients treated with SBRT alone and 25-32 â€‹Gy in 4-5 fractions for those treated with SBRT â€‹+ â€‹WBRT. LC and overall survival (OS) were estimated using Kaplan-Meier curves. Response was also assessed using RECIST guidelines. RESULTS: Median follow-up was 32 (range: 3.4-70.4) months. Imaging at median 2.2 (0.6-8.1) months post-SBRT showed median 43.2 â€‹% (range: 2-100 â€‹%) decrease in the largest diameter and median 68.7 â€‹% (range: 27.9-100 â€‹%) SUV reduction. There were 3 cases of local progression at 8.7-10.6 months. Estimated LC was 100 â€‹% at 6 months and 71.6 â€‹% at 12, 24 and 36 months. Estimated median OS was 100 â€‹% at 6 months, 76.9 â€‹% at 12 months, and 61.5 â€‹% at 24 and 36 months. Acute toxicity (n â€‹= â€‹13; 92.9 â€‹%) included grade (G)1 (n â€‹= â€‹8), G2 (n â€‹= â€‹4), and G4 (necrosis; n â€‹= â€‹1). Late toxicity included G2 edema (n â€‹= â€‹1) and G4 necrosis (n â€‹= â€‹2, including 1 consequential late effect). Only patients treated with SBRT â€‹+ â€‹WBRT experienced acute/late G4 toxicity, managed with resection or steroids. CONCLUSIONS: SBRT to primary breast cancer resulted in good LC in non-surgical/metastatic patients. Although necrosis (n â€‹= â€‹2) occurred in the SBRT â€‹+ â€‹WBRT group, it was successfully salvaged.

Top Ten Tips Palliative Care Clinicians Should Know About Acute Myeloid Leukemia.

Acute myeloid leukemia (AML) is the most common form of acute leukemia in adults. Rapidly proliferating leukemic cells cause symptoms and increase the risk of infection. While individuals may initially benefit from supportive measures, disease-directed therapy may ultimately be required for symptom management, even at the end of life, although this may also inadvertently increase symptom burden. This unpredictable illness trajectory complicates prognostic uncertainty and the timing of hospice referral, which may prohibit access to palliative therapies and lead to recurrent hospitalizations. However, emerging evidence demonstrates that early palliative care (PC) integration with standard leukemia care results in improved quality of life, psychological outcomes, and greater participation in advance care planning. To orient PC clinicians asked to care for patients with AML, this article highlights 10 salient considerations.

SEAFARER - A new concept for validating radiotherapy patient specific QA for clinical trials and clinical practice.

BACKGROUND: The quality of radiotherapy delivery has been shown to significantly impact clinical outcomes including patient survival. To identify errors, institutions perform Patient Specific Quality Assurance (PSQA) assessing each individual radiotherapy plan prior to starting patient treatments. Externally administered Dosimetry Audits have found problems despite institutions passing their own PSQA. Hence a new audit concept which assesses the institution's ability to detect errors with their routine PSQA is needed. METHODS: Purposefully introduced edits which simulated treatment delivery errors were embedded into radiation treatment plans of participating institutions. These were designed to produce clinically significant changes yet were mostly within treatment delivery specifications. Actual impact was centrally assessed for each plan. Institutions performed PSQA on each plan, without knowing which contained errors. RESULTS: Seventeen institutions using six radiation treatment planning systems and two delivery systems performed PSQA on twelve plans each. Seventeen erroneous plans (across seven institutions) passed PSQA despite causing >5% increase in spinal cord dose relative to the original plans. Six plans (from four institutions) passed despite a >10% increase. CONCLUSIONS: This novel audit concept evolves beyond testing an institution's ability to deliver a single test case, to increasing the number of errors caught by institutions themselves, thus increasing quality of radiation therapy and impacting every patient treated. Administered remotely this audit also provides advantages in cost, environmental impact, and logistics.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Muslims.

Islam is the fastest-growing religion across the world and in the United States. Adherents of Islam are known as Muslims. Globally, Muslims comprise the second largest religious group with 1.8 billion people, or 24% of the world's population, and range in racial and ethnic diversity.1 As this population continues to grow, palliative care clinicians will invariably care for a Muslim patient therefore making it important to have a basic understanding of values, traditions, and beliefs held by them. This article outlines 10 basic principles held by many Muslim patients and their families that can allow for palliative care to be delivered in a culturally inclusive way. This article should serve as a point of initiation for further exploration of their needs as it is not a comprehensive guide.

Potential alternative treatment approach for pediatric patient with diffusely infiltrative primary rhabdomyosarcoma of the liver.

Primary hepatic rhabdomyosarcoma is rare, making decisions regarding locoregional management with resection and/or conventional radiation difficult. We present a novel treatment approach for a pediatric patient diagnosed with rhabdomyosarcoma diffusely involving the liver. This patient underwent treatment with yttrium-90 (Y-90) microspheres followed by external beam radiation therapy (EBRT ) to residual disease, interdigitated with systemic chemotherapy. Initial post-radiation imaging showed significant response to treatment, and she experienced minimal acute toxicities and no long-term toxicities. She developed recurrent PET-avid disease 23 months after Y-90 treatment, necessitating further local and continued systemic therapies. We report on the tumor control following Y-90 and EBRT treatment.

Tumor control and cosmetic outcome of weekly iridium-192 high-dose-rate brachytherapy for nonmelanoma skin cancers in the elderly.

PURPOSE: Radiotherapy with high-dose-rate (HDR) brachytherapy is used to treat nonmelanoma skin cancers. We retrospectively analyzed a hypofractionated regimen to assess its safety and efficacy in elderly patients ≥70 years. METHODS AND MATERIALS: Forty-eight patients with 67 lesions treated since 2016 with catheter-based iridium-192 HDR brachytherapy using a custom mold or three-dimensional-printed applicator met inclusion criteria. Treatment was 36 Gy in six weekly fractions. Local and locoregional control were assessed with Kaplan-Meier curves. Acute and late toxicity were graded as per Common Terminology Criteria for Adverse Events, version 5. Cosmesis was defined as "excellent" (indistinguishable from untreated skin), "good" (minimal changes), or "poor" (extensive changes). Univariate analyses were performed. RESULTS: Median age was 85.7 years, and 21 were female. Durable local control occurred in 63 lesions (94.0%), giving estimated local control of 100% at 6 months, 95.1% at 1 year, and 88.8% at 2 years. No factors were predictive of local control on univariate analysis. All experienced acute toxicity that ultimately resolved: 28.4% Grade 2 and 4.5% Grade 3. Larger treatment volume receiving ≥36 Gy was associated with increased Grade ≥2 acute toxicity. Patients experienced late Grade 2 and late Grade 4 toxicity after 6.5% treatments each. Younger age was associated with increased Grade ≥2 late toxicity. "Good" or better cosmesis occurred in 93.2%, and "poor" cosmesis was associated with lower extremities and larger lesions. CONCLUSIONS: Hypofractionated HDR brachytherapy using 36 Gy in six weekly fractions is associated with satisfactory locoregional control and cosmesis with minimal risk of severe acute or late toxicities.

Dysphagia in the elderly population: A Videofluoroscopic study.

OBJECTIVE: To examine the impact of age and underlying comorbid conditions on swallowing in elderly patients with dysphagia. METHODS: Charts of consecutive patients aged >64 studied by Videofluoroscopic swallowing study (VFSS) between 2010 and 2018 at our institution were reviewed (n = 731). Patients were categorized based on age into young old (aged 65-74), older old (aged 75-84) and oldest old (aged 85+). The underlying comorbidities and VFSS results were compared between different age groups. RESULTS: Dysphagia was more likely to be caused by presbyphagia (p < 0.01) and dementia (p < 0.0001) in the oldest old, whereas, head and neck cancers (p < 0.0001) were more common in the young old cohort. In the absence of organic disease (e.g. cancer, stroke, dementia), aging was associated with prolonged oral transit time (OTT) (p < 0.05) and aspiration after swallow (p < 0.05). Compared to those with presbyphagia, patients with organic disease were more likely to have delayed pharyngeal swallow response (p < 0.05) and aspiration during swallow (p < 0.005). CONCLUSION: There are significant differences in the etiology of dysphagia between different age cohorts amongst the dysphagic elderly population. In addition, organic diseases affect swallowing differently than does mere aging. The rate of prolonged OTT and post-swallow aspiration increase with aging in patients with presbyphagia, likely due to age-related sarcopenia of the swallowing muscles. Whereas, those with organic diseases have a higher rate of delayed pharyngeal swallow response and aspiration during swallow, likely due to sensorineural impairment. Thus, it is important to view the elderly as a heterogeneous group when evaluating patients with dysphagia.

Multi-institutional dosimetric delivery assessment of intracranial stereotactic radiosurgery on different treatment platforms.

BACKGROUND AND PURPOSE: Assessment of dosimetric accuracy of radiosurgery on different treatment platforms. MATERIAL AND METHODS: Thirty-three single fraction treatment plans were assessed at thirty centres using an anthropomorphic head phantom with target and brainstem structures. The target being a single irregular shaped target, ~8 cc, 10 mm from the brainstem. The phantom was "immobilised", scanned, planned and treated following the local protocols. EBT-XD films and alanine pellets were used to measure absolute dose, inside both the target and the brainstem, and compared with TPS predicted dose distributions. RESULTS: PTV alanine measurements from gantry-based linacs showed a median percentage difference to the TPS of 0.65%. Cyberknife (CK) had the highest median difference of 2.3% in comparison to the other platforms. GammaKnife (GK) showed the smallest median of 0.3%. Similar trends were observed in the OAR with alanine measurements showing median percentage differences of1.1%, 2.0% and 0.4%, for gantry-based linacs, CK and GK respectively. All platforms showed comparable gamma passing rates between axial and sagittal films. CONCLUSIONS: This comparison has highlighted the dosimetric variation between measured and TPS calculated dose for each delivery platform. The results suggest that clinically acceptable agreement with the predicted dose distributions is achievable by all treatment delivery systems.

Top Ten Things Palliative Care Clinicians Should Know About Caring for Hindus.

Hinduism is one of the five major world religions with >1 billion followers worldwide and encompasses a diversity of belief systems. As of 2010, an estimated 1.8 million Hindus lived in the United States, and this number is expected to increase to 4.8 million by 2050, making the United States home to the largest Hindu population outside of South Asia. As this population continues to grow, it will become increasingly important that clinicians of all disciplines develop a basic understanding of their beliefs and practices to address their palliative care needs. This article highlights 10 considerations for Hindu patients and their families relevant to inpatient care, symptom management, and advance care planning.

Automatic evaluation of contours in radiotherapy planning utilising conformity indices and machine learning.

BACKGROUND AND PURPOSE: Peer-review of Target Volume (TV) and Organ at Risk (OAR) contours in radiotherapy planning are typically conducted visually; this can be time consuming and subject to interobserver variation. This study investigated automatic evaluation of contouring using conformity indices and supervised machine learning. METHODS: A total of 393 contours from 253 Stereotactic Ablative Body Radiotherapy (SABR) benchmark cases (adrenal gland, liver, pelvic lymph node and spine), delineated by 132 clinicians from 25 centres, were visually evaluated for conformity against gold standard contours. Contours were scored as "pass" or "fail" on visual peer review and six Conformity Indices (CIs) were applied. CI values were mapped to pass/fail scores for each contour and used to train supervised machine learning models. A 5-fold cross validation method was employed to determine the predictive accuracies of each model. RESULTS: The stomach structure produced models with the highest predictive accuracy overall (96% using Support Vector Machine and Ensemble models), whilst the liver GTV produced models with the lowest predictive accuracy (76% using Logistic Regression). Predictive accuracies across all models ranged from 68-96% (68-87% for TV and 71-96% for OARs). CONCLUSIONS: Although a final visual review by an experienced clinician is still required, the automatic contour evaluation method could reduce the time for benchmark case reviews by identifying gross contouring errors. This method could be successfully implemented to support departmental training and the continuous assessment of outlining for clinical staff in the peer-review process, to reduce interobserver variability in contouring and improve interpretation of radiological anatomy.

Multi-center evaluation of dose conformity in stereotactic body radiotherapy.

BACKGROUND AND PURPOSE: Stereotactic body radiotherapy (SBRT) is an emerging technique for treating oligometastases, but limited data is available on what plan quality is achievable for a range of modalities and clinical sites. METHODS: SBRT plans for lung, spine, bone, adrenal, liver and node sites from 17 participating centers were reviewed. Centers used various delivery techniques including static and rotational intensity-modulation and multiple non-coplanar beams. Plans were split into lung and other body sites and evaluated with different plan quality metrics, including two which are independent of target coverage; "prescription dose spillage" (PDS) and "modified gradient index" (MGI). These were compared to constraints from the ROSEL and RTOG 0813 clinical trials. RESULTS: Planning target volume (PTV) coverage was compromised (PTV V100% < 90%) in 29% of patient plans in order to meet organ-at-risk (OAR) tolerances, supporting the use of plan quality metrics which are independent of target coverage. Both lung (n = 48) and other body (n = 99) site PDS values agreed well with ROSEL constraints on dose spillage, but RTOG 0813 values were too high to detect sub-optimal plans. MGI values for lung plans were mis-matched to both sets of previous constraints, with ROSEL values too high and RTOG 0813 values too low. MGI values were lower for other body plans as expected, though this was only statistically significant for PTV volumes <20 cm3. CONCLUSIONS: Updated guidance for lung and other body site SBRT plan quality using the PDS and MGI metrics is presented.

Stereotactic radiosurgery for benign brain tumors: Results of multicenter benchmark planning studies.

PURPOSE: Stereotactic radiosurgery (SRS) is strongly indicated for treatment of surgically inaccessible benign brain tumors. Various treatment platforms are available, but few comparisons have included multiple centers. As part of a national commissioning program, benchmark planning cases were completed by all clinical centers in the region. METHODS AND MATERIALS: Four benign cases were provided, with images and structures predelineated, including intracanalicular vestibular schwannoma (VS), larger VS, skull base meningioma, and secreting pituitary adenoma. Centers were asked to follow their local practice, and plans were reviewed centrally using metrics for target coverage, selectivity, gradient falloff, and normal tissue sparing. RESULTS: Sixty-eight plans were submitted using 18 different treatment platforms. Fourteen plans were subsequently revised following feedback, and review of 5 plans led to a restriction of service on 2 platforms (2 centers). Prescription doses were consistent for VS and meningioma submissions, but a wide range of doses were used for the pituitary case. All centers prioritized coverage, with the prescription isodose covering ≥95% of 78/82 target volumes. Lower values may be expected next to air cavities when using advanced algorithms, and in general may be acceptable for some benign lesions. Selectivity was much more variable, and in some cases this was combined with high gradient index and/or >1 mm margin, resulting in large volumes of normal tissue being irradiated. Normal tissue doses were more variable across linear accelerator (LINAC)-based plans than with Gamma Knife or CyberKnife, and dose spillage seemed independent of prescription isodose (inhomogeneity). This may reflect the variety of LINAC-based approaches represented or the necessary tradeoff between different objectives. CONCLUSIONS: These benchmarking exercises have highlighted areas of different clinical practice and priorities and potential for improvement. The subsequent sharing of plan data and margin philosophies between the neurosurgery and oncology communities allowed for meaningful comparison between centers and their peers.

Study protocol for the SARON trial: a multicentre, randomised controlled phase III trial comparing the addition of stereotactic ablative radiotherapy and radical radiotherapy with standard chemotherapy alone for oligometastatic non-small cell lung cancer.

INTRODUCTION: Following growing evidence to support the safety, local control (LC) and potential improvement in overall survival (OS) in patients with oligometastatic non-small cell lung cancer (NSCLC) that have been treated with local ablative therapy such as stereotactic ablative radiotherapy (SABR) and stereotactic radiosurgery (SRS), we initiate the SARON trial to investigate the impact and feasibility of adding SABR/SRS and radical radiotherapy (RRT) following standard chemotherapy on OS. METHODS AND ANALYSIS: SARON is a large, randomised controlled, multicentre, phase III trial for patients with oligometastatic EGFR, ALK and ROS1 mutation negative NSCLC (1-3 sites of synchronous metastatic disease, one of which must be extracranial). 340 patients will be recruited over 3 years from approximately 30 UK sites and randomised to receive either standard platinum-doublet chemotherapy only (control arm) or standard chemotherapy followed by RRT/SABR to their primary tumour and then SABR/SRS to all other metastatic sites (investigational arm). The primary endpoint is OS; the study is powered to detect an improvement in median survival from 9.9 months in the control arm to 14.3 months in the investigational arm with 85% power and two-sided 5% significance level. The secondary endpoints are LC, progression-free survival, new distant metastasis-free survival, toxicity and quality of life. An early feasibility review will take place after 50 randomised patients. Patients requiring both conventional thoracic RT to the primary and SABR to a thoracic metastasis will be included in a thoracic SABR safety substudy to assess toxicity and planning issues in this subgroup of patients more thoroughly. ETHICS AND DISSEMINATION: All participants are given a SARON patient information sheet and required to give written informed consent. Results will be submitted for presentation at local and international conferences and expected to be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT02417662. SPONSOR REFERENCE: UCL/13/0594.

Native paraneurial tissue and paraneurial adhesions alter nerve strain distribution in rat sciatic nerves.

Paraneurial adhesions have been implicated in the pathological progression of entrapment neuropathies. Surgical decompression of adhesions is often performed, with the intent of restoring nerve kinematics. The normal counterpart of adhesions, native paraneurium, is also thought to influence nerve deformation and mobility. However, influences of native or abnormal paraneurial structures on nerve kinematics have not been investigated. We measured regional strains in rat sciatic nerves before and immediately after decompression of native paraneurial tissue, and before and after decompression of abnormal paraneurial adhesions, which formed within 6 weeks of the initial decompression. Strain was significantly higher in the distal-femoral than in the mid-femoral region of the nerve before either decompression. Decompression of native and abnormal paraneurial tissue removed this regional strain difference. Paraneurial tissues appear to play a major role in distributing peripheral nerve strain. Normal nerve strain distributions may be reconstituted following decompression, even in the presence of paraneurial adhesions.

An external dosimetry audit programme to credential static and rotational IMRT delivery for clinical trials quality assurance.

PURPOSE: External dosimetry audits give confidence in the safe and accurate delivery of radiotherapy. The RTTQA group have performed an on-site audit programme for trial recruiting centres, who have recently implemented static or rotational IMRT, and those with major changes to planning or delivery systems. METHODS: Measurements of reference beam output were performed by the host centre, and by the auditor using independent equipment. Verification of clinical plans was performed using the ArcCheck helical diode array. RESULTS: A total of 54 measurement sessions were performed between May 2014 and June 2016 at 28 UK institutions, reflecting the different combinations of planning and delivery systems used at each institution. Average ratio of measured output between auditor and host was 1.002±0.006. Average point dose agreement for clinical plans was -0.3±1.8%. Average (and 95% lower confidence intervals) of gamma pass rates at 2%/2mm, 3%/2mm and 3%/3mm respectively were: 92% (80%), 96% (90%) and 98% (94%). Moderately significant differences were seen between fixed gantry angle and rotational IMRT, and between combination of planning systems and linac manufacturer, but not between anatomical treatment site or beam energy. CONCLUSION: An external audit programme has been implemented for universal and efficient credentialing of IMRT treatments in clinical trials. Good agreement was found between measured and expected doses, with few outliers, leading to a simple table of optimal and mandatory tolerances for approval of dosimetry audit results. Feedback was given to some centres leading to improved clinical practice.