The American Society for Radiation Oncology Workforce Taskforce Review of the United States Radiation Oncology Workforce Analysis.

Over the past decade, concerns have arisen in radiation oncology regarding potential workforce supply and demand imbalance. The American Society for Radiation Oncology commissioned an independent analysis in 2022, looking at supply and demand in the United States radiation oncology workforce and projecting future trends for 2025 and 2030. The final report, titled Projected Supply and Demand for Radiation Oncologists in the U.S. in 2025 and 2030, is now available. The analysis included evaluating radiation oncologist (RO) supply (new graduates, exits from the specialty), potential changes in demand (growth of Medicare beneficiaries, hypofractionation, loss of indications, new indications) as well as RO productivity (growth of work relative value units [wRVUs] produced), and demand per beneficiary. The results demonstrated a relative balance between radiation oncology supply and demand for radiation services; the growth in ROs was balanced by the rapid growth of Medicare beneficiaries over the same period. The primary factors driving the model were found to be growth of Medicare beneficiaries and change in wRVU productivity, with hypofractionation and loss of indication having only a moderate effect; although the most likely scenario was a balance of workforce supply and demand, scenarios did demonstrate the possibility of over- and undersupply. Oversupply may become a concern if RO wRVU productivity reaches the highest region; beyond 2030, this is also possible if growth in RO supply does not parallel Medicare beneficiary growth, which is projected to decline and will require corresponding supply adjustment. Limitations of the analysis included uncertainty regarding the true number of ROs, the lack of inclusion of most technical reimbursement and its effect as well as failing to account for stereotactic body radiation therapy. A modeling tool is available to allow individuals to evaluate different scenarios. Moving forward, continued study will be needed to evaluate trends (particularly wRVU productivity and Medicare beneficiary growth) to allow for continued assessment of workforce supply and demand in radiation oncology.

The design of a novel direction modulated brachytherapy vaginal cylinder applicator for optimizing coverage of the apex.

PURPOSE: High-dose-rate (HDR) vaginal cuff brachytherapy is an effective adjuvant therapy for women with stage I endometrial cancer. Although infrequent, failures do occur, most frequently at the vaginal vault. A potential cause of failure is insufficient dosimetric coverage at the vaginal apex due to cold spots from the anisotropic dose distribution of the source. Here, we propose a novel direction modulated brachytherapy (DMBT)-concept vaginal cylinder (VC) applicator that resolves this dosimetric issue. METHODS AND MATERIALS: The novel DMBT-VC applicator was designed and simulated with the GEANT4 Monte Carlo code. The outer cylinder material chosen was polyphenylsulfone (PPSU) plastic, and the central part was a detachable rod, housing a single lumen made of either polyether ether ketone (PEEK) plastic or an MR-compatible tungsten alloy. The PPSU-based outer cylinder, together with the inner PEEK rod provides the dose distribution of a conventional VC applicator. The PEEK rod is then replaced with an MR-compatible tungsten alloy rod of the same dimensions to generate directional "pencil-like" beams to compensate for the anisotropic cold spots. Two widely used 192 Ir HDR sources, VS2000 and GammaMedPlus, were also simulated. RESULTS: The novel DMBT-VC applicator was able to remove the underdosage at the apex due to the anisotropy effect regardless of the HDR sources without unnecessarily increasing the dose to the periphery of the applicator. Also, further directional modulation to reach deeper in the apex by up to 14 mm beyond the VC surface was achievable, again without increasing the peripheral doses. Total treatment dwell times increased only by 7-13%. CONCLUSIONS: The novel DMBT-VC applicator provides improved dose coverage at the vaginal apex by overcoming the classical anisotropy issue ubiquitous to all HDR brachytherapy sources. The next step in development of the device is manufacturing a prototype for clinical testing.

Introductory Radiation Oncology Curriculum: Report of a National Needs Assessment and Multi-institutional Pilot Implementation.

PURPOSE: To assess the optimal structure of an introductory curriculum (IC) for radiation oncology residents, including the perceived utility of a 2-day off-site "boot camp," and evaluate the success of a pilot introductory radiation oncology curriculum (IROC) based on these initial data. METHODS AND MATERIALS: In the first phase, anonymous, web-based surveys were sent to US radiation oncology program directors and residents. Likert-type scores (1, not at all; 5, extremely) are reported as the median and interquartile range. Using the phase 1 results, IROC was developed, piloted, and evaluated. RESULTS: Of the 89 program directors and 697 residents, 47 (53%) and 165 (24%) responded, respectively. Of the 89 program directors, 37 (79%) reported offering a formal IC. However, only 83 residents (50%) reported having a formal IC. Program directors reported resident preparation for clinical training as "moderate" (median 3, interquartile range 2-3) on entering residency and "moderate" (median 3, interquartile range 3-4) after IC completion (P = .03). However, residents only believed they were "slightly" prepared (median 2, interquartile range 1-2) on entering residency and "moderately" (median 3, interquartile range 2-3) prepared after IC completion (P < .01). Program directors believed an off-site boot camp would be of "moderate" utility (median 3, interquartile range 3-4) with participation limited by funding (57%). Residents without an IC reported that having an IC would be "quite" beneficial (median 4, interquartile range 3-5). Residents preferred instruction before the clinical training (49%) and over 1 week (40%). Both program directors and residents rated lectures on radiation emergencies and simulation highly. Using these data, IROC was developed and piloted with incoming residents at 4 institutions. After IROC, residents reported improvement in overall preparedness for clinical training (before: median 1, interquartile range 1-2; vs after: median 3, interquartile range 2-3; P < .01) and among specific practice domains. CONCLUSIONS: Beginning radiation oncology residents frequently lack structured introductory curricula but desire instruction before the clinical training with a focus on practical aspects (emergency management, contouring). Program directors recognize the value of both off-site and on-site boot camps. An on-site IC could mitigate funding barriers. A standardized IC, IROC, piloted at 4 programs, showed promising outcomes.

Management of male breast cancer in the United States: a surveillance, epidemiology and end results analysis.

PURPOSE: To analyze the stage-specific management of male breast cancer (MBC) with surgery and radiation therapy (RT) and relate them to outcomes and to female breast cancer (FBC). METHODS AND MATERIALS: The Surveillance, Epidemiology, and End Results database was queried for all primary invasive MBC and FBC diagnosed from 1973 to 2008. Analyzable data included age, race, registry, grade, stage, estrogen and progesterone receptor status, type of surgery, and use of RT. Stage was defined as localized (LocD): confined to the breast; regional (RegD): involving skin, chest wall, and/or regional lymph nodes; and distant: M1. The primary endpoint was cause-specific survival (CSS). RESULTS: A total of 4276 cases of MBC and 718,587 cases of FBC were identified. Male breast cancer constituted 0.6% of all breast cancer. Comparing MBC with FBC, mastectomy (M) was used in 87.4% versus 38.3%, and breast-conserving surgery in 12.6% versus 52.6% (P<10(-4)). For males with LocD, CSS was not significantly different for the 4.6% treated with lumpectomy/RT versus the 70% treated with M alone (hazard ratio [HR] 1.33; 95% confidence interval [CI] 0.49-3.61; P=.57). Postmastectomy RT was delivered in 33% of males with RegD and was not associated with an improvement in CSS (HR 1.11; 95% CI 0.88-1.41; P=.37). There was a significant increase in the use of postmastectomy RT in MBC over time: 24.3%, 27.2%, and 36.8% for 1973-1987, 1988-1997, and 1998-2008, respectively (P<.0001). Cause-specific survival for MBC has improved: the largest significant change was identified for men diagnosed in 1998-2008 compared with 1973-1987 (HR 0.73; 95% CI 0.60-0.88; P=.0004). CONCLUSIONS: Surgical management of MBC is dramatically different than for FBC. The majority of males with LocD receive M despite equivalent CSS with lumpectomy/RT. Postmastectomy RT is greatly underutilized in MBC with RegD, although a CSS benefit was not demonstrated. Outcomes for MBC are improving, attributable to improved therapy and its use in this unscreened population.