Racial and Gender Differences in Patient Satisfaction Scores Among Oncologists.

BACKGROUND: Patient satisfaction scores (PSS) have been adopted in health care reimbursement and faculty promotion metrics. Oncology patients face a challenging prognosis, where PSS may be perceived differently. We hypothesized that PSS differed based on gender and racial demographics of oncologists. MATERIALS AND METHODS: This was an institutional review board exempt cross-sectional study utilizing PSS data for outpatient oncologists within a large comprehensive cancer center. Patient demographics included age, gender, race/ethnicity, geographical residence, and disease site. Characteristics of oncologists included gender and race/ethnicity. We used PSS ≥95 to make comparisons. The association between patient and physician characteristics were evaluated using the t test and χ2 test. RESULTS: A total of 15,849 oncology patients were identified between 2011 and 2020. Survey respondents were predominantly female (53.2%), white (93.4%), between 50 and 70 years of age (55.3%), and living in an urban setting (63.6%). There were 303 oncologists with the majority being male (64.4%) and white (58.1%). Compared with white oncologists, Asian and Hispanic oncologists received lower PSS (P=0.001 and 0.0085, respectively). On subset analysis, these differences were significant among patients older than 50 years, living in rural counties, and reporting white or non-Hispanic race/ethnicity, or among patients of either gender (all P<0.05). Patients with genitourinary malignancies provided lower PSS for female oncologists (P=0.005). CONCLUSIONS: Asian and Hispanic oncologists were more likely to receive lower PSS. In addition, female oncologists treating genitourinary malignancies received lower PSS. Appropriate statistical adjustments are needed for PSS among oncologists to account for race, gender, and physician subspecialization to allow for equitable professional opportunities across demographics.

The Trials (and Tribulations) of Complementary and Alternative Medicine in Oncology.

Two decades following the creation of the Office of Cancer Complementary and Alternative Medicine at the National Cancer Institute, the status of complementary and alternative medicine (CAM) research within oncology remains opaque. To better understand the landscape of CAM studies in oncology, we identified CAM-related phase III randomized controlled trials (RCTs) through ClinicalTrials.gov and compared these CAM trials to all non-CAM oncologic RCTs. Pearson χ2 testing was used to compare proportions across groups; all tests were two-sided. Comparing the 25 identified CAM RCTs with 739 non-CAM RCTs, CAM studies were more likely to be sponsored by a cooperative group (64.0% vs 28.6%, P < .001) and less likely to be industry funded (8.0% vs 76.5%, P < .001). CAM trials disproportionately excluded disease-related outcomes as endpoints (8.0% vs 84.6%, P < .001), were unsupported by prior early-phase data (55.0% vs 96.1%, P < .001), and did not meet the primary endpoint (8.7% vs 53.0%, P < .001). Given the observed relationship between encouraging pilot data and subsequent phase III trial success, we contend that future CAM RCTs may yield more promising findings if better supported by appropriately designed and well-characterized early-phase signals.

Radiation Dose and Fractionation for Limited-stage Small-cell Lung Cancer: Survey of US Radiation Oncologists on Practice Patterns.

BACKGROUND: Thoracic radiotherapy (TRT) with concurrent chemotherapy is standard for limited-stage small-cell lung cancer (LS-SCLC). However, the optimal dosing and fractionation remain unclear. The National Comprehensive Cancer Network guidelines have recommended either 45 Gy delivered twice daily (BID) or 60 to 70 Gy delivered once daily (QD). However, the current practice patterns among US radiation oncologists are unknown. MATERIALS AND METHODS: We surveyed US radiation oncologists using an institutional review board-approved questionnaire. The questions covered demographic data, self-rated knowledge of key trials, and treatment recommendations. RESULTS: We received 309 responses from radiation oncologists. Of the 309 radiation oncologists, 60% preferred TRT QD and 76% acknowledged QD to be more common in their practice. The respondents in academic settings were more likely to endorse BID treatment by both preference (P = .001) and actual practice (P = .009). The concordance between preferring QD and administering QD in practice was 100%. In contrast, 40% of respondents who preferred BID actually administered QD more often. Also, 15% of physicians would be unwilling to switch from QD to BID and 3% would be unwilling to switch from BID to QD, even on patient request. Most respondents (88%) recommended a dose of 45 Gy for BID treatment. For QD treatment, the division was greater, with 54% recommending 60 Gy, 30% recommending 63 to 66 Gy, and 10% recommending 70 Gy. CONCLUSION: Substantial variation exists in how US radiation oncologists approach TRT dosing and fractionation for LS-SCLC. Three quarters of our respondents reported administering TRT QD most often. The most common doses were 60 Gy QD and 45 Gy BID. The results of the present survey have provided the most up-to-date information on US practice patterns for LS-SCLC.

Timing of Thoracic Radiation Therapy With Chemotherapy in Limited-stage Small-cell Lung Cancer: Survey of US Radiation Oncologists on Current Practice Patterns.

INTRODUCTION: For limited-stage small-cell lung cancer (LS-SCLC), National Comprehensive Cancer Network guidelines recommend that thoracic radiotherapy (TRT) be delivered concurrently with chemotherapy and early in the regimen, with cycle 1 or 2. Evidence is conflicting regarding the benefit of early timing of TRT. A Korean randomized trial did not see a survival difference between early (cycle 1) and late (cycle 3) TRT. Current United States (US) practice patterns are unknown. MATERIALS AND METHODS: We surveyed US radiation oncologists using an institutional review board-approved online questionnaire. Questions covered treatment recommendations, self-rated knowledge of trials, and demographics. RESULTS: We received 309 responses from radiation oncologists. Ninety-eight percent recommend concurrent chemoradiotherapy over sequential. Seventy-one percent recommend starting TRT in cycle 1 of chemotherapy, and 25% recommend starting in cycle 2. In actual practice, TRT is started most commonly in cycle 2 (48%) and cycle 1 (44%). One-half of respondents (54%) believe starting in cycle 1 improves survival compared with starting in cycle 3. Knowledge of the Korean trial was associated with flexibility in delaying TRT to cycle 2 or 3 (P = .02). Over one-third (38%) treat based on pre-chemotherapy volume. CONCLUSION: US radiation oncologists strongly align with National Comprehensive Cancer Network guidelines, which recommend early concurrent chemoradiotherapy. Nearly three-quarters of respondents prefer starting TRT with cycle 1 of chemotherapy. However, knowledge of a trial supporting a later start was associated with flexibility in delaying TRT. Treating based on pre-chemotherapy volume-endorsed by over one-third of respondents-may add unnecessary toxicity. This survey can inform development of future trials.

microRNA-451a regulates colorectal cancer proliferation in response to radiation.

BACKGROUND: Colorectal cancer (CRC) is a leading cause of cancer-related death. The biologic response of CRC to standard of care adjuvant therapies such as chemotherapy and radiation are poorly understood. MicroRNAs (miRs) have been shown to affect CRC progression and metastasis. Therefore, we hypothesized that specific miRs modulate CRC response to chemoradiation. METHODS: In this study, we used miR expression profiling and discovered a set of microRNAs upregulated rapidly in response to either a single 2 Gy dose fraction or a 10 Gy dose of γ-radiation in mouse colorectal carcinoma models. We used gain and loss-of-function studies in 2D and 3Dcell proliferation assays and colony formation assays to understand the role of the top miR candidate from our profiling. We used Student's T-tests for simple comparisons and two-factor ANOVA for evaluating significance. RESULTS: The most upregulated candidate at early time points in our signature, miR-451a inhibited tumor cell proliferation and attenuated surviving fraction in longer-term cultures. Conversely, inhibition of miR-451a increased proliferation, tumorsphere formation, and surviving fraction of tumor cells. Using a bioinformatics approach, we identified four genes, CAB39, EMSY, MEX3C, and EREG, as targets of miR-451a. Transfection of miR-451a decreased both mRNA and protein levels of these targets. Importantly, we found miR-451a expression was high and CAB39, EMSY levels were low in a small subset of rectal cancer patients who had a partial response to chemoradiation when compared to patients that had no response. Finally, analysis of a TCGA colorectal cancer dataset revealed that CAB39 and EMSY are upregulated at the protein level in a significant number of CRC patients. Higher levels of CAB39 and EMSY correlated with poorer overall survival. CONCLUSIONS: Taken together, our data indicates miR-451a is induced by radiation and may influence colorectal carcinoma proliferation via CAB39 and EMSY pathways.

Prophylactic Cranial Irradiation for Limited-Stage Small-Cell Lung Cancer: Survey of US Radiation Oncologists on Current Practice Patterns.

PURPOSE: Prophylactic cranial irradiation (PCI) in patients with limited-stage small-cell lung cancer (LS-SCLC) is considered the standard of care. Meta-analysis of 7 clinical trials indicates a survival benefit to PCI, but all of these trials were conducted in the pre-magnetic resonance imaging (MRI) era. Therefore, routine brain imaging with MRI before PCI-as recommended by National Comprehensive Cancer Network guidelines-is not directly supported by the evidence. Current US practice patterns for patients with LS-SCLC are unknown. MATERIALS AND METHODS: We surveyed practicing US radiation oncologists via an institutional review board-approved online questionnaire. Questions covered demographic information and treatment recommendations for LS-SCLC. RESULTS: We received 309 responses from US radiation oncologists. Ninety-eight percent recommended PCI for patients with LS-SCLC, 96% obtained brain MRI before PCI, 33% obtained serial brain imaging with MRI after PCI to detect new metastases, and 35% recommended memantine for patients undergoing PCI. Recommending memantine was associated with fewer years of practice (P < .001), fewer lung cancer patients treated per year (P = .045), and fewer LS-SCLC patients treated per year (P = .024). CONCLUSION: Almost all responding radiation oncologists recommended PCI and pre-PCI brain MRI for LS-SCLC patients with disease responsive to initial therapy. Only a third of respondents followed these patients with serial brain MRI. Approximately one third provided memantine therapy to try to limit neurocognitive effects of PCI. Further research is warranted to determine the best treatment for patients with LS-SCLC. This survey can inform the development of future trials that depend on participation from radiation oncologists.

The Relationships Between Spiritual Well-Being, Quality of Life, and Psychological Factors Before Radiotherapy for Prostate Cancer.

Given shifting trends of religious identities in the USA, better understanding the impact of patients' religious identities on health-related quality of life (QOL) may help tailor the use of psychological interventions. Men with prostate cancer (N = 43) completed measures of quality of life (QOL), spiritual well-being in two domains (i.e., Faith and Meaning/Peace), psychological state, and psychological trait before undergoing radiotherapy. We hypothesized that (1) higher existential Meaning/Peace would correlate with higher QOL and psychological trait protective factors (e.g., Agreeableness) and that (2) higher existential Meaning/Peace would correlate with lower depression, anxiety, and Neuroticism (i.e., a psychological trait risk factor). We did not anticipate similar relationships between religious Faith and QOL, depression, anxiety, or psychological traits and consider related analyses to be exploratory in nature. Meaning/Peace was indeed negatively associated with depression, anxiety, and Neuroticism. Meaning/Peace was positively correlated with Physical, Social, Functional, and Emotional well-being, as well as Extraversion. Religious Faith was positively associated with Functional well-being, but not the other state, trait, or QOL domains. In sum, prostate cancer patients' sense of existential Meaning/Peace prior to radiotherapy was associated with well-being in many domains, whereas religious Faith appeared less so.

Current patterns of care for patients with extensive stage small cell lung cancer: Survey of US radiation oncologists on their recommendations regarding thoracic consolidation radiotherapy.

OBJECTIVES: Current National Comprehensive Cancer Network (NCCN) guidelines recommend thoracic consolidation radiation therapy (TCRT) for patients with Extensive Stage Small Cell Lung Cancer (ES-SCLC) with response to systemic chemotherapy, based on two randomized clinical trials, which varied in patient selection and radiation therapy doses administered. The current pattern of practice among US radiation oncologists is unknown. MATERIALS AND METHODS: We have surveyed practicing US radiation oncologist via a short online questionnaire. Respondents' characteristics and their self-rated knowledge base were analyzed for association with their treatment recommendations. RESULTS: We received 473 responses from practicing US radiation oncologists. Over half of respondents were practicing for over 10 years after completing residency training and 70% treated more than 10 lung cancer patients per year. 96% of respondents recommend TCRT for patients with ES-SCLC after systemic chemotherapy. Patient selection and radiation therapy doses vary greatly. High self-rated knowledge of individual clinical trials is associated with lower TCRT recommended doses. Patients treated at academic centers are less likely to receive TCRT than patients treated in private clinics (p=0.0101). CONCLUSION: Our analysis revealed that among the respondents, there was a very high adherence to current NCCN guidelines, which recommend TCRT for ES-SCLC patients with clinical response to systemic chemotherapy. The great variability in patient selection and radiation therapy doses is concerning and calls for future clinical trials to standardize treatment approaches and improve treatment outcomes among patients with ES-SCLC. Until such data exists and in light of poor long-term survival of patients with ES-SCLC, the shorter and less toxic regimen of 30Gy in 10 fractions should be used as the standard of care and the more aggressive regimens studied on clinical protocols.

"Even if I Don't Remember, I Feel Better". A Qualitative Study of Patients with Early-Stage Non-Small Cell Lung Cancer Undergoing Stereotactic Body Radiotherapy or Surgery.

RATIONALE: While surgical resection is recommended for most patients with early stage lung cancer according to the National Comprehensive Cancer Network guidelines, stereotactic body radiotherapy is increasingly being used. Provider-patient communication regarding the risks and benefits of each approach may be a modifiable factor leading to improved patient-centered outcomes. OBJECTIVES: To qualitatively describe the experiences of patients undergoing either surgery or stereotactic body radiotherapy for early stage non-small cell lung cancer. METHODS: We qualitatively evaluated and used content analysis to describe the experiences of 13 patients with early clinical stage non-small cell lung cancer before undergoing treatment in three health care systems in the Pacific Northwest, with a focus on knowledge obtained, communication, and feelings of distress. MEASUREMENTS AND MAIN RESULTS: Although most participants reported rarely having been told about other options for treatment and could not readily recall many details about specific risks of recommended treatment, they were satisfied with their care. The patients paradoxically described clinicians as displaying caring and empathy despite not explicitly addressing their concerns and worries. We found that the communication domains that underlie shared decision making occurred infrequently, but that participants were still pleased with their role in the decision-making process. We did not find substantially different themes based on where the participant received care or the treatment selected. CONCLUSIONS: Patients were satisfied with all aspects of their care, despite reporting little knowledge about risks or other treatment options, no direct elicitation of worries from providers, and a lack of shared decision making. While the development of effective communication strategies to address these gaps is warranted, their effect on patient-centered outcomes, such as distress and decisional conflict, is unclear.

Current Patterns of Care for Patients with Extensive-Stage SCLC: Survey of U.S. Radiation Oncologists on Their Recommendations Regarding Prophylactic Cranial Irradiation.

INTRODUCTION: Conflicting data from randomized clinical trials incite the debate over the appropriate use of prophylactic cranial irradiation (PCI) for patients with extensive-stage SCLC (ES-SCLC) who achieve clinical response to systemic chemotherapy. The current pattern of practice among U.S. radiation oncologists is unknown. METHODS: We surveyed practicing U.S. radiation oncologists through a short online questionnaire. Respondents' characteristics and their self-rated knowledge base were analyzed for association with their treatment recommendations. RESULTS: We received 473 responses from practicing U.S. radiation oncologists. More than half of the respondents had been practicing for more than 10 years after completing residency training, and 70% had treated more than 10 patients with lung cancer per year. Of the respondents, 90% recommended brain magnetic resonance imaging (MRI) before initiation of PCI and 98% recommended PCI for patients with ES-SCLC after systemic chemotherapy. Half of the respondents followed their patients with brain MRI after completion of PCI. One-third of the respondents prescribed memantine to patients undergoing PCI. Among the respondents, recent graduates (p = 0.004) and physicians practicing in academic centers (p = 0.005) were more likely to prescribe memantine. Self-rated knowledge base was not associated with any treatment recommendations. CONCLUSIONS: Our analysis revealed that among the respondents, there was a very high adherence to current National Comprehensive Cancer Network guidelines, which recommend providing universal PCI and obtaining brain MRI before initiation of PCI for patients with ES-SCLC with clinical response to systemic chemotherapy. These guidelines and practice patterns are not supported by clinical evidence because patients in the European Organization for Research and Treatment of Cancer trial did not undergo brain MRI before PCI and the Japanese randomized trial has shown a possible detrimental effect of PCI on overall survival when brain MRI was incorporated. A critical reevaluation of current guidelines is essential to determine the appropriate management of these patients.

SWOG S0809: A Phase II Intergroup Trial of Adjuvant Capecitabine and Gemcitabine Followed by Radiotherapy and Concurrent Capecitabine in Extrahepatic Cholangiocarcinoma and Gallbladder Carcinoma.

PURPOSE: The role of postoperative therapy in extrahepatic cholangiocarcinoma (EHCC) or gallbladder carcinoma (GBCA) is unknown. S0809 was designed to estimate 2-year survival (overall and after R0 or R1 resection), pattern of relapse, and toxicity in patients treated with this adjuvant regimen. PATIENTS AND METHODS: Eligibility criteria included diagnosis of EHCC or GBCA after radical resection, stage pT2-4 or N+ or positive resection margins, M0, and performance status 0 to 1. Patients received four cycles of gemcitabine (1,000 mg/m(2) intravenously on days 1 and 8) and capecitabine (1,500 mg/m(2) per day on days 1 to 14) every 21 days followed by concurrent capecitabine (1,330 mg/m(2) per day) and radiotherapy (45 Gy to regional lymphatics; 54 to 59.4 Gy to tumor bed). With 80 evaluable patients, results would be promising if 2-year survival 95% CI were > 45% and R0 and R1 survival estimates were ≥ 65% and 45%, respectively. RESULTS: A total of 79 eligible patients (R0, n = 54; R1, n = 25; EHCC, 68%; GBCA, 32%) were treated (86% completed). For all patients, 2-year survival was 65% (95% CI, 53% to 74%); it was 67% and 60% in R0 and R1 patients, respectively. Median overall survival was 35 months (R0, 34 months; R1, 35 months). Local, distant, and combined relapse occurred in 14, 24, and nine patients. Grade 3 and 4 adverse effects were observed in 52% and 11% of patients, respectively. The most common grade 3 to 4 adverse effects were neutropenia (44%), hand-foot syndrome (11%), diarrhea (8%), lymphopenia (8%), and leukopenia (6%). There was one death resulting from GI hemorrhage. CONCLUSION: This combination was well tolerated, has promising efficacy, and provides clinicians with a well-supported regimen. Our trial establishes the feasibility of conducting national adjuvant trials in EHCC and GBCA and provides baseline data for planning future phase III trials.

Changes in spirituality and quality of life in patients undergoing radiation therapy.

PURPOSE: Investigations into the role of spirituality in cancer confirm the association of good spiritual well-being with many positive outcomes. This study aimed to evaluate potential changes in spirituality over the course of radiation therapy (RT). PATIENTS AND MATERIALS: The Functional Assessment of Chronic Illness Therapy-Spiritual questionnaire measuring spiritual well-being and quality of life (QOL) was administered to adult patients undergoing RT. Scores were compared using student t tests and chi-square analysis. RESULTS: Despite statistically significant declines in QOL measures such as physical well-being (P < .001) and overall well-being (P < .001), no significant changes were noted in spirituality for all comers. A significant increase in the Sp-12 spirituality measure (P = .001) was noted in patients with breast cancer, independent of age, gender, and purpose of treatment. Sp-12 scores were positively correlated with overall QOL scores (P < .001).

S0356: a phase II clinical and prospective molecular trial with oxaliplatin, fluorouracil, and external-beam radiation therapy before surgery for patients with esophageal adenocarcinoma.

PURPOSE: Pathologic complete response (pCR) after neoadjuvant therapy for locally advanced esophageal adenocarcinoma is associated with improved survival. The Southwest Oncology Group designed a trimodality, phase II, single-arm trial with objectives of achieving a pCR rate of 40% with prospective exploratory analyses of intratumoral molecular markers postulated to affect response and survival. PATIENTS AND METHODS: Patients with clinically staged II or III esophageal adenocarcinoma received oxaliplatin 85 mg/m(2) on days 1, 15, and 29; protracted-infusion fluorouracil (PI-FU) 180 mg/m(2)/d on days 8 through 43; and external-beam radiation therapy (EBRT) 5 days a week at 1.8 Gy/d for 25 fractions; surgery was performed 28 to 42 days after neoadjuvant therapy. Chemotherapy was planned after surgery. Tumors were analyzed for mRNA expression and polymorphisms in genes involved in drug metabolism and DNA repair. RESULTS: Ninety-three patients were evaluable. Two deaths (2.2%) were attributable to preoperative therapy, and two deaths (2.2%) were attributable to surgery. Grade 3 and 4 toxicities were recorded for 47.3% and 19.4% of patients, respectively. Seventy-nine patients (84.9%) underwent surgery; 67.7% of patients had R0 resections. Twenty-six patients (28.0%) had confirmed pCR (95% CI, 19.1% to 38.2%). At a median follow-up of 39.2 months, estimates of median and 3-year overall survival (OS) were 28.3 months and 45.1%, respectively. Intratumoral ERCC-1 gene expression was inversely related to progression-free survival and OS. CONCLUSION: Neoadjuvant oxaliplatin, PI-FU, and EBRT for esophageal adenocarcinoma is active and tolerable. Because the regimen failed to meet the primary end point, it does not define a new standard. However, future trials can be built on this platform to validate the role of ERCC-1 in determining the best systemic regimen for individual patients.

Phase III study of adjuvant chemotherapy and radiation therapy compared with chemotherapy alone in the surgical adjuvant treatment of colon cancer: results of intergroup protocol 0130.

PURPOSE: Some patients with colon cancer have a high risk of local recurrence postoperatively. This trial was undertaken to determine whether radiation therapy added to an adjuvant chemotherapy regimen improves outcome in high-risk patients. PATIENTS AND METHODS: Patients with resected colon cancer with tumor adherence or invasion of surrounding structures, or with T3N1 or T3N2 tumors of the ascending or descending colon were randomly assigned to receive fluorouracil and levamisole therapy with or without radiation therapy. Patients who received chemotherapy and radiation therapy (chemoRT) received 45 to 50.4 Gy in 25 to 28 fractions beginning 28 days after starting chemotherapy. Patient enrollment was terminated because of slow accrual after 222 patients enrolled (original goal was 700 patients); 187 patients were assessable. RESULTS: Overall 5-year survival was 62% for chemotherapy patients and 58% for chemoRT patients (P >.50); 5-year disease-free survival was 51% for both groups (P >.50). Toxicity (>/= grade 3) occurred in 42% of chemotherapy patients and 54% of chemoRT patients (P =.04). Leukopenia (>/= grade 3) occurred in 10% of chemotherapy patients and 22% of chemoRT patients (P =.02). No significant difference in nonhematologic toxicity (>/= grade 3) was observed between chemoRT and chemotherapy patients (35% v 44%; P =.26). CONCLUSION: Patients who received chemotherapy or chemoRT had similar overall survival and disease-free survival. Toxicity was higher among chemoRT patients. These results must be interpreted with caution because of the high number of ineligible patients and the limited power of the study to detect potentially meaningful differences.