Management of inguinal lymph nodes in locally advanced, surgically unresectable, squamous cell carcinoma of the vulva.

OBJECTIVE: To assess clinical outcomes of inguinal lymph node surgical resection compared to primary groin radiotherapy for locally advanced, surgically unresectable vulvar cancer. METHODS: All patients treated with radiation for vulvar cancer were identified between Jan 1, 2000 - Dec 31, 2020 at 2 academic centres. Inclusion criteria were those treated with curative intent primary radiotherapy +/- chemotherapy, tumors >4 cm, and surgically unresectable squamous cell vulvar carcinoma. Groin recurrence-free survival (RFS) was compared for groin surgery and primary groin radiotherapy using the Kaplan Meier method and log rank test. Groin failures are described by treatment modality, radiation dose and lymph node size. RESULTS: Of 476 patients treated with radiation for vulvar cancer, 112 patients (23.5%) met inclusion and exclusion criteria. The median (95% CI) follow up was 1.9 (1.4-2.5) years. Complete clinical response was significantly higher (80.0%) in patients with surgical groin resection compared to patients treated with primary groin radiotherapy (58.2%) (p = 0.04). On multivariable analysis, after adjusting for clinical and/or radiologically abnormal lymph nodes (p = 0.67), surgical groin resection was significantly associated with lower groin recurrence (HR 0.2 (95%CI 0.05-0.92), p = 0.04). The 3-year groin recurrence-free survival (RFS) was significantly higher at 94.4% (87.1-100) in patients with surgical groin resection compared to 79.2% (69.1-90.9) in patients treated with primary radiation (p = 0.02). CONCLUSIONS: In locally advanced squamous cell vulvar cancer, surgical groin management improves groin RFS compared to radiotherapy alone.

A phase I study of the Wee1 kinase inhibitor adavosertib (AZD1775) in combination with chemoradiation in cervical, upper vaginal, and uterine cancers.

OBJECTIVE: Wee1 kinase is a crucial regulator of the G2/M checkpoint which prevents entry of damaged DNA into mitosis. Adavosertib (AZD1775), a selective inhibitor of Wee1, induces G2 escape and increases cytotoxicity when combined with DNA damaging agents. We aimed to evaluate the safety and efficacy of adavosertib in combination with definitive pelvic radiotherapy and concurrent cisplatin in patients with gynecological cancers. METHODS: A multi-institutional, open-label phase I trial was designed to assess dose escalation (3+3 design) of adavosertib in combination with standard chemoradiation. Eligible patients with locally advanced cervical, endometrial or vaginal tumors were treated with a 5-week course of pelvic external beam radiation 45-50 Gy in 1.8-2 Gy daily fractions plus concurrent weekly cisplatin 40 mg/m2 and adavosertib 100 mg/m2 on days 1, 3 and 5 of each week during chemoradiation. The primary endpoint was to determine the recommended phase II dose of adavosertib. Secondary endpoints included toxicity profile and preliminary efficacy. RESULTS: Ten patients were enrolled (nine locally advanced cervical and one endometrial cancer). Two patients experienced a dose-limiting toxicity at dose level 1 (adavosertib 100 mg by mouth daily on days 1, 3 and 5), including one patient with grade 4 thrombocytopenia, and one with treatment hold >1 week due to grade 1 creatinine elevation and grade 1 thrombocytopenia. At dose level -1 (adavosertib 100 mg by mouth daily on days 3 and 5), one out of five patients enrolled had a dose-limiting toxicity in the form of persistent grade 3 diarrhea. The overall response rate at 4 months was 71.4%, including four complete responses. At 2 years follow-up, 86% of patients were alive and progression-free. CONCLUSION: The recommended phase II dose could not be determined due to clinical toxicity and early trial closure. Preliminary efficacy appears promising, yet selecting the adequate dose/schedule in combination chemoradiation warrants further investigation to limit overlapping toxicities.

Exploring Brachytherapy Discharge Educational Needs of Gynecological Cancer Patients.

Brachytherapy (BT) plays a fundamental role in the treatment of gynecological cancers. Patient education for vaginal self-management and dilator use post-BT involves an interdisciplinary team of healthcare professionals (HCPs) and there is a paucity of post-BT education guidelines. Our objective was to determine the educational needs of gynecological cancer patients surrounding vaginal self-management post-BT and to determine enablers and barriers to the provision of education by HCPs. This cross-sectional study recruited gynecological oncology patients receiving external beam radiotherapy and BT for curative intent. Patients completed a questionnaire to assess their vaginal self-management educational needs, preferred education modality, and desired timing of post-BT education. HCPs were invited to complete a questionnaire to identify enablers and barriers to providing BT education. Twenty patients and 53 HCPs participated. All patients rated each topic as very important/important with information about preventing vaginal stenosis as the most important overall (89%). When asked about topics they addressed during BT education, most HCPs reported that "explaining what vaginal stenosis is and the negative effects of stenosis" was always discussed with patients (N = 37/49, 77%). Barriers to providing post-BT education, including the patients' language and culture, as well as enablers, such as the use of written resources and tools for patients, were identified. Despite a high level of engagement, current education surrounding vaginal self-management post-BT may be inadequate.

Evaluating Healthcare Professionals' Knowledge, Attitudes, Practices and Education Interest in LGBTQ2 + Cancer Care.

The lesbian, gay, bisexual, transgender, queer/questioning and two-spirited, plus (LGBTQ2 +) community experiences cancer-related health disparities and inequities. Our objective was to assess LGBTQ2 + knowledge, attitudes, practices and education interest of healthcare professionals (HCPs), identify opportunities to improve care and inform the development of an HCP education curriculum. This was a mixed methods quality improvement study conducted within a tertiary academic cancer centre. An email was sent to all gynaecologic oncology disease site staff (n = 92) with a secure link to an online survey. We measured respondents' sociodemographic characteristics and LGBTQ2 + knowledge, attitudes, practice behaviours and education interest. Open comments explored HCP experiences and reservations caring for LGBTQ2 + patients and suggestions to improve care. Seventy-five out of ninety-two (82%) HCPs completed the survey, with 7% identifying as LGBTQ2 + . HCPs reported feeling less comfortable (88% vs. 80%, p = 0.031) and knowledgeable (44% vs. 27%, p < 0.001) caring for transgender patients compared to LGBQ2 + patients. Most (76%) were unaware whether LGBTQ2 + -specific patient educational materials existed within their institution. Almost all (92% strongly agreed/agreed) were interested in receiving LGBTQ2 + -specific education. Two themes emerged from analysis of open comments: (i) HCPs are concerned of offending LGBTQ2 + individuals because of their lack of knowledge and (ii) HCPs desire LGBTQ2 + -specific health training, specifically in asking pronouns and caring for transgender patients. HCPs report competency gaps in caring for LGBTQ2 + patients with cancer but desire education. In response, we recommend institutions develop an educational curriculum for HCPs improve communication and inclusivity in cancer care.

Exploring the Perceived Educational Impact of COVID-19 on Postgraduate Training in Oncology.

This study sought to report the degree to which postgraduate trainees in radiation oncology perceive their education has been impacted by the COVID-19 pandemic. A cross-sectional online survey was administered from June to July 2020 to trainee members of the Canadian Association of Radiation Oncology (CARO) (n = 203). Thirty-four trainees responded with a 17% response rate. Just under half of participants indicated that COVID-19 had a negative/very negative impact on training (n = 15; 46%). The majority agreed/strongly agreed that they feared family/loved ones would contract COVID-19 (n = 29, 88%), felt socially isolated from friends and family because of COVID-19 (n = 23, 70%), and had difficulty concentrating on tasks because of concerns about COVID-19 (n = 17, 52%). Changes that had a negative/very negative impact on learning included limitations to travel and networking (n = 31; 91%) and limited patient contact (n = 19; 58%). Virtual follow-ups (n = 25: 76%) and in-patient care activities (n = 12; 36%) increased. Electives were cancelled in province (n = 10; 30%), out-of-province (n = 16; 49%), and internationally (n = 15; 46%). Teaching from staff was moderately reduced to completely suppressed (n = 23, 70%) and teaching to medical students was moderately reduced to completely suppressed (n = 27, 82%). Significant changes to radiation oncology training were wrought by the pandemic, and roughly half of trainees perceive that these changes had a negative impact on training. Innovations in training delivery are needed to adapt to these new changes.

Management of Malignant Bowel Obstruction: An Innovative Proactive Outpatient Nurse-Led Model of Care for Patients With Advanced Gynecologic Cancer.

BACKGROUND: Malignant bowel obstruction (MBO) in patients with advanced gynecologic cancer (GyCa) can negatively impact clinical outcomes and quality of life. Oncology nurses can support these patients with adequate tools/processes. PROBLEM: Patients with GyCa with/at risk of MBO endure frequent emergency or hospital admissions, impacting patient care. APPROACH: Optimizing oncology nurses' role to improve care for patients with GyCa with/at risk of MBO, the gynecology oncology interprofessional team collaborated to develop a proactive outpatient nurse-led MBO model of care (MOC). OUTCOMES: The MBO MOC involves a risk-based algorithm engaging interdisciplinary care, utilizing standardized tools, risk-based assessment, management, and education for patients and nurses. The MOC has improved patient-reported confidence level of bowel self-management and decreased hospitalization. Following education, nurses demonstrated increased knowledge in MBO management. CONCLUSIONS: An outpatient nurse-led MBO MOC can improve patient care and may be extended to other cancer centers, fostering collaboration and best practice.

Patient Engagement: an Assessment of Canadian Radiotherapy Programs' Current Practices, Perceived Barriers, and Facilitators.

Patient engagement and education have been mandated across Canadian radiation oncology programs (ROP). Guidance documents include the 2014 Canadian Association of Radiation Oncology (CARO) Radiation Therapy Patient Charter, the 2016 Canadian Partnership for Quality Radiotherapy (CPQR) Patient Engagement Guidelines (PEG) for Canadian Radiation Treatment Programs, and Accreditation Canada's 2017 refresh of Cancer Care Standards. Since little is known regarding uptake of these guidance statements, Canadian ROP were surveyed to assess current patient engagement and education practices. An e-survey was sent to Canadian ROP (n = 44). The survey focused on awareness and uptake of the CARO Patient Charter, CPQR PEG, and patient education practices. Survey development was guided by these documents and expert consensus, including CARO's Quality and Standards Patient Education/Engagement working group. Many (71%) responding ROP were familiar with the CARO Patient Charter, while 24% reported use. More than half (53%) of ROP were aware of the CPQR PEG, but approximately third (37%) had previously completed a self-audit. Most (88%) ROP view a pan-Canadian, evidence-based approach to educational materials beneficial and feasible (80%), with the majority (89%) willing to share their best practices across the radiotherapy community. Patient engagement and education are nationally mandated and supported by guidance documents. However, gaps have been identified across ROP for awareness and use of available tools, as well as uptake of their processes critical to quality of care. Understanding current practices will inform CPQR/CARO-supported pan-Canadian initiatives to optimize uptake, including development of CPQR Patient Education Guidance for Canadian Radiation Treatment Programs.

Feedback Delivery in an Academic Cancer Centre: Reflections From an R2C2-based Microlearning Course.

Feedback delivery and training have not been characterized in the context of academic cancer centres. The purpose of this study was to assess the feasibility and utility of a microlearning course based on the R2C2 (Relationship, Reaction, Content, Coaching) feedback model and characterize multidisciplinary healthcare provider (HCP) perspectives on existing feedback practices in an academic cancer centre. Five HCP (two radiation oncologists, one medical oncologist, and two allied health professionals) with supervisory roles were selected by purposive sampling to participate in a prospective longitudinal qualitative study. Each participant completed a web-based multimedia course. Semi-structured one-on-one interviews were conducted with each participant at four time points: pre- and immediately post-course, and at one- and three-months post course. All participants found the course to be time feasible and completed it in 10-20 min. Participants expressed that the course fulfilled their need for feedback training and that its adoption may normalize a feedback culture in the cancer centre. Three themes were identified regarding perceptions of existing feedback practices: (1) hierarchical and interdisciplinary relationships modulate feedback delivery, (2) interest in feedback delivery varies by duration of the supervisory relationship, and (3) the transactionality of supervisor-trainee relationships influences feedback delivery. This study demonstrates the perceived feasibility and utility of a digital microlearning approach for development of feedback competencies in an academic cancer centre, perceptions of cultural barriers to feedback delivery, and the need for organizational commitment to developing a feedback culture.

Feasibility of implementing a cervix cancer-specific patient-reported outcome measure in routine ambulatory clinics.

OBJECTIVE: To evaluate the implementation of a cervix cancer-specific patient-reported outcome measure, the European Organization for Research and Treatment of Cancer Quality of Life Cervical Cancer module (EORTC QLQ-CX24), into gynecologic oncology clinics. METHODS: This was a prospective, multi-institutional, cross-sectional study involving cervix cancer patients previously treated with curative intent radiotherapy who were attending routine follow-up appointments. Between January 2017 and August 2018, eligible patients were approached to complete the EORTC QLQ-CX24 prior to their clinical encounter and then review it with their oncologist. Patient and oncologist experience was evaluated using Feedback Questionnaires following the encounter. Descriptive statistics were used to summarize the results of the EORTC QLQ-CX24 and Feedback Questionnaires. Open-ended questions within the Feedback Questionnaires were analyzed to identify themes. RESULTS: Eighty-four patients consented to participate in the study. Of these, 80 (95.2%) completed the EORTC QLQ-CX24 and 76 (90.4%) completed both the EORTC QLQ-CX24 and the Feedback Questionnaires. There were high rates of completion for most items within the EORTC QLQ-CX24 (93-98%), except for items pertaining to vaginal symptoms and sexual health (34-35%). All eligible oncologists participated (n = 9). Overall, patients and oncologists positively endorsed use of the questionnaire during clinical encounters. The majority of patients (80%) and oncologists (89%) reported use of the questionnaire improved communication, including discussion of sensitive topics. Interestingly, only a minority of patients and oncologists stated a perceived preference for electronic completion (18% and 44%, respectively). CONCLUSION: Implementation of the EORTC QLQ-CX24 in gynecologic oncology clinics was feasible and acceptable according to patients and oncologists.

Effectiveness of a Multiprofessional, Online and Simulation-Based Difficult Conversations Training Program on Self-Perceived Competence of Oncology Healthcare Provider Trainees.

Effective communication between healthcare providers (HCPs) and patients is important for HCP well-being, patient engagement, and health outcomes. Yet, HCPs do not receive adequate communication skills training and report feeling unprepared for difficult conversations. A needs assessment of 64 cancer HCP trainees in Toronto, Canada, found that a majority of trainees rated themselves with low competency in communication skills to support patients through difficult conversations, while nearly all rated these skills as important to their practice. A blended multiprofessional communications program was developed including online theoretical learning and reflective practice in addition to in-person simulation with standardised patient actors. Since communication skills mastery is highly unlikely to occur at the termination of a single training program, the goal of the program was to stimulate participants' motivational beliefs about difficult conversations communication skills in order to deepen their commitment to learning and mastery. The motivational beliefs assessed included self-efficacy (self-perceived competence), intent to use techniques learned, and confidence in task mastery. After completing the course, participants' self-perceived competence in dealing with difficult conversations significantly increased by an average of 25 points (p < 0.001) on a rating scale of 1-100 (n = 40). Participants' intent to use techniques did not change significantly and remained high with an overall average of 89 points. After the course, participants rated their confidence in mastering techniques learned at an average score of 71 points. Multiprofessional, simulation-based training is an effective way to improve HCP trainees' motivational beliefs around having difficult conversations.

Patient-reported acute fatigue in elderly breast cancer patients treated with and without regional nodal radiation.

PURPOSE: Although regional nodal irradiation (RNI) improves outcomes in breast cancer (BC) patients, it is associated with increased toxicity. Therefore, controversy still exists surrounding its indications. The purpose of this study was to evaluate and compare patient-reported acute fatigue in elderly BC patients with and without regional nodal radiation (RNI). METHODS: Elderly breast cancer patients (≥ 65 years) treated with adjuvant radiotherapy (RT) between 2012 and 2017 were identified from a prospective database. The validated Edmonton Symptom Assessment System-revised (ESAS-r) questionnaire, which assesses fatigue, was completed prior to (baseline), during, at end of RT and first follow-up (3-6 months). Symptoms were rated on a 10-point Likert scale, with higher scores indicating higher fatigue. Patient's treatment characteristics were also recorded prospectively. This was a retrospective study which identified elderly breast cancer patients who had received adjuvant radiation, completed ESAS-r prospectively and provided research consent for using ESAS-r. Patients were divided into two cohorts: those who received RNI (cohort 1) and those who did not (cohort 2). A minimal clinically important difference (MID) was defined using an anchor of ≥ 1-point compared to baseline. The proportion of patients reporting a change in fatigue at the end of RT was evaluated. To test the robustness of the results, dynamic changes of fatigue scores over time were further compared between the cohorts using a general linear mixed model (GLMM) after assuming individual patient with random effect. Univariate and multivariable logistic regression were conducted to assess the association between RNI and MID after adjusting for potential confounders. In addition to longitudinal analysis, a multivariable mixed effect model was developed to determine the association of RNI with fatigue after adjusting for potential confounders. A two-tailed p value ≤ 0.05 was considered statistically significant. RESULTS: Of the 1198 patients, 859 had provided research consent and completed the ESAS-r at baseline and any other time-point and were included in the longitudinal analysis (cohort 1 = 159, cohort 2 = 700), while 637 (cohort 1 = 135, cohort 2 = 502) patients completed the ESAS-r at baseline and end of radiotherapy and were included in the anchor-based analysis. Mean age at diagnosis was similar between the groups: cohort 1; 71.5 ± 5.7 vs. cohort; 2 72 ± 5.4 years (total 71.8 ± 5.5). Overall, cohort 1 had higher stage (Stage 3: 32.7% vs 3.6%, p < 0.001) and reception of chemotherapy (68.6% vs. 16.1%, p < 0.001). Mean baseline fatigue was higher for cohort 1 vs. 2 (2.7 ± 2.5 vs. 2.1 ± 2.3, p = 0.006). On univariate and multivariable analyses, RNI was not associated with an increased odd of MID for fatigue at the end of RT (44% vs. 47%; OR 0.89, 95% CI 0.61-1.30, p = 0.56). After adjusting for confounders (age, duration of RT, endocrine therapy), treatment with RNI was not associated with increased odds of worse fatigue at the end of RT (OR 1.33, 95% CI 0.85-2.10, p = 0.22). Higher baseline fatigue (OR 0.86, 95% CI 0.79-0.92, p < 0.001) and receipt of chemotherapy had decreased odds (OR 0.50, 95% CI 0.32-0.86, p = 0.001) and were the only factors associated with decreased odds of MID. Dynamic changes showed a significant worsening of fatigue scores over time (p < 0.001) towards the end of RT and recovery at first follow-up (p < 0.001) with no difference between the cohorts (p = 0.38); both experienced parallel worsening of fatigue levels over time (cohort*time p = 0.71 and cohort*time2p = 0.78). On multivariable analysis earlier stage, the absence of chemotherapy and higher baseline depression were independent predictors of worse fatigue scores over time (p = 0.01, p = 0.003, and p = 0.02, respectively). CONCLUSION: The addition of RNI in elderly BC patients is not associated with a significant worsening of patient-reported fatigue. Predictors of acute fatigue will enable shared decision making between patients and clinicians.

The Impact on Peer Mentorship After Implementation of a Competency-Based Residency Curriculum in Canadian Radiation Oncology Training Programs.

Purpose: Peer mentorship provides professional and personal support between physicians with similar experiences and levels of training. While peer mentorship has shown to benefit academic success and professional growth, little data has examined contextual factors, such as curricular change, that may affect the quality of these relationships. This study aims to explore the impact of a new, nationwide radiation oncology (RO) residency curriculum, known as competence by design (CBD), on peer mentorship experiences between Canadian RO residents. Methods and Materials: A qualitative study, with a social constructivist approach, was conducted with 2 groups of Canadian RO residents. The first were those in the academic year before CBD implementation (non-CBD cohort), and the second were those in the inaugural year of CBD (CBD cohort). Semistructured 1-on-1 interviews were conducted to explore experiences of peer mentorship as it related to curriculum change. Interviews were transcribed and analyzed with deductive and inductive methods until data saturation. Results: Between April and December 2021, 14 participants (6 non-CBD and 8 CBD residents) from 8 out of 10 eligible English-speaking RO training programs across Canada participated. Three major themes were identified: (1) the CBD cohort identified fewer opportunities for peer mentorship, with specific concerns regarding new evaluation processes and uncertainty about the later stages of training; (2) there was minimal impact on specialty-specific learning; and (3) peer mentorship thrived when occurring as spontaneous in-person interactions. Conclusions: Inaugural residents of a CBD curriculum perceived fewer opportunities for peer mentorship. There were specific concerns about new evaluative processes, though this did not affect specialty-specific learning. Peer mentorship was most impactful as informal and in-person interactions. Our findings suggest that unintended consequences of curriculum change may be mitigated by improving communication about new training objectives and increasing opportunities for informal interactions between residents.

Utilization and Impact of a Radiation Nursing Clinic to Address Acute Care Needs for Patients with Gynecologic Cancers.

BACKGROUND: The risk factors for acute care utilization in gynecologic oncology patients are poorly understood. This study aimed to evaluate risk factors for the utilization of our centre's acute care radiation nursing clinic (RNC) by gynecologic oncology patients receiving radiotherapy (RT). METHODS: This was a retrospective cohort study of gynecological cancer patients treated with RT at an academic cancer centre between 1 August 2021 and 31 January 2022. Data on socio-demographics, clinical and treatment characteristics, and RNC visits were collected and summarized by descriptive statistics. The Wilcoxon rank sum test and chi-squared test/Fisher's exact test were used for comparisons of continuous and categorical variables, respectively. RESULTS: RT was delivered to 180 patients, of whom 42 (23%) received concurrent chemoradiation (CCR). Compared to those receiving RT alone, patients receiving CCR had higher rates of RNC utilization (55% vs. 19%, p < 0.001). Within the CCR cohort, patients who presented to the RNC were more likely to be unpartnered (43% vs. 11%, p = 0.04), receive a referral to Psychosocial Oncology (39% vs. 5.3%, p = 0.01), and experience treatment interruptions (52% vs. 16%, p = 0.02). There were no associations between RNC visits and age, disease site, or distance from the cancer centre. CONCLUSIONS: The receipt of CCR and specific psychosocial risk factors were associated with increased RNC utilization. Targeted strategies and early intervention to better meet the supportive care and psychosocial needs of this vulnerable population are needed.

Clinical outcomes of three vs four fractions of MRI-guided brachytherapy in cervical cancer.

PURPOSE: MRI-guided brachytherapy (MRgBT) is essential in the management of locally advanced cervical cancer. This study compares disease and toxicity outcomes in cervical cancer patients treated with 24 Gy/3 fractions (Fr) versus the conventional 28 Gy/4 Fr. METHODS AND MATERIALS: This retrospective study included 241 consecutive patients with FIGO 2018 stage IB-IVA cervical cancer treated with definitive chemoradiation between April 2014 - March 2021. Disease-free survival (DFS) was estimated using the Kaplan-Meier method and compared using the log-rank test. Cumulative incidence of local failure (LF), distant failure (DF) and G2+ gastrointestinal (GI), urinary (GU) and vaginal toxicity were estimated using the cumulative incidence function with death as a competing risk and compared using the Gray's test. RESULTS: Of the 241 patients, 42% received 24 Gy/3 Fr and 58% received 28 Gy/4 Fr. With a median follow up of 3.2 (range 0.2-9.2) years, there were 14 local, 41 regional nodal and 51 distant failures in 63 (26%) patients. No significant differences were found between the 24 Gy/3 Fr vs 28 Gy/4 Fr group in 3-year DFS (77% vs 68%, P = 0.21), 3-year cumulative incidence of LF (5% vs 7%, P = 0.57), DF (22% vs 25%, P = 0.86), G2+ GI toxicity (11% vs 20%, P = 0.13), or G2+ vaginal toxicity (14% vs 17%, P = 0.48), respectively. The 3-year cumulative G2+ urinary toxicity rate was lower in the 24 Gy/3 Fr group (9% vs 23%, P = 0.03). CONCLUSION: Cervical cancer patients treated with 24 Gy/3 Fr had similar DFS, LF, DF, GI and vaginal toxicity rates, and a trend towards lower G2+ urinary toxicity rate compared to those treated with 28 Gy/4 Fr. A less resource-intensive brachytherapy fractionation schedule of 24 Gy/3 Fr is a safe alternative to 28 Gy/4 Fr for definitive treatment of cervical cancer.

Patient Education Practices and Preferences of Radiation Oncologists and Interprofessional Radiation Therapy Care Teams: A Mixed-Methods Study Exploring Strategies for Effective Patient Education Delivery.

PURPOSE: Patients' understanding of radiation therapy (RT) and data regarding optimal approaches to patient education (PE) within radiation oncology (RO) are limited. We aimed to evaluate PE practices of radiation oncologists and interprofessional RT care team members to inform recommendations for delivering inclusive and accessible PE. METHODS AND MATERIALS: An anonymous survey was administered to all Radiation Oncology Education Collaborative Study Group members (10/5/22-11/23/22). Respondent demographics, individual practices/preferences, and institutional practices were collected. Qualitative items explored strategies, challenges, and desired resources for PE. Descriptive statistics summarized survey responses. The Fisher exact test compared PE practices by respondent role and PE timing. Thematic analysis was used for qualitative responses. RESULTS: One hundred thirteen Radiation Oncology Education Collaborative Study Group members completed the survey (28.2% response rate); RO attendings comprised 68.1% of respondents. Most practiced in an academic setting (85.8%) in North America (80.5%). Institution-specific materials were the most common PE resource used by radiation oncologists (67.6%). Almost half (40.2%) reported that their PE practices differed based on clinical encounter type, with paper handouts commonly used for in-person and multimedia for telehealth visits. Only 57.7% reported access to non-English PE materials. PE practices among radiation oncologists differed according to RT clinical workflow timing (consultation versus simulation versus first RT, respectively): one-on-one teaching: 88.5% versus 49.4% versus 56.3%, P < .01, and paper handouts: 69.0% versus 28.7% versus 16.1%, P < .01. Identified challenges for PE delivery included limited time, administrative barriers to the development or implementation of new materials or practices, and a lack of customized resources for tailored PE. Effective strategies for PE included utilization of visual diagrams, multimedia, and innovative education techniques to personalize PE delivery/resources for a diverse patient population, as well as fostering interprofessional collaboration to reinforce educational content. CONCLUSIONS: Radiation oncologists and interprofessional RO team members engage in PE, with most using institution-specific materials often available only in English. PE practices differ according to clinical encounter type and RT workflow timing. Increased adoption of multimedia materials and partnerships with patients to tailor PE resources are needed to foster high-quality, patient-centered PE delivery.

Clinical Validation of Human Papilloma Virus Circulating Tumor DNA for Early Detection of Residual Disease After Chemoradiation in Cervical Cancer.

PURPOSE: Most cervical cancers are caused by human papilloma virus (HPV), and HPV circulating tumor DNA (ctDNA) may identify patients at highest risk of relapse. Our pilot study using digital polymerase chain reaction (dPCR) showed that detectable HPV ctDNA at the end of chemoradiation (CRT) is associated with inferior progression-free survival (PFS) and that a next-generation sequencing approach (HPV-seq) may outperform dPCR. We aimed to prospectively validate HPV ctDNA as a tool for early detection of residual disease. METHODS: This prospective, multicenter validation study accrued patients with stage IB-IVA cervical cancer treated with CRT between 2017 and 2022. Participants underwent phlebotomy at baseline, end of CRT, 4-6 weeks post-CRT, and 3 months post-CRT for HPV ctDNA levels. Plasma HPV genotype-specific DNA levels were quantified using both dPCR and HPV-seq. The primary end point was 2-year PFS. RESULTS: With a median follow-up of 2.2 (range, 0.5-5.5) years, there were 24 PFS events among the 70 patients with HPV+ cervical cancer. Patients with detectable HPV ctDNA on dPCR at the end of CRT, 4-6 weeks post-CRT, and 3 months post-CRT had significantly worse 2-year PFS compared with those with undetectable HPV ctDNA (77% v 51%, P = .03; 82% v 15%, P < .001; and 82% v 24%, P < .001, respectively); the median lead time to recurrence was 5.9 months. HPV-seq showed similar results as dPCR. On multivariable analyses, detectable HPV ctDNA on dPCR and HPV-seq remained independently associated with inferior PFS. CONCLUSION: Persistent HPV ctDNA after CRT is independently associated with inferior PFS. HPV ctDNA testing can identify, as early as at the end of CRT, patients at high risk of recurrence for future treatment intensification trials.

Artificial intelligence applications in brachytherapy: A literature review.

PURPOSE: Artificial intelligence (AI) has the potential to simplify and optimize various steps of the brachytherapy workflow, and this literature review aims to provide an overview of the work done in this field. METHODS AND MATERIALS: We conducted a literature search in June 2022 on PubMed, Embase, and Cochrane for papers that proposed AI applications in brachytherapy. RESULTS: A total of 80 papers satisfied inclusion/exclusion criteria. These papers were categorized as follows: segmentation (24), registration and image processing (6), preplanning (13), dose prediction and treatment planning (11), applicator/catheter/needle reconstruction (16), and quality assurance (10). AI techniques ranged from classical models such as support vector machines and decision tree-based learning to newer techniques such as U-Net and deep reinforcement learning, and were applied to facilitate small steps of a process (e.g., optimizing applicator selection) or even automate the entire step of the workflow (e.g., end-to-end preplanning). Many of these algorithms demonstrated human-level performance and offer significant improvements in speed. CONCLUSIONS: AI has potential to augment, automate, and/or accelerate many steps of the brachytherapy workflow. We recommend that future studies adhere to standard reporting guidelines. We also stress the importance of using larger sample sizes and reporting results using clinically interpretable measures.

The Impact of Parent and Family Caregiver Roles Among Canadian Radiation Oncologists.

PURPOSE: Working parents, and a rising number of adults delivering care for aging relatives, experience numerous challenges in their personal, family, professional, and financial lives owing to multiple responsibilities. This study describes the experiences of Canadian radiation oncologist (RO) parents and family caregivers, reporting challenges that may exist in providing family care with clinical and academic work commitments. METHODS AND MATERIALS: Canadian ROs, via RO heads of departments in cancer centers across Canada, and physician members of the Canadian Association of Radiation Oncology were invited to participate in an anonymous online survey between November 2021 and January 2022. The survey focused on demographics, experiences of pregnancy and leave, parenting and adult caregiving responsibilities, and self-care. RESULTS: A total of 103 staff ROs (38%) completed the survey and 78 (75.7%) identified as having a parental (76 [89.7%]) and/or other family caregiver (8 [10.3%]) role; 41% were female and 59% were male, with no difference between genders in the number of children (median, 2; interquartile range, 1-3; P = .17). More female respondents took parental leave for their first child compared with male respondents (mean, 29 vs 6 weeks; P < .001). Of male respondents who started caring for their first child during residency, 27% took parental leave, compared with 77% who started caring for their first child as a staff member (P = .003). The majority of respondents described "always/usually" having collegial support for each pregnancy and parental leave. Both genders described parental responsibilities as negatively affecting attendance at conferences (male, 65%; female, 77%; P = .31) and early or late work-related meetings (male, 76%; female, 79%; P = 1.0). More female respondents described parental responsibilities as negatively affecting their career (50% vs 29%; P = .085). Of female respondents, 52% (vs 26% of male respondents; P = .044) identified a physician mentor or positive role model around parenting issues. CONCLUSIONS: Parental and other family caregiving responsibilities are not gender unique in Canadian ROs, but competing work and family roles may affect genders differently.

Comparing dosimetry of locally advanced cervical cancer patients treated with 3 versus 4 fractions of MRI-guided brachytherapy.

PURPOSE: To demonstrate the feasibility of treating cervical cancer patients with MRI-guided brachytherapy (MRgBT) using 24 Gy in 3 fractions (F) versus a standard, more resource-intensive regimen of 28 Gy in 4F, and its ability to meet EMBRACE II planning aims. METHODS AND MATERIALS: A retrospective review of 224 patients with FIGO Stage IB-IVA cervical cancer treated with 28 Gy/4F (n = 91) and 24 Gy/3F (n = 133) MRgBT between 2016-2021 was conducted. Multivariable linear regression models were fitted to compare dosimetric parameters between the two groups, adjusting for CTVHR and T stage. RESULTS: Most patients had squamous cell carcinoma, T2b disease, and were treated with intracavitary applicator plus interstitial needles (96%). The 28 Gy/4F group had higher CTVHR (median 28 vs. 26 cm3, p = 0.04), CTVIR D98% (mean 65.5 vs. 64.5 Gy, p = 0.03), rectum D2cm3 (mean 61.7 vs. 59.2 Gy, p = 0.04) and bladder D2cm3 (81.3 vs. 77.9 Gy, p = 0.03). There were no significant differences in the proportion of patients meeting the EMBRACE II OAR dose constraints and planning aims, except fewer patients treated with 28 Gy/4F met rectum D2cm3 < 65 Gy (73 vs. 85%, p = 0.027) and ICRU rectovaginal point < 65 Gy (65 vs. 84%, p = 0.005). CONCLUSIONS: Cervical cancer patients treated with 24 Gy/3F MRgBT had comparable target doses and lower OAR doses compared to those treated with 28 Gy/4F. A less-resource intense fractionation schedule of 24 Gy/3F is an alternative to 28 Gy/4F in cervix MRgBT.

Treatment of cervical cancer: overcoming challenges in access to brachytherapy.

INTRODUCTION: Brachytherapy is an essential component of the cervical cancer treatment paradigm as it contributes to improved clinical outcomes and overall survival. Yet brachytherapy remains globally underutilized, with disparities in access at both national and international levels. AREAS COVERED: The review explores current brachytherapy utilization practices and efforts being undertaken to address barriers to implementation in low-, middle-, and high-income countries, and how these efforts are projected to impact future brachytherapy access. The content presented is based on a review of published literature and the authors' collective clinical experiences. EXPERT OPINION: There exists a tremendous opportunity to expand access to essential brachytherapy services for women with cervical cancer. Many national and international brachytherapy efforts exist; yet it remains imperative that such focused efforts continue to grow and provide further access to this critical treatment modality for women in need worldwide.