Radiation oncologist perceptions of therapeutic cannabis use among cancer patients.

INTRODUCTION: Cancer patients are increasingly incorporating medical marijuana into the management of treatment-related side effects. Currently however, data is limited regarding the risks and benefits of therapeutic cannabis for cancer patients. We sought to characterize radiation oncologists' practices and opinions regarding therapeutic cannabis via a nationwide survey. MATERIALS AND METHODS: An anonymous survey was distributed via email to 873 radiation oncologists in the American Society for Radiation Oncology member database. Radiation oncologists were asked their opinions and practices regarding the use of therapeutic cannabis for their patients. Bivariate analyses of potential predictors for responses were conducted using standard statistical techniques. RESULTS: One hundred seven radiation oncologists completed the survey. According to the survey, 36% of respondents would recommend therapeutic cannabis to their patients to mitigate treatment toxicity. Physicians practicing in states where medical marijuana is legal were more likely to recommend it compared to physicians working in states that have not legalized medical marijuana (OR = 3.79, 1.19-12.1, p = 0.01). Seventy-one percent of respondents reported therapeutic cannabis as being effective at least some of the time for managing treatment-related toxicities. Fifty-eight percent of physicians reported lacking sufficient knowledge to advise patients regarding therapeutic cannabis, while 86% of respondents were interested in learning more about therapeutic cannabis for cancer patients. CONCLUSIONS: Although a majority of radiation oncologists believe there are benefits to therapeutic cannabis, many are hesitant to recommend for or against its use. Radiation oncologists appear to be interested in learning more about how therapeutic cannabis may play a role in their patients' care.

Comfort Level of US Radiation Oncology Graduates: Assessment of Transition to Independent Clinical Practice.

Radiation training programs are designed to prepare graduates for independent practice, with metrics in place to assess appropriateness of clinical decision-making. Here, we investigated the self-assessed preparedness of US graduates during the transition to independent practice.An anonymous, Internet-based survey was distributed to recent graduates of radiation oncology residencies (2016-2017). A Likert scale was used to assess comfort with various aspects of practice, as well as "time" to development of comfort in independent practice.Responses were obtained from 70/210 (33%), the majority reported training in programs with 5-8 residents (n = 35). Most (77%) reported designing between 500 and 900 treatment plans during training (n = 54). Only 41% of respondents reported the opportunity to review treatment plans and make decisions about safety/adequacy without attending input > 50% of the time (n = 29). Thirty percent of residents reported being responsible for seeing/managing on-treatment visits (OTVs) ≤ 75% of the time. Aspects with which practitioners reported the least comfort were understanding of billing/application to practice (2.43, IQR 2-3), orthovoltage (superficial radiation) setup and field design (2.57, IQR 1-4), and planning/delivery of prostate implants (2.82, IQR 2-4). Increased mean comfort levels were reported by those designing > 700 treatment plans in training as well as those reporting an opportunity to evaluate plans and make clinical decisions prior to attending input > 50% of the time during residency. Comfort with the delivery of stereotactic body radiation (SBRT) correlated with caseload for liver, spine, prostate, and CNS disease sites but not lung.Variations in training experiences exist across institutions. Here, a lower than expected number of residents reported seeing/managing OTVs as well as reviewing treatment plans prior to attending input during training. Overall comfort was correlated with case volume and opportunities to independently review treatment plans prior to attending input. These data highlight areas of opportunity for improving resident education with implications for ease of transition to independent clinical practice.

Student Perspectives on Oncology Curricula at United States Medical Schools.

Delivering a cohesive oncology curriculum to medical students is challenging due to oncology's multidisciplinary nature, predominantly outpatient clinical setting, and lack of data describing effective approaches to teaching it. We sought to better characterize approaches to oncology education at US medical schools by surveying third and fourth year medical students who serve on their institution's curriculum committee. We received responses from students at 19 schools (15.2% response rate). Key findings included the following: (1) an under-emphasis of cancer in the curriculum relative to other common diseases; (2) imbalanced involvement of different clinical subspecialists as educators; (3) infrequent requirements for students to rotate through non-surgical oncologic clerkships; and (4) students are less confident in their knowledge of cancer treatment compared to basic science/natural history or workup/diagnosis. Based on these findings, we provide several recommendations to achieve robust multidisciplinary curriculum design and implementation that better balances the clinical and classroom aspects of oncology education.

Readability of Online Patient Educational Resources Found on NCI-Designated Cancer Center Web Sites.

BACKGROUND: The NIH and Department of Health & Human Services recommend online patient information (OPI) be written at a sixth grade level. We used a panel of readability analyses to assess OPI from NCI-Designated Cancer Center (NCIDCC) Web sites. METHODS: Cancer.gov was used to identify 68 NCIDCC Web sites from which we collected both general OPI and OPI specific to breast, prostate, lung, and colon cancers. This text was analyzed by 10 commonly used readability tests: the New Dale-Chall Readability Formula, Flesch Reading Ease scale, Flesch-Kinaid Grade Level, FORCAST scale, Fry Readability Graph, Simple Measure of Gobbledygook test, Gunning Frequency of Gobbledygook index, New Fog Count, Raygor Readability Estimate Graph, and Coleman-Liau Index. We tested the hypothesis that the readability of NCIDCC OPI was written at the sixth grade level. Secondary analyses were performed to compare readability of OPI between comprehensive and noncomprehensive centers, by region, and to OPI produced by the American Cancer Society (ACS). RESULTS: A mean of 30,507 words from 40 comprehensive and 18 noncomprehensive NCIDCCs was analyzed (7 nonclinical and 3 without appropriate OPI were excluded). Using a composite grade level score, the mean readability score of 12.46 (ie, college level: 95% CI, 12.13-12.79) was significantly greater than the target grade level of 6 (middle-school: P<.001). No difference between comprehensive and noncomprehensive centers was identified. Regional differences were identified in 4 of the 10 readability metrics (P<.05). ACS OPI provides easier language, at the seventh to ninth grade level, across all tests (P<.01). CONCLUSIONS: OPI from NCIDCC Web sites is more complex than recommended for the average patient.

Development of a United States Radiation Oncology Curricular Framework: A Stakeholder Delphi Consensus.

PURPOSE: A United States (US) radiation oncology curriculum, developed using best practices for curriculum inquiry, is needed to guide residency education and qualifying examinations. Competency-based training, including entrustable professional activities (EPAs), provides an outcomes-based approach to modern graduate medical education. This study aimed to define US radiation oncology EPAs and curricular content domains using a deliberative process with input from multiple stakeholder groups. METHODS AND MATERIALS: The Radiation Oncology Education Collaborative Study Group Core Curriculum Project Leadership Committee developed initial content domains and EPAs. Following recruitment of stakeholders, a Delphi process was used to achieve consensus. In the first round, content domains and EPAs were reviewed for inclusion and exclusion, clarity, time allocation (content domains), and level of training (EPAs). Participants submitted additional content domains and EPAs for consideration. Any content domains or EPAs 1 standard deviation below the median for inclusion and exclusion underwent Leadership Committee review. All participants completing the first Delphi round were invited to the second round. Percent curriculum time allocated for content domains and a single subdomain were finalized. New EPAs or EPAs undergoing major revisions were reviewed. RESULTS: A total of 186 participants representing diverse stakeholder groups participated. One hundred fourteen completed the first Delphi round (61.3%). Of 114 invited, 77 participants completed the second round of the Delphi process (67.5%). Overall, 6 of 9 content domains met consensus, 1 content domain was removed, and 2 content domains were combined. Four subdomains of a single content domain were reviewed and met consensus. Consensus on percent time allocated per content domain and subdomain was reached. Of 55 initial EPAs, 52 final EPAs met consensus. CONCLUSIONS: Deliberative curriculum inquiry was successfully used to develop a consensus on US radiation oncology content domains and EPAs. These data can guide the allocation of educational time in training programs, help inform weighting for qualifying examinations, and help guide clinical training and resident assessment.

Effect of COVID-19 on Gynecologic Oncology Care: A Survey of Practicing Gynecologic Radiation Oncologists in the United States.

Purpose: The COVID-19 pandemic has placed demands and limitations on the delivery of health care. We sought to assess the effect of COVID-19 on the delivery of gynecologic oncologic care from the perspective of practicing radiation oncologists in the United States. Methods and Materials: An anonymous online survey was created and distributed to preidentified radiation oncologists in the United States with clinical expertise in the management of gynecologic patients. The survey consisted of demographic questions followed by directed questions to assess specific patterns of care related to the COVID-19 pandemic. Results: A total of 47 of 96 invited radiation oncologists responded to the survey for a response rate of 49%. Fifty-six percent of respondents reported an increase in locally advanced cervical cancer with no similar increase for endometrial, vulvar, or vaginal patients. Most respondents (66%) reported a pause in surgical management, with a duration of 1 to 3 months being most common (61%). There was a reported increased use of shorter brachytherapy regimens during the pandemic. Most providers (61%) reported caring for at least 1 patient with a positive COVID-19 test. A pause or delay in treatment due to COVID-19 positivity was reported by 45% of respondents, with 55% reporting that patients chose to delay their own care because of COVID-19-related concerns. Total treatment times >8 weeks for patients with cervical cancer were observed by 33% of respondents, but occurred in >25% of patients. Conclusions: Data from this prospectively collected anonymous survey of practice patterns among radiation oncologists reveal that the COVID-19 pandemic resulted in delays initiating care, truncated brachytherapy treatment courses, and a reported increase in locally advanced cervical cancer cases at presentation. These data can be used as a means of self-assessment to ensure appropriate decision making for gynecologic patients during the endemic phase of COVID-19.

Attitudes and access to resources and strategies to improve quality of radiotherapy among US radiation oncologists: A mixed methods study.

INTRODUCTION: We aimed to assess contouring-related practices among US radiation oncologists and explore how access to and use of resources and quality improvement strategies vary based on individual- and organization-level factors. METHODS: We conducted a mixed methods study with a sequential explanatory design. Surveys were emailed to a random 10% sample of practicing US radiation oncologists. Participating physicians were invited to a semi-structured interview. Kruskal-Wallis and Wilcoxon rank-sum tests and a multivariable regression model were used to evaluate associations. Interview data were coded using thematic content analysis. RESULTS: Survey overall response rate was 24%, and subsequent completion rate was 97%. Contouring-related questions arise in ≥50% of clinical cases among 73% of respondents. Resources accessed first include published atlases (75%) followed by consulting another radiation oncologist (60%). Generalists access consensus guidelines more often than disease-site specialists (P = 0.04), while eContour.org is more often used by generalists (OR 4.3, 95% CI 1.2-14.8) and younger physicians (OR 1.33 for each 5-year increase, 95% CI 1.08-1.67). Common physician-reported barriers to optimizing contour quality are time constraints (58%) and lack of access to disease-site specialists (21%). Forty percent (40%, n = 14) of physicians without access to disease-site specialists indicated it could facilitate the adoption of new treatments. Almost all (97%) respondents have formal peer review, but only 43% have contour-specific review, which is more common in academic centres (P = 0.02). CONCLUSION: Potential opportunities to improve radiation contour quality include improved access to disease-site specialists and contour-specific peer review. Physician time must be considered when designing new strategies.

Prospective Study of PET/MRI Tumor Response During Chemoradiotherapy for Patients With Low-risk and Intermediate-risk p16-positive Oropharynx Cancer.

OBJECTIVE: The objective of this study was to examine tumor response with positron emission tomography (PET)/magnetic resonance imaging (MRI) during chemoradiotherapy as a predictor of outcome in patients with p16-positive oropharynx cancer. MATERIALS AND METHODS: Patients with p16-positive oropharynx cancer were treated with chemoradiotherapy. Low-risk (LR) disease was defined as T1-T3 and N0-2b and ≤10 pack-years and intermediate-risk (IR) disease as T4 or N2c-3 or >10 pack-years. Patients underwent a PET/MRI scan pretreatment and at fraction 10. Change in value of imaging means were analyzed by analysis of variance. K-means clustering with Euclidean distance functions were used for patient clustering. Silhouette width was used to determine the optimal number of clusters. Linear regression was performed on all radiographic metrics using patient and disease characteristics. RESULTS: Twenty-four patients were enrolled with 7 LR and 11 IR patients available for analysis. Pretreatment imaging characteristics between LR and IR patients were similar. Patients with LR disease exhibited a larger reduction in maximum standardized uptake value (SUV) compared with IR patients (P<0.05). Cluster analysis defined 2 cohorts that exhibited a similar intratreatment response. Cluster 1 contained 7 of 7 LR patients and 8 of 11 IR patients. Cluster 2 contained 3 of 11 IR patients. Cluster 2 exhibited significant differences compared with cluster 1 in the change in primary tumor peak SUV and largest lymph node median SUV. CONCLUSIONS: We identified that IR p16-positive oropharynx cancers exhibit heterogeneity in their PET/MRI response to chemoradiotherapy. These data support further study of intratreatment imaging response as a potential mechanism to identify patients with IR oropharynx cancer suitable for treatment deintensification.

Why an Increasing Number of Unmatched Residency Positions in Radiation Oncology? A Survey of Fourth-Year Medical Students.

PURPOSE: The number of US fourth-year medical students applying to radiation oncology has decreased during the past few years. We conducted a survey of fourth-year medical students to examine factors that may be influencing the decision to pursue radiation oncology. METHODS AND MATERIALS: An anonymous online survey was sent to medical students at 9 participating US medical schools. RESULTS: A total of 232 medical students completed the survey. Of the 153 students who stated they were never interested in radiation oncology, 77 (50%) reported never having been exposed to the specialty as their reason for not pursuing radiation oncology. The job market was the most commonly cited factor among students who said they were once interested in but ultimately chose not to pursue radiation oncology. Conversely, the recent low pass rates for board examinations and a perception of a lack of diversity within radiation oncology had the least influence. CONCLUSIONS: Despite discussion of potential measures to address this disquieting trend, there have been minimal formal attempts to characterize and address potential causes of a decreasing interest in radiation oncology. This study's data are consistent with previous research regarding the trend of decreased medical student interest in radiation oncology and may be used as part of ongoing introspective assessment to inform future change within radiation oncology.

Differential CpG island methylation of murine adenine nucleotide translocase genes.

Adenine nucleotide translocase (Ant) mediates the exchange of ADP and ATP across the inner mitochondrial membrane in eukaryotes. Mice possess three distinct but highly homologous Ant isoforms, encoded by independent genes, whose transcription depends upon tissue type. Ant1 is expressed selectively in heart and skeletal muscles, Ant2 is ubiquitously expressed in most tissues but lower in skeletal muscle and testis, while Ant4 is exclusively expressed in the testis. Of interest, each of these Ant genes contains CpG islands in their proximal promoter regions. We investigated the methylation status of the three Ant genes in various tissues with active and inactive transcription. In contrast to the Ant4 gene in which CpG island methylation is essential for gene repression, the CpG islands of Ant1 and Ant2 are hypomethylated regardless of the gene expression status throughout the tissues of male mice. Despite the tissue specific expression profile of Ant1, CpG methylation is unlikely involved in the regulation of the gene. Consistent with these findings, addition of a CpG-demethylating agent, 5-aza-2'-deoxycitidine, to fibroblasts increased the expression of Ant4 but not Ant1 or Ant2 genes. This study provides insight regarding the differential regulation of Ant isoforms in mammals, whereby both the Ant1 and Ant2 genes are capable of expression, but the Ant4 gene is completely repressed throughout somatic tissues. To the best of our knowledge, this is a first example to clearly demonstrate a differential usage of CpG island methylation within a family of genes.

Nonclinical Time in U.S. Radiation Oncology Residency Programs: Number of Months and Resident Opinion of Value.

PURPOSE: Data regarding the amount and use of nonclinical time (NCT) in radiation oncology residency programs are scarce. We surveyed every U.S. radiation oncology residency program to obtain benchmark data to inform decisions about optimal program structure. METHODS AND MATERIALS: An anonymous, web-based survey was distributed to postgraduate year 5 residents at Accreditation Council for Graduate Medical Education-accredited radiation oncology training programs. The survey included 33 yes/no, Likert-scale, and free-response questions. Program data were analyzed for all programs, including those considered "top 10" per Doximity and those "not top 10." Likert-scale responses were dichotomized as "not as satisfied" (1, 2, 3) or "very satisfied" (4, 5). RESULTS: One hundred twenty-six residents (69%) completed the survey. Program-specific data were obtained for 100% of programs (n = 82). Almost all training programs (98%) provide residents with protected NCT. Including programs with no NCT, the median NCT is 10 months in all programs. The median NCT is 12 months in "top 10" programs and 9 months in "not top 10" programs (P < .01). Most programs (68%) reported >6 months of NCT. The proportion of residents wanting more NCT decreased as the amount of NCT increased (73%, 52%, and 19% for 4-6, 7-9, and 10-12 months, respectively; P < .01). The proportion of residents who were very satisfied with NCT flexibility increased with more NCT (64%, 79%, and 94% for 4-6, 7-9, and 10-12 months, respectively; P < .01), as did the proportion of residents who were very satisfied with accomplishments during NCT (35%, 53%, and 72% for 4-6, 7-9, and 10-12 months, respectively; P < .01). When asked whether residents would theoretically give up some NCT to shorten residency, the proportion of residents willing to shorten their residencies decreased as the amount of NCT increased (65%, 47%, and 33% for 4-6, 7-9, and 10-12 months respectively; P = .04). CONCLUSIONS: Programs should maintain an emphasis on NCT and implement measures to ensure meaningful resident experiences.

Adenine nucleotide translocase 4 deficiency leads to early meiotic arrest of murine male germ cells.

Male fertility relies on the highly specialized process of spermatogenesis to continually renew the supply of spermatozoa necessary for reproduction. Central to this unique process is meiosis that is responsible for the production of haploid spermatozoa as well as for generating genetic diversity. During meiosis I, there is a dramatic increase in the number of mitochondria present within the developing spermatocytes, suggesting an increased necessity for ATP production and utilization. Essential for the utilization of ATP is the translocation of ADP and ATP across the inner mitochondrial membrane, which is mediated by the adenine nucleotide translocases (Ant). We recently identified and characterized a novel testis specific Ant, ANT4 (also known as SLC25A31 and Aac4). The generation of Ant4-deficient animals resulted in the severe disruption of the seminiferous epithelium with an apparent spermatocytic arrest of the germ cell population. In the present study utilizing a chromosomal spread technique, we determined that Ant4-deficiency results in an accumulation of leptotene spermatocytes, a decrease in pachytene spermatocytes, and an absence of diplotene spermatocytes, indicating early meiotic arrest. Furthermore, the chromosomes of Ant4-deficient pachytene spermatocyte occasionally demonstrated sustained gammaH2AX association as well as synaptonemal complex protein 1 (SYCP1)/SYCP3 dissociation beyond the sex body. Large ATP supplies from mitochondria may be critical for normal progression of spermatogenesis during early stages of meiotic prophase I, including DNA double-strand break repair and chromosomal synapsis.

Regional Influence of Radiation Oncology Residency Training on Job Securement over Two Time Periods.

Purpose Recent reports have noted conflicting predictions regarding the future of the radiation oncology job market. Residents and practicing radiation oncologists (ROs) report perceptions of an increasingly saturated market. An important factor contributing to the job landscape is the potential geographic maldistribution of ROs in the United States. Given the importance of the evolving job market and appropriate supply and demand for future ROs, this study investigated whether residency training region influences employment region and whether "portability" of residency training has changed over time from 2003-2015. Methods Radiation oncology residency graduates were identified from Association of Residents in Radiation Oncology (ARRO) directories from 2003-2012. This information was cross-referenced with the American Society of Radiation Oncology directory to determine current employment location. The region of residency training and employment were categorized into four regions per the US Census Bureau: Northeast (NE), South (S), Midwest (MW), and West (W). The change in "portability" of residency training over time was determined from the results of an anonymous internet-based survey which provided information on year of graduation and location of first job. "Portability" was defined as the rate at which a trainee in one region could find employment in another region. From the survey, two cohorts were identified: early (graduated from 2003-2006) and late (graduated from 2012-2015). Results Current employment location was available for 817/1168 (70%) residents identified in the ARRO directories from 2003-2012. The percentages of residents who trained in the NE, S, MW, and W were 29%, 28%, 27%, and 15%, respectively. The percentages of residents with current employment in the NE, S, MW, and W were 20%, 34%, 22%, and 24%, respectively. Residents were more likely to remain employed in the region in which they trained (p < 0.05), with 58% having current employment in the region of their training. Residency graduation year and location of first job (in the United States) were available for 139/198 (70%) survey respondents. Portability of residency training did not significantly change from 2003-2012 with 49% of the early cohort securing their first job in the region in which they trained compared to 57% of the late cohort (p = 0.39). Conclusions This study suggests that recent residents are not moving to different geographic regions at an increased rate than previous and that residents are more likely to find employment in the region in which they trained.

The role of radiation therapy in the treatment of Stage II endometrial cancer: A large database study.

PURPOSE: The optimum adjuvant treatment for Stage II endometrial cancer patients is unknown. External beam radiation therapy (EBRT) is often considered the standard of care; however, retrospective series suggest that brachytherapy (BT) alone may be sufficient for selected patients. As randomized data are lacking, we used a large database to explore this question. METHODS AND MATERIALS: The National Cancer Data Base was queried for patients with pathologic International Federation of Gynecology and Obstetrics Stage II disease. Demographic, clinic-pathologic, and treatment details were compared between patients. Multivariable analysis was used to determine factors associated with receiving radiation therapy (RT). To account for imbalances between groups, a matched-pair analysis was completed. RESULTS: Eight thousand one hundred forty patients were included. RT was associated with overall survival (OS), with EBRT (hazard ratio [HR] 0.64), BT (HR 0.47), and combination (HR 0.54) showing increased OS on univariate analysis. Facility, urban location, diagnosis year, hysterectomy type, and chemotherapy did not reach significance. On multivariate analysis, RT was associated with OS, with EBRT (HR 0.69), BT (HR 0.60), and combination (HR 0.54) showing benefit. Using propensity-score matching, RT continued to show improved OS regardless of type: BT (82% vs. 73% 5-year OS) and EBRT (77% vs. 71%). BT as compared to EBRT had equivalent survival (81% vs. 79%, not statistically significant). CONCLUSION: This study of over 8,000 patients demonstrates that adjuvant RT confers a survival benefit in Stage II endometrial cancer and supports the continued use of RT in these patients. BT alone may be reasonable in carefully selected patients.