A new wave of leaders: Early evaluation of the interdisciplinary Foundations of Leadership in Radiation Oncology (FLiRO) program.

Purpose: Effective leadership across all areas of radiation oncology (RO) is vital to fully realise the benefits of radiation therapy in cancer care. We report outcomes of a novel interdisciplinary leadership program designed for RO professionals under a global joint society initiative. Methods: The Foundations of Leadership in RO (FLiRO) program was designed for aspiring RO leaders. Initially delivered in a blended learning format, it was adapted to fully virtual in 2021. It comprised a webinar tutorial, on-line modules and homework followed by 'live' in-person/virtual workshops over an approximately 6-week period. Topics included personal awareness, effective teamwork, quality improvement skills, leading change and conflict management. An immediate post-program online survey was performed using Likert scales to measure self-reported educational value, interaction with others and the likely application of learning to practice. Open comments were invited. Results: 170 participants from 36 countries and 6 continents took part from 2018 to 2021 (99 doctors, 36 physicists, 32 radiation therapists/RTTs and 3 others). 141 (83%) participants responded to the post-program survey. Average weightings for responders' views on whether pre-determined learning objectives were met ranged from 4.30 to 4.61 on a 5-point scale (1 = 'not met at all' and 5 = completely met). For the question addressing potential value of learning for application to their workplace, 124 of 130 (95%) of responders indicated that FLIRO would be 'very useful' or 'extremely useful'. Conclusion: Initial evaluation of the FLiRO program supports its continuation and expansion with ongoing evolution based on emerging evidence around leadership education and participant feedback.

Defining a Leader Role curriculum for radiation oncology: A global Delphi consensus study.

BACKGROUND AND PURPOSE: The need for radiation oncologists and other radiation oncology (RO) professionals to lead quality improvement activities and contribute to shaping the future of our specialty is self-evident. Leadership knowledge, skills and behaviours, like other competencies, can be learned (Blumenthal et al., 2012). The objective of this study was to define a globally applicable competency set specific to radiation oncology for the CanMEDS Leader Role (Frank et al., 2015). METHODS: A modified Delphi consensus process delivering two rounds of on-line surveys was used. Participants included trainees, radiation/clinical oncologists and other RO team members (radiation therapists, physicists, and nurses), professional educators and patients. RESULTS: 72 of 95 (76%) invitees from nine countries completed the Round 1 (R1) survey. Of the 72 respondents to RI, 70 completed Round 2 (R2) (97%). In R1, 35 items were deemed for 'inclusion' and 21 for 'exclusion', leaving 41 'undetermined'. After review of items, informed by participant comments, 14 competencies from the 'inclusion' group went into the final curriculum; 12 from the 'undetermined' group went to R2. In R2, 6 items reached consensus for inclusion. CONCLUSION: This process resulted in 20 RO Leader Role competencies with apparent global applicability. This is the first step towards developing learning, teaching and assessment tools for this important area of training.

Radiation Oncology Training Program Curriculum developments in Australia and New Zealand: Design, implementation and evaluation--What next?

INTRODUCTION: The Australian and New Zealand Radiation Oncology Training Program has undergone major changes to align with pedagogical principles and best-evidence practice. The curriculum was designed around the Canadian Medical Education Directives for Specialists framework and involved structural programme changes and new in-training assessment. This paper summarises the work of programme design and implementation and presents key findings from an evaluation of the revised programme. METHODS: An independent team conducted the evaluation during the last year of the first 5-year curriculum cycle. Opinions were sought from trainees, supervisors and directors of training (DoTs) through online surveys, focused interviews and group consultations. One hundred nineteen participated in surveys; 211 participated in consultations. All training networks were represented. RESULTS: The new curriculum was viewed favourably by most participants with over 90% responding that it 'provided direction in attaining competencies'. Most (87/107; 81%) said it 'promotes regular, productive interaction between trainees and supervisors'. Adequacy of feedback to trainees was rated as only 'average' by trainees/trainers in one-third of cases. Consultations revealed this was more common where trainers were less familiar with curriculum tools. Half of DoTs/supervisors felt better supported. Nearly two-third of all responders (58/92; 63%) stated that clinical service requirements could be met during training; 17/92 (18.5%) felt otherwise. When asked about 'work-readiness', 59/90 (66%) respondents, including trainees, felt this was improved. CONCLUSION: Findings suggest that the 'new' curriculum has achieved many of its aims, and implementation has largely been successful. Outcomes focus future work on better supporting trainers in using curriculum tools and providing useful feedback to trainees.

15-Year Experience of 18F-FDG PET Imaging in Response Assessment and Restaging After Definitive Treatment of Merkel Cell Carcinoma.

UNLABELLED: The objective of this study was to evaluate the utility of (18)F-FDG PET in restaging and response assessment of patients who underwent definitive treatment for Merkel cell carcinoma (MCC). METHODS: A retrospective review of patients undergoing (18)F-FDG PET imaging for MCC between January 1997 and October 2010 at the Peter MacCallum Cancer Centre with follow-up until February 2015 was performed. Data analysis was performed on patients who were treated definitively and underwent post-treatment PET imaging performed either as a restaging scan for ongoing monitoring, suspicion of recurrence, or assessment for suitability of salvage treatment or as response assessment within 1-6 mo of treatment. Management plans were recorded prospectively before (18)F-FDG PET imaging and compared with post-imaging management to assess the impact of the study as per our previously defined categories: high if the primary treatment modality or intent was changed and medium if the radiotherapy technique or dose was altered. In total, 62 patients were included in the analysis. Thirty-six patients underwent 53 restaging scans, and 37 patients underwent a response-assessment scan. The median follow-up of patients in the restaging group was 5.3 y (95% confidence interval [CI], 4.6-9.4), and it was 5.7 y (95% CI, 4.3-10.8) in the response-assessment group. RESULTS: Restaging (18)F-FDG PET scans had a high impact in 24 of 53 cases (45%) and a medium impact in 6 of 53 cases (11%). In the response-assessment group, 24 of 37 patients had a complete metabolic response (CMR). Patients without a CMR had a 15% 1-y overall survival (95% CI, 0.04-0.55). Those with a CMR had an 88% 2-y overall survival (95% CI, 0.75-1.00) and a 68% 5-y overall survival (95% CI, 0.49-0.95). The presence of a CMR (P < 0.001) and nodal involvement (P = 0.016) were statistically significant prognostic factors for overall survival. CONCLUSION: (18)F-FDG PET imaging had a high impact on restaging after definitive treatment in patients with MCC. Metabolic response was significantly associated with overall survival. (18)F-FDG PET may play an important role in ongoing post-treatment management of MCC.

18F-FDG PET provides high-impact and powerful prognostic stratification in the staging of Merkel cell carcinoma: a 15-year institutional experience.

UNLABELLED: Merkel cell carcinoma (MCC) is a rare but aggressive skin cancer with limited evidence on the role of PET scanning. The primary aim of this study was to assess the impact of (18)F-FDG PET in the staging and management of MCC. METHODS: A single-institution review using clinical outcome data collected until February 2012 was performed of patients with MCC who underwent staging PET scanning between January 1997 and October 2010. Management plans were recorded prospectively at the time of the PET request, and follow-up outcomes were recorded retrospectively. The clinical impact of PET was scored using our previously published criteria: "high" if the PET scan changed the primary treatment modality or intent; "medium" if the treatment modality was unchanged but the radiation therapy technique or dose was altered. The primary objective was to test the hypothesis that the true proportion of patients who have a high- or medium-impact scan would be greater than 25%. RESULTS: The median follow-up of 102 consecutive patients was 4.8 y. The results of staging PET had an impact on patient management in 37% of patients (P < 0.003). High- and medium-impact scans were recorded for 22% and 15% of patients, respectively. PET staging results differed from conventional staging results in 22% of patients, with PET upstaging 17% and downstaging 5%. The 3- and 5-y overall survival was 60% (95% confidence interval, 50%-71%) and 51% (95% confidence interval, 41%-64%), respectively. In stratification by PET-defined stage, the 5-y overall survival was 67% for patients with stage I/II disease but only 31% for patients with stage III disease (log-rank P < 0.001). The 5-y cumulative incidence of locoregional failure, distant failure, and death was 16.6%, 22.3% and 14.3%, respectively. On multivariate analysis, only PET stage (P < 0.001) and primary treatment modality (P = 0.050) were significantly associated with overall survival. The primary treatment modality was not associated with progression-free survival when stratification was by tumor stage. CONCLUSION: The use of (18)F-FDG PET scans had a great impact on patients and may play an important role in the prognostic stratification and treatment of this disease.

Treatment of regional cutaneous nodular metastases from melanoma using high-dose rate mould brachytherapy.

INTRODUCTION: The involvement of a wide body surface area by regional cutaneous nodular metastases (RCNM) from melanoma poses a significant therapeutic challenge. We report our experience from Waikato Hospital, Hamilton, New Zealand in successfully treating this condition with high-dose rate (HDR) surface mould brachytherapy (BT). METHODS: We analysed six patients who had surgery and then developed RCNM, which was treated in our department by HDR mould BT using Iridium 192. Five out of six patients were treated with a dose of 30 Gy in five fractions to wide field with a further 6 Gy boost to tumour nodules. Our first patient received a higher dose of 36 Gy in six fractions followed by 6 Gy boost to tumour nodules. RESULTS: All patients experienced a complete response (CR). Median follow up was 23 months and side effects were minimal, only Radiation Therapy Oncology Group (RTOG) grade I/II early and late toxicity. To date, no in-field recurrence has been observed. Two patients died from metastatic disease at 33 and 34 months of follow up. CONCLUSION: There was a CR in all cases without in-field recurrence. To our knowledge, this is the first reported experience in treating skin melanoma with a BT surface mould. We recommend that BT surface mould should be considered when treating patients with RCNM.

Merkel cell carcinoma: 27-year experience at the Peter MacCallum Cancer Centre.

PURPOSE: To retrospectively evaluate the treatment outcome of patients with Merkel cell carcinoma after local and/or regional treatment. METHODS AND MATERIALS: Patients presenting to our center between January 1980 and July 2006 with Merkel cell carcinoma and without distant metastases were reviewed. The primary endpoint was locoregional control. Secondary endpoints were distant recurrence, survival and treatment toxicity. RESULTS: A total of 176 patients were identified. The median age was 79 years. The median follow-up was 2.2 years for all patients and 3.9 years for those alive at the last follow-up visit. The most common primary site was the head and neck (56%), and 62 patients(35%) had regional disease at presentation. The initial surgery to the primary tumor involved (wide) local excision in 140 patients and biopsy only in 28 patients (8 patients had no identifiable primary tumor); 33 patients underwent nodal surgery. Of the 176 patients, 165 (94%) underwent radiotherapy (RT) and 29 of them also underwent concurrent chemotherapy. The median radiation dose was 50 Gy (range, 18-60). Locoregional recurrence developed in 33 patients(19%), with a median interval to recurrence of 8 months. Distant metastases developed in 43 patients(24%). Age, primary tumor size, and RT (no RT vs. < 45 Gy vs. ≥ 45 Gy) were predictive of locoregional control on univariate analysis. However, only RT remained significant on multivariate analysis. The estimated 5-year actuarial rate for locoregional control, progression-free survival, and overall survival was 76%, 60%, and 45%, respectively. CONCLUSION: The locoregional control rate for Merkel cell carcinoma in our study was comparable to those from other series using combined modality treatment with RT an integral part of treatment.

Use of the keystone island flap for advanced head and neck cancer in the elderly--a principle of amelioration.

Traditional management strategies of advanced head and neck cancer in the elderly include palliation and radical resection with microsurgical reconstruction. The keystone flap approach is an alternate reconstructive technique with a range of benefits for the aging population. This publication presents a series of elderly patients with head and neck cancer who underwent resection and reconstruction using the keystone flap principles. The aim is to demonstrate the value of this reconstructive technique in the various anatomical regions of the head and neck. Various operative sequences are accompanied by illustrations and discussions of the underlying principles.

Waiting for radiation therapy: does it matter?

The aim of this study was to determine the direct and indirect effects of prolonged waiting times for radiation therapy. We used the Medline, CancerNet and EMBASE databases to search the international research using the keywords radiotherapy, waiting times and delay. The negative effects of prolonged waiting times for radiation therapy can be broken down into direct and indirect effects. Direct effects include tumour control factors and patient factors. Indirect effects include changes in referral patterns and change in management of tumours. The precise effects of prolonged waiting times for radiation therapy are difficult to define. Evidence exists for some tumour sites, such as postoperative head and neck, small-cell lung cancer and high-grade cerebral gliomas, that tumour control might be adversely affected. The effect on other tumour sites is less established. Patient factors are likely to be consistent across all tumour types and indirect effects are hard to quantify.