Multiparametric Magnetic Resonance Imaging- Guided Dose-Escalated Radiation Therapy for Localized Prostate Cancer: A Prospective Phase 2 Trial.

PURPOSE: This trial's purpose was to determine the late toxicity associated with dose escalation to Prostate Imaging Reporting and Data System (PI-RADS) III-V lesions on multiparametric magnetic resonance imaging (MRI) with an image guided combined IMRT-stereotactic body radiation therapy (SBRT) approach in men with localized prostate cancer. METHODS AND MATERIALS: In this phase 2 trial patients with localized prostate cancer with clinical tumor stage T1-T3bN0 and at least one PIRADS III-V lesion were recruited to receive 45 Gy in 25 fractions to the prostate and seminal vesicles followed by a boost of 18 Gy in 3 fractions to the prostate with a simultaneous integrated boost 21 Gy in 3 fractions to the PI-RADS lesion(s). The primary endpoint was the cumulative incidence of late grade ≥3 genitourinary and gastrointestinal toxicity by 18 months (National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0). RESULTS: Overall, 50 patients were enrolled in this study, and 43 patients completed at least 18 months of follow-up. The cumulative incidence of grade 1, 2, and 3 late genitourinary toxicity at 18 months was 18%, 53%, and 2%. One patient was noted to have grade 3 hematuria and needed cystoscopy-guided cauterization. No acute grade 3 gastrointestinal or genitourinary toxicities were observed. The cumulative incidence of grade 1, 2, and 3 late gastrointestinal toxicity at 18 months was 31%, 4%, and 0%, respectively. At a median follow-up of 43.5 months, 3 patients developed biochemical recurrence, each with distant bone metastases without local or nodal recurrence. At 3 years, freedom from biochemical failure rate was 95.3% (95% CI, 89.2%-100%). CONCLUSIONS: Multiparametric MRI-guided dose escalation to PI-RADS III-V lesions using a combined image guided IMRT-SBRT approach is associated with an acceptable risk of late gastrointestinal and genitourinary toxicity. The results should be interpreted with caution considering their single institutional nature, small sample size, and short follow-up and should be validated in a larger study.

American Society of Clinical Oncology 2022 Annual Meeting Highlights for Radiation Oncologists.

The American Society of Clinical Oncology annual meeting is the largest multidisciplinary oncology-focused conference in the world. With almost 5000 total abstracts in 2022, it is difficult for individuals to evaluate all the results. Here we present a review of 28 selected abstracts, across all disease sites, focusing on those of greatest relevance to radiation oncologists.

Prospective 5-Year Analysis of the United States Radiation Oncology Job Market Using the ASTRO Career Center Website.

PURPOSE: We provide 5-year results of prospectively collected radiation oncology (RO) job opportunities and a longitudinal assessment of RO graduate numbers within the United States. METHODS AND MATERIALS: Full-time domestic RO job opportunities were collected and categorized using the American Society for Radiation Oncology (ASTRO) Career Center from July 1, 2016 to June 30, 2021. A chi-square test was used to compare regional job availability by city size and position type. The corresponding number of graduating United States (US) RO residents (2017-2021) was collected. US census and Medicare database resources were used as comparators for population and workforce estimates. Pearson's correlation coefficients were used to examine changes in data over time and a 2-tailed t test was used to assess for statistical significance. RESULTS: Over the 5-year study period, 819 unique job offers were posted, compared with 935 RO graduates (0.88 total jobs-to-graduates ratio). Most jobs were nonacademic (57.6%), located in populated areas >1 million (57.1%; median: 1.57M), with the largest proportion of jobs seen in the South region (32.4%). One-third of academic jobs were located at satellites. Regional differences were seen between academic versus nonacademic job availability (P < .01), with the highest proportion of academic jobs seen in the Northeast (60.3%) and the lowest in the Midwest (34.5%). Differences between regions were also observed for jobs in areas >1 million versus ≤1 million (P < .01), with the most jobs in areas >1 million seen in the West (64.6%) and the least in the South (51.3%). Regional job availability over time did not differ by position type (academic vs nonacademic) or population area size (P = .11 and P = .27, respectively). Annual graduate numbers increased with time (P = .02), with the highest percentage of graduates trained in the South (30.8%). Regional distribution of jobs versus graduates significantly differed (P < .01) with the lowest jobs-to-graduates ratio observed in the Northeast (0.67) and highest ratio in the West (1.07). Regional RO workforce estimates based on the 4336 radiation oncologists who were Medicare providers in 2020 were compared with total jobs and graduates by region with no difference observed between the distributions of the workforce and jobs (P = .39), but comparisons between the workforce and graduates were proportionally different (P < .01). The number of total jobs (vs graduates) per 10 million population in the Northeast, South, Midwest, and West were 30.2 (45.1), 21.0 (22.7), 30.6 (33.4), and 22.6 (21.2), respectively. CONCLUSIONS: This multiyear quantitative assessment of the RO job market and graduates identified fewer job opportunities than graduates overall in most regions, most notably in the Northeast. Regional differences were seen between available job type (academic vs nonacademic) and population size (>1 million vs ≤1 million). The findings are worrisome for trainee oversupply and geographic maldistribution. The number and distribution of RO trainees and residency programs across the US should be evaluated to minimize job market imbalance for future graduates, promote workforce stability, and continue to meet the future societal needs of patients with cancer.

Unsealed Source: Scope of Practice for Radiopharmaceuticals Among United States Radiation Oncologists.

Purpose: Our purpose was to determine the utilization of and barriers to implementation of radiopharmaceutical therapy (RPT) among U.S. radiation oncologists. Methods and Materials: An anonymous, voluntary 21-item survey directed toward attending radiation oncologists was distributed via social media platforms (Twitter, LinkedIn, Facebook, Student Doctor Network). Questions assessed practice characteristics, specific RPT prescribing patterns, RPT prescribing interest, and perceived barriers to RPT implementation. Nonparametric χ2 test was used for correlation statistics. Results: Of the 142 respondents, 131 (92.3%) practiced in the United States and were included for this analysis. Respondents were well balanced in terms of practicing region, population size served, practice setting, and years in practice. Forty-eight percent (n = 63) reported prescribing at least 1 RPT. An additional 7% (n = 8) participate in RPT administration without billing themselves. Among those that actively prescribed RPT, the mean cumulative cases per month was 4.2 (range, 1-5). The most commonly prescribed radionuclides were radium-223 (40%; mean 2.8 cases/mo), iodine-131 (18%; mean 2.3 cases/mo), yttrium-90 (13%; mean 3.4 cases/mo), "other" (8%), samarium-153 (6%; mean 1.0 cases/mo), and strontrium-89 and phosphorous-32 (2% each; mean 1.8 and 0.4 cases/mo, respectively). Of those who answered "other," lutetium-177 dotatate was most commonly prescribed (8%). No significant (P < .05) association was noted between practice type, practice location, years of practice, or practice volume with utilization of any RPTs. Most radiation oncologists (56%, n = 74) responded they would like to actively prescribe more RPT, although 27% (n = 35) were indifferent, and 17% (n = 22) said they would not like to prescribe more RPT. Perceived barriers to implementation were varied but broadly categorized into treatment infrastructure (44%, n = 57), interspecialty relations (41%, n = 53), lack of training (23%, n = 30), and financial considerations (16%, n = 21). Conclusions: Among surveyed U.S. radiation oncologists, a significant number reported prescribing at least 1 RPT. The majority expressed interest in prescribing additional RPT. Wide-ranging barriers to implementation exist, most commonly interspecialty relations, treatment infrastructure, lack of training, and financial considerations.

From Beaming Cancer to Beaming Parent: Paternity Leave Experiences in Radiation Oncology.

PURPOSE: Although supported by most men and women, paternity leave is heavily underused across industries owing in part to external pressures and inconsistent availability. The goal of this study was to assess the use of paternity leave in radiation oncology (RO) practices and identify any associated barriers. METHODS AND MATERIALS: A 36-item survey was distributed via e-mail to 536 male domestic RO attending and resident physicians. Questions assessed paternity leave policies, use, and departmental support. Data were collected using Research Electronic Data Capture from January to February 2021. Descriptive statistics were obtained for analysis, and logistic regression was performed to analyze the association between practice type and presence of policy. RESULTS: The survey response rate was 20% (n = 108), with 98% of participants completing all applicable questions. Respondents included 63 attending physicians (58%) and 45 resident physicians (42%). The median age of all respondents was 35 years. Among all participants, 51 (47%) stated their practice had a formal paternity leave policy. The median time allowed for leave was 4 weeks (range, 0.5 weeks to unlimited), whereas the median time taken was 2 weeks (range, 0.5-12 weeks). Sixteen men felt pressure to take less leave than what was allowed by their policy, and 46% of men stated that in retrospect, they would have taken more time off for paternity leave. CONCLUSIONS: To the authors' knowledge, this is the first study to investigate the use of paternity leave in RO practices in the United States. Integrating expanded family leave policies, including specifically allowing for paternity leave and accompanying these policies with cultural changes acknowledging the importance of family leave, would be beneficial to improving quality of life and work-life balance for parents.

The Use of Low-Dose Radiation Therapy in Osteoarthritis: A Review.

Despite its clinical use and investigation in other countries, low dose radiation therapy (LDRT) in the treatment of osteoarthritis (OA) is minimally used in the United States (US). Numerous recent studies published outside the US have shown moderate to long-term pain relief and improvement of mobility after treatment with LDRT for joints affected by OA. Here, we review the most recent literature published on the use of LDRT in OA. We provide a brief outline on the epidemiology, pathophysiology, current treatments, and health care burden of OA within the US. We provide a brief history of the historic use of LDRT in the US as well as a history of LDRT within the modern era of radiation oncology, discuss criticisms of LDRT including recently published randomized trials questioning its benefit as well as the risk of secondary malignancy from LDRT, and provide an outline of treatment planning considerations and recommendations regarding dose and fractionation, energy, beam arrangements, and immobilization techniques. LDRT has been shown to be a cost-effective, noninvasive treatment with minimal side effects. Further investigation into the potential role in the treatment of OA with modern LDRT is recommended.

Disparities in Radiation Therapy: Practice Patterns Analysis of Deep Inspiratory Breath Hold Use in Non-English Speakers.

PURPOSE: Our purpose was to examine current practice patterns in non-English-speaking patients with breast cancer undergoing deep inspiratory breath hold (DIBH). METHODS AND MATERIALS: An anonymous, voluntary REDCap survey was distributed to 60 residency program coordinators of US radiation oncology departments to survey their faculty and recent graduates. Eligibility was limited to board-certified radiation oncologists who had treated breast cancer within the prior 6 months. RESULTS: There were 69 respondents, 53 of whom were eligible. Forty-two percent (n = 22) of eligible respondents were from the main site at an academic center, with 28% (n = 15) representing a satellite site and 30% (n = 16) from private practice. Fifty-three percent reported at least 10% of their patients were non-English speaking. Ninety percent offered DIBH at their institution; of those, 74% used DIBH for at least one-fourth of their patients with breast cancer. Ninety-eight percent of those who use DIBH performed coaching at simulation, with 32% answering they would be "less likely" to use DIBH for non-English speakers. When used, 94% take into consideration potential language barriers for proper execution of DIBH. However, 51% had an interpreter present 76% to 100% of the time at computed tomography simulation, which decreased to 31% at first fraction and 11% at subsequent treatments. For non-English-speaking patients undergoing DIBH coaching without a certified interpreter, 55% of respondents indicated that they provided verbal coaching in English, 32% indicated "not applicable" because they always use a certified interpreter, 11% used visual aids, and 32% indicated "other." Of those who answered "other," the most commonly cited response was using therapists or staff who spoke the patient's native language. CONCLUSIONS: Disparities in the application of DIBH exist despite its established utility in reducing cardiac dose. This study provides evidence that language barriers may affect physician treatment practices from initial consideration of DIBH to subsequent delivery. These data suggest that breast cancer treatment considerations and subsequent execution are negatively affected in non-English-speaking patients.

Demographics of ASTRO Student Members and Potential Implications for Future U.S. Radiation Oncology Workforce Diversity.

PURPOSE: The radiation oncology workforce in the United States is comparatively less diverse than the U.S. population and U.S. medical school graduates. Workforce diversity correlates with higher quality care and outcomes. The purpose of this study was to determine whether student members of the American Society for Radiation Oncology (ASTRO) are any more diverse than resident members-in-training using the recently established medical student membership category. METHODS AND MATERIALS: Self-reported sex, race and Hispanic ethnicity, medical school, and degree(s) earned for all medical students (n = 268) and members-in-training (n = 713) were collected from the ASTRO membership database. International members were excluded. The χ2 test was used to assess for differences between subgroups. RESULTS: Compared with members-in-training, student members were more likely to be female (40.0% vs 31.5%, P = .032), black or African American (10.7% vs 4.8%, P = .009), candidates for or holders of a DO rather than MD degree (5.2% vs 1.5%, P = .002), and from a U.S. medical school that is not affiliated with a radiation oncology residency program (30.5% vs 20.9%, P = .001). There was no significant difference in self-reported Hispanic ethnicity (7.3% vs 5.4%, P = .356). There were no indigenous members in either category assessed. CONCLUSIONS: Medical student members of ASTRO are more diverse in terms of black race, female sex, and osteopathic training, though not in terms of Hispanic ethnicity or nonmultiracial indigenous background, than the members-in-training. Longitudinal engagement with these students and assessment of the factors leading to specialty retention versus attrition may increase diversity, equity, and inclusion in radiation oncology.

American Society of Clinical Oncology 2021 Annual Meeting Highlights for Radiation Oncologists.

The annual meeting of the American Society of Clinical Oncology is the largest multidisciplinary oncology-focused conference in the world. With more than 4900 total abstracts in 2021 alone, it is difficult for individuals to evaluate all the results. This article presents a review of 32 selected abstracts across all disease sites, focusing on those of greatest relevance to radiation oncologists.

United States Radiation Oncology Fellowship Growth From 2010 to 2020.

PURPOSE: To provide a comprehensive analysis of radiation oncology (RO) fellowship growth from 2010 to 2020. METHODS AND MATERIALS: A collated database of RO fellowship programs and matriculants was created using (1) RO residency program (n = 92) and graduate (n = 2082) web searches, (2) prospective American Society for Radiation Oncology (ASTRO) Career Center postings database, (3) Association of Residents in Radiation Oncology Fellowship Directory, (4) RO fellowship survey data, (5) ASTRO Membership Directory, and (6) direct e-mail contact with fellowship program directors. Linear regression was used to assess the statistical significance of RO fellowship program, position, and matriculant growth over time. RESULTS: From 2010 to 2020, the number of RO fellowship programs and annual positions significantly increased from 20 to 37 (1.60 increase per year; 95% confidence interval, 1.32-1.89; P < .001) and 20 to 39 (1.81 increase per year; 95% confidence interval, 1.52-2.10; P < .001), respectively. The most commonly offered fellowship disciplines were proton therapy (n = 10), brachytherapy (n = 7), stereotactic radiosurgery/stereotactic body radiation therapy (n = 6), general RO (n = 5), and customizable to trainees' interests (n = 3). Only 10 (27%) fellowships had a formal curriculum. All fellowships were unaccredited. Four (10.8%) programs were offered at institutions without an Accreditation Council for Graduate Medical Education-accredited RO residency training program, all established within the past 2 years. In addition, 54.8% (171 of 312) of available fellowship positions were filled between 2010 to 2020. Of these, 94 (55.0%) were graduates of US RO residency programs. The mean number of total fellows and US-residency trained fellows per year was 15 (range, 5-23) and 8 (range, 2-20), respectively. There was no significant increase in the number of annual matriculated fellows over time (P = .077). Among US-residency trained fellows, 27 (28.7%), 37 (39.4%), and 29 (30.9%) were from small (≤6), medium (7-12), and large (>12) residency programs, respectively. Twenty-eight (29.8%), 13 (13.8%), 25 (26.6%), and 27 (28.7%) trained in the Northeast, Midwest, South, and West, respectively. CONCLUSIONS: There has been significant growth in unaccredited RO fellowship programs and annual positions during the past decade, although the number of matriculants has remained stable. We report for the first time the recent establishment of fellowships at institutions without an Accreditation Council for Graduate Medical Education-accredited RO residency program. The impact of fellowship programs on the training of RO residents should be studied.

New Pulmonary Infiltrates Observed on Computed Tomography-Based Image Guidance for Radiotherapy Warrant Diagnostic Workup for Coronavirus Disease 2019.

INTRODUCTION: Screening for coronavirus disease 2019 (COVID-19) exposure, coupled with engaged decision making to prioritize cancer treatment in parallel with reducing risk of exposure and infection, is crucial in the management of COVID-19 during cancer treatment. After two reported case studies of imaging findings during daily computed tomography (CT)-based image-guided radiotherapy (RT) scans, a call for submission of anonymized case reports was published with the objective of rapidly determining if there was a correlation between the onset of new pulmonary infiltrates found during RT and COVID-19. We hereby report the results of the aggregate analysis. METHODS: Data of deidentified case reports for patients who developed biochemically confirmed COVID-19 during RT were submitted through an online portal. Information requested included a patient's sex, age, cancer diagnosis and treatment, and COVID-19 diagnosis and outcome. Coplanar CT-based imaging was requested to reveal the presence or absence of ground-glass opacities or infiltrates. RESULTS: A total of seven reports were submitted from Turkey, Spain, Belgium, Egypt, and the United States. Results and imaging from the patients reported by Suppli et al. and McGinnis et al. were included for a total of nine patients for analysis. All patients were confirmed COVID-19 positive using polymerase chain reaction-based methods or nasopharyngeal swabs. Of the nine patients analyzed, abnormalities consistent with ground-glass opacities or infiltrates were observed in eight patients. CONCLUSIONS: This is the largest case series revealing the potential use of CT-based image guidance during RT as a tool for identifying patients who need further workup for COVID-19. Considerations for reviewing image guidance for new pulmonary infiltrates and immediate COVID-19 testing in patients who develop new infiltrates even without COVID-19 symptoms are strongly encouraged.

US Primary Care vs Specialty Care Trainee Positions and Physician Incomes: Trends From 2001 to 2019.

BACKGROUND: Much of the Affordable Care Act (ACA) and subsequent US health care policies were designed to address deficiencies in health care access and enhance primary care services. How residency positions and physician incomes have changed in the post-ACA era is not well characterized. OBJECTIVE: We evaluated the growth of US trainee positions and physician income, in the pre- vs post-ACA environment by specialty and among primary care vs specialty care. METHODS: Total resident complement by specialty and year was extracted from the National Graduate Medical Education (GME) Census and stratified into primary care vs specialty care. Median incomes were extracted from Medical Group Management Association surveys. Piecewise linear regression with interaction terms (pre-ACA, 2001-2010, vs post-ACA, 2011-2019) assessed growth rate by specialty and growth rate differences between primary care and specialty care. Sensitivity analyses were performed by focusing on family medicine and excluding additional GME positions contributed by the introduction of the 2015 single GME accreditation system. RESULTS: Resident complements increased for primary care (+0.16%/year pre-ACA to +2.06%/year post-ACA, P < .001) and specialty care (+1.49%/year to +2.07%/year, P = .005). Specialty care growth outpaced primary care pre-ACA (P < .001) but not post-ACA (P = .10). Family medicine had the largest increase in the pre- vs post-ACA era (-0.77%/year vs +2.09%/year, P < .001). Excluding positions contributed by the single GME accreditation system transition did not result in any statistically significant changes to the findings. Income growth increased for primary care (+0.84%/year to +1.37%/year, P = .044), but decreased for specialty care (+1.44%/year to +0.49%/year, P = .011). Specialty care income growth outpaced primary care pre-ACA (P < .001), but not post-ACA (P = .22). CONCLUSIONS: We found significant growth differences in resident complement and income among primary care versus specialty care in the pre-/post-ACA eras.

Quantitative Medical Physics National Job Data Distribution Analysis.

PURPOSE: The purpose of this study was to investigate the contemporary distribution of medical physics (MP) employment opportunities across the United States. METHODS AND MATERIALS: An annual record (2018-2019) of advertised full-time MP jobs was created using publicly available information from the American Association of Physicists in Medicine and Indeed websites. Listed jobs were categorized based on position name, work experience, job function, and geographic region. To account for regional population differences, a preponderance of employment opportunities per 10 million people was computed. Using Commission on Accreditation of Medical Physics Education Programs residency accreditation data, the nationwide locations of the MP training centers and the number of residency positions per annum were identified. A chi-square goodness-of-fit test was used for statistical analysis. RESULTS: A total of 441 unique MP jobs were identified nationwide per annum (2018-2019). The highest percentage of MP jobs was reported from the South region (33.6%), and the lowest (17.2%) was from the West. Analysis revealed that 148 jobs (33.6%) were academic and 293 (66.4%) were nonacademic. The South had the most academic jobs overall (31.8%), whereas the West had the fewest (13.5%). Regionally, the highest percentage of academic jobs (46.9%) was reported from the Northeast, whereas the West had the lowest percentage (26.3%). The analysis of academic versus nonacademic job comparison by regions showed statistically significant differences (P = .0133). The Midwest and the West regions, respectively, showed the highest (18.2) and lowest (10.24) number of jobs per unit population, measured in 10 million. CONCLUSIONS: To our knowledge, this is one of the first national quantitative job data analyses of MP job distributions. This study revealed the level of demand for qualified candidates in 2018 to 2019, showing an imbalance between academic and nonacademic positions across the regions of the United States. Moreover, the geographic distribution of job listings deviated significantly from expectation given the relative population of each region.

Variations in Resources Among Radiation Oncology Residency Programs in the United States.

The purpose of this research was to assess the existing variations in the residency training resources among radiation oncology (RO) residency programs in the United States. We queried each residency program website and Fellowship Residency Electronic Interactive Data Access System website (www.freida.ama-assn.org) to obtain information on faculty and available treatment modalities. The data were continuously updated, most recently as of April 30, 2019. A total of 94 RO residency programs were identified during the academic year 2018-2019, and data were collected. The median number of attending physicians was 13 (range, 4 -71). The median number of physicists and biologists were 9 and 3, respectively. The conventional techniques, including 3 dimensional conformal radation therapy, intensity modulated radiation therapy, electron therapy, and stereotactic body radiation therap/stereotactic radiosurgery, were available in all residency programs. In terms of specialized external beam radiation therapy machines, gamma knife, CyberKnife, and magnetic resonance imaging (MRI) linear accelerator were available in 49 (52%), 21(22%), and 7 (8%) programs, respectively. Only 19 programs (20%) had in-house proton therapy availability; however, 37 programs (39%) offered proton therapy training via resident rotation at an affiliated institution. Prostate, gynecologic, and breast brachytherapy were available in 81 (86%), 82 (87%), and 58 (62%) programs, respectively. Eighty-one (86%) programs reported to have high dose rate, and only 20 (21%) programs had low dose rate brachytherapy. Our study found that marked variations exist among RO residency programs in the United States during academic year 2018-2019 and will serve as a baseline for future intervention.

A National Survey of Radiation Oncology Experiences Completing Tele-Consultations During the Coronavirus Disease (COVID-19) Pandemic.

PURPOSE: The emergence of the coronavirus disease (COVID-19) global pandemic has led to a significant shift in the delivery of health care, including an explosive growth of telemedicine services. This reverberated in the field of radiation oncology, with a recent American Society for Radiation Oncology (ASTRO) nationwide survey reporting 89% of surveyed clinics began to offer telemedicine programs to patients because of the pandemic. However, this survey did not study the perceptions and experiences of those clinicians delivering telemedicine services. METHODS AND MATERIALS: We investigated through a national physician survey the merits and limitations of radiation oncology tele-consultations. An anonymous web-based survey was distributed using SurveyMonkey (www.surveymonkey.com) via email. RESULTS: Seventy six respondents (16.1% overall response rate) completed the survey, with broad representation from both academic and community-based practices. Many respondents agreed that transitioning to tele-consultations was a needed step given the emergence of the pandemic, despite most having never previously offered this service. Despite many radiation oncologists having little prior experience with tele-consultations, a majority were satisfied in being able to explain the details of a medical diagnosis, provide results of imaging and bloodwork, and discuss recommendations around radiation treatments through this format. Nearly half of the respondents agreed that tele-consultations felt impersonal, with the inability to complete physical examinations noted as a contributor to the impersonality. Nevertheless, respondents still agreed that telemedicine will play an important role going forward, and almost 90% agreed that they would offer tele-consultations even after the pandemic has resolved.