Improving Survival Prognostication in Patients With Metastatic Cancer Through Clinical Judgment.

BACKGROUND/AIM: NEAT is a validated prognostic model that calculates survival estimates based on the number of active tumors, ECOG performance status, albumin, and primary tumor site. Since models are imperfect, we hypothesized that experienced clinicians could predict the survival of patients with metastatic cancer better than a validated prognostic model alone, thereby quantifying the previously unmeasured value of clinical judgment. PATIENTS AND METHODS: This prospective, single-institution cohort study conducted at a large community hospital recruited 73 patients with metastatic cancer referred to radiation oncology between October 2016 and December 2017. The consulting nurse and physician were prospectively surveyed on whether the patient would survive a longer or shorter duration than the calculated NEAT survival estimates. The accuracy of predictions between groups was assessed using the McNemar's chi-squared test. RESULTS: The median survival for enrolled patients was 9.2 months. Nursing and physician predictions were similarly accurate (61.6% vs. 60.3%, p=0.85). The accuracy of confident clinical predictions was similar to less confident predictions (64.2% vs. 58.2%, p=0.46). Radiation dose intensity was informed by predicted survival, and median survival was significantly higher in patients receiving an EQD2≥40 (17 months vs. 2 months, p<0.001). CONCLUSION: Experienced clinicians, both nurses and oncologists, have insight that modestly supplements the accuracy of a validated model to predict survival in patients with advanced cancer.

Impact on mental health of the COVID-19 pandemic in a radiation oncology department.

AIM: To evaluate the emotional state and organizational well-being of healthcare workers in radiation oncology departments, during the COVID pandemic. METHODS: A survey was carried out with three questionnaires: Impact of Event Scale-Revised (IES-R); Italian ANAC questionnaire; and Maslach Burnout Inventory (MBI). Comparisons between groups were done by Student's t test. RESULTS: Seventy-eight questionnaires for 26 workers were analyzed. Thirty-three percent of the sample obtained an IES-R high score, such as post-traumatic syndrome. In terms of organizational well-being, younger age and lower working seniority were statistically significant for higher score of ANAC items (p < 0.5). Regarding MBI, 0, 27 and 50% high scores of emotional exhaustion, depersonalization and personal accomplishment were reported, respectively. Low working seniority and male sex were correlated with high score of personal accomplishment (p:0.05; p:0.03). CONCLUSION: Intervention to promote mental health well-being should be implemented in radiation oncology department.

Postoperative radiotherapy after upfront radical prostatectomy: debated issues at a turning point-a survey exploring management trends on behalf of AIRO (Italian Association of Radiotherapy and Clinical Oncology).

OBJECTIVES: Postoperative prostate cancer patients are a heterogeneous population, and many prognostic factors (e.g., local staging, PSA kinetics, margin status, histopathological features) may influence their clinical management. In this complex scenario, univocal recommendations are often lacking. For these reasons, the present survey was developed by the Italian Association of Radiotherapy and Clinical Oncology (AIRO) to collect the opinion of Italian radiation oncologists and delineate a representation of current clinical practice in our country. METHODS: A questionnaire was administered online to AIRO (Italian Association of Radiotherapy and Clinical Oncology) members registered in 2020 with a clinical interest in uro-oncological disease. RESULTS: Sixty-one per cent of AIRO members answered the proposed survey. Explored topics included career and expertise, indications to adjuvant RT, additional imaging in biochemical recurrence setting, use of salvage radiotherapy (SRT), management of clinically evident locoregional recurrence and future considerations. CONCLUSIONS: Overall, good level of agreement was found between participants for most of the topics. Most debated issues regarded, as expected, implementation of new imaging methods in this setting. Notably, trend in favour of early SRT vs. immediate adjuvant RT was underlined, and preference for global evaluation rather than isolated risk factors for RT indications was noticed.

Evaluation of practical experiences of German speaking radiation oncologists in combining radiation therapy with checkpoint blockade.

The results of this survey reveal current clinical practice in the handling of combined radioimmunotherapy with Immune Checkpoint Inhibitors (RT + ICI). We aim to provide a basis to open a discussion for clinical application of RT + ICI by analyzation of experts' assessment. We conducted a survey with 24 items with a focus on side effects of RT + ICI, common practice of scheduling and handling of adverse events. After pilot testing by radiation oncology experts the link to the online survey was sent to all members of the German Society of Radiation Oncology (DEGRO). In total, 51 radiation oncologists completed the questionnaire. Pulmonary toxicity under RT + ICI with ICIs was reported most frequently. Consensus was observed for bone and soft tissue RT of the limbs in favor for no interruption of ICIs. For cranial RT half of the participants do not suspend ICIs during normofractionated radiotherapy (nfRT) or stereotactic hypofractionated RT (SRT). More participants pause ICIs for central than for peripheral thoracic region. Maintenance therapy with ICIs is mostly not interrupted prior to RT. For management of RT associated pneumonitis under durvalumab the majority of 86.3% suggest corticosteroid therapy and 76.5% would postpone the next cycle of ICI therapy. The here obtained assessment and experiences by radiation oncologists reveal a large variability in practical handling of combined RT + ICI. Until scientific evidence is available a discussion for current clinical application of RT + ICI should be triggered. Interdisciplinary consensus guidelines with practical recommendations are required.

Victoria (Australia) radiotherapy response to working through the first and second wave of COVID-19: Strategies and staffing.

INTRODUCTION: The COVID-19 pandemic demanded a rapid response within Radiation Oncology services to minimise the risk of infection to patients and workforce. This study aimed to assess whether the operational changes put in place to reduce infection risks were effective in engaging and supporting staff. METHODS: Our service's response saw staff and patients split into morning or afternoon shifts without overlap. Changes included extended clinic hours, modified treatment regimens, expanded online/electronic communication and remote working. Staff were invited to respond to an electronic questionnaire in September 2020, just after the peak of the second COVID-19 wave in Victoria. Responses captured demographic data, parental status, profession, happiness levels, fear of COVID-19 and e-communication efficacy. RESULTS: A 57% response rate was achieved. 69% of respondents were female; 40% were aged 45+ and 35% had school-aged children. Staff aged 45+ showed a significantly greater fear of COVID-19 than younger staff. 36% of respondents reported feeling nervous or anxious watching news reports about COVID-19. 92% of staff were happy with their work arrangements; staff with children were happier than staff without children with their shifts. Online chat/channels were reported as the preferred e-communication method between colleagues. CONCLUSION: Staff provided predominantly positive feedback to the changes made in response to the pandemic, reporting high levels of happiness and willingness to continue with the changes implemented during COVID-19. The strategies adopted worked well and the overall high levels of staff satisfaction will allow our service to quickly pivot should further surges, or another pandemic, arise.

Choosing a career in radiation oncology in India: A survey among young radiation oncologists.

BACKGROUND: Radiation oncology in India is much debated as a career option to take up. This survey among young radiation oncologists (YROs), the first of its kind, attempts to assess the career expectations and concerns that affect most of us. MATERIALS AND METHODS: This survey was conducted using the online survey tool of SurveyMonkey in October 2018. The Association of Radiation Oncologists of India (AROI) members' database was used to send the survey link over E-mail to recipients (AROI life member after 2004). RESULTS: Out of 1685 invitees, 492 (29.19%) recipients took the survey. Most (69.14%) of the respondents were males who worked as senior residents and junior consultants and employed in private hospitals and state-level teaching institutes. Postspecialization (MD/DNB) experience was mostly <3 years (56.52%). Most of YROs worked in Tier-I city (48.9%) mostly in telecobalt-based facilities. Most of our respondents (73.01%) aspired to work in academic teaching hospital/research institute, and the primary concern was academics/research (39.88%) followed by income (23.31%). There was a similar distribution of respondents with respect to their desire to shift to medical oncology. There was marked dissatisfaction over remuneration, job openings, job security, and poor scope of career improvement. 56.50% of respondents believed that they need to move abroad to improve their quality of life. However, 76.69% of respondents still felt very passionate about their professional choice. Finally, 61.97% of professionals believed that this survey will correctly reflect the present scenario among YROs. CONCLUSIONS: The survey portrays a mixed picture as expected. Major policy changes are required to improve the infrastructure and job opportunities of this profession.

Do Coordinated Knowledge Translation Campaigns Persuade Radiation Oncologists to Use Single-Fraction Radiation Therapy Compared With Multiple-Fraction Radiation Therapy for Bone Metastases?

PURPOSE: Although level 1 evidence supports the use of single-fraction radiation therapy (SFRT) compared with multiple-fraction radiation therapy (MFRT) for the palliative management of bone metastases, SFRT is underused. In early 2017, the Canadian Partnership Against Cancer and CancerCare Manitoba undertook a comprehensive knowledge translation campaign in Manitoba, Canada featuring educational outreach visits, local consensus meetings, and audit and feedback interventions to encourage greater use of SFRT. This study assessed the impact of this campaign on SFRT use and identified variables associated with MFRT usage. METHODS AND MATERIALS: This retrospective, population-based cohort study identified all patients treated with palliative radiation therapy for bone metastases in Manitoba, Canada, from January 1, 2017, to December 31, 2017, using the provincial radiation therapy database. Baseline characteristics were extracted and tabulated by fractionation schedule. The proportion of patients treated with SFRT in 2017 (postintervention) was compared with the 2016 (preintervention) levels. Univariable and multivariable logistic regression analyses were performed to identify risk factors associated with MFRT use. RESULTS: In 2017, 927 patients received palliative radiation therapy for bone metastasis, of which 548 (59.1%) received SFRT, a 21.1% absolute increase in SFRT use compared with 2016 levels (38.0%). With use of multivariable analysis, variables associated with receipt of MFRT included: complicated bone metastasis, soft tissue extension, hematological primary malignancy, and treatment at a subsidiary center. CONCLUSION: The comprehensive knowledge translation campaign carried out in Manitoba resulted in a significant increase in SFRT use for bone metastases. Continued audit/feedback strategies are recommended to further reinforce knowledge translation efforts supporting SFRT use in the future.

Behavioral Determinants of Canadian Radiation Oncologists' Use of Single Fraction Palliative Radiation Therapy for Uncomplicated Bone Metastases.

BACKGROUND: A mainstay therapy for pain relief from uncomplicated bone metastases is external beam radiation therapy. Single fraction radiation therapy (SFRT) is more convenient and cost-effective, causes fewer acute side effects, and is equivalent to multiple fraction radiation therapy for pain relief. Despite these advantages, radiation oncologists seldom prescribe SFRT. PURPOSE: To identify the behavioral determinants to Canadian radiation oncologists' use of SFRT for uncomplicated bone metastases. METHODS AND MATERIALS: Semistructured interviews were conducted with 38 radiation oncologists from all 10 Canadian provinces. The interview guide and analysis were guided by the Theoretical Domains Framework (TDF). Transcripts were analyzed using a 5-phase thematic content analysis process: coding, generation of belief statements, generation of themes within TDF domains, generation of overarching themes, and classification of themes as barriers or facilitators to SFRT use, or as divergent (a barrier or facilitator depending on the participant). RESULTS: Thirteen overarching themes were identified of which 2 were barriers, 7 were facilitators, and 4 were divergent. The most commonly identified theme was the facilitator "most radiation oncologists are aware of evidence and guidelines on the use SFRT" (n = 38, 100%). The 3 next most reported themes (n = 37, 97.4% ) were (1) "radiation oncologists' use of SFRT can influence their colleagues" use of it (divergent), (2) experience with SFRT can increase its use (facilitator), and (3) SFRT is convenient for patients (facilitator). The most commonly identified barrier (n = 31, 81.6%) was "SFRT is associated with a higher risk of retreatment." CONCLUSIONS: Our use of the TDF to explore the behavioral determinants of Canadian radiation oncologists' use of SFRT for uncomplicated bone metastases identified a range of factors that are perceived to encourage and discourage its use. Our results will inform the design of future interventions to increase the use of SFRT.

Radiation Oncologist Perceptions of Telemedicine from Consultation to Treatment Planning: A Mixed-Methods Study.

PURPOSE: Telemedicine was rapidly implemented for initial consultations and radiation treatment planning in the wake of the coronavirus disease 2019 (COVID-19) pandemic. In this study, we explore utilization of and physician perspectives on this approach in an attempt to identify patient populations that may benefit most from virtual care. METHODS AND MATERIALS: This is a mixed-methods study with a convergent design. Approximately 6 to 8 weeks after implementation of telemedicine, all radiation oncologists in a single academic radiation oncology department were invited to participate in either semistructured interviews with embedded survey questions or a concurrently administered survey only. Rapid qualitative analysis was used to identify common themes, and quantitative data was assessed using descriptive statistics and univariable analyses. RESULTS: At the apex of the pandemic, 92% of radiation oncology visits were conducted via telemedicine. In total, 51 of 61 radiation oncologists participated in the study (response rate 84%). Most (71%) reported no difference in ability to treat cancer appropriately via telemedicine, which was more common among specialized physicians (P = .01) but not those with higher visit volume or years of experience. Over half (55%) perceived no difference or even improvement in overall visit quality with telemedicine. Virtual visits were deemed acceptable for a median of 70% to 96% of patients, which varied by disease site. Need for physical examination, and availability of an acceptable proxy, factored into telemedicine acceptability. Most (88%) found telemedicine better than expected, but opinions were split on how telemedicine would affect physician burnout. Almost all (96%) foresaw a role for telemedicine beyond the pandemic and would opt for a median of 50% (interquartile range 20%-66%) of visits conducted via telemedicine. CONCLUSIONS: Among radiation oncologists in an academic setting, telemedicine was perceived to be highly appropriate and acceptable for most patients. Future studies should focus on identifying the 5% to 30% of patients whose care may be optimized with in-person visits, and if there is alignment with patient preferences.

Views of healthcare professionals about the role of active monitoring in the management of ductal carcinoma in situ (DCIS): Qualitative interview study.

BACKGROUND: Ductal carcinoma in situ (DCIS) is an in-situ (pre-cancerous) breast malignancy whereby malignant cells are contained within the basement membrane of the breast ducts. Increasing awareness that some low-risk forms of DCIS might remain indolent for many years has led to concern about overtreatment, with at least 3 clinical trials underway internationally assessing the safety of active monitoring for low-risk DCIS. This study aimed to understand healthcare professionals' (HCPs) views on the management options for patients with DCIS. METHODS: Qualitative study using semi-structured interviews with HCPs involved in the diagnosis and management of DCIS in Australia and New Zealand. Interviews were audio-recorded, transcribed and analysed thematically using Framework Analysis method. RESULTS: Twenty-six HCPs including 10 breast surgeons, 3 breast physicians, 6 radiation oncologists, and 7 breast care nurses participated. There was a strong overall consensus that DCIS requires active treatment. HCPs generally felt uncomfortable recommending active monitoring as a management option for low-risk DCIS as they viewed this as outside current standard care. Overall, HCPs felt that active monitoring was an unproven strategy in need of an evidence base; however, many acknowledged that active monitoring for low-risk DCIS could be appropriate for patients with significant co-morbidities or limited life expectancy. They believed that most patients would opt for surgery wherever possible. CONCLUSIONS: This study highlights the important need for robust randomised controlled trial data about active monitoring for women with low-risk DCIS, to provide HCPs with confidence in their management recommendations and decision-making.

Survey of clinician opinions on the role of proton beam therapy in Australia and New Zealand.

INTRODUCTION: We surveyed the Australian and New Zealand (ANZ) radiation oncology community to assess their perceptions, understanding and experience of the current role of proton beam therapy (PBT) and the existing referral process to access PBT overseas, ahead of the development of the first PBT centre in Australia. METHODS: The survey was conducted between September and October 2019 using a 17-question instrument, which was distributed by email to all 632 radiation oncology fellows and trainees listed in the Royal Australian and New Zealand College of Radiologists database. RESULTS: One hundred and one respondents completed the survey, with an overall response rate of 16%. Most respondents were based in Australia (93%), with the majority working in public centres only (59%); 51% were > 10 years post fellowship and 17% were trainees. Most respondents (76%) reported moderate or high levels of confidence in the role of PBT. Only 28% had previously referred a patient for PBT overseas, with the most common referral indication being chordoma. Of those who had not previously referred a patient, 48% were not convinced about the rationale of PBT over current therapies available locally, 33% were not aware of the referral process, and 24% had concerns about the timeliness of a decision for government-funded PBT abroad. CONCLUSION: This survey has demonstrated that, although there is reasonable confidence in the role of PBT among ANZ radiation oncologists, there are a number of important aspects of PBT awareness, education and access that need to be developed prior to commencement of PBT in Australia.

Radiation oncologists' attitudes and beliefs about intensity-modulated radiation therapy and stereotactic body radiation therapy for prostate cancer.

BACKGROUND: To better understand how radiation oncologists perceive intensity-modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT) for prostate cancer and how these perceptions may influence treatment decisions. METHODS: We conducted semi-structured interviews of radiation oncologists between January-May, 2016. We used a purposeful sampling technique to select participants across a wide range of experience, regions, and practice types. Two trained qualitative researchers used an inductive, iterative approach to code transcripts and identify themes. We then used content analysis and thematic analysis of the coded transcripts to understand radiation oncologists' attitudes and beliefs about IMRT and SBRT. RESULTS: Thematic saturation was achieved after 20 interviews. Participants were affiliated with academic (n = 13; 65%), private (n = 5; 25%), and mixed (n = 2; 10%) practices and had a wide range of clinical experience (median 19 years; range 4-49 years). Analysis of interview transcripts revealed four general themes: 1) most radiation oncologists offered surgery, brachytherapy, IMRT, and active surveillance for low-risk patients; 2) there was no consensus on the comparative effectiveness of IMRT and SBRT; 3) key barriers to adopting SBRT included issues related to insurance, reimbursement, and practice inertia; and 4) despite these barriers, most participants envisioned SBRT use increasing over the next 5-10 years. CONCLUSIONS: In the absence of strong opinions about effectiveness, nonclinical factors influence the choice of radiation treatment. Despite a lack of consensus, most participants agreed SBRT may become a standard of care in the future.

Adapting to a global pandemic through live virtual delivery of a cancer collaborative trial group conference: The TROG 2020 experience.

INTRODUCTION: The global COVID-19 pandemic forced the cancellation of the TROG 2020 face to face Annual Scientific Meeting (ASM). It was instead delivered as a live virtual meeting with 6 days of planning. Here, we report the participants' experience of this live virtual meeting. METHOD: Participants were invited to complete custom-developed, pre- and post-meeting surveys to assess their expectations of and satisfaction with the live virtual format. Speakers and moderators were also invited to complete a custom-developed satisfaction survey. The working parties of TROG (head/neck/skin, genitourinary, breast and lung) were also sampled. RESULTS: In total, 188/273 (69%) registered participants logged in to the live virtual meeting. The online engagement for each of the oral sessions ranged from 53 to 66%. There were 102 and 57 responders to the online pre- and post-meeting surveys, respectively. The majority of pre-meeting responders indicated a significant level of employer support to attend the virtual meeting. Post-meeting satisfaction exceeded pre-meeting expectations ('very much' and 'quite a bit'; 86% vs. 54%; P < 0.0001). The majority indicated they would be 'quite a bit' or 'very much' interested in future live virtual meetings. CONCLUSION: The TROG 2020 ASM was conducted as a live virtual meeting. Participant satisfaction and future interest in a live virtual meeting was high, indicating this is a viable platform for other CCTG's faced with the decision to deliver virtual content at times of global public health threats.

Elective Nodal Irradiation for Limited-stage Small-cell Lung Cancer: Survey of US Radiation Oncologists on Practice Patterns.

BACKGROUND: Traditionally, elective nodal irradiation (ENI) has been used in clinical trials that have established thoracic radiotherapy as instrumental in improving survival for patients with limited-stage small-cell lung cancer (LS-SCLC). However, several reports have suggested that the omission of ENI might be appropriate. Current US practice patterns are unknown regarding ENI for patients with LS-SCLC. MATERIALS AND METHODS: We surveyed US radiation oncologists via an institutional review board-approved questionnaire. The questions covered demographics, treatment recommendations, and self-assessed knowledge of key clinical trials. χ2 and Cochran-Armitage tests were used to evaluate for statistically significant correlations between responses. RESULTS: We received 309 responses. Of the respondents, 21% recommended ENI for N0 LS-SCLC, 29% for N1, and 30% for N2; 64% did not recommend ENI for any of these clinical scenarios. The respondents who recommended ENI were more likely to have been practicing for > 10 years (P < .001), more likely to be in private practice (P = .04), and less likely to be familiar with the ongoing Cancer and Leukemia Group B 30610 trial (P = .04). Almost all respondents (93%) prescribed the same radiation dose to the primary disease and involved lymph nodes. When delivering ENI, 36% prescribed the same dose to the involved and elective nodes, and 64% prescribed a lower dose to the elective nodes. CONCLUSION: Nearly two thirds of respondents did not recommend ENI, which represents a shift in practice. A recent large clinical trial that omitted ENI reported greater overall survival than previously reported and lower-than-expected radiation toxicities, lending further evidence that omitting ENI should be considered a standard treatment strategy.

Medical Student Exposure to Radiation Oncology Through the Pre-clerkship Residency Exploration Program (PREP): Effect on Career Interest and Understanding of Radiation Oncology.

Medical students receive little exposure to Radiation Oncology (RO) during pre-clinical training and clerkship. Pre-clerkship Residency Exploration Program (PREP) was developed by medical students at our institution to provide students with exposure to disciplines like RO with which they may not have had previous exposure, with the goal of helping with career decision making. The purpose of this study was to review how PREP affected self-reported interest in RO. PREP is a 2-week intensive elective developed by students at Dalhousie University that provides exposure to 12 specialties, including RO. PREP includes five components: half day clinical rotations, skills sessions, simulations, specialty-specific workshops, and lunchtime panel discussions. PREP participants completed questionnaires pre- and post-participation to assess career interest and understanding of Radiation Oncology. Forty participants took part in PREP. Thirty-six responded to pre-PREP questionnaires and 37 to the post-PREP questionnaire. Participants reported increasing interest in RO (24 students, 64.8%) and an increase in the understanding of the role and responsibilities of a radiation oncologist such that they felt comfortable making a career decision about RO. In pre-PREP, five (13.8%) participants listed RO as a top 3 career choice. Post-program, this number increased to nine (25.0%) of the same surveyed participants. PREP has demonstrated early exposure to RO can increase interest in RO as a career choice. Early clinical exposure experiences like we describe here may be useful for specialties such as RO, which is having difficulty filling residency positions in Canada despite an optimistic job forecast for trainees.

Radiation oncologists' perspectives on reducing radiation-induced heart disease in early breast cancer.

Radiotherapy (RT) as an adjuvant treatment for breast cancer (BC), has caused a reduction of recurrences and BC-related deaths. But it has also induced cardiovascular mortality. Oxidative stress is the principle mediator of RT-induced heart disease, similar to many conventional cardiovascular risk factors. The aggregate effect of cardiovascular conditions, RT of heart substructures, implied techniques, and population cardiac mortality rates is not well understood. Due to uncertainties in this field, this article aims to briefly review the recommended strategies for risk assessment, plan optimization, and screening for prevention of RT-induced heart disease in BC patients.

Complementary and alternative therapy use in a regional radiation oncology treatment centre: Can staff knowledge, views, confidence and documentation be improved?

INTRODUCTION: Complementary and alternative therapies (CATs) are widely used by cancer patients but are infrequently disclosed and documented. This study aimed to improve radiation therapy staff knowledge, confidence, views and documentation of radiation oncology patients' use of CATs. METHOD: Participants completed a baseline questionnaire regarding their knowledge, confidence, views and documentation relating to patients' CAT use. An intervention was undertaken whereby participants attended an educational session and a CAT screening tool was implemented simultaneously. Participants immediately completed a post-intervention questionnaire and later a 6-month follow-up questionnaire. A patient record audit was conducted to measure the documentation of CAT use pre- and post-intervention. RESULTS: From baseline to post-intervention, there was a statistically significant shift in staff knowledge and confidence (P = 0.001-0.01). The observed shift was sustained over a 6-month period, (P = 0.453-1.00). Participants' perceived views of CATs did not change as a result of the intervention (P = 0.261-1.000). The post-intervention audit compared to the baseline audit yielded a statistically significant increase in documentation. There was an increase in CAT use mentioned in patient records from 14% (15/108) to 40% (35/88) (P < 0.001). CONCLUSIONS: The implementation of a screening tool and staff education increased radiation therapy staff knowledge of CATs and increased staff confidence when discussing CAT use with patients. Documentation of CATs in the patient record increased post-intervention. These changes positively affected radiation therapy staff understanding the use of CATs by cancer patients.

End-of-life discussions in practice: survey among Canadian radiation oncologists.

BACKGROUND: Early end-of-life (EOL) discussions improve patient satisfaction, quality of care, and the cost-effectiveness of care. However, some US studies show that radiation oncologists (ROs) are unlikely to discuss EOL issues until the patients develop significant symptoms or the families initiate the discussion. There have been no prior studies describing the patterns of EOL discussions among Canadian ROs. The objectives of this study were: (I) to describe the patterns of EOL discussions among Canadian ROs; (II) to identify the barriers to EOL conversation among Canadian ROs; (III) to assess the attitudes of Canadian ROs toward Medical Assistance in Dying (MAiD). METHODS: The 22-question online survey was distributed to the members of Canadian Association of Radiation Oncologists (CARO). Demographics, EOL discussion patterns, perception of EOL discussions, barriers, and the impact of MAiD were evaluated. RESULTS: Sixty ROs responded out of 326. Prognosis (57%) and goals of care (58%) were routinely discussed, while advanced directive (40%) and planned site of death (12%) were not. More than 90% felt that early EOL discussions with palliative patients were important. The amount of palliative discussion training was correlated with confidence in EOL discussion (P <0.01), perceived importance of RO role in EOL (P=0.006), and the frequency of planned site of death discussion (P=0.041). The most frequently identified barriers were lack of time, uncertainty about prognosis, and concern for patient disappointment. Many ROs provided MAiD information upon request or case-by-case, but only 3% provided the information routinely. CONCLUSIONS: Canadian ROs recognize the importance of EOL discussions, but they do not routinely incorporate advanced directive or site of death in their discussions. ROs with more palliative discussion training were more confident in EOL discussion and likely to engage in them earlier. Short structured training may improve the confidence and quality of EOL discussion. Time constraint is the number one barrier that may be alleviated by delegation of tasks and patient education tools. Discussion about MAiD is supported but not routine among Canadian ROs.

Radiation Oncologists' Role in End-of-Life Care: A Perspective From Medical Oncologists.

PURPOSE: Multidisciplinary communication and collaboration are key to planning and delivering end-of-life care for patients with advanced and metastatic cancer. We sought to characterize medical oncologists' perspectives on the role of radiation oncologists in end-of-life care. MATERIALS AND METHODS: A sample of US medical oncologists was recruited using snowball sampling methods. Audio recordings of 4 professionally moderated focus groups were transcribed. Investigators from diverse backgrounds (medical oncology, radiation oncology, critical care medicine, palliative care, and public health) independently reviewed each transcript. Qualitative content analysis was used to create consensus codes that were applied to subsequent focus group transcripts in an iterative process. RESULTS: Medical oncologists expressed complex views regarding the role of radiation oncologists in end-of-life care. Identified themes included the limited role of radiation oncologists, territorial concerns, capability, and desire of radiation oncologists in this realm, and the need for communication between providers. Radiation oncologists were compared with surgeons, whose interaction with patients ceased after their service had been performed. In this regard, control of palliative care referral or end-of-life care discussions was thought to be in the territory of medical oncologists who had longitudinal relationships with patients from diagnosis. Medical oncologists were concerned about the capability of radiation oncologists to accurately prognosticate, and stated radiation oncologists lacked knowledge of subsequent lines of systemic therapy available to patients. Radiation oncologists' fear of upsetting medical oncologists was thought to be justified if they engaged in end-of-life care planning without direct permission from the referring medical oncologist. CONCLUSIONS: Participation of radiation oncologists in end-of-life care planning was viewed with skepticism by medical oncologists. Radiation oncologists should focus on increasing open communication and teamwork with medical oncologists and demonstrate their ability to prognosticate and counsel patients regarding end-of-life care decisions.