Acute toxicity and health-related quality of life outcomes of localized prostate cancer patients treated with magnetic resonance imaging-guided high-dose-rate brachytherapy: A prospective phase II trial.

PURPOSE: To report acute toxicity and health-related quality of life (HRQoL) outcomes of a phase II clinical trial of magnetic resonance imaging (MRI)-guided prostate high-dose-rate brachytherapy (HDR-BT) combined with external beam radiotherapy. METHODS AND MATERIALS: Patients with intermediate- and high-risk prostate cancer (PCa) were eligible. Treatment consisted of a single 15 Gy MRI-guided HDR-BT followed by external beam radiotherapy (37.5-46 Gy depending on their risk category). Dosimetry, toxicity and HRQoL outcomes were collected prospectively at baseline, 1 and 3 months using Common Terminology Criteria for Adverse Events Version 4.0 and the expanded PCa index composite, respectively. General linear mixed modeling was conducted to assess the changes in expanded PCa index composite domain scores over time. A minimally important difference was defined as a deterioration of HRQoL scores at 3 months compared to baseline ≥ 0.5 standard deviation. A p value ≤ 0.05 was considered statistically significant. RESULTS: Sixty-one patients were included. Acute grade (G)2 urinary toxicity was observed in 18 (30%) patients while 1 (2%) patient had G3 toxicity, and none had G4 toxicity. Two patients had an acute urinary retention. G2 gastrointestinal toxicity was reported by 5 (8%) patients with no G3-4. Compared to baseline, urinary HRQoL scores significantly declined at 1 month (p < 0.001) but recovered at 3 months (p > 0.05). Bowel (p < 0.001) and sexual (p < 0.001) domain scores showed a significant decline over the 3-month follow-up period. At 3 months, 44%, 49% and 57% of patients reported a minimally important difference respectively in the urinary bowel and sexual domains. CONCLUSION: MRI-guided HDR-BT boost is a safe and well tolerated treatment of intermediate- and high-risk PCa in the acute setting. A longer follow-up and a comparison to ultrasound-based HDR-BT are needed to assess the potential benefit of MRI-guided prostate HDR-BT.

Definitive radiotherapy for vaginal recurrence of early-stage endometrial cancer: survival outcomes and effect of mismatch repair status.

OBJECTIVE: To evaluate clinical outcomes, prognostic factors, and toxicity in patients with vaginal recurrence of early-stage endometrial cancer treated with definitive radiotherapy. METHODS: Retrospective review identified 62 patients with stage I-II endometrial cancer and vaginal recurrence treated with external beam radiotherapy and image-guided brachytherapy with definitive intent from November 2004 to July 2017. All patients had prior hysterectomy without adjuvant radiotherapy and >3 months follow-up. Mismatch repair (MMR) status was determined by immunohistochemical staining of the four mismatch repair proteins (MLH1, MSH2, PMS2, and MSH6) when available in the pathology record. Rates of vaginal control, recurrence-free survival, and overall survival were calculated by Kaplan-Meier. Univariate and multivariate analyses were performed by Cox proportional hazards. RESULTS: Most patients had endometrioid histology (55, 89%), grade 1 or 2 tumor (53, 85%), and vaginal-only recurrence (55, 89%). With a median follow-up of 39 months (range, 3-167), 3- and 5-year rates of vaginal control, recurrence-free survival, and overall survival were 86% and 82%, 69% and 55%, and 80% and 61%, respectively. On multivariate analysis, non-endometrioid histology (HR 12.5, P<0.01) was associated with relapse when adjusted for chemotherapy use. Patients with non-endometrioid histology also had a 4.5-fold higher risk of death when adjusted for age (P=0.02). Twenty patients had known MMR status, all with grade 1-2 endometrioid tumors and 10 (50%) with MMR deficiency. The 3-year recurrence-free survival was 100% for MMR-proficient tumors and 52% for MMR-deficient (P=0.03). Late grade 2 and 3 gastrointestinal, genitourinary and vaginal toxicity was reported in 27% and 3%, 15% and 2%, and 16% and 2% of patients, respectively. CONCLUSION: Definitive radiotherapy with image-guided brachytherapy resulted in 5-year local control rates exceeding 80% and late severe toxicity rates were under 3%. Distant recurrence was common and highest for those with grade 3 or non-endometrioid tumors and MMR deficient grade 1-2 disease.

Impact of a global radiation oncology scholarship for trainees: An evaluation of early outcomes.

Global Oncology capacity in Radiation Oncology (RO) needs development. We report on early outcomes of a Canadian Global Oncology elective scholarship program for trainees (2014-2019). The number of global oncology electives increased. Academic deliverables and collaborations were observed. There was evidence of personal and professional development.

An Innovative Learning Tool for Radiation Therapy Treatment Plan Evaluation: Implementation and Evaluation.

PURPOSE: To design, develop, and evaluate an interactive simulation-based learning tool for treatment plan evaluation for radiation oncology and medical physics residents to address gaps in learning. METHODS AND MATERIALS: We first conducted a needs assessment for optimal learning tool design and case selection. Next, we generated a curated database of cases with clinically unacceptable treatment plans accessible through an in-house developed interactive web-based digital imaging and communications in medicine-radiation therapy viewer. We then developed an interactive user module that allows case selection, learner participation, and immediate feedback, including the final clinically acceptable plan. We pilot tested this case bank learning tool with current radiation oncology and medical physics residents within our institution. Afterward, residents completed an evaluation of tool design, content, and perceived impact on learning and provided suggestions for improvement. RESULTS: We generated 70 cases and learning modules for the case bank, encompassing various clinical sites, levels of difficulty, and classified errors. Residents positively endorsed the learning tool, including design, content, and perceived impact on learning. The learning tool's interactivity was perceived to provide increased educational value compared with other current learning methods. CONCLUSIONS: We created a high-fidelity simulation platform for treatment plan evaluation linked to a curated case bank. Evaluation of the pilot deployment demonstrated a benefit for resident learning and competency attainment. Future directions include external validation and expansion.

Dose to the bladder neck in MRI-guided high-dose-rate prostate brachytherapy: Impact on acute urinary toxicity and health-related quality of life.

PURPOSE: To assess the impact of the dose to the bladder neck (BN) on acute urinary toxicity (AUT) and health-related quality of life (uHRQoL) in patients with prostate cancer treated with MRI-guided high-dose-rate brachytherapy combined to external beam radiotherapy. METHODS AND MATERIALS: Sixty-one patients were treated with a single 15-Gy MRI-guided high-dose-rate brachytherapy followed by external beam radiotherapy as part of a prospective Phase II trial. The BN was delineated in retrospect on T2-weighted images. AUT and uHRQoL data were collected prospectively using Common Terminology Criteria for Adverse Events version 4.0 and the expanded prostate index composite. A minimally important difference (MID) was defined as a deterioration of uHRQoL scores at 3 months ≥ 0.5 standard deviation of baseline score. Linear and logistic regression models were used. RESULTS: The median BN volume was 0.6 cc. The median BN and urethral maximum dose (BNDmax and UDmax) were 22 Gy and 20 Gy, respectively. BNDmax was significantly associated with UDmax (p = 0.03). AUT Grade 2 + was observed in 32% of patients. Among those, 4 patients had an acute urinary retention (AUR). No Grade 4 + toxicity was reported. At 3 months, 47% of patients reported an MID in urinary uHRQoL. None of the dosimetric parameters including BNDmax was associated with acute Grade 2 + urinary toxicity or MID. However, 3 of 4 patients with AUR had a BNDmax in the highest quartile; >175% of prescription dose. CONCLUSIONS: Although a high BN dose was observed in patients who had an AUR, the predictive value of this parameter is yet to be determined in a larger cohort.

Development of a Quality and Safety Competency Curriculum for Radiation Oncology Residency: An International Delphi Study.

PURPOSE: To develop an entry-to-practice quality and safety competency profile for radiation oncology residency. METHODS AND MATERIALS: A comprehensive list of potential quality and safety competency items was generated from public and professional resources and interprofessional focus groups. Redundant or out-of-scope items were eliminated through investigator consensus. Remaining items were subjected to an international 2-round modified Delphi process involving experts in radiation oncology, radiation therapy, and medical physics. During Round 1, each item was scored independently on a 9-point Likert scale indicating appropriateness for inclusion in the competency profile. Items indistinctly ranked for inclusion or exclusion were re-evaluated through web conference discussion and reranked in Round 2. RESULTS: An initial 1211 items were compiled from 32 international sources and distilled to 105 unique potential quality and safety competency items. Fifteen of the 50 invited experts participated in round 1: 10 radiation oncologists, 4 radiation therapists, and 1 medical physicist from 13 centers in 5 countries. Round 1 rankings resulted in 80 items included, 1 item excluded, and 24 items indeterminate. Two areas emerged more prominently within the latter group: change management and human factors. Web conference with 5 participants resulted in 9 of these 24 items edited for content or clarity. In Round 2, 12 participants rescored all indeterminate items resulting in 10 items ranked for inclusion. The final 90 enabling competency items were organized into thematic groups consisting of 18 key competencies under headings adapted from Deming's System of Profound Knowledge. CONCLUSIONS: This quality and safety competency profile may inform minimum training standards for radiation oncology residency programs.

Competency in Quality: Defining the Scope and Nature of Quality Competencies for Radiation Oncology Residency Programs.

INTRODUCTION: Quality and safety in radiation treatment have garnered increasing attention in recent years. With the introduction of the CanMEDS 2015 Physician Competency Framework, incorporation of patient safety and quality improvement will be required across all seven established physician roles for radiation oncology residents. An appreciation for the competency areas relevant to radiation oncologists (ROs) in the quality and safety domain is thus needed to inform training in this area. METHODS: Semistructured interprofessional focus groups were held with ROs, medical physicists, and radiation therapists to ascertain the scope of quality principles required of newly certified ROs, to identify current teaching best practices, and to define required competencies in this area. Audio recordings were transcribed verbatim and data analyzed iteratively and coded using a constant comparison method. RESULTS: Three focus groups were held with 20 participants overall, and an average duration of 68 minutes (range 47-81 minutes). Participants found it difficult to define quality but noted that for residents it might encompass competencies in peer review, incident and change management, and quality culture. Although addressed in various ways in current residency programs, it was thought that explicit acknowledgment of relevant "nonmedical expert" quality competencies would ensure adequate attention in residency. CONCLUSIONS: Quality and safety are important concepts in radiation oncology, warranting attention in residency training to develop the knowledge, skills, and behaviour necessary in practice.

Medical Problems Referred to a Care of the Elderly Physician: Insight for Future Geriatrics CME.

PURPOSE: Family physicians provide the majority of elderly patient care in Canada. Many experience significant challenges in serving this cohort. This study aimed to examine the medical problems of patients referred to a care of the elderly physician, to better understand the geriatric continuing medical education (CME) needs of family doctors. METHODS: A retrospective chart review of patients assessed at an urban outpatient seniors' clinic between 2003 and 2008 was conducted. Data from 104 charts were analyzed and survey follow-up with 28 of the referring family physicians was undertaken. Main outcomes include the type and frequency of medical problems actually referred to a care of the elderly physician. Clarification of future geriatric CME topics of need was also assessed. RESULTS: Preventive care issues were addressed with 67 patients. Twenty-four required discussion of advance directives. The most common medical problems encountered were osteoarthritis (42), hypertension (34), osteoporosis (32), and depression or anxiety (23). Other common problems encountered that have not been highly cited as being a target of CME included musculoskeletal and joint pain (41), diabetes (23), neck and back pain (20), obesity (11), insomnia (11), and neuropathic, fibromyalgia and "leg cramps" pain (10). The referring family physicians surveyed agreed that these were topics of need for future CME. CONCLUSIONS: The findings support geriatric CME for the common medical problems encountered. Chronic pain, diabetes, obesity and insomnia continue to be important unresolved issues previously unacknowledged by physicians as CME topics of need. Future CME focusing more on process of geriatric care may also be relevant.