Implications of Medical Board Certification Practices on Family Planning and Professional Trajectory for Early Career Female Radiation Oncologists.

PURPOSE: Our purpose was to evaluate the effect of the current structure and schedule of the American Board of Radiology (ABR) radiation oncology initial certification (RO-IC) examinations, with a primary focus on implications for family planning and early professional barriers among female radiation oncologists. METHODS AND MATERIALS: A survey was conducted of crowdsourced ABR candidates and diplomates for radiation oncology between June and July of 2020. The primary study cohort was early career female radiation oncologists of the 2016 through 2021 graduating classes. RESULTS: The survey response rate of early career female radiation oncologists was 37% (126 of an estimated 337). Among this cohort, 58% (73 of 126) reported they delayed or are currently delaying/timing pregnancy or adoption to accommodate the annual schedule of the 4 qualifying and certifying examinations required to achieve board certification in radiation oncology. One in every 3 respondents who had attempted to become pregnant reported experiencing infertility (25 of 79, 32%). Women who reported intentionally delaying pregnancy to accommodate the ABR RO-IC examination schedule were significantly more likely to experience infertility (46% vs 18%, P = .008). Seven women (6%) reported at least a 1-year delay in sitting for a RO-IC examination due to an unavoidable scheduling conflict related to childbirth and/or the peripartum period. A majority reported that full board certification had a significant effect on achieving academic promotion or professional partnership (52%), annual compensation (54%), and nonclinical professional commitments (58%) - these rates mirror those of surveyed early career male counterparts (n = 101). CONCLUSIONS: The current structure and scheduling of the ABR RO-IC examinations imposes noteworthy hurdles for many female radiation oncologists when entering the workforce. The recent transition to virtual examination platforms creates an important opportunity to increase flexibility in the structure and scheduling of the board examination process to improve equitable board certification practices.

Stereotactic Body Radiation Therapy for Apical Lung Tumors: Dosimetric Analysis of the Brachial Plexus and Preliminary Clinical Outcomes.

PURPOSE: Dosimetric constraints of the brachial plexus have not yet been well-established for patients undergoing stereotactic body radiation therapy (SBRT). This study evaluated long-term experience with the treatment of early-stage apical lung tumors with SBRT and reports on dosimetric correlates of outcome. METHODS AND MATERIALS: Between 2009 and 2018, a total of 78 consecutive patients with 81 apical lung tumors underwent SBRT for T1-3N0 non-small cell lung cancer. Apical tumors were those with tumor epicenter superior to the aortic arch. The brachial plexus (BP) was anatomically contoured according to the Radiation Therapy Oncology Group atlas. Patient medical records were reviewed retrospectively to determine incidence of brachial plexus injury (BPI) and a normal tissue complication probability model was applied to the dosimetric data. RESULTS: Five patients (6.4%) reported neuropathic symptoms consistent with BPI and occurred a median 11.9 months after treatment (range, 5.2-28.1 months). Most common dose and fractionation in those developing BPI were 50 Gy in 5 fractions (4 patients). Symptoms consisted of pain in 2 patients (40.0%), numbness in the hand or axilla in 4 patients (80.0%), and ipsilateral hand weakness in 1 patient (20.0%). In the overall cohort the median BP Dmax (EQD23 Gy) was 5.13 Gy (range, 0.18-217.2 Gy) and in patients with BPI the median BP Dmax (EQD23 Gy) was 32.14 Gy (range, 13.4-99.9 Gy). The normal tissue complication probability model gave good fit with an area under the curve of 0.75 (odds ratio, 7.3; 95% confidence interval, 0.8-68.3) for BP Dmax (EQD23 Gy) threshold of 20 Gy. CONCLUSIONS: Significant variation exists in the dose delivered to the brachial plexus for patients treated by SBRT for apical lung tumors. The incidence of neuropathic symptoms in the post-SBRT setting was appreciable and prospective clinical correlation with dosimetric information should be used to develop evidence-based dose constraints.

A Survey Study of Female Radiation Oncology Residents' Experiences to Inform Change.

PURPOSE: Women remain underrepresented at all levels within the field of radiation oncology. We sought to study current female residents' experiences and concerns to inform interventions to promote gender equity. Furthermore, we evaluated interest in a professional society specifically for women radiation oncologists. METHODS AND MATERIALS: An anonymous 76-item survey was designed and distributed to current women residents in radiation oncology in 2017-2018. Analyses describe personal, program, and family characteristics and experiences before and after joining the field. RESULTS: Of 170 female residents surveyed, 125 responded (74% response rate). Over one-quarter were in programs with ≤2 female residents (29%) and ≤2 female attendings (29%). One-third (34%) reported having children. Over half (51%) reported that lack of mentorship affected career ambitions. Over half (52%) agreed that gender-specific bias existed in their programs, and over a quarter (27%) reported they had experienced unwanted sexual comments, attention, or advances by a superior or colleague. Only 5% reported no symptoms of burnout. Almost all (95%) agreed that radiation oncology is perceived as family friendly; however, only 52% agreed that it actually is. An overwhelming majority (90%) expressed interest in joining a professional group for women in radiation oncology. CONCLUSIONS: In the first study to our knowledge to focus specifically on the experiences of women residents in radiation oncology, a number of areas for potential improvement were highlighted, including isolation and underrepresentation, mentorship needs, bias and harassment, and gender-based obstacles such as need for support during pregnancy and motherhood. These findings support the organization of groups such as the Society for Women in Radiation Oncology, which seeks to target these needs to promote gender equity.

#WomenWhoCurie: Leveraging Social Media to Promote Women in Radiation Oncology.

The proportion of female trainees in radiation oncology has generally declined despite increasing numbers of female medical students; as a result, radiation oncology is among the bottom 5 specialties in terms of the percentage of female applicants. Recently, social media has been harnessed as a tool to bring recognition to underrepresented groups within medicine and other fields. Inspired by the wide-reaching social media campaign of #ILookLikeASurgeon to promote female physicians, members of the Society for Women in Radiation Oncology penned a new hashtag and launched the #WomenWhoCurie social media campaign on Marie Curie's birthday November 7th, as part of their strategy to raise public awareness. From November 6, 2018 until November 10, 2018, the #WomenWhoCurie hashtag delivered 1,135,000 impressions, including 408 photos from all over the world including United States, Spain, Canada, France, Australia, Ireland, the United Kingdom, Mexico, Japan, the Netherlands, India, Ecuador, Panama, Brazil, and Nigeria. Alongside continued gender disparity research, social media should continue to be used as a tool to engage the community and spur conversations to formulate solutions for gender inequity.

Fellowship Training Programs in Radiation Oncology: A Snapshot From 2005 to 2017.

PURPOSE: Despite the proliferation of radiation oncology fellowship training programs over the last decade, limited data exist on their actual details. We present findings from a focused survey aiming to evaluate the experiences of fellowship-trained physicians. METHODS AND MATERIALS: A customized 23-item questionnaire was systematically distributed to 127 board-certified or eligible physicians who had completed a radiation oncology fellowship in the United States between 2005 and 2017 and whose contact information was available. The survey queried motivations for pursuing fellowship and aspects of training pertaining to expertise, mentorship, salary, employment outcome, satisfaction, and regret. RESULTS: A total of 92 subjects responded. Five were still in fellowship and 3 failed to complete the survey in its entirety, leaving 84 (56 male; 28 female) eligible for analysis. Graduates of US residencies comprised 62% of respondents. The desire to build a career in a particular treatment modality was most commonly cited as the primary motivation for pursuing fellowship (58%), followed by the desire to secure an academic faculty position (16%) and the desire to secure a job in a specific geographic location (14%). Subspecialty fellowships were most often done in proton therapy (27%) and brachytherapy (24%). Among the 26 people who completed proton fellowships, only 10 were currently practicing using protons (38%). The majority of fellows (52%) were compensated between $50,000 and $75,000 annually. Seventy-eight (93%) and 72 (86%) physicians were satisfied with fellowship training and their job after fellowship, respectively. Six of the 52 US graduates (12%) and 0 of the 32 international graduates (0%) reported that they would not recommend fellowship to others. CONCLUSIONS: The motivations for pursuing radiation oncology fellowships appear to be complex, and variability exists with respect to multiple aspects of training, including those related to satisfaction and employment outcomes.

Brachytherapy Training Survey of Radiation Oncology Residents.

PURPOSE: As brachytherapy utilization rates decline, we sought to evaluate the state of brachytherapy training during radiation oncology residency. METHODS AND MATERIALS: US radiation oncology residents in the Association of Residents in Radiation Oncology database were sent an online questionnaire regarding brachytherapy training. Survey questions addressed a wide array of topics, and responses were often given on a 1 to 5 Likert-type scale that reflected strength of opinion. Postgraduate year (PGY) 4/5 respondents' answers were analyzed. Descriptive statistics were generated, and rank correlation analyses (Kendall's τ coefficient and Wilcoxon signed-rank test) were used for comparisons. RESULTS: The survey was completed by 145 of 567 residents (62% being PGY4/5). Of PGY4/5 respondents, 96% (86 of 90) believed learning brachytherapy during residency was important, and 72% (65 of 90) felt their program valued brachytherapy training. Resident brachytherapy comfort varied by site, decreasing as follows: gynecologic, prostate, breast, skin. The current intracavitary 15-case minimum was believed adequate by most, but only a minority believed the 5-case interstitial minimum was adequate. Most respondents (59%) believed that caseload was the greatest barrier to achieving independence in brachytherapy. Significant support exists for American Brachytherapy Society training courses and on-the-job education to enhance training, but enthusiasm about pursuing brachytherapy fellowship training was low. Most respondents expressed confidence in developing a brachytherapy practice (54%); however, this was significantly lower than the rate of those confident in developing a stereotactic body radiation therapy/stereotactic radiosurgery program (97%) (P < .001). Furthermore, there was an association between aggregate number of brachytherapy cases performed and resident confidence in starting a brachytherapy practice (τ = 0.37; P < .001). CONCLUSIONS: Brachytherapy is an important component of residency training that is valued by residents and programs. Because caseload was the greatest perceived barrier in brachytherapy training, with confidence correlated with case volume, attempts should be made to expand opportunities for training experiences that are feasible to complete during residency.

The Employment Experience of Recent Graduates From US Radiation Oncology Training Programs: The Practice Entry Survey Results From 2012 to 2017.

PURPOSE: The Practice Entry Survey presentation is a highly anticipated session for the radiation oncology (RO) resident at the American Society for Radiation Oncology annual meeting. Each year the senior author reports the employment outcomes and job market experiences for the most recently graduated RO residents. METHODS: The Practice Entry Survey has been continuously administered annually to graduated RO residents since 1984 via the Association of Residents in Radiation Oncology directory. Six years of individual-level data, from 2012 to 2017, were readily available for analysis. The questionnaire queries the workforce placement experience and collects debt, salary, and benefits information. Respondents were subgrouped by practice type (academic vs private practice), and results were tested for trends over time. RESULTS: Survey data were collected from 302 recently graduated residents. There were 7 in fellowship and 1 practicing internationally, leaving 294 eligible for analysis. They identified themselves as working in either an academic setting (n = 150 [51%]) or private practice (n = 144 [49%]). First-year salaries for those in private practice were more than those in academics ($303,000; [interquartile range, $270,000-$375,000] versus $280,000 [interquartile range, $260,000-$325,000]; P < .01). With regard to the job search, 21.8% of respondents found their jobs through the online American Society for Radiation Oncology Career Center, while most respondents, 77.2%, found their jobs through other means. Respondents also ranked the items they found to be most helpful during the interview process. CONCLUSIONS: These data can help gauge the competitiveness of an offer as well as what to expect during the job hunt and interview process.

Quantitative clinical outcomes of therapy for head and neck lymphedema.

PURPOSE: Head and neck surgery and radiation cause tissue fibrosis that leads to functional limitations and lymphedema. The objective of this study was to determine whether lymphedema therapy after surgery and radiation for head and neck cancer decreases neck circumference, increases cervical range of motion, and improves pain scores. METHODS AND MATERIALS: A retrospective review of all patients with squamous cell carcinoma of the oral cavity, oropharynx, or larynx who were treated with high-dose radiation therapy at a single center between 2011 and 2012 was performed. Patients received definitive or postoperative radiation for squamous cell carcinoma of the oral cavity, oropharynx, or larynx. Patients were referred to a single, certified, lymphedema therapist with specialty training in head and neck cancer after completion of radiation treatment and healing of acute toxicity (typically 1-3 months). Patients underwent at least 3 months of manual lymphatic decongestion and skilled fibrotic techniques. Circumferential neck measurements and cervical range of motion were measured clinically at 1, 3, 6, 9, and 12 months after completion of radiation therapy. Pain scores were also recorded. RESULTS: Thirty-four consecutive patients were eligible and underwent a median of 6 months of lymphedema therapy (Range, 3-12 months). Clinically measured total neck circumference decreased in all patients with 1 month of treatment. Cervical rotation increased by 30.2% on the left and 27.9% on the right at 1 month and continued to improve up to 44.6% and 55.3%, respectively, at 12 months. Patients undergoing therapy had improved pain scores from 4.3 at baseline to 2.0 after 1 month. CONCLUSIONS: Lymphedema therapy is associated with objective improvements in range of motion, neck circumference, and pain scores in the majority of patients.

Concomitant HPV and MenACWY vaccination among sixth and seventh graders receiving Tdap.

OBJECTIVE: To describe use of human papilloma virus (HPV) and meningococcal (MenACWY) vaccines among sixth and seventh grade Kansas children receiving their school-required tetanus, diphtheria, and acellular pertussis (Tdap) booster. METHODS: We used Medicaid and commercial claims data in Kansas from 2013, 2014, and 2015 to identify HPV and MenACWY vaccinations among sixth and seventh graders receiving a Tdap booster. Rates of concomitant vaccinations were calculated at the state and county level, and logistic regression was used to identify predictors of concomitant vaccination. RESULTS: Of sixth and seventh graders in Kansas receiving their required Tdap booster, 53-82% failed to receive a concomitant HPV vaccine and 36-47% failed to receive a concomitant MenACWY vaccine from 2013 to 2015. Rates of concomitant vaccinations varied more than four-fold across counties. Female gender, younger age, and Medicaid (versus commercial insurance) were positively associated with concomitant vaccination; concomitant vaccination rates increased from 2013 to 2015 (p < 0.001). Of children continuously enrolled in Medicaid from 2013 to 2015, who did not receive concomitant vaccination in 2013, 72.3% and 68.6% remained unvaccinated against HPV and MenACWY, respectively by the end of 2015. CONCLUSIONS: Failure to get a concomitant vaccination at the time of their Tdap booster identifies children at high risk of not getting immunized in the ensuing 2-3 years. 'Back to school' programs focusing only on school-required vaccinations could have negative impacts on overall vaccination rates. Tracking rates of concomitant vaccination might be useful in supporting quality assessment and improvement efforts. CLINICAL TRIAL REGISTRATION: This study was not a clinical trial.

Current Therapeutic Approaches to DCIS.

Treatment for ductal carcinoma in-situ (DCIS) has historically been extrapolated from studies of invasive breast cancer. Accepted local therapy approaches range from small local excisions, with or without radiation, to bilateral mastectomies. Systemic treatment with endocrine therapy is often recommended for hormone positive patients. With improvements in imaging, pathologic review, and treatment techniques in the modern era, combined with new information regarding tumor biology, the management of DCIS is rapidly evolving. A multidisciplinary approach to treatment is now more important than ever, with a shift towards de-escalating therapy to reduce treatment related toxicity. This review focuses on nuances of clinical management of DCIS in the modern era, highlighting key differences between DCIS as compared to invasive breast cancer. The American Cancer Society (ACS) currently recommends beginning screening with annual mammograms for women age 45, with the option to start at age 40. As treatment of DCIS has not been shown to impact survival, the USPSTF has more conservative screening recommendations of biennial mammograms from age 50-74. Unlike invasive breast cancer, DCIS is almost exclusively diagnosed by mammographic detection, and lymph node evaluation is not recommended. Pathologic review of biopsy specimens should follow the guidelines of the College of American Pathologists. Surgical management options include breast conservation, mastectomy, or possibly nipple sparing mastectomy, with upfront sentinel lymph node evaluation in the case of mastectomy. Radiation therapy is generally recommended as a component of breast conserving therapy for patients with DCIS, though in some low risk patients, there is trial data to suggest that adjuvant radiation may be omitted. Techniques for minimizing radiation toxicity should always be emphasized. Endocrine therapy is offered to women with hormone positive DCIS who have undergone lumpectomy for risk reduction, and has the benefit of decreasing incidence of events in both the ipsilateral and contralateral breast. More recent studies have explored use of targeted treatments such as trastuzumab in DCIS for HER2 overexpression. Future directions include tailoring therapy based on patient characteristics and tumor biology. With so many different options for treatment, it is also critical to engage in a discussion with the patient to arrive at a treatment decision that balances patient preferences for disease control versus treatment toxicity, financial toxicity, cosmesis, and quality of life.