PRECISE: Preoperative Radiation Therapy to Elicit Critical Immune Stimulating Effects - A Phase 2 Clinical Trial.

PURPOSE: Radiation therapy is an underinvestigated tool for priming the immune system in intact human breast cancers. We sought here to investigate if a preoperative radiation therapy boost delivered was associated with a significant change in tumor-infiltrating lymphocytes (TILs) in the tumor in estrogen receptor positive, HER2Neu nonamplified breast cancers. METHODS AND MATERIALS: A total of 20 patients were enrolled in a phase 2 clinical trial and received either 7.5 Gy × 1 fraction or 2 Gy × 5 fractions, completed 6 to 8 days before surgery. Percent stromal TILs were evaluated on hematoxylin and eosin-stained samples. Short-term safety was assessed based on time to surgery, toxicities, and cosmesis up to 6 months after boost. RESULTS: Stromal TIL increased 6 to 8 days after completion of boost radiation therapy (median 3.0 [IQR, 1.0-6.5]) before radiation therapy versus median 5.0 (IQR, 1.5-8.0) after radiation therapy, P = .0037. Zero grade ≥3 toxicities up to 6 months after boost were experienced. In all, 94% (16/17) patients with 6-month follow-up cosmetic assessment after breast conservation had good-excellent cosmesis by physician assessment. CONCLUSION: In this phase 2 trial, preoperative radiation therapy boost resulted in a short-term increase in stromal TIL with minimal toxicities. Preoperative breast radiation therapy appears to be safe and may be a feasible means for priming the tumor microenvironment.

A method for empirically validating FMEA RPN scores in a radiation oncology clinic using physics QC data.

In failure modes and effects analysis (FMEA), the components of the risk priority number (RPN) for a failure mode (FM) are often chosen by consensus. We describe an empirical method for estimating the occurrence (O) and detectability (D) components of a RPN. The method requires for a given FM that its associated quality control measure be performed twice as is the case when a FM is checked for in an initial physics check and again during a weekly physics check. If instances of the FM caught by these checks are recorded, O and D can be computed. Incorporation of the remaining RPN component, Severity, is discussed. This method can be used as part of quality management design ahead of an anticipated FMEA or afterwards to validate consensus values.

Partial breast irradiation for patients with early-stage invasive breast cancer or ductal carcinoma in situ: an ASTRO clinical practice guideline

This guideline provides evidence-based recommendations on appropriate indications and techniques for partial breast irradiation (PBI) for patients with early-stage invasive breast cancer and ductal carcinoma in situ. ASTRO convened a task force to address 4 key questions focused on the appropriate indications and techniques for PBI as an alternative to whole breast irradiation (WBI) to result in similar rates of ipsilateral breast recurrence (IBR) and toxicity outcomes. Also addressed were aspects related to the technical delivery of PBI, including dose-fractionation regimens, target volumes, and treatment parameters for different PBI techniques. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. PBI delivered using 3-dimensional conformal radiation therapy, intensity modulated radiation therapy, multicatheter brachytherapy, and single-entry brachytherapy results in similar IBR as WBI with long-term follow-up. Some patient characteristics and tumor features were underrepresented in the randomized controlled trials, making it difficult to fully define IBR risks for patients with these features. Appropriate dose-fractionation regimens, target volume delineation, and treatment planning parameters for delivery of PBI are outlined. Intraoperative radiation therapy alone is associated with a higher IBR rate compared with WBI. A daily or every-other-day external beam PBI regimen is preferred over twice-daily regimens due to late toxicity concerns.

Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ: An ASTRO Clinical Practice Guideline.

PURPOSE: This guideline provides evidence-based recommendations on appropriate indications and techniques for partial breast irradiation (PBI) for patients with early-stage invasive breast cancer and ductal carcinoma in situ. METHODS: ASTRO convened a task force to address 4 key questions focused on the appropriate indications and techniques for PBI as an alternative to whole breast irradiation (WBI) to result in similar rates of ipsilateral breast recurrence (IBR) and toxicity outcomes. Also addressed were aspects related to the technical delivery of PBI, including dose-fractionation regimens, target volumes, and treatment parameters for different PBI techniques. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS: PBI delivered using 3-dimensional conformal radiation therapy, intensity modulated radiation therapy, multicatheter brachytherapy, and single-entry brachytherapy results in similar IBR as WBI with long-term follow-up. Some patient characteristics and tumor features were underrepresented in the randomized controlled trials, making it difficult to fully define IBR risks for patients with these features. Appropriate dose-fractionation regimens, target volume delineation, and treatment planning parameters for delivery of PBI are outlined. Intraoperative radiation therapy alone is associated with a higher IBR rate compared with WBI. A daily or every-other-day external beam PBI regimen is preferred over twice-daily regimens due to late toxicity concerns. CONCLUSIONS: Based on published data, the ASTRO task force has proposed recommendations to inform best clinical practices on the use of PBI.

Coping strategies to achieve food security among households with children in an urban poor community in Quezon City during COVID-19

Background@#In the Philippines, the prevalence of food insecurity increased during the COVID-19 pandemic, affecting the nutritional status of communities nationwide. Urban areas in particular are vulnerable to the harmful effects of food insecurity, and the effects are extended and magnified when it comes to children.@*Objectives@#This study aims to evaluate the coping strategies of households with children aged 0-10 years old in an urban poor community in Quezon City. In particular, the study will determine Coping Strategies Index (CSI) scores and the frequency of specific coping strategies used.@*Methods@#A descriptive cross-sectional study was conducted to assess the coping strategies of 405 households with children in the community during the pandemic. Mothers or caregivers were given a survey inquiring about the sociodemographic data and CSI.@*Results@#Sociodemographic profiling showed that the households generally belonged to class D and E (PhP 15,000 and below) income households (73.8%). The majority of the household heads (52.6%) have their highest educational attainment at the high school level. The majority (77.5%) of the households were categorized as having low CSI classification (90%CI: 73.9, 80.8). This could indicate that relief operations conducted in the community may have helped ease their food insecurity. Coping strategies that were most frequently employed by the households were depending on less preferred or more affordable food (74.8%), rationing money for prepared food (69.1%), and purchasing food on credit (58.5%).@*Conclusion@#Low CSI classification was noted, which may be due to increased adaptation to persistent food insecurity and the utilization of coping strategies not indicated in the questionnaire. Common coping strategies used by households include reliance on less favored or less costly food items, rationing resources for prepared food, and food on credit. It is recommended that the results collected be used to target food availability and accessibility interventions in the community.

It's the little THANGS: Recording frequently unreported errors for dosimetry quality improvement.

The reporting of errors resulting in dose deviations are well-studied. Less studied is the amount of inconsequential errors that will not harm the patient but could lead to inefficiency. This paper reports an institutional effort to quantify and reduce these less significant errors. Dosimetry items discovered during physicist plan/record and verify (R&V) check prior to treatment were recorded in a shared document and called Therapy Anomaly Gathering System (THANGS) and individual items were called a "thang." Items were categorized to 1 of 4 types: Treatment Plan, Plan Document, R&V, and Secondary MU. The aggregate numbers were presented to the dosimetry staff at regular staff meetings. It was emphasized to the staff that this was a Quality Improvement (QI) study and would not be used punitively. Thangs were tracked over a 4-year period. In Q1 of year 1 of the study, the average number of errors identified was 179/month. This was reduced to 114/month by Q4 of year 1 and 68/month by the end of year 4, a 62% reduction. The number of errors/plan in Q1 Year 1 was 1.25, and that was reduced by Q4 Year 4 to 0.4, a 68% reduction. The percentage of errors by type did not vary much over the 4 years. By far, R&V errors were the most common, and QI efforts were primarily aimed at them. We have developed a simple method to identify areas in dosimetric work that are vulnerable to minor errors and, through consistent reminders, drastically reduce them. This leads to a seamless throughput for a given plan ultimately resulting in improved physics, therapist, and most importantly patient satisfaction.

MPLA case: I didn't realize those were the expectations!

This work of fiction is part of a case study series developed by the Medical Physics Leadership Academy (MPLA). It is intended to facilitate the discussion of how students and advisors can better communicate expectations and navigate difficult conversations. In this case, a fourth-year Ph.D. student Emma learns that her advisor Dr. So is leaving the institution and has not arranged to bring any students with him. As Emma and Dr. So meet to discuss Emma's next steps, the conversation reveals misunderstandings and miscommunications of expectations, including a specific publication requirement for graduation from Dr. So. Having just learned of Dr. So's publication requirement, Emma realizes that graduating before the lab shuts down is not feasible. The intended use of this case, through group discussion or self-study, is to encourage readers to discuss the situation at hand and inspire professionalism and leadership thinking. This case study falls under the scope of and is supported by the MPLA, a committee in the American Association of Physicists in Medicine (AAPM).

MPLA case: How do you lead as a lead physicist?

This work of fiction is part of a case study series developed by the Medical Physics Leadership Academy (MPLA). It is intended to facilitate the discussion of the managerial and leadership challenges faced by a clinical medical physicist. In this case, a physicist David used to work in a clinic where he thrived and felt like a leader, despite not having the title. After a job change, he is now officially the "Lead Physicist" at a hospital newly affiliated with a large academic healthcare system. He believes he will be equally successful. Yet he struggles to bring about changes and get buy-in from coworkers. In the end, he feels like giving up and considers changing his job. This case is in the scenario of Problem Diagnosis.i The intended use of this case, through group discussion or self-study, is to encourage readers to perform a comprehensive analysis that identifies the root cause of the problem. This case study falls under the scope of and is supported by the MPLA, a committee in the American Association of Physicists in Medicine (AAPM).

Food security status of households with children aged 0-10 in an urban poor community in Quezon City, Philippines during the COVID-19 pandemic

Background@#The COVID-19 pandemic and its effects such as community restrictions, lockdowns, and unemployment have greatly affected the household food security status in urban poor communities leading to poor accessibility of sufficient nutritious food and subsequently affecting the nutrition of children.@*Objectives@#This present study aims to determine the prevalence of household food insecurity in households with children aged 0-10 amid the COVID-19 pandemic in an urban poor community in Quezon City.@*Methodology@#A descriptive cross-sectional study was done to evaluate the food security status and experiences of households amid the COVID-19 pandemic.@*Results@#A total of 405 households were surveyed to answer questions designed to determine their general profile relative to their food security experiences during the pandemic. It was observed that the majority of the households in the urban poor community belong to Class D earning between PhP 8,001.00 - PhP 15,000.00. The heads of these households as well as caregivers mostly belong to the high school graduate level. Based on the conducted survey, it was revealed that 59.5% of the households were severely food insecure (90% CI: 55.4-63.4) and only 4.2% ( 90% CI: 2.8-6.2) were food secure. @*Conclusion@#The prevalence of food insecurity in the urban poor community is determined to be high, with 31.6% households having moderate food insecurity, while only 4.2% households are food secure. The majority of surveyed households were anxious and uncertain about their food supply, and also reported experiencing varying levels of food insecurity related to sufficiency of food quality.

Implementation and Evaluation of a TG-275 Key Recommendation: An Additional Early Physics Check.

PURPOSE: We report our experience of performing an extra, earlier physics plan check as recommended by the American Association of Physicists in Medicine Task Group 100 and Task Group 275 reports. We assessed utilization and timing of the extra check as well as the time required in a medium-sized clinic. METHODS AND MATERIALS: We retrospectively extracted and analyzed timestamp data from the record and verify system for the quality checklist (QCL) items related to treatment planning and physics "prechecks" for 3487 patients treated at our institution from February 2017 to February 2021. The dosimetry staff was interviewed for their perception of the value and efficacy of the practice. RESULTS: Physics prechecks were requested for 19.0% of plans. The number of requests declined from 43.9% of cases in 2017 to 18.4% in 2018. The introduction of automated plan-check tools and a dosimetrist checklist further contributed to a drop in number of precheck requests to 3.5% in 2019. For patients who received a physics precheck, the treatment planning process was a median 3.6 hours longer compared with those without (P < .001). A total of 12.9% of the precheck requests were canceled by the dosimetrist after waiting a median time of 5.3 hours. There was a strong positive correlation (0.899) between a precheck being requested and the time remaining until treatment start. Higher complexity plans and plans with a specific concern (eg, possible collision) were more likely to have a precheck requested. CONCLUSIONS: Physics prechecks have become standard practice for certain cases in our clinic. However, the perception in the department was that, as a universal practice, waiting for a precheck was not worth the time saved redoing work on the few cases in which an error was caught. Dosimetrist access to automated checking tools and checklists, which were motivated by the precheck process, contributed to this perception.

MPLA Case 3: Don't criticize me in public!

This work of fiction re-enacts a scenario in which a medical physics resident was not able to address a physics call during patient simulation and was criticized by the supervising faculty physicist in front of the team and the patient. The resident and the faculty agreed to meet afterwards to debrief the situation, in the hope of establishing a better working relationship. The intended use of this case, through group discussion, self-study, or role-play, is to encourage readers to discuss the situation at hand, inspire professionalism and leadership thinking, and allow the practice of conflict management. Facilitator's notes are available upon request to the MPLA Cases Subcommittee. This case study falls under the scope of and is supported by the Medical Physics Leadership Academy (MPLA), a committee in the American Association of Physicists in Medicine (AAPM).

MPLA Case 1: Implementing Cone-Beam CT in a Community Hospital.

This fictional case describes a managerial situation of implementing cone-beam computed tomography faced by a solo medical physicist in a rural community hospital. The intended use of the case study, in either a facilitated learning session or self-study, is to inspire the readers to discuss the situation, analyze the institutional and personal factors, apply relevant leadership skills, and propose action plans. This case study falls under the scope of, and is supported by, the Medical Physics Leadership Academy (MPLA). A sample facilitator's guide or self-study guide is included in the manuscript for reference by users of this case study.

MPLA Case 2: A junior physicist attempts to improve radiotherapy workflow.

This fictional case describes the challenging situation for a junior physicist, who joined her hometown's cancer center as a solo physicist after graduating from residency. She is concerned about providing optimal patient care as well as improving her work/life balance. She wonders how to move forward. The intended use of the case study, in either a facilitated learning session or self-study, is to inspire the readers to discuss the situation, analyze the institutional and personal factors, apply relevant leadership skills, and propose action plans. This case study falls under the scope of, and is supported by, the Medical Physics Leadership Academy (MPLA). A sample facilitator's guide or self-study guide is available upon request to the MPLA Cases Subcommittee.

Rural and Urban Differences in Household Food Insecurity and Diet Diversity of Preschool Children (PSC) in Occidental Mindoro

Objective@#Rural and urban differences affect food availability, accessibility, and sustainability; thus, it has a great impact on household food security and dietary diversity. The relationship between the human environment and other factors threatens different domains of food systems resulting in food security. The objective of this study is to determine significant differences between the prevalence of household food security and diet diversity between urban and rural communities in Occidental Mindoro. Specifically, to determine the pattern of usual food intake of preschool children between rural and urban communities @*Methods@#This study utilized a comparative, cross-sectional, analytic study design in order to determine the prevalence of each variable of interest in the two study areas. Radimer-Cornell Tool was utilized to assess the food security status of the household while the FAO-Dietary Diversity Score Questionnaire was used to the diversity of diet among PSC. A total of 480 (rural: n=240; urban: n=240) preschool children were recruited to participate in this study. Ratio and proportion using the point and interval estimate were used to determine the prevalence in different areas, meanwhile, chi-square of homogeneity was used to determine significant difference in the two areas under study. @* Results@#Food insecurity in rural communities was found to be at 56.25% (95% CI: 49.97% to 62.53%) while the prevalence in urban communities was 45.83% (95% CI: 39.53% to 52.14%). There was a significant difference in the prevalence of household food insecurity between rural and urban communities (p=0.0224). Meanwhile, the prevalence of less dietary diversity among preschool children in rural communities was 37.08% (95%: 30.97% to 43.19%) and 26.25% (CI: 20.68% to 31.82%) for urban communities. There was a significant difference in prevalence of low dietary diversity score among preschool children between rural and urban communities (p=0.0107). @*Conclusion@#There were significant differences in terms of household food insecurity and less diverse diet between two community settings. Higher prevalence in rural areas signifies that there is a need to prioritize these vulnerable communities in terms of hunger mitigation and nutrition programs. A combination of milk-rice-meat-fish was observed in the diet of preschool children for both communities however, higher prevalence of less dietary diversity was detected among rural communities.

Rural and Urban Differences in Household Food Insecurity and Diet Diversity of Preschool Children (PSC) in Occidental Mindoro

@#Objective. Rural and urban differences affect food availability, accessibility, and sustainability; thus, it has a great impact on household food security and dietary diversity. The relationship between the human environment and other factors threatens different domains of food systems resulting in food security. The objective of this study is to determine significant differences between the prevalence of household food security and diet diversity between urban and rural communities in Occidental Mindoro. Specifically, to determine the pattern of usual food intake of preschool children between rural and urban communities Methods. This study utilized a comparative, cross-sectional, analytic study design in order to determine the prevalence of each variable of interest in the two study areas. Radimer-Cornell Tool was utilized to assess the food security status of the household while the FAO-Dietary Diversity Score Questionnaire was used to the diversity of diet among PSC. A total of 480 (rural: n=240; urban: n=240) preschool children were recruited to participate in this study. Ratio and proportion using the point and interval estimate were used to determine the prevalence in different areas, meanwhile, chi-square of homogeneity was used to determine significant difference in the two areas under study. Results. Food insecurity in rural communities was found to be at 56.25% (95% CI: 49.97% to 62.53%) while the prevalence in urban communities was 45.83% (95% CI: 39.53% to 52.14%). There was a significant difference in the prevalence of household food insecurity between rural and urban communities (p=0.0224). Meanwhile, the prevalence of less dietary diversity among preschool children in rural communities was 37.08% (95%: 30.97% to 43.19%) and 26.25% (CI: 20.68% to 31.82%) for urban communities. There was a significant difference in prevalence of low dietary diversity score among preschool children between rural and urban communities (p=0.0107). Conclusion. There were significant differences in terms of household food insecurity and less diverse diet between two community settings. Higher prevalence in rural areas signifies that there is a need to prioritize these vulnerable communities in terms of hunger mitigation and nutrition programs. A combination of milk-rice-meat-fish was observed in the diet of preschool children for both communities however, higher prevalence of less dietary diversity was detected among rural communities.