Prognostic impact and causality of age on oncological outcomes in women with endometrial cancer: a multimethod analysis of the randomised PORTEC-1, PORTEC-2, and PORTEC-3 trials.

BACKGROUND: Numerous studies have shown that older women with endometrial cancer have a higher risk of recurrence and cancer-related death. However, it remains unclear whether older age is a causal prognostic factor, or whether other risk factors become increasingly common with age. We aimed to address this question with a unique multimethod study design using state-of-the-art statistical and causal inference techniques on datasets of three large, randomised trials. METHODS: In this multimethod analysis, data from 1801 women participating in the randomised PORTEC-1, PORTEC-2, and PORTEC-3 trials were used for statistical analyses and causal inference. The cohort included 714 patients with intermediate-risk endometrial cancer, 427 patients with high-intermediate risk endometrial cancer, and 660 patients with high-risk endometrial cancer. Associations of age with clinicopathological and molecular features were analysed using non-parametric tests. Multivariable competing risk analyses were performed to determine the independent prognostic value of age. To analyse age as a causal prognostic variable, a deep learning causal inference model called AutoCI was used. FINDINGS: Median follow-up as estimated using the reversed Kaplan-Meier method was 12·3 years (95% CI 11·9-12·6) for PORTEC-1, 10·5 years (10·2-10·7) for PORTEC-2, and 6·1 years (5·9-6·3) for PORTEC-3. Both overall recurrence and endometrial cancer-specific death significantly increased with age. Moreover, older women had a higher frequency of deep myometrial invasion, serous tumour histology, and p53-abnormal tumours. Age was an independent risk factor for both overall recurrence (hazard ratio [HR] 1·02 per year, 95% CI 1·01-1·04; p=0·0012) and endometrial cancer-specific death (HR 1·03 per year, 1·01-1·05; p=0·0012) and was identified as a significant causal variable. INTERPRETATION: This study showed that advanced age was associated with more aggressive tumour features in women with endometrial cancer, and was independently and causally related to worse oncological outcomes. Therefore, our findings suggest that older women with endometrial cancer should not be excluded from diagnostic assessments, molecular testing, and adjuvant therapy based on their age alone. FUNDING: None.

Survival in esophageal cancer with nonregional lymphadenopathy: a propensity score-matched analysis.

BACKGROUND: Survival among patients with esophageal cancer with stage IV nonregional lymphadenopathy treated with neoadjuvant therapy and surgical resection is not well described. This study aimed to compare the survival outcomes of patients with nonregional lymphadenopathy with a propensity-matched cohort of patients with locoregional disease. METHODS: This was a retrospective cohort analysis of a prospectively maintained database from a regional upper gastrointestinal cancer network in Quebec, Canada. From January 2010 to December 2022, patients with radiologically suspicious nonregional retroperitoneal or supraclavicular lymphadenopathy were identified. Using 1:1 propensity score matching, a control group without nonregional disease was created. RESULTS: Of the 1235 patients identified, 39 met the inclusion criteria and were allocated to the study group of whom 35 of 39 (89%) had adenocarcinoma. Retroperitoneal and supraclavicular lymphadenopathy occurred in 26 of 39 patients (67%) and 13 of 39 patients (33%). Of the 39 patients, 34 (87%) received neoadjuvant chemotherapy, and 5 (13%) received chemoradiotherapy. After resection, ypN0 of nonregional lymph node stations occurred in 21 of 39 patients (54%). When comparing the study group with a matched non-stage IV control group, the median overall survival was similar in patients with retroperitoneal lymphadenopathy (21.0 months [95% CI, 8.0-21.0] vs 27.0 months [95% CI, 13.0-41.0]; P = .262) but not with supraclavicular disease (13.0 months; 95% CI, 8.0-18.0; P = .039). The median follow-up intervals were 40.1 months (95% CI, 1.0-83.0) for the study group and 70.0 (95% CI, 33.0-106.0) for the control groups. CONCLUSION: Compared with a matched cohort of patients with similar disease burden but not stage IV disease, retroperitoneal lymphadenopathy did not negatively affect survival outcomes. Multimodal curative intent therapy may be appropriate in select cases.

The Impact on Peer Mentorship After Implementation of a Competency-Based Residency Curriculum in Canadian Radiation Oncology Training Programs.

Purpose: Peer mentorship provides professional and personal support between physicians with similar experiences and levels of training. While peer mentorship has shown to benefit academic success and professional growth, little data has examined contextual factors, such as curricular change, that may affect the quality of these relationships. This study aims to explore the impact of a new, nationwide radiation oncology (RO) residency curriculum, known as competence by design (CBD), on peer mentorship experiences between Canadian RO residents. Methods and Materials: A qualitative study, with a social constructivist approach, was conducted with 2 groups of Canadian RO residents. The first were those in the academic year before CBD implementation (non-CBD cohort), and the second were those in the inaugural year of CBD (CBD cohort). Semistructured 1-on-1 interviews were conducted to explore experiences of peer mentorship as it related to curriculum change. Interviews were transcribed and analyzed with deductive and inductive methods until data saturation. Results: Between April and December 2021, 14 participants (6 non-CBD and 8 CBD residents) from 8 out of 10 eligible English-speaking RO training programs across Canada participated. Three major themes were identified: (1) the CBD cohort identified fewer opportunities for peer mentorship, with specific concerns regarding new evaluation processes and uncertainty about the later stages of training; (2) there was minimal impact on specialty-specific learning; and (3) peer mentorship thrived when occurring as spontaneous in-person interactions. Conclusions: Inaugural residents of a CBD curriculum perceived fewer opportunities for peer mentorship. There were specific concerns about new evaluative processes, though this did not affect specialty-specific learning. Peer mentorship was most impactful as informal and in-person interactions. Our findings suggest that unintended consequences of curriculum change may be mitigated by improving communication about new training objectives and increasing opportunities for informal interactions between residents.

A Qualitative Analysis of Medical Student Reflections Following Participation in a Canadian Radiation Oncology Studentship.

Exposure to radiation oncology in medical school curricula is limited; thus, mentorship and research opportunities like the Dr. Pamela Catton Summer Studentship Program attempt to bridge this gap and stimulate interest in the specialty. In 2021, the studentship was redesigned as virtual research, mentorship, and case-based discussions due to the COVID-19 pandemic. This study explores the impact of COVID-19 on the studentship, on students' perceptions of the program, and on medical training and career choice. Fifteen studentship completion essays during 2021-2022 were obtained and anonymized. Thematic analysis was performed to interpret the essays with NVivo. Two independent reviewers coded the essays. Themes were established by identifying connections between coded excerpts. Consensus was achieved through multiple rounds of discussion and iteratively reviewing each theme. Representative quotes were used to illustrate the themes. The themes confirmed the studentship was feasible during the pandemic. Perceived benefits of the program included mentorship and networking opportunities; gaining practical and fundamental knowledge in radiation oncology; developing clinical and research skills; and creating positive attitudes towards radiation oncology and the humanistic aspect of the field. The studentship supported medical specialty selection by helping define student values, shaping perceptions of the specialty, and promoting self-reflection upon students' personal needs. This study informs future iterations of the studentship to promote radiation oncology in Canadian medical school curricula. It serves as a model for studentships in other specialties that have limited exposure and similar challenges with medical student recruitment.

Survival and perioperative outcomes of octo- and nonagenarians with resectable esophageal carcinoma.

The outcomes of different treatment modalities for patients aged 80 and above with locally advanced and resectable esophageal carcinoma are not well described. The aim of this study was to explore survival and perioperative outcomes among this specific group of patients. A retrospective, cohort analysis was performed on a prospectively maintained esophageal cancer database from the McGill regional upper gastroinestinal cancer network. Between 2010 and 2020, all patients ≥80 years with cT2-4a, Nany, M0 esophageal carcinoma were identified and stratified according to the treatment modality: Neoadjuvant chemotherapy (nCT) or chemoradiotherapy (nCRT); definitive CRT (dCRT); upfront surgery; palliative CT/RT; or best supportive care (BSC). Of the 162 patients identified, 79 were included in this study. The median age was 83 years (80-97), most were cT3 (73%), cN- (56%), and had adenocarcinoma (62%). Treatment included: nCT/nCRT (16/79, 20%); surgery alone (19/79, 24%); dCRT (12/29, 15%); palliative RT/CT (27/79, 34%); and BSC (5/79, 6%). Neoadjuvant treatment was completed in 10/16 (63%). Of the 35/79 who underwent surgery, major complications occurred in 13/35 (37%) and 90-day mortality in 3/35 (9%). Overall survival (OS) for the cohort at 1- and 3-years was 58% and 19%. Among patients treated with nCT/nCRT, this was 94% and 46% respectively. Curative intent treatment (nCT/nCRT/upfront surgery/dCRT) had significantly increased 1- and 3- year OS compared with non-curative treatment (76%/31% vs. 34%/3.3%). Multimodal standard of care treatment is feasible and safe in select octo/nonagenarians, and may be associated with improved OS. Age alone should not bias against treatment with curative intent.

Safety and Efficacy of 2D Brachytherapy vs. 3D Image-Guided Adaptive Brachytherapy for Locally Advanced Cervical Cancer-A Single Institution Retrospective Study.

BACKGROUND: The treatment paradigm for locally advanced cervical cancer (LACC) has shifted from two-dimensional-brachytherapy (2D-BT) to three-dimensional-image-guided adaptive BT (3D-IGABT). In this retrospective study, we report our experience with the change from 2D-BT to 3D-IGABT. METHODS: We reviewed 146 LACC patients (98 3D-IGABT and 48 2D-BT) who received chemoradiation between 2004 and 2019. The multivariable odds ratio (OR) for treatment-related toxicities and hazard ratios (HR) for locoregional control (LRC), distant control (DC), failure-free survival (FFS), cancer-specific survival (CSS) and overall survival (OS) are reported. RESULTS: The median follow-up was 50.3 months. There was a significant decrease in overall late toxicities in the 3D-IGABT group compared to the 2D-BT group (OR 0.22[0.10-0.52]), late gastrointestinal (OR 0.31[0.10-0.93]), genitourinary (OR 0.31[0.09-1.01]) and vaginal toxicities (0% vs. 29.6%). Grade ≥ 3 toxicity was low in both groups (2D-BT: 8.2% acute, 13.3% late vs. 3D-IGABT: 6.3% acute, 4.4% late, NS). The five-year LRC, DC, FFS, CSS and OS for 3D-IGABT were 92.0%, 63.4%, 61.7%, 75.4% and 73.6%, compared to 87.3%, 71.8%, 63.7%, 76.3% and 70.8% for 2D-BT (NS). CONCLUSIONS: 3D-IGABT for the treatment of LACC is associated with a decrease in overall late gastrointestinal, genitourinary and vaginal toxicities. The disease control or survival outcomes were comparable to contemporary 3D-IGABT studies.

Advances in Radiation Oncology for the Treatment of Cervical Cancer.

BACKGROUND: Over the past two decades, there has been significant advancement in the management of cervical cancer, particularly in the domain of definitive chemoradiotherapy for locally advanced cervical cancer (LACC). Indeed, radiation treatment paradigms have shifted from a two-dimensional (2D) approach solely based on anatomical bony landmarks, to an image-guided three-dimensional (3D) approach, with the goal of delivering doses more precisely to clinical targets with an increased sparing of organs-at-risk. METHODS: This is a narrative review on the advances in radiation technologies for the treatment of cervical cancer. Using the PubMed database, we identified articles published in English up until November 18, 2021 on the treatment of LACC with external beam radiotherapy (EBRT) and brachytherapy. A search of the Clinicaltrials.gov and Clinicaltrialsregister.eu retrieved information on ongoing clinical trials on the topic of combined immunotherapy and radiotherapy in cervical cancer. RESULTS: We highlight the historical evolution from the use of 2D radiotherapy to 3D-conformal radiotherapy, and then intensity modulated radiotherapy (IMRT) for the delivery of EBRT. We also discuss advances in brachytherapy, notably the transition to 3D image-guided adaptive brachytherapy (3D-IGABT). In this context, we highlight large cohort studies that were recently constructed and have shown significant improvement in local control and treatment-related toxicities with 3D-IGABT. Finally, we discuss other advances in the field, notably the use of stereotactic body radiotherapy (SBRT) as a substitute to brachytherapy, and the addition of immunotherapy to chemoradiation. CONCLUSIONS: The use of IG-IMRT and 3D-IGABT have considerably improved treatment outcomes and toxicity profiles for patients with LACC, and are now considered the gold standard in many countries. The use of SBRT boost as a replacement for brachytherapy has been associated with increased toxicity and decreased efficacy and should be used with caution in the context of clinical trials. New experimental approaches include the addition of immunotherapy to chemoradiation regimens.

A transfer learning approach to facilitate ComBat-based harmonization of multicentre radiomic features in new datasets.

PURPOSE: To facilitate the demonstration of the prognostic value of radiomics, multicenter radiomics studies are needed. Pooling radiomic features of such data in a statistical analysis is however challenging, as they are sensitive to the variability in scanner models, acquisition protocols and reconstruction settings, which is often unavoidable in a multicentre retrospective analysis. A statistical harmonization strategy called ComBat was utilized in radiomics studies to deal with the "center-effect". The goal of the present work was to integrate a transfer learning (TL) technique within ComBat-and recently developed alternate versions of ComBat with improved flexibility (M-ComBat) and robustness (B-ComBat)-to allow the use of a previously determined harmonization transform to the radiomic feature values of new patients from an already known center. MATERIAL AND METHODS: The proposed TL approach were incorporated in the four versions of ComBat (standard, B, M, and B-M ComBat). The proposed approach was evaluated using a dataset of 189 locally advanced cervical cancer patients from 3 centers, with magnetic resonance imaging (MRI) and positron emission tomography (PET) images, with the clinical endpoint of predicting local failure. The impact performance of the TL approach was evaluated by comparing the harmonization achieved using only parts of the data to the reference (harmonization achieved using all the available data). It was performed through three different machine learning pipelines. RESULTS: The proposed TL technique was successful in harmonizing features of new patients from a known center in all versions of ComBat, leading to predictive models reaching similar performance as the ones developed using the features harmonized with all the data available. CONCLUSION: The proposed TL approach enables applying a previously determined ComBat transform to new, previously unseen data.

Satisfaction among Cancer Patients Undergoing Radiotherapy during the COVID-19 Pandemic: An Institutional Experience.

The COVID-19 pandemic has shifted oncology practices to prioritize patient safety while maintaining necessary treatment delivery. We obtained patient feedback on pandemic-based practices in our radiotherapy department to improve quality of patient care and amend policies as needed. We developed a piloted questionnaire which quantitatively and qualitatively assessed patients' pandemic-related concerns and satisfaction with specific elements of their care. Adult patients who were treated at our Centre between 23 March and 31 May 2020, had initial consultation via telemedicine, and received at least five outpatient fractions of radiotherapy were invited to complete the survey by telephone or online. Relative frequencies of categorical and ordinal responses were then calculated. Fifty-three (48%) out of 110 eligible patients responded: 32 patients by phone and 21 patients online. Eighteen participants (34%) admitted to feeling anxious about hospital appointments, and only five (9%) reported treatment delays. Forty-eight patients (91%) reported satisfaction with their initial telemedicine appointment. The majority of patients indicated that healthcare workers took appropriate precautions, making them feel safe. Overall, all 53 patients (100%) reported being satisfied with their treatment experience during the pandemic. Patient feedback is needed to provide the highest quality of patient care as we adapt to the current reality.

Convolutional neural networks for PET functional volume fully automatic segmentation: development and validation in a multi-center setting.

PURPOSE: In this work, we addressed fully automatic determination of tumor functional uptake from positron emission tomography (PET) images without relying on other image modalities or additional prior constraints, in the context of multicenter images with heterogeneous characteristics. METHODS: In cervical cancer, an additional challenge is the location of the tumor uptake near or even stuck to the bladder. PET datasets of 232 patients from five institutions were exploited. To avoid unreliable manual delineations, the ground truth was generated with a semi-automated approach: a volume containing the tumor and excluding the bladder was first manually determined, then a well-validated, semi-automated approach relying on the Fuzzy locally Adaptive Bayesian (FLAB) algorithm was applied to generate the ground truth. Our model built on the U-Net architecture incorporates residual blocks with concurrent spatial squeeze and excitation modules, as well as learnable non-linear downsampling and upsampling blocks. Experiments relied on cross-validation (four institutions for training and validation, and the fifth for testing). RESULTS: The model achieved good Dice similarity coefficient (DSC) with little variability across institutions (0.80 ± 0.03), with higher recall (0.90 ± 0.05) than precision (0.75 ± 0.05) and improved results over the standard U-Net (DSC 0.77 ± 0.05, recall 0.87 ± 0.02, precision 0.74 ± 0.08). Both vastly outperformed a fixed threshold at 40% of SUVmax (DSC 0.33 ± 0.15, recall 0.52 ± 0.17, precision 0.30 ± 0.16). In all cases, the model could determine the tumor uptake without including the bladder. Neither shape priors nor anatomical information was required to achieve efficient training. CONCLUSION: The proposed method could facilitate the deployment of a fully automated radiomics pipeline in such a challenging multicenter context.

Can intermediate-energy sources lead to elevated bone doses for prostate and head & neck high-dose-rate brachytherapy?

PURPOSE: Several radionuclides with high (60Co, 75Se) and intermediate (169Yb, 153Gd) energies have been investigated as alternatives to 192Ir for high-dose-rate brachytherapy. The purpose of this study was to evaluate the impact of tissue heterogeneities for these five high- to intermediate-energy sources in prostate and head & neck brachytherapy. METHODS AND MATERIALS: Treatment plans were generated for a cohort of prostate (n = 10) and oral tongue (n = 10) patients. Dose calculations were performed using RapidBrachyMCTPS, an in-house Geant4-based Monte Carlo treatment planning system. Treatment plans were simulated using 60Co, 192Ir, 75Se, 169Yb, and 153Gd as the active core of the microSelectron v2 source. Two dose calculation scenarios were presented: (1) dose to water in water (Dw,w), and (2) dose to medium in medium (Dm,m). RESULTS: Dw,w overestimates planning target volume coverage compared with Dm,m, regardless of photon energy. The average planning target volume D90 reduction was ∼1% for high-energy sources, whereas larger differences were observed for intermediate-energy sources (1%-2% for prostate and 4%-7% for oral tongue). Dose differences were not clinically relevant (<5%) for soft tissues in general. Going from Dw,w to Dm,m, bone doses were increased two- to three-fold for 169Yb and four- to five-fold for 153Gd, whereas the ratio was close to ∼1 for high-energy sources. CONCLUSIONS: Dw,w underestimates the dose to bones and, to a lesser extent, overestimates the dose to soft tissues for radionuclides with average energies lower than 192Ir. Further studies regarding bone toxicities are needed before intermediate-energy sources can be adopted in cases where bones are in close vicinity to the tumor.

Promoting Career Selection Through a Comprehensive Enrichment Experience: A Review of the Canadian Radiation Oncology Summer Studentship.

PURPOSE: The impact that early clinical exposure to radiation oncology has on medical students' understanding of oncology and career choice is understudied. This study aims to review the experience and outcomes of medical students who participated in the Canadian Association of Radiation Oncology-Canadian Radiation Oncology Foundation 6-week summer studentship. METHODS AND MATERIALS: Medical students who participated in the nationally funded studentship from 2014 to 2018 were asked to fill out a survey after completing the program. The survey asked about student experience related to radiation oncology before the studentship, student satisfaction with the studentship (scale of 1-5; 5 = outstanding, 3 = meets expectations, 1 = unsatisfactory), and student willingness to recommend it to other students (scale of 1-10; 1 = strongly disagree, 5 = neutral, 10 = strongly agree). The effect of studentship on interest in the specialty was assessed (scale of 1-10; 1 = strongly disagree, 5 = neutral, 10 = strongly agree), including intent to direct their career toward radiation oncology. Match rates to radiation oncology residency are reported for students who participated in the studentship from 2013 to 2016. RESULTS: All 31 students responded to the survey. Overall, the program was highly rated: inclusion of a broad range of clinical problems (mean = 4.6/5); opportunity to learn assessment, investigation, and management (mean = 4.2/5); and overall educational value (mean = 4.8/5). Poststudentship, most students reported an increased interest in oncology (76%, n = 22/29), and specifically radiation oncology (83%, n = 24/29). They would highly recommend this program to another medical student (mean = 9.8/10). The average percentage of these students entering a radiation oncology career (30.5%) each year was higher than national residency match rates in radiation oncology (0.7%). CONCLUSIONS: Clinical exposure to radiation oncology through a nationally funded Canadian Association of Radiation Oncology-Canadian Radiation Oncology Foundation summer studentship positively affected medical student interest in oncology. This study suggests a potential effect of the studentship program on career selection of radiation oncology.

A guide to curriculum inquiry for brachytherapy simulation-based medical education.

PURPOSE: Brachytherapy is a required clinical competency within radiation oncology training but decreased utilization and volume have limited trainee exposure. Simulation-based medical education is an established educational tool that allows learners to engage in higher-order learning in a safe space and has unique application in brachytherapy instruction. METHODS AND MATERIALS: We reviewed best practices in curriculum development for simulation-based medical education in brachytherapy, current works in brachytherapy simulation, and identify areas for future development. RESULTS: The systematic curriculum inquiry method as it relates to brachytherapy was described using the "six-step approach" of problem identification and general needs assessment, targeted needs assessment, goals and objectives, educational strategies, implementation, and evaluation and feedback. Best practices in simulation identified several features of effective learning, including feedback, repetitive practice, and curriculum integration. A review of current simulation-based medical education brachytherapy publications revealed five manuscripts to date with a focus on feasibility across a variety of disease sites, including the prostate, cervical, breast, and head and neck. Potential areas of future development include curricular quality improvement, long-term outcomes, objectives that scale to the learner's competencies, and expansion beyond psychomotor skills. CONCLUSIONS: Brachytherapy is an essential modality in radiation oncology. Simulation-based medical education provides a powerful opportunity to improve brachytherapy training effectively.

MRI-based interstitial brachytherapy for vaginal tumors: A multi-institutional study on practice patterns, contouring, and consensus definitions of target volumes.

PURPOSE: Interstitial brachytherapy (ISBT) can be effective for vaginal tumors due to its ability to deliver conformal treatment with 3D planning. As there is no consensus for 3D vaginal brachytherapy (BT) contouring, the goals of this study are to evaluate the variability in practices and contouring, and to develop consensus concepts on target definitions. METHODS: A survey/contouring study was conducted with 16 radiation oncologists from 10 Canadian academic centers. The study included three vaginal ISBT cases. Participants were provided staging, prebrachytherapy (pre-BT), and BT MRIs. Participants responded to a questionnaire and contoured on the provided images. Agreement between contours was analyzed. A meeting was held to develop consensus definitions of targets. RESULTS: Median ISBT experience was 3.5 years. All 16 participants regularly contour with MRI, whereas three also plan on MRI. For the three cases, there was variation into how CTVHR and CTVIR was defined. Kappa statistics showed higher agreement with bulky tumors (mean 0.59) as compared with small residual tumors (mean 0.29). For all cases, kappa was highest in pre-BT GTVres as compared with BT GTVres (mean 0.58, 0.46). Consensus concepts to define targets were developed. CONCLUSIONS: Variations exist in how ISBT targets are defined for vaginal tumors. Highest contouring variability was seen with small residual at BT. Contouring is more consistent on pre-BT MRI as compared with BT MRI suggesting a needle distortion effect. Consensus CTVHR and CTVIR definitions have been developed and further work is warranted to establish international standards.

Tumor Board Shadowing: A Unique Approach for Integrating Radiation Oncologists Into General Medical Student Education.

PURPOSE: Radiation oncology is often overlooked in US medical school curricula, with few opportunities for most students to learn about the specialty or the value of radiation therapy in cancer care. Tumor boards represent a potential avenue not only to increase students' exposure to radiation oncologists but also to provide a fundamental understanding of the multidisciplinary nature of cancer care and effective collaboration in clinical practice. METHODS AND MATERIALS: In this study, we evaluated a novel radiation oncologist-driven tumor board shadowing experience at 3 medical schools in the United States and Canada. A total of 323 first- and second-year medical students participated, of whom 77.4% completed a follow-up survey assessing the effectiveness of the program as a learning tool. RESULTS: Compared with traditional clinical shadowing, students were more likely to believe that tumor board shadowing provided a similar or better experience in terms of educational content (85%), exposure to a new field (96%), and overall experience (89%). Forty-eight percent of students perceived a greater amount of multidisciplinary collaboration in oncologic care than they thought existed prior to attending. Forty-eight percent of students also felt more competent interacting with oncologists after participating, whereas 21% felt more competent interacting with patients with cancer. Students' perception of increased competence was correlated with the amount of time their assigned physician mentor spent answering their questions after the tumor board (P < .01). Second-year medical students also had a more favorable overall experience than first-year medical students did (P = .04). CONCLUSIONS: Multidisciplinary tumor boards can be used effectively as a unique immersive learning opportunity that can be feasibly implemented to improve knowledge of clinical oncology and multidisciplinary care in medical schools and expose students to physicians in smaller fields such as radiation oncology.

Adjuvant therapy in stage III endometrial cancer confined to the pelvis.

OBJECTIVE: To review outcomes of patients with stage III endometrial cancer confined to the pelvis treated with adjuvant pelvic radiotherapy (RT) or sequential chemoradiotherapy (CRT). METHODS: Between 1990 and 2012, 144 patients diagnosed with stage IIIA, B or C1 endometrial cancer were treated in our institution. All were treated with total hysterectomy, bilateral salpingo-oophorectomy ±â€¯lymph node dissection. Post-operatively, 67 patients received adjuvant RT alone, 37 CRT, 21 chemotherapy alone and 19 had no adjuvant therapy. This analysis focuses on the 104 patients treated with RT or CRT. RESULTS: The median follow-up was 61 months. Forty-six patients (44%) were stage IIIA, 6 (6%) were stage IIIB and 52 (50%) stage IIIC1. The 5-year overall survival (OS), disease-free survival (DFS) and disease-specific survival (DSS) for patients treated by RT alone vs. CRT were, respectively, 67% vs. 61% (p = 0.55); 67% vs. 51% (p = 0.35); and 76% vs. 65% (p = 0.21). Grade 3 disease was an independent predictor for worse OS (HR = 6.01, p = 0.001), DFS (HR = 3.16, p = 0.03), and DSS (HR = 3.77, p = 0.02). In patients with grade 3 disease (n = 49), the 5-year OS was superior for the CRT (42% vs. 56%, p = 0.007). CONCLUSIONS: In patients with stage III endometrial cancer confined to the pelvis, the addition of adjuvant chemotherapy with RT significantly improved OS in grade 3 disease. Grade 3 histology is a strong predictor for poor outcome. Further randomized studies aiming specifically at stage III disease are warranted.

External validation of a combined PET and MRI radiomics model for prediction of recurrence in cervical cancer patients treated with chemoradiotherapy.

PURPOSE: The aim of this study was to validate previously developed radiomics models relying on just two radiomics features from 18F-fluorodeoxyglucose positron emission tomography (PET) and magnetic resonance imaging (MRI) images for prediction of disease free survival (DFS) and locoregional control (LRC) in locally advanced cervical cancer (LACC). METHODS: Patients with LACC receiving chemoradiotherapy were enrolled in two French and one Canadian center. Pre-treatment imaging was performed for each patient. Multicentric harmonization of the two radiomics features was performed with the ComBat method. The models for DFS (using the feature from apparent diffusion coefficient (ADC) MRI) and LRC (adding one PET feature to the DFS model) were tuned using one of the French cohorts (n = 112) and applied to the other French (n = 50) and the Canadian (n = 28) external validation cohorts. RESULTS: The DFS model reached an accuracy of 90% (95% CI [79-98%]) (sensitivity 92-93%, specificity 87-89%) in both the French and the Canadian cohorts. The LRC model reached an accuracy of 98% (95% CI [90-99%]) (sensitivity 86%, specificity 100%) in the French cohort and 96% (95% CI [80-99%]) (sensitivity 83%, specificity 100%) in the Canadian cohort. Accuracy was significantly lower without ComBat harmonization (82-85% and 71-86% for DFS and LRC, respectively). The best prediction using standard clinical variables was 56-60% only. CONCLUSIONS: The previously developed PET/MRI radiomics predictive models were successfully validated in two independent external cohorts. A proposed flowchart for improved management of patients based on these models should now be confirmed in future larger prospective studies.

Creation and Pilot-testing of Virtual Patients for Learning Oncologic Emergency Management.

Purpose or objective Management of oncologic emergencies becomes critical at the start of the second year of a radiation oncology residency. Considering the limited exposure to oncology in the medical school curriculum, this knowledge gap needs to be filled prior to managing real patients. The aim of this project was to create virtual patients (VPs) to ease this transition and improve learner readiness for independently managing oncologic emergencies on call. Material and methods A curriculum mapping exercise was done to identify gaps. The main oncologic emergencies that needed to be addressed were selected for development of the modules. Review of the key concepts for management was elucidated and validated. These included history, physical examination, imaging interpretation, staging, as well as anatomy, epidemiology, pertinent literature, differential diagnosis, prognostication, radiation treatment planning, summarizing, and patient- and peer-communication skills. Clinical vignettes were then designed, in collaboration with a virtual patient education expert, to mimic the clinical presentation and evolution of a typical patient for three common oncologic emergencies: spinal cord compression, superior vena cava syndrome, and tumor-induced hemorrhage. Results Three virtual modules were developed: spinal cord compression, superior vena cava syndrome, and tumor-induced hemorrhage. Each case included 25 to 30 vignettes that participants progressed through, with a total estimated completion time of 30 to 45 minutes. Each node branched out to provide a detailed answer and explanation of the key concept. Figures were included to mimic real patients and to provide a more authentic learning experience. The modules also included quantitative pre- and post-testing assessments, including multiple-choice questions, true or false, fill in the blank, short answers, and text response. The cases were then transcribed onto a virtual patient simulation platform. Following completion of the module, a report was generated for each individual learner to track all responses and used as the assessment tool. The pilot test showed an increase of 28% in the pre-to-post-test results in a cohort of nine residents. The mean pre-test result of 58% increased to a mean post-test result of 86% (range: 70-100%) after completing the three modules. Conclusion VPs can be used for learning the management of oncologic emergencies and can be done on a simulation-based learning platform. The modules can be used as both, a learning and an assessment tool for junior residents. The results of the pilot test show a significant improvement in knowledge acquisition between pre- and post-test scores after completion of the three modules.