Pilot Study Demonstrating the Value of Interdisciplinary Education on the Integration of Radiation Therapy in Lung Cancer Management.

This study aimed to understand baseline knowledge of basic principles of radiation therapy for lung cancer among medical oncology, thoracic surgery, and pulmonology trainees and practicing physicians and also assess whether a didactic lecture will improve objective knowledge and perceived comfort level in making appropriate referrals to radiation oncology (RO). Radiation oncologists at 8 academic institutions offered a presentation covering indications, logistics, efficacy, and toxicity of thoracic radiation. Participants completed a survey to assess their prior exposures to RO and perceived value of the lecture, and objective knowledge gained based on pre/post-lecture questions. Among 121 attendees, 76 completed the pre-test, and 25 the post-test (response rates 62.8% and 20.7%, respectively). Fifty-seven (75.0%) had never previously experienced a RO didactic about lung cancer, 62 (81.6%) had never seen a linear accelerator, and 65 (85.5%) had never rotated in a RO department. The mean pre-test score was 53.5% (SD 17.6%), with a trend (p = 0.066) towards thoracic surgeons (61.5%) performing better than medical oncologists (55.5%) or pulmonologists (48.3%). Level of training (p = 0.130), and prior RO exposures (p = 0.240), did not significantly impact pre-test scores. The mean post-test score of 75.1% (SD 3.6%) was significantly higher than mean pre-test score (p < 0.001). After the lecture, 25 participants (100%) felt more knowledgeable about RO, and 24 (96%) felt more comfortable making appropriate referrals to RO. A didactic lecture about RO for trainees and physicians who treat lung cancer at 8 academic institutions was feasible, filled a gap in exposure, and improved knowledge.

Can Sex and Seniority Predict the Quality of a Journal Reviewer's Manuscript Critique?

PURPOSE: To evaluate reviewers' timeliness and review quality for the International Journal of Radiation Oncology, Biology, Physics (IJROBP) by sex and seniority. METHODS AND MATERIALS: The IJROBP editorial office provided data on 3962 individuals invited to review manuscripts from 2011 through 2014. We identified 1657 reviewers who had been invited to provide a review on at least 3 occasions during the study period and compared review timeliness and scoring between male and female reviewers. We confirmed the reviewers' sex after having unblinded their names based on our personal acquaintance with them and via an Internet search on their department websites. We then did a subset analysis of 124 US-based reviewers who had returned a "major revision" decision. We used the Review Quality Instrument (RQI) to rate their reviews. We used odds ratios and t tests to look for differences in mean RQI scores and factors that might be associated with quality-in particular, Hirsch indices (h indices) and year of first certification. RESULTS: Of the 1657 reviewers of interest, 1245 (75.1%) were men and 412 (24.9%) were women. We found no statistically significant differences between men and women in the time to respond to invitations. There were no statistically significant differences in timeliness or review reminders based on sex. Our subset analysis showed no difference in quality (RQI scores) based on the reviewers' sex, h index, or year of first certification. CONCLUSIONS: Women and men render reviews of equal quality regardless of seniority and h index, yet women have been invited less frequently to review. This is likely because of the underrepresentation of women in radiation oncology. A more balanced academic population is needed to address this continuing disparity of women's representation in academic publishing.

Tweet for the cure: A snapshot of Twitter usage by 3 U.S. oncologic professional societies.

PURPOSE: Medical societies are incorporating Twitter to communicate with their members and connect with patients. This study compares the online presence of 3 major oncologic societies. METHODS AND MATERIALS: All available tweets in 2014 by the American Society for Radiation Oncology (ASTRO), American Society of Clinical Oncology (ASCO), and Society of Surgical Oncology (SSO) were collected. We analyzed whether posts were original content or retweets. The monthly tweet rate was followed to assess trends. We created 2 new metrics, supporter ratio and tweet density, to correlate online presence and engagement with offline membership breadth. The supporter ratio is the number of people following the organization divided by the number of registered members of each society. The tweet density is the total number of posts divided by the number of registered members of each society. RESULTS: In February 2015, ASCO, ASTRO, and SSO had 36,385; 10,899; and 2721 members, respectively. ASCO's Twitter handle had 33,974 followers, with a supporter ratio of 0.93. A total of 2563 original tweets and 1416 retweets were estimated, which represents a tweet density of 0.11. @ASTRO_org had 5445 followers and a supporter ratio of 0.50. In 2014, ASTRO posted 415 original content tweets and 9 retweets, with a tweet density of 0.039. SSO had a supporter ratio of 0.91 on the basis of 2481 followers. In 2014, SSO posted 207 original tweets and 190 retweets, with a tweet density of 0.15. An increase in tweets and retweets was seen during the month of each society's annual meeting. ASTRO's 61% increase in September 2014 was smaller than SSO's 462% and ASCO's 84%. CONCLUSION: ASTRO's use of Twitter lags behind ASCO and SSO. Although all 3 societies show increased Twitter use during their annual meetings, they should work toward more meaningful engagement throughout the year. The new metrics of tweet density and supporter ratio will serve as benchmarks for member engagement in future studies.

Breast conservation therapy for ductal carcinoma in situ (DCIS): does presentation of disease affect long-term outcomes?

BACKGROUND: For DCIS patients eligible for breast conservation treatment (BCT), it remains unclear whether presenting with physical signs/symptoms (Phys) confers a worse long-term prognosis compared to mammographically detected DCIS (Mam). METHODS: We collected data on 669 DCIS patients treated with BCT from 1974 to 2007 of whom 80 were identified as category "Phys" and 589 were in category "Mam." RESULTS: Treatment parameters (i.e., the RT dose delivered, boost, rates of stereotactic biopsy, re-excision, node dissection) did not differ significantly between the two cohorts (p = NS). At a 60-month median follow-up, significant associations included younger age at presentation (p < 0.001), non-white race (p = 0.041), larger tumor size (p = 0.002), more 1°/2° papillary histology (1°, p = 0.001; 2°, p = 0.005) for the Phys cohort. As expected, mammograms were more likely to show mass/nodules/asymmetrical densities and less likely to show microcalcifications for the Phys versus Mam group (p < 0.0001). There were no differences in family history, multifocality, grade, necrosis, or residual disease at re-excision, nodal involvement, status of margins, or ER/PR/HER-2 between the cohorts. The local relapse-free survival was similar at 5 years (100 vs. 96.9 %, p = 0.116) and 10 years (96.2 vs. 96.2 %, p = 0.906), with no significant overall survival difference at 10 years (97.5 vs. 95.9 %, p = 0.364) between the Phys and Mam patients, respectively. On multivariate analysis, presentation was not an independent predictor of local relapse-free survival or overall survival when accounting for age, race, tumor size, mammogram appearance, and adjuvant hormone treatment. CONCLUSIONS: Our findings suggest that although some clinicopathological differences exist between DCIS patients presenting with physical signs/symptoms compared with those presenting with mammographically detected disease, long-term outcomes are similar for patients appropriately selected for BCT.

Radiation dose escalation for loco-regional recurrence of breast cancer after mastectomy.

BACKGROUND: Radiation is a standard component of treatment for patients with locoregional recurrence (LRR) of breast cancer following mastectomy. The current study reports the results of a 10% radiation dose escalation in these patients. METHODS: 159 patients treated at MD Anderson Cancer Center between 1994-2006 with isolated LRR after mastectomy alone were reviewed. Patients in the standard treatment group (65 pts, 40.9%) were treated to 50 Gy comprehensively plus a boost of 10 Gy. The dose escalated group (94 pts, 59.1%) was treated to 54 Gy comprehensively and a minimum 12 Gy boost. Median dose in the standard dose and dose escalated group was 60 Gy (±1 Gy, 95% CI) and 66 Gy (±0.5 Gy, 95% CI) respectively. Median follow up for living patients was 94 months from time of recurrence. RESULTS: The actuarial five year locoregional control (LRC) rate was 77% for the entire study population. The five year overall survival and disease-free survival was 55% and 41%, respectively. On multivariate analysis, initial tumor size (p = 0.03), time to initial LRR (p = 0.03), absence of gross tumor at the time of radiation (p = 0.001) and Her2 status (p = 0.03) were associated with improved LRC. Five year LRC rates were similar in patients with a complete response to chemotherapy without surgery and patients with a complete surgical excision (77% vs 83%, p = NS), compared to a 63% LRC rate in patients with gross disease at the time of radiation (p = 0.024). LRC rates were 80% in the standard dose group and 75% in the dose escalated group (p = NS). CONCLUSIONS: While LRR following mastectomy is potentially curable, distant metastasis and local control rates remain suboptimal. Radiation dose escalation did not appear to improve LRC. Given significant local failure rates, these patients are good candidates for additional strategies to improve their outcomes.

Ductal carcinoma in situ treated with breast-conserving surgery and radiotherapy: a comparison with ECOG study 5194.

BACKGROUND: Recent data from Eastern Cooperative Oncology Group (ECOG) Study 5194 (E5194) prospectively defined a low-risk subset of ductal carcinoma in situ (DCIS) patients where radiation therapy was omitted after lumpectomy alone. The purpose of the study was to determine the ipsilateral breast tumor recurrence (IBTR) in DCIS patients who met the criteria of E5194 treated with lumpectomy and adjuvant whole breast radiation therapy (RT). METHODS: A total of 263 patients with DCIS were treated between 1980 and 2009 who met the enrollment criteria for E5194: 1) low to intermediate grade (LIG) with size >0.3 cm but <2.5 cm and margins >3 mm (n = 196), or 2) high grade (HG), size <1 cm and margins >3 mm (n = 67). All patients were treated with lumpectomy and whole breast RT with a boost to a median total tumor bed dose of 6400 cGy. Standard statistical analyses were performed with SAS (v. 9.2). RESULTS: The average follow-up time was 6.9 years. The 5-year and 7-year IBTR for the LIG cohort in this study was 1.5% and 4.4% compared with 6.1% and 10.5% in E5194, respectively. The 5-year and 7-year IBTR for the HG cohort was 2.0% and 2.0% in this study compared with 15.3% and 18% in E5194, respectively. CONCLUSIONS: Adjuvant whole breast radiation therapy reduced the rate of local recurrence by more than 70% in patients with DCIS who met the criteria of E5194 (6.1% to 1.5% in the LIG cohort and 15.3% to 2% in the HG cohort). Additional follow-up is necessary given that 70% of IBTRs occurred after 5 years.

Multi-institutional review of repeat irradiation of chest wall and breast for recurrent breast cancer.

PURPOSE: To review the toxicity and clinical outcomes for patients who underwent repeat chest wall or breast irradiation (RT) after local recurrence. METHODS AND MATERIALS: Between 1993 and 2005, 81 patients underwent repeat RT of the breast or chest wall for locally recurrent breast cancer at eight institutions. The median dose of the first course of RT was 60 Gy and was 48 Gy for the second course. The median total radiation dose was 106 Gy (range, 74.4-137.5 Gy). At the second RT course, 20% received twice-daily RT, 54% were treated with concurrent hyperthermia, and 54% received concurrent chemotherapy. RESULTS: The median follow-up from the second RT course was 12 months (range, 1-144 months). Four patients developed late Grade 3 or 4 toxicity. However, 25 patients had follow-up >20 months, and no late Grade 3 or 4 toxicities were noted. No treatment-related deaths occurred. The development of Grade 3 or 4 late toxicity was not associated with any repeat RT variables. The overall complete response rate was 57%. No repeat RT parameters were associated with an improved complete response rate, although a trend was noted for an improved complete response with the addition of hyperthermia that was close to reaching statistical significance (67% vs. 39%, p = 0.08). The 1-year local disease-free survival rate for patients with gross disease was 53% compared with 100% for those without gross disease (p < 0.0001). CONCLUSIONS: The results of our study have shown that repeat RT of the chest wall for patients with locally recurrent breast cancer is feasible, because it is associated with acceptable acute and late morbidity and encouraging local response rates.

The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy.

PURPOSE: To quantify the impact of immediate breast reconstruction on postmastectomy radiation therapy (PMRT) planning. METHODS: A total of 110 patients (112 treatment plans) who had mastectomy with immediate reconstruction followed by radiotherapy were compared with contemporaneous stage-matched patients who had undergone mastectomy without intervening reconstruction. A scoring system was used to assess optimal radiotherapy planning using four parameters: breadth of chest wall coverage, treatment of the ipsilateral internal mammary chain, minimization of lung, and avoidance of heart. An "optimal" plan achieved all objectives or a minor 0.5 point deduction; "moderately" compromised treatment plans had 1.0 or 1.5 point deductions; and "major" compromised plans had > or =2.0 point deductions. RESULTS: Of the 112 PMRT plans scored after reconstruction, 52% had compromises compared with 7% of matched controls (p < 0.0001). Of the compromised plans after reconstruction, 33% were considered to be moderately compromised plans and 19% were major compromised treatment plans. Optimal chest wall coverage, treatment of the ipsilateral internal mammary chain, lung minimization, and heart avoidance was achieved in 79%, 45%, 84%, and 84% of the plans in the group undergoing immediate reconstruction, compared respectively with 100%, 93%, 97%, and 92% of the plans in the control group (p < 0.0001, p < 0.0001, p = 0.0015, and p = 0.1435). In patients with reconstructions, 67% of the "major" compromised radiotherapy plans were left-sided (p < 0.16). CONCLUSIONS: Radiation treatment planning after immediate breast reconstruction was compromised in more than half of the patients (52%), with the largest compromises observed in those with left-sided cancers. For patients with locally advanced breast cancer, the potential for compromised PMRT planning should be considered when deciding between immediate and delayed reconstruction.