Harmonica consensus, controversies, and future directions in radiotherapy for pediatric Wilms tumors.

Radiotherapy (RT) is essential for multimodality treatment of pediatric renal tumors, particularly in higher-risk and metastatic disease. Despite decades of use, particularly for Wilms tumor, there remain controversies regarding RT indications, timing, dose, and targets. To align global management, we address these issues in this international HARMONIsation and CollAboration (HARMONICA) project. There are multiple knowledge gaps and opportunities for future research including: (1) utilization of advanced RT technologies, including intensity-modulated RT, proton beam therapy, combined with image-guided RT to reduce target volumes; (2) impact of molecular biomarkers including loss of heterozygosity at 1p, 16q, and 1q gain on RT indications; (3) mitigation of reproductive toxicity following RT; (4) promotion of RT late effects research; and (5) support to overcome challenges in RT utilization in low- and middle-income countries where 90% of the world's children reside. Here, we outline current status and future directions for RT in pediatric renal tumors.

No evidence of task co-representation in a joint Stroop task.

People working together on a task must often represent the goals and salient items of their partner. The aim of the present study was to study the influence of joint task representations in an interference task in which the congruency relies on semantic identity. If task representations are shared between partners in a joint Stroop task (co-representation account), we hypothesized that items in the response set of one partner might influence performance of the other. In Experiment 1, pairs of participants sat side by side. Each participant was instructed to press one of two buttons to indicate which of two colors assigned to them was present, ignoring the text and responding only to the pixel color. There were three types of incongruent distractor words: names of colors from their own response set, names of colors from the other partner's response set, and neutral words for colors not used as font colors. The results of Experiment 1 showed that when people were doing this task together, distractor words from the partner's response set interfered more than neutral words and just as much as the words from their own response color set. However, in three follow-up experiments (Experiments 2a, 2b, and 2c), we found an elevated interference for the other response-set words even though no co-actor was present. The overall pattern of results across our study suggests that an alternative response set, regardless of whether it belonged to a co-actor or to a non-social no-go condition, evoked equal amounts of interference comparable to those of the own response set. Our findings are in line with a theory of common coding, in which all events-irrespective of their social nature-are represented and can influence behavior.

Evaluation of boost irradiation in patients with intermediate-risk stage III Wilms tumour with positive lymph nodes only: Results from the SIOP-WT-2001 Registry.

OBJECTIVE: To evaluate the value of radiotherapy boost omission in patients with intermediate-risk, stage III Wilms tumours (WT) with positive lymph nodes (LN). METHODS AND MATERIALS: All patients with intermediate-risk, stage III (LN positive) WT consecutively registered in the SIOP-WT-2001 study were included in this analysis. Endpoints were 5-year event-free survival (EFS), loco-regional control (LRC) and overall survival (OS). RESULTS: Between June 2001 and May 2015, 2,569 patients with stage I to III WT after preoperative chemotherapy were registered in the SIOP-WT-2001 study. Five hundred and twenty-three (20%) had stage III disease, of which 113 patients had stage III due to positive LN only. Of those, 101 (89%) received radiotherapy, 36 of which (36%) received, apart from flank irradiation, a boost dose to the LN positive area. Four patients (4%) did not receive any adjuvant radiotherapy. In eight patients information on radiotherapy was not available. With a median follow-up of 71 months, no difference in 5-year EFS (84% vs. 83%, P = 0.77) and LRC (96% vs. 97%, P = 0.91) was observed between patients receiving a radiotherapy boost and those without boost, respectively. Five-year OS, including salvage therapy, was excellent (boost vs. no boost: 97% vs. 95%, P = 0.58). CONCLUSIONS: Outcome data demonstrate that omission of the radiotherapy boost to the loco-regional positive lymph nodes in patients with intermediate-risk, stage III WT who receive preoperative chemotherapy and postoperative flank irradiation (14.4 Gy) can be considered a safe approach for future SIOP protocols.

The UK Experience of a Treatment Strategy for Pediatric Metastatic Medulloblastoma Comprising Intensive Induction Chemotherapy, Hyperfractionated Accelerated Radiotherapy and Response Directed High Dose Myeloablative Chemotherapy or Maintenance Chemotherapy (Milan Strategy).

BACKGROUND: Historically, the 5-year overall survival (OS) for metastatic medulloblastoma (MMB) was less than 40%. The strategy of post-operative induction chemotherapy (IC) followed by hyperfractionated accelerated radiotherapy (HART) and response directed high dose chemotherapy (HDC) was reported in a single center study to improve 5-year OS to 73%. We report outcomes of this strategy in UK. METHODS: Questionnaires were sent to all 20 UK pediatric oncology primary treatment centers to collect retrospective data on delivered treatment, toxicity and survival with this strategy in children aged 3-19 years with MMB. RESULTS: Between February 2009 and October 2011, 34 patients fulfilled the entry criteria of the original study. The median age was 7 years (range 3-15). Median interval from surgery to HART was 109 versus 85 days in the original series. The incidence of grade 3 or 4 hematological toxicities with IC and HDC was 83-100%. All 16 patients who achieved complete response by the end of the regimen remain in remission but only three of 18 patients with lesser responses are still alive (P < 0.0001). With a median follow-up of 45 months for survivors, the estimated 3-year OS is 56% (95% CI 38, 71). This result is outside the 95% CI of the original study results and encompasses the historical survival result of 40%. CONCLUSION: Within the limits of statistical significance, we did not replicate the improved survival results reported in the original series. The reasons include differences in patient sub-groups and protocol administration. International randomized phase III studies are needed.

Direct measurement of the system latency of gaze-contingent displays.

Gaze-contingent displays combine a display device with an eyetracking system to rapidly update an image on the basis of the measured eye position. All such systems have a delay, the system latency, between a change in gaze location and the related change in the display. The system latency is the result of the delays contributed by the eyetracker, the display computer, and the display, and it is affected by the properties of each component, which may include variability. We present a direct, simple, and low-cost method to measure the system latency. The technique uses a device to briefly blind the eyetracker system (e.g., for video-based eyetrackers, a device with infrared light-emitting diodes (LED)), creating an eyetracker event that triggers a change to the display monitor. The time between these two events, as captured by a relatively low-cost consumer camera with high-speed video capability (1,000 Hz), is an accurate measurement of the system latency. With multiple measurements, the distribution of system latencies can be characterized. The same approach can be used to synchronize the eye position time series and a video recording of the visual stimuli that would be displayed in a particular gaze-contingent experiment. We present system latency assessments for several popular types of displays and discuss what values are acceptable for different applications, as well as how system latencies might be improved.

Crowdsourcing a normative natural language dataset: a comparison of Amazon Mechanical Turk and in-lab data collection.

BACKGROUND: Crowdsourcing has become a valuable method for collecting medical research data. This approach, recruiting through open calls on the Web, is particularly useful for assembling large normative datasets. However, it is not known how natural language datasets collected over the Web differ from those collected under controlled laboratory conditions. OBJECTIVE: To compare the natural language responses obtained from a crowdsourced sample of participants with responses collected in a conventional laboratory setting from participants recruited according to specific age and gender criteria. METHODS: We collected natural language descriptions of 200 half-minute movie clips, from Amazon Mechanical Turk workers (crowdsourced) and 60 participants recruited from the community (lab-sourced). Crowdsourced participants responded to as many clips as they wanted and typed their responses, whereas lab-sourced participants gave spoken responses to 40 clips, and their responses were transcribed. The content of the responses was evaluated using a take-one-out procedure, which compared responses to other responses to the same clip and to other clips, with a comparison of the average number of shared words. RESULTS: In contrast to the 13 months of recruiting that was required to collect normative data from 60 lab-sourced participants (with specific demographic characteristics), only 34 days were needed to collect normative data from 99 crowdsourced participants (contributing a median of 22 responses). The majority of crowdsourced workers were female, and the median age was 35 years, lower than the lab-sourced median of 62 years but similar to the median age of the US population. The responses contributed by the crowdsourced participants were longer on average, that is, 33 words compared to 28 words (P<.001), and they used a less varied vocabulary. However, there was strong similarity in the words used to describe a particular clip between the two datasets, as a cross-dataset count of shared words showed (P<.001). Within both datasets, responses contained substantial relevant content, with more words in common with responses to the same clip than to other clips (P<.001). There was evidence that responses from female and older crowdsourced participants had more shared words (P=.004 and .01 respectively), whereas younger participants had higher numbers of shared words in the lab-sourced population (P=.01). CONCLUSIONS: Crowdsourcing is an effective approach to quickly and economically collect a large reliable dataset of normative natural language responses.

Trajectory prediction of saccadic eye movements using a compressed exponential model.

Gaze-contingent display paradigms play an important role in vision research. The time delay due to data transmission from eye tracker to monitor may lead to a misalignment between the gaze direction and image manipulation during eye movements, and therefore compromise the contingency. We present a method to reduce this misalignment by using a compressed exponential function to model the trajectories of saccadic eye movements. Our algorithm was evaluated using experimental data from 1,212 saccades ranging from 3° to 30°, which were collected with an EyeLink 1000 and a Dual-Purkinje Image (DPI) eye tracker. The model fits eye displacement with a high agreement (R² > 0.96). When assuming a 10-millisecond time delay, prediction of 2D saccade trajectories using our model could reduce the misalignment by 30% to 60% with the EyeLink tracker and 20% to 40% with the DPI tracker for saccades larger than 8°. Because a certain number of samples are required for model fitting, the prediction did not offer improvement for most small saccades and the early stages of large saccades. Evaluation was also performed for a simulated 100-Hz gaze-contingent display using the prerecorded saccade data. With prediction, the percentage of misalignment larger than 2° dropped from 45% to 20% for EyeLink and 42% to 26% for DPI data. These results suggest that the saccade-prediction algorithm may help create more accurate gaze-contingent displays.

Patriarchy's Link to Intimate Partner Violence: Applications to Survivors' Asylum Claims.

Eligibility for asylum for survivors of intimate partner violence (IPV) has recently been contested. We summarize social science evidence to show how such survivors generally meet asylum criteria. Studies consistently show a relationship between patriarchal factors and IPV, thereby establishing a key asylum criterion that women are being persecuted because of their status as women. Empirical support is also provided for other asylum criteria, specifically: patriarchal norms contribute to state actors' unwillingness to protect survivors, and survivors' political opinions are linked to an escalation of perpetrators' violence. The findings have implications for policy reform and supporting individual asylum-seekers.

Knowing to Ask and Feeling Safe to Tell - Understanding the Influences of HCP-Patient Interactions in Cancer Care for LGBTQ+ Children and Young People.

Background: Lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ+) people experience healthcare inequalities in cancer care. Previous studies have focused on knowledge, attitudes and behaviours of healthcare professionals (HCPs) treating adults with cancer and how these contribute to inequalities. To date, no research has focused on HCPs treating LGBTQ+ children and adolescents with cancer in the UK. This is important given that this group may be at a critical time for exploring their gender identity and sexual orientation, whilst also facing a cancer diagnosis. We aimed to explore the knowledge, attitudes and behaviours of paediatric, teenage and young adult oncology HCPs treating LGBTQ+ patients in the UK. Methods: We carried out semi-structured interviews with 8 HCPs in paediatric, teenage and young adult (TYA) oncology from the Royal Marsden NHS Foundation Trust. Eight questions were asked, which centred around participants' knowledge, attitudes and behaviours regarding management of LGBTQ+ patients in oncology. Interview transcripts were analysed by inductive thematic analysis. Results: We identified 10 themes, including novel themes (how HCPs acquire knowledge and expectations of a 'third party' to be the expert) which may underlie previously observed trends in knowledge, attitudes and behaviours of HCPs. We highlight other themes and HCP concerns specific to care of LGBTQ+ patients in paediatrics (influence of the parental-carer dynamic, concerns around patient age and development as a barrier to disclosure) which require further research. We found evidence of the interrelatedness of HCP knowledge, attitudes and behaviours and the ability of these elements to positively influence each other. We mapped our themes across these elements to form a new suggested framework for improving HCP-patient interactions in LGBTQ+ Cancer Care. We found a need both for individual HCP education and organisational change, with creation of a culture of psychological safety to improve patient care. Conclusion: Knowledge, attitudes and behaviours of HCPs are closely interdependent when providing care to young LGBTQ+ patients with cancer. The authors suggest that future efforts to improve care of these patients address this complexity by spanning the domains of our suggested framework. Whilst HCP education is essential, change must also occur at an organisational level.

International Comparisons of Clinical Demographics and Outcomes in the International Society of Pediatric Oncology Wilms Tumor 2001 Trial and Study.

PURPOSE: International comparisons of patient demographics, tumor characteristics, and survival can shed light on areas for health care system improvement. The International Society of Pediatric Oncology Wilms Tumor 2001 trial/study registered patients through national clinical study groups in Western Europe and Brazil. This retrospective post hoc analysis of the International Society of Pediatric Oncology Wilms Tumor 2001 database aims to make visible and suggest reasons for any variations in outcomes. METHODS: All patients with unilateral Wilms tumor (WT), age > 6 months, treated with preoperative chemotherapy as per protocol, and registered between 2001 and 2011 were eligible. Countries were grouped to give comparable case numbers and geographical representation. Cox univariable and multivariable (MVA) statistics were applied, with the German collaborative group (Gesellschaft für Pädiatrische Onkologie und Hämatologie-Austria, Germany, and Switzerland) as reference for hazard ratios for event-free survival (EFS) and overall survival (OS). RESULTS: A total of 3,176 eligible patients were registered from 24 countries assigned into six groups. Age and histologic risk group distribution were similar across all groupings. The distribution of WT stage varied by country grouping, with 14.9% (range, 11.1%-18.2%) metastatic at diagnosis. Median follow-up was 78.9 months. For localized WT, 5-year EFS varied from 80% (Brazilian group) to 91% (French group; P < .0001), retaining significance only for Brazil in MVA (P = .001). Five-year OS varied from 89% (Brazilian group) to 98% (French group; P < .0001). In MVA, only superior OS in France was significant (P = .001). Five-year EFS/OS for stage IV did not vary significantly. High-risk histology and tumor volume at surgery were significantly associated with increased risk of death in MVA for metastatic disease. CONCLUSION: International benchmarking of survival rates from WT within a large trial/study database has demonstrated statistically significant differences. Clinical interpretation should take account of variation in tumor stage but also treatment factors.

Body configuration modulates the usage of local cues to direction in biological-motion perception.

The presence of information in a visual display does not guarantee its use by the visual system. Studies of inversion effects in both face recognition and biological-motion perception have shown that the same information may be used by observers when it is presented in an upright display but not used when the display is inverted. In our study, we tested the inversion effect in scrambled biological-motion displays to investigate mechanisms that validate information contained in the local motion of a point-light walker. Using novel biological-motion stimuli that contained no configural cues to the direction in which a walker was facing, we found that manipulating the relative vertical location of the walker's feet significantly affected observers' performance on a direction-discrimination task. Our data demonstrate that, by themselves, local cues can almost unambiguously indicate the facing direction of the agent in biological-motion stimuli. Additionally, we document a noteworthy interaction between local and global information and offer a new explanation for the effect of local inversion in biological-motion perception.

Allocation of attention to biological motion: local motion dominates global shape.

Directional information can be retrieved from a point-light walker (PLW) in two different ways: either from recovering the global shape of the articulated body or from signals in the local motion of individual dots. Here, we introduce a voluntary eye movement task to assess how the direction of a centrally presented, task-irrelevant PLW affects the onset latency and accuracy of saccades to peripheral targets. We then use this paradigm to design experiments to study which aspects of biological motion-the global form mediated by the motion of the walker or the local movements of critical features-drive the observed attentional effects. Putting the two cues into conflict, we show that saccade latency and accuracy were affected by the local motion of the dots representing the walker's feet-but only if they retain their familiar, predictable location within the display.

"The System Had Choked Me Too": Abused Mothers' Perceptions of the Custody Determination Process That Resulted in Negative Custody Outcomes.

Intimate partner violence (IPV) is a public health problem that continues to affect abused mothers after separation from an abusive partner. In addition to the risk of ongoing control and violence by abusers, the custody determination process may present challenges for mothers who end up with negative custody outcomes (e.g., share custody with abusers or lose custody). Using constructivist grounded theory techniques, we conducted a qualitative analysis of interviews with 24 abused mothers with negative custody outcomes to understand how they perceive and make sense of the process as a whole, and how they cope with these outcomes. The custody determination process was reportedly complex and stressful, and most mothers did not anticipate a negative custody outcome. Mothers' perceptions and experiences followed three phases: "trusting "the system" to protect them and their children, adapting to "the system" in search of positive outcomes, and, once custody decisions were determined, coping with the aftermath of the judicial system process, either by accepting or resisting the outcome. This study echoes previous calls for further training and policies that make the custody determination process less burdensome and harmful for survivors and their children.

The potential role of MR-guided adaptive radiotherapy in pediatric oncology: Results from a SIOPE-COG survey.

BACKGROUND AND PURPOSE: Magnetic resonance guided radiotherapy (MRgRT) has been successfully implemented for several routine clinical applications in adult patients. The purpose of this study is to map the potential benefit of MRgRT on toxicity reduction and outcome in pediatric patients treated with curative intent for primary and metastatic sites. MATERIALS AND METHODS: Between May and August 2020, a survey was distributed among SIOPE- and COG-affiliated radiotherapy departments, treating at least 25 pediatrics patients annually and being (candidate) users of a MRgRT system. The survey consisted of a table with 45 rows (clinical scenarios for primary (n = 28) and metastatic (n = 17) tumors) and 7 columns (toxicity reduction, outcome improvement, PTV margin reduction, target volume daily adaptation, online re-planning, intrafraction motion compensation and on-board functional imaging) and the option to answer by 'yes/no' . Afterwards, the Dutch national radiotherapy cohort was used to estimate the percentage of pediatric treatments that may benefit from MRgRT. RESULTS: The survey was completed by 12/17 (71% response rate) institutions meeting the survey inclusion criteria. Responders indicated an 'expected benefit' from MRgRT for toxicity/outcome in 7% (for thoracic lymphomas and abdominal rhabdomyosarcomas)/0% and 18% (for mediastinal lymph nodes, lymph nodes located in the liver/splenic hilum, and liver metastases)/0% of the considered scenarios for the primary and metastatic tumor sites, respectively, and a 'possible benefit' was estimated in 64%/46% and 47%/59% of the scenarios. When translating the survey outcome into a clinical perspective a toxicity/outcome benefit, either expected or possible, was anticipated for 55%/24% of primary sites and 62%/38% of the metastatic sites. CONCLUSION: Although the benefit of MRgRT in pediatric radiation oncology is estimated to be modest, the potential role for reducing toxicity and improving clinical outcomes warrants further investigation. This fits best within the context of prospective studies or registration trials.

Inter-clinician delineation variation for a new highly-conformal flank target volume in children with renal tumors: A SIOP-Renal Tumor Study Group international multicenter exercise.

BACKGROUND AND PURPOSE: Recently, the SIOP-RTSG developed a highly-conformal flank target volume definition for children with renal tumors. The aims of this study were to evaluate the inter-clinician delineation variation of this new target volume definition in an international multicenter setting and to explore the necessity of quality assurance. MATERIALS AND METHODS: Six pediatric renal cancer cases were transferred to ten radiation oncologists from seven European countries ('participants'). These participants delineated the pre- and postoperative Gross Tumor Volume (GTVpre/post), and Clinical Target Volume (CTV) during two test phases (case 1-2 and 3-4), followed by guideline refinement and a quality assurance phase (case 5-6). Reference target volumes (TVref) were established by three experienced radiation oncologists. The Dice Similarity Coefficient between the reference and participants (DSCref/part) was calculated per case. Delineations of case 5-6 were graded by four independent reviewers as 'per protocol' (0-4 mm), 'minor deviation' (5-9 mm) or 'major deviation' (≥10 mm) from the delineation guideline using 18 standardized criteria. Also, a major deviation resulting in underestimation of the CTVref was regarded as an unacceptable variation. RESULTS: A total of 57/60 delineation sets were completed. The median DSCref/part for the CTV was 0.55 without improvement after sequential cases (case 3-4 vs. case 5-6: p = 0.15). For case 5-6, a major deviation was found for 5/18, 12/17, 18/18 and 4/9 collected delineations of the GTVpre, GTVpost, CTV-T and CTV-N, respectively. An unacceptable variation from the CTVref was found for 7/9 participants for case 5 and 6/9 participants for case 6. CONCLUSION: This international multicenter delineation exercise demonstrates that the new consensus for highly-conformal postoperative flank target volume delineation leads to geometrical variation among participants. Moreover, standardized review showed an unacceptable delineation variation in the majority of the participants. These findings strongly suggest the need for additional training and centralized pre-treatment review when this target volume delineation approach is implemented on a larger scale.

Outcome of Stage IV Completely Necrotic Wilms Tumour and Local Stage III Treated According to the SIOP 2001 Protocol.

OBJECTIVE: Wilms tumour (WT) patients with a localised completely necrotic nephroblastoma after preoperative chemotherapy are a favourable outcome group. Since the introduction of the SIOP 2001 protocol, the SIOP- Renal Tumour Study Group (SIOP-RTSG) has omitted radiotherapy for such patients with low-risk, local stage III in an attempt to reduce treatment burden. However, for metastatic patients with local stage III, completely necrotic WT, the recommendations led to ambiguous use. The purpose of this descriptive study is to demonstrate the outcomes of patients with metastatic, completely necrotic and local stage III WT in relation to the application of radiotherapy or not. METHODS AND MATERIALS: all metastatic patients with local stage III, completely necrotic WT after 6 weeks of preoperative chemotherapy who were registered in the SIOP 2001 study were included in this analysis. The pattern of recurrence according to the usage of radiation treatment and 5 year event-free survival (EFS) and overall survival (OS) was analysed. RESULTS: seven hundred and three metastatic WT patients were registered in the SIOP 2001 database. Of them, 47 patients had a completely necrotic, local stage III WT: 45 lung metastases (11 combined localisations), 1 liver/peritoneal, and 1 tumour thrombus in the renal vein and the inferior vena cava with bilateral pulmonary arterial embolism. Abdominal radiotherapy was administered in 29 patients (62%; 29 flank/abdominal irradiation and 9 combined with lung irradiation). Eighteen patients did not receive radiotherapy. Median follow-up was 6.6 years (range 1-151 months). Two of the 47 patients (4%) developed disease recurrence in the lung (one combined with abdominal relapse) and eventually died of the disease. Both patients had received abdominal radiotherapy, one of them combined with lung irradiation. Five-year EFS and OS were 95% and 95%, respectively. CONCLUSIONS: the outcome of patients with stage IV, local stage III, completely necrotic Wilms tumours is excellent. Our results suggest that abdominal irradiation in this patient category may not be of added value in first-line treatment, consistent with the current recommendation in the SIOP-RTSG 2016 UMBRELLA protocol.

Gaze patterns during perception of direction and gender from biological motion.

Humans can perceive many properties of a creature in motion from the movement of the major joints alone. However it is likely that some regions of the body are more informative than others, dependent on the task. We recorded eye movements while participants performed two tasks with point-light walkers: determining the direction of walking, or determining the walker's gender. To vary task difficulty, walkers were displayed from different view angles and with different degrees of expressed gender. The effects on eye movement were evaluated by generating fixation maps, and by analyzing the number of fixations in regions of interest representing the shoulders, pelvis, and feet. In both tasks participants frequently fixated the pelvis region, but there were relatively more fixations at the shoulders in the gender task, and more fixations at the feet in the direction task. Increasing direction task difficulty increased the focus on the foot region. An individual's task performance could not be predicted by their distribution of fixations. However by showing where observers seek information, the study supports previous findings that the feet play an important part in the perception of walking direction, and that the shoulders and hips are particularly important for the perception of gender.

An evaluation of self-perceived knowledge, attitudes and behaviours of UK oncologists about LGBTQ+ patients with cancer.

INTRODUCTION: Over one million people in the UK identify as LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning). Research has shown that this population experience differing cancer risk factors compared with non-LGBTQ+ patients and persistent inequalities in cancer care. Literature concerning the knowledge of oncologists of this group's healthcare needs is limited; our study aimed to evaluate knowledge, attitudes and behaviours of UK oncologists about LGBTQ+ patients. METHODS: A 53-question survey was delivered via a secure online platform. Questions covered respondent demographics, knowledge, attitudes and behaviours with the majority of responses on a Likert scale. Oncologists were recruited via email from professional bodies and social media promotion. Informed consent was sought and responses fully anonymised. Multifactorial ordinal logistic regression and Fisher's exact test were used to assess for interactions between demographics and responses with Holm-Bonferroni multiple testing correction. RESULTS: 258 fully completed responses were received. Respondents had a median age of 43 years (range 28-69); 65% consultants and 35% registrars; 42% medical, and 54% clinical, oncologists. 84% felt comfortable treating LGBTQ+ patients but only 8% agreed that they were confident in their knowledge of specific LGBTQ+ patient healthcare needs. There were low rates of routine enquiry about sexual orientation (5%), gender identity (3%) and preferred pronouns (2%). 68% of oncologists felt LGBTQ+ healthcare needs should be a mandatory component of postgraduate training. CONCLUSIONS: This survey showed that UK oncologists feel comfortable treating LGBTQ+ patients but may fail to identify these patients in their clinic, making it more difficult to meet LGBTQ+ healthcare needs. There is self-awareness of deficits in knowledge of LGBTQ+ healthcare and a willingness to address this through postgraduate training. Educational resources collated and developed in accordance with this study would potentially improve the confidence of oncologists in treating LGBTQ+ patients and the cancer care these patients receive.

Protocol for tumour-focused dose-escalated adaptive radiotherapy for the radical treatment of bladder cancer in a multicentre phase II randomised controlled trial (RAIDER): radiotherapy planning and delivery guidance.

INTRODUCTION: Daily radiotherapy delivered with radiosensitisation offers patients with muscle invasive bladder cancer (MIBC) comparable outcomes to cystectomy with functional organ preservation. Most recurrences following radiotherapy occur within the bladder. Increasing the delivered radiotherapy dose to the tumour may further improve local control. Developments in image-guided radiotherapy have allowed bladder tumour-focused 'plan of the day' radiotherapy delivery. We aim to test within a randomised multicentre phase II trial whether this technique will enable dose escalation with acceptable rates of toxicity. METHODS AND ANALYSIS: Patients with T2-T4aN0M0 unifocal MIBC will be randomised (1:1:2) between standard/control whole bladder single plan radiotherapy, standard dose adaptive tumour-focused radiotherapy or dose-escalated adaptive tumour-focused radiotherapy (DART). Adaptive tumour-focused radiotherapy will use a library of three plans (small, medium and large) for treatment. A cone beam CT taken prior to each treatment will be used to visualise the anatomy and inform selection of the most appropriate plan for treatment.Two radiotherapy fractionation schedules (32f and 20f) are permitted. A minimum of 120 participants will be randomised in each fractionation cohort (to ensure 57 evaluable DART patients per cohort).A comprehensive radiotherapy quality assurance programme including pretrial and on-trial components is instituted to ensure standardisation of radiotherapy planning and delivery.The trial has a two-stage non-comparative design. The primary end point of stage I is the proportion of patients meeting predefined normal tissue constraints in the DART group. The primary end point of stage II is late Common Terminology Criteria for Adverse Events grade 3 or worse toxicity aiming to exclude a rate of >20% (80% power and 5% alpha, one sided) in each DART fractionation cohort. Secondary end points include locoregional MIBC control, progression-free survival overall survival and patient-reported outcomes. ETHICS AND DISSEMINATION: This clinical trial is approved by the London-Surrey Borders Research Ethics Committee (15/LO/0539). The results when available will be disseminated via peer-reviewed scientific journals, conference presentations and submission to regulatory authorities. TRIAL REGISTRATION NUMBER: NCT02447549; Pre-results.

The SIOP-Renal Tumour Study Group consensus statement on flank target volume delineation for highly conformal radiotherapy.

For decades, radiotherapy with two opposing photon beams has been the standard technique used to cover the flank target volume in paediatric patients with renal tumours. Nowadays, many institutes are implementing advanced radiotherapy techniques that spare healthy tissue. To decrease the radiotherapy dose to healthy structures while preserving oncological efficacy, the conventional approach of flank irradiation has been adapted into a guideline for highly conformal flank target-volume delineation by paediatric radiation oncologists and representatives of the International Society of Paediatric Oncology's Renal Tumour Study Group (SIOP-RTSG) board during four live international consensus meetings. The consensus was refined by delineation exercises and videoconferences by ten collaborating paediatric radiation oncologists. The final guideline includes eight chronological steps to generate the tumour bed and clinical, internal, and planning target volumes, and it describes the optional use of surgical clips to optimise treatment planning. This guideline will be added into the radiotherapy guideline of the UMBRELLA SIOP-RTSG protocol for paediatric renal tumours to improve international consistency of highly conformal flank target-volume delineation.