Impact of a Virtual Introduction to Radiation Oncology Presentation on Stimulating Interest in the Specialty Among Diverse Medical Students at Multiple Institutions

PURPOSE

Many US medical students lack access to radiation oncology (RO). The authors' hypothesis was that a virtual, cross-institutional presentation introducing students to a career in RO would be valuable in exposing students to RO who are less likely to access it otherwise and would increase students' interest in a career in RO regardless of their gender, race, or ethnicity.

METHODS

A 1-hour, live, virtual, extracurricular presentation was offered to deans of US medical schools lacking affiliated RO departments and/or having high enrollments of students underrepresented in medicine (UIM) and also student groups composed primarily of UIM students. Presentations were given individually to each school by a single radiation oncologist. An electronic survey captured data from participating students.

RESULTS

One hundred ninety-seven students from 13 institutions attended presentations; 114 students responded to the survey (response rate, 58%). Ninety-two students (81%) were aware of the specialty of RO before the presentation; however, UIM students were significantly less likely to be aware of RO than all others (69% versus 87%, P = .05). Only 19 students (17%) reported previously hearing presentations from radiation oncologist (29% among second- to fourth-year students versus 9% among first-year students, P = .01). Ninety-eight students (86%) expressed more interest in pursuing a career in RO after the presentation. There was no significant difference in interest in RO for any demographic subgroups.

CONCLUSIONS

Virtual RO exposure was feasible to deliver to students less likely to be exposed otherwise and successfully stimulated interest in the specialty regardless of students' gender, race, or ethnicity.

Shorter Radiation Regimens and Treatment Noncompletion Among Patients With Breast and Prostate Cancer in the United States: An Analysis of Racial Disparities in Access and Quality

PURPOSE

Compared with conventional external-beam radiation therapy (cEBRT) for patients with breast cancer (BC) and prostate cancer (PC), shorter radiation regimens may be associated with lower treatment noncompletion rates. We assess disparities in receipt of shorter radiation regimens and treatment noncompletion for BC and PC.

PATIENTS AND METHODS

The 2004-2017 National Cancer Database was queried for adjuvant cEBRT or hypofractionated EBRT (hEBRT) for nonmetastatic BC; and definitive cEBRT, moderate hypofractionation (mEBRT), or stereotactic body radiotherapy (SBRT) for localized PC. Multivariable logistic regression identified factors associated with treatment noncompletion and receipt of shorter regimens.

FINDINGS

We identified 170,386 men with PC (median age [interquartile range], 70 [64-75] years; Black, 17.5%; White, 82.5%) and 306,846 women with BC (61 [52-69] years; Black, 12.3%; White, 87.7%). Among patients who received cEBRT for PC, Black men had higher treatment noncompletion rates compared with White (14.1% v 13.0%; odds ratio [95% CI] 1.07 [1.03 to 1.12]; P < .001). In contrast, treatment noncompletion was not disparate with SBRT (Black 1.6% v White 1.3%; 1.20 [0.72 to 2.00], P = .49) or mEBRT (Black 9.0% v White 7.1%; 1.05 [0.72 to 1.54], P = .79). From 2004 to 2017, SBRT (0.07% to 11.8%; 1.32 [1.31 to 1.33]) and mEBRT (0.35% to 9.1%; 1.27 [1.25 to 1.28]) increased (both P < .001); however, Black men were consistently less likely to receive SBRT (7.4% v White, 8.3%; 0.84 [0.79 to 0.89], P < .001). Among women with BC, there were no racial differences in treatment noncompletion; however, hEBRT was associated with lower treatment noncompletion rates (1.0% v cEBRT 2.3%; 0.39 [0.35 to 0.44], P < .001). Although hEBRT for BC increased (0.8% to 35.6%) between 2004 and 2017, Black women were less likely to receive hEBRT (10.4% v 15.3%; 0.78 [0.75 to 0.81], P < .001).

INTERPRETATION

Black patients were consistently less likely to receive hypofractionated radiation for PC or BC, despite evidence suggesting that shorter regimens may lower rates of treatment noncompletion with similar oncologic outcomes.

Radiotherapy Deserts: Impact of Race, Poverty and the Rural-Urban Continuum on Density of Providers and Utilization of Radiotherapy in the United States

PURPOSE

Prior efforts to characterize disparities in radiotherapy access and receipt have not comprehensively investigated interplay between race, socioeconomic status, and geography relative to oncologic outcomes. We sought to define these complex relationships at the US county level for prostate (PC) and invasive breast (BC) cancer in order to build a tool that facilitates identification of "radiotherapy deserts"-regions with mismatch between radiotherapy resources and oncologic need.

METHODS

We constructed an ecologic study model using national databases to evaluate 3141 US counties. Radiotherapy resources and utilization densities were operationalized as physician (PPR) and utilization (UPR) per person at risk: number of attending radiation oncologists and Medicare beneficiaries per 100,000 persons at risk, respectively. Oncologic need was defined by "hot zone" counties with ≥2 standard deviations (SD) above mean incidence and death rates. Uni- and multivariable logistic regressions examined links between PPR and UPR densities, epidemiologic variables, and hot zones for oncologic outcomes. Reported statistics are p<.05.

RESULTS

Mean (SD) PPR and UPR densities were 2.1 (5.9) and 192.6 (557.6) for PC and 1.9 (5.3) and 174.4 (501.0) for BC, respectively. Counties with high PPR and UPR densities were predominately Metro [odds ratio (OR) 2.9-4.4], generally with higher %Black Non-Hispanic population (OR 1.5-2.3). Incidence and death rate hot zones were largely Non-Metro (OR 0.3-0.6), generally with higher %Black Non-Hispanic constituents (OR 3.2-6.3). Lower PPR density was associated with death rate hot zones for both cancers (OR 0.8-0.9); UPR density was generally not linked to oncologic outcomes on multivariable analysis.

CONCLUSIONS

Mismatch between oncologic need with PPR and UPR disproportionately affects Non-Metro communities with higher %Black Non-Hispanic population. We developed an interactive web platform (bit.ly/densitymaps) to visualize "radiotherapy deserts" and drive targeted investigation of underlying barriers to care in areas of highest need, with the goal of reducing health inequities in this context.

Pilot Study Exploring the Feasibility of Incorporating Radiation Oncology Into Pre-existing Early Pathway Programs for Diverse Premedical Students

PURPOSE

Many medical schools in the United States have affiliated pathway, preparatory, and/or prematriculation programs that enroll a high percentage of students historically underrepresented in medicine (URiM). The purpose of this pilot study was to better characterize exposures to radiation oncology (RO) among students in these programs and determine the feasibility of incorporating a radiation oncologist within their pre-existing format if nonexistent.

METHODS AND MATERIALS

During the summers of 2021 and 2022, a radiation oncologist gave a presentation about basic principles of cancer care to 18 unique student groups in 12 premedical programs affiliated with 8 medical schools. Participating students were asked to complete an anonymous postpresentation questionnaire. Descriptive statistics are reported.

RESULTS

A total of 467 students attended the presentations, and 241 completed the questionnaire (response rate 52.0%). The majority of participants reported being female (63.5%), URiM (66.4%), and low income (57.3%). Students were less likely to report previous teaching from a radiation oncologist (11.2%) than a surgical (17.0%) or medical oncologist (18.3%). Prior clinical shadowing with a radiation oncologist (2.9%) was also less likely than shadowing a surgical oncologist (5.0%), medical oncologist (6.6%), or any other physician (53.1%). Students were also less likely to previously believe that radiation could cure cancer (65.8%) compared with surgery (74.9%) or chemotherapy (89.3%). After the presentation, 168 students (69.7%) were more interested in a career in RO, and 211 students (87.6%) responded that the presentation was either quite or extremely valuable (median Likert-type score, 5; interquartile range, 4-5).

CONCLUSIONS

Many of the students in premedical programs lack prior exposure to RO or knowledge of multidisciplinary cancer care, which was ameliorated by a simple yet effective presentation across a variety of different types of programs in this study. Longitudinal assessment of different types of educational initiatives and students' ultimate career trajectory will help optimize future RO initiatives among premedical URiM students.

Using Holistic Residency Applicant Review and Selection in Radiation Oncology to Enhance Diversity and Inclusion, an ASTRO SCAROP-ADROP-ARRO Collaboration

Disproportionate gender, racial, and ethnic diversity remains in the radiation oncology physician workforce despite widespread awareness and longitudinal efforts to improve representation. In this collaborative review, we define the rationale and components of holistic review and how it can be best utilized to provide a comprehensive evaluation of applicants to residency programs in radiation oncology. We initially discuss the current state of diversity in the field of radiation oncology and highlight the components of the residency selection process that may serve to perpetuate existing biases. Subsequently, the ACGME and AAMC holistic review framework is reviewed in detail to demonstrate the balanced assessment of potential applicants. The implementation of holistic review in medical school and residency selection to-date are examined to underscore the potential value of holistic review in the radiation oncology residency selection process. Finally, recommendations for the practical implementation of holistic review in radiation oncology trainee selection are outlined.

Comparing Ultra-hypofractionated Proton versus Photon Therapy in Extremity Soft Tissue Sarcoma

Purpose

Recent single institution, phase II evidence has demonstrated the feasibility and efficacy of ultra-hypofractionated, preoperative photon therapy in 5 fractions for the treatment of soft tissue sarcoma (STS). Our purpose was to evaluate the dosimetric benefits of modern scanning beam proton therapy compared with conventional photon radiation therapy (RT) for the neoadjuvant treatment of adult extremity STS.

Materials and Methods

Existing proton and photon plans for 11 adult patients with STS of the lower extremities previously treated preoperatively with neoadjuvant RT at our center were used to create proton therapy plans using Raystation Treatment Planning System v10.A. Volumes were delineated, and doses reported consistent with International Commission on Radiation Units and Measurements reports 50, 62, and 78. Target volumes were optimized such that 100% clinical target volume (CTV) was covered by 99% of the prescription dose. The prescribed dose was 30 Gy for PT and RT delivered in 5 fractions. For proton therapy, doses are reported in GyRBE = 1.1 Gy. The constraints for adjacent organs at risk (OARs) within 1 cm of the CTV were the following: femur V30Gy ≤ 50%, joint V30Gy < 50%, femoral head V30Gy ≤ 5 cm3, strip V12 ≤ 10%, and skin V12 < 50%. Target coverage goals, OAR constraints, and integral dose were compared by Student t test with P < .05 significance.

Results

A minimum 99% CTV coverage was achieved for all plans. OAR dose constraints were achieved for all proton and photon plans; however, mean doses to the femur (10.7 ± 8.5 vs 16.1 ± 7.7 GyRBE), femoral head (2.0 ± 4.4 vs 3.6 ± 6.4 GyRBE), and proximal joint (1.8 ± 2.4 vs 3.5 ± 4.4 GyRBE) were all significantly lower with PT vs intensity-modulated radiation therapy (IMRT) (all P < .05). Integral dose was significantly reduced for proton vs photon plans. Conformity and heterogeneity indices were significantly better for proton therapy.

Conclusion

Proton therapy maintained target coverage while significantly reducing integral and mean doses to the proximal organs at risk compared with RT. Further prospective investigation is warranted to validate these findings and potential benefit in the management of adult STS.

Treatment Planning of Bulky Tumors Using Pencil Beam Scanning Proton GRID Therapy

Purpose

To compare spatially fractionated radiation therapy (GRID) treatment planning techniques using proton pencil-beam-scanning (PBS) and photon therapy.

Materials and Methods

PBS and volumetric modulated arc therapy (VMAT) GRID plans were retrospectively generated for 5 patients with bulky tumors. GRID targets were arranged along the long axis of the gross tumor, spaced 2 and 3 cm apart, and treated with a prescription of 18 Gy. PBS plans used 2- to 3-beam multiple-field optimization with robustness evaluation. Dosimetric parameters including peak-to-edge ratio (PEDR), ratio of dose to 90% of the valley to dose to 10% of the peak VPDR(D90/D10), and volume of normal tissue receiving at least 5 Gy (V5) and 10 Gy (V10) were calculated. The peak-to-valley dose ratio (PVDR), VPDR(D90/D10), and organ-at-risk doses were prospectively assessed in 2 patients undergoing PBS-GRID with pretreatment quality assurance computed tomography (QACT) scans.

Results

PBS and VMAT GRID plans were generated for 5 patients with bulky tumors. Gross tumor volume values ranged from 826 to 1468 cm³. Peak-to-edge ratio for PBS was higher than for VMAT for both spacing scenarios (2-cm spacing, P = .02; 3-cm spacing, P = .01). VPDR(D90/D10) for PBS was higher than for VMAT (2-cm spacing, P = .004; 3-cm spacing, P = .002). Normal tissue V5 was lower for PBS than for VMAT (2-cm spacing, P = .03; 3-cm spacing, P = .02). Normal tissue mean dose was lower with PBS than with VMAT (2-cm spacing, P = .03; 3-cm spacing, P = .02). Two patients treated using PBS GRID and assessed with pretreatment QACT scans demonstrated robust PVDR, VPDR(D90/D10), and organs-at-risk doses.

Conclusions

The PEDR was significantly higher for PBS than VMAT plans, indicating lower target edge dose. Normal tissue mean dose was significantly lower with PBS than VMAT. PBS GRID may result in lower normal tissue dose compared with VMAT plans, allowing for further dose escalation in patients with bulky disease.

A liquid immunogenic fiducial eluter for image-guided radiotherapy

Introduction

Fiducials are routinely used to provide image-guidance during radiotherapy. Here, a new nanoparticle-based liquid immunogenic fiducial is investigated for its potential to provide image-guidance, while also enhancing treatment outcomes.

Methods

This fiducial, liquid immunogenic fiducial eluter (LIFE) biomaterial, is formulated with natural biodegradable polymers, chitosan and sodium alginate with radio-sensitizing nanoparticles, and immunoadjuvant like anti-CD40 monoclonal antibody. Once administered intra-tumorally, this liquid smart radiotherapy biomaterial congeals within the calcium rich tumor microenvironment. The potential use of LIFE biomaterial for providing image guidance in magnetic resonance imaging (MRI) and computed tomography (CT) was investigated over different time period in a pre-clinical tumored mouse model.

Results

Results showed that the LIFE biomaterial can provide both MRI contrast and CT imaging contrast over 3-weeks, with gradual decrease of the contrast over time, as the LIFE biomaterial biodegrades. Results also showed the LIFE biomaterial significantly slowed tumor growth and prolonged mice survival (p < 0.0001) over time.

Discussion

The results highlight the potential use of the LIFE biomaterial as a multi-functional smart radiotherapy biomaterial that could be developed and optimized for hypo-fractionated radiotherapy applications and combining radiotherapy with immunoadjuvants.

Radiation Oncology resident perspectives on diversity, equity, and inclusion: an Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee (ARRO EISC) inaugural resident survey

PURPOSE

In this study, radiation oncology residents were surveyed on perceptions of diversity, equity, inclusion, and belonging in their residency training programs.

METHODS AND MATERIALS

A 23-item survey was developed by the Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee resident members and faculty advisors. The survey was divided into 4 sections: institutional culture, support and resources, interview and recruitment, and experiences of bias. The survey was sent individually to residents from all Accreditation Council for Graduate Medical Education-accredited radiation oncology programs.

RESULTS

The survey was issued to 757 residents. A total of 319 residents completed the survey, for a response rate of 42%. All postgraduate years and geographic regions were represented. Significant racial, ethnic, and gender differences were present in survey response patterns. White residents (94%, 164 of 174) and male residents (96%, 186 of 194) were more likely to strongly agree/agree that they were treated with respect by their colleagues and their coworkers than other racial groups (P < .005) or gender groups (P < .008). Only 3% (5 of 174) of White residents strongly agreed/agreed that they were treated unfairly because of their race/ethnicity, while 31% (5 of 16) of Black residents and 10% (9 of 94) of Asian residents strongly agreed/agreed (P < .0001). Similarly, Hispanic residents were more likely to strongly agree/agree (24%, 5 of 21) than non-Hispanic residents (7%, 20 of 298) (P = .003). Regarding mentorship, there were no differences by gender or ethnicity. There were differences by race in residents reporting that they had a supportive mentor (P = .022), with 89% (154 of 174) of White residents who strongly agreed/agreed, 88% (14 of 16) of Black residents, and 91% of Asian residents (86 of 94).

CONCLUSIONS

This survey reveals that experiences of support, mentorship, inclusion, and bias vary significantly among radiation oncology residents based on race, ethnicity, and gender. Radiation oncology has opportunity for growth to ensure an equitable experience for all residents.

Demographic trends among ASTRO clinical practice guideline task force participants from 2010-2022

PURPOSE

The American Society for Radiation Oncology (ASTRO) has produced evidence-based clinical practice guidelines since 2009. It is unknown whether task force members for these guidelines are representative of the diversity of the radiation oncology field, particularly in comparison to the ASTRO membership demographics. We sought to characterize the demographic composition of all task force members to date.

METHODS

The author list for ASTRO-led published guidelines from 2010 to 2022 was assessed. Main practice location/institution was extracted from the guideline publication. Self-identified gender and race/ethnicity were obtained from the ASTRO membership database. Years of experience were measured as the number of years post-board certification at time of guideline development. For United States (US)-based physicians, gender was confirmed with the National Provider Identifier database. Proportions of task force members overall and by individual guideline were described by gender, underrepresented in medicine (URM) status, geography (US vs international), US region (if US based), years of experience (separated into ≤5 years including residents, 6-12 years, and >12 years), and type of practice. Proportions for gender, URM, and geography were compared with ASTRO membership demographics.

RESULTS

Between 2010 and 2022, there were 25 guideline task forces, with a total of 366 participants: 233 men, 126 women, and 7 unknown gender. There were more men than women serving on most individual task force topics, with 28% of all task forces having >80% composition of men. Of those with self-identified race/ethnicity, 9/204 (4.4%) were URM, which was lower in proportion to URM self-identified ASTRO members (336/3277, 10.3%; P = .007). Most participants were based in the US (n = 323, 88.3%), had >12 years of experience (n = 141, 38.5%), and were from academic institutions (n = 302, 82.5%). Community practitioners were less likely to be women or URM.

CONCLUSIONS

Improved data collection and more intentional efforts are needed to ensure that the diversity of guidelines task forces is representative of ASTRO membership and the specialty.

Gender Differences Among Academic Radiation Oncology National Institutes of Health (NIH) Funding Recipients

Purpose

The purpose of our study was to evaluate National Institutes of Health (NIH) funding recipients between 2016 and 2019 to determine if there was an association between gender, research productivity, academic rank, leadership positions, and post-graduate awards.

Materials and Methods

The NIH Research Portfolio Online Reporting Tools Expenditure and Results (RePORTER) website was used to retrieve data for grants in Radiation Oncology from 2016-2019. Demographics and profiles of awardees were retrieved from institutional websites, LinkedIn, and Doximity. Publication metrics were collected through the Scopus database. Mann-Whitney U tests and chi-square analyses were performed to compare and determine associations between gender and other variables. 

Results

Three hundred and forty radiation oncology principal investigators (PIs) were included in this study, of whom 76% were men. Of the 776 total NIH grants awarded, 62% of the grants had a sole male PI and 1% had two or more PIs in which the contact PI and co-PI were women. Between the genders of PIs in this sample, there was no significant difference in highest academic rank, leadership positions (i.e., chair, director, founder, president, and other), and post-graduate honors and awards. Total publications, years of active research, h-index, and m-index were higher amongst men in the professor category but were largely similar between genders in the associate and assistant professor categories.

Conclusions

The results demonstrate that most NIH grants in radiation oncology were awarded to men. Strategies that increase women in radiation oncology (RO), as well as those that increase NIH grants amongst women may also increase the prevalence of women in senior academic ranks and leadership positions.

Genomic Testing in Localized Prostate Cancer Can Identify Subsets of African Americans With Aggressive Disease

BACKGROUND

Personalized genomic classifiers have transformed the management of prostate cancer (PCa) by identifying the most aggressive subsets of PCa. Nevertheless, the performance of genomic classifiers to risk classify African American men is thus far lacking in a prospective setting.

METHODS

This is a prospective study of the Decipher genomic classifier for National Comprehensive Cancer Network low- and intermediate-risk PCa. Study-eligible non-African American men were matched to African American men. Diagnostic biopsy specimens were processed to estimate Decipher scores. Samples accrued in NCT02723734, a prospective study, were interrogated to determine the genomic risk of reclassification (GrR) between conventional clinical risk classifiers and the Decipher score.

RESULTS

The final analysis included a clinically balanced cohort of 226 patients with complete genomic information (113 African American men and 113 non-African American men). A higher proportion of African American men with National Comprehensive Cancer Network-classified low-risk (18.2%) and favorable intermediate-risk (37.8%) PCa had a higher Decipher score than non-African American men. Self-identified African American men were twice more likely than non-African American men to experience GrR (relative risk [RR] = 2.23, 95% confidence interval [CI] = 1.02 to 4.90; P = .04). In an ancestry-determined race model, we consistently validated a higher risk of reclassification in African American men (RR = 5.26, 95% CI = 1.66 to 16.63; P = .004). Race-stratified analysis of GrR vs non-GrR tumors also revealed molecular differences in these tumor subtypes.

CONCLUSIONS

Integration of genomic classifiers with clinically based risk classification can help identify the subset of African American men with localized PCa who harbor high genomic risk of early metastatic disease. It is vital to identify and appropriately risk stratify the subset of African American men with aggressive disease who may benefit from more targeted interventions.

Évolution des paramètres nutritionnels après la discontinuation des collations intradialytiques à cause de l’épidémie COVID-19

Introduction

Pendant l’épidémie par le COVID-19 plusieurs centres de dialyse ont arrêté de fournir des collations pendant la séance de dialyse par mesure de protection de propagation du virus. Le but de cette étude est d’évaluer l’état nutritionnel des patients hémodialysés chroniques avant et après la suspension des collations intradialytiques.

Description

Sur cette étude rétrospective on a étudié l’évolution des paramètres nutritionnelles de notre cohorte des patients hémodialysés pour 12 mois avant et après le 20/03/2020, date de suspension des collations pendant la dialyse à cause des mesures de protection contre la COVID-19. On a suivi l’évolution du poids, IMC, CRP, sérum Potassium et Phosphore avant la séance de dialyse, le taux d’albumine et prealbumine sérique ainsi que le nPCR (normalised Protein Catabolic Ratio).

Méthodes

Les résultats pour les paramètres continues sont présentés comme Moyenne ± Erreur standard moyenne. Pour l’analyse statistique on a effectué un t-test pour mesures indépendantes. Les résultats avec un p < 0,05 était considérés statistiquement significatifs.

Résultats

On a étudié 121 patients en hémodialyse (80 M,41F) avec un âge moyen à l’inclusion de 68,45 ± 0,45 ans. Ils étaient dialysés au moins depuis 6 mois dans un état stable. Un tiers de ces patients était diabétique. On a mesuré la moyenne des paramètres étudiés pour douze mois avant et après la suppression de collations intradialytiques (voir (Tableau 1). Ces collations comprenaient en moyenne de 395 kcal d’énergie (44 % des besoins journaliers), 13,3 g de protides (40 % des besoins journaliers). Il y avait une dégradation des paramètres nutritionnelles (poids, IMC, Albumine et Prealbumine serique ainsi que le nPCR après la suppression des collations confirmant leur rôle important sur l’état nutritionnel des patients hémodialysés chroniques.

Conclusion

En conclusion, la suppression des collations intradialytiques pendant la période épidémique de COVID-19 a aggravé les paramètres nutritionnels des patients en hémodialyse chronique.