Does Prophylactic Paraortic Lymph Node Irradiation Improve Outcomes in Women With Stage IIIC1 Endometrial Carcinoma?

PURPOSE

To evaluate the impact of prophylactic paraortic lymph node (PALN) radiation therapy (RT) on clinical outcomes in patients with International Federation of Obstetrics and Gynecology 2018 stage IIIC1 endometrial cancer (EC).

METHODS AND MATERIALS

A multi-institutional retrospective study included patients with International Federation of Obstetrics and Gynecology 2018 stage IIIC1 EC lymph node assessment, status postsurgical staging, followed by adjuvant chemotherapy and RT using various sequencing regimens. Overall survival (OS) and recurrence-free survival (RFS) rates were estimated by the Kaplan-Meier method. Univariable and multivariable analysis were performed by Cox proportional hazard models for RFS/OS. In addition, propensity score matching was used to estimate the effect of the radiation field extent on survival outcomes.

RESULTS

A total of 378 patients were included, with a median follow-up of 45.8 months. Pelvic RT was delivered to 286 patients, and 92 patients received pelvic and PALN RT. The estimated OS and RFS rates at 5 years for the entire cohort were 80% and 69%, respectively. There was no difference in the 5-year OS (77% vs 87%, P = .47) and RFS rates (67% vs 70%, P = .78) between patients treated with pelvic RT and those treated with pelvic and prophylactic PALN RT, respectively. After propensity score matching, the estimated hazard ratios (HRs) of prophylactic PALN RT versus pelvic RT were 1.50 (95% confidence interval, 0.71-3.19; P = .28) for OS and 1.24 (95% confidence interval, 0.64-2.42; P = .51) for RFS, suggesting that prophylactic PALN RT does not improve survival outcomes. Distant recurrence was the most common site of first recurrence, and the extent of RT field was not associated with the site of first recurrence (P = .79).

CONCLUSIONS

Prophylactic PALN RT was not significantly associated with improved survival outcomes in stage IIIC1 EC. Distant metastasis remains the most common site of failure despite routine use of systemic chemotherapy. New therapeutic approaches are necessary to optimize the outcomes for women with stage IIIC1 EC.

Introductory patient communication training for medical physics graduate students: Pilot experience

Despite medical physics becoming a more patient‐facing part of the radiation oncology team, medical physics graduate students have no training in patient communication. An introductory patient communication training for medical physics graduate students is presented here. This training exposes participants to foundational concepts and effective communication skills through a lecture and it allows them to apply these concepts through realistic simulated patient interactions. The training was conducted virtually, and eight students participated. The impact of the training was evaluated based on changes in both confidence and competence of the participants’ patient communication skills. Participants were asked to fill out a survey to assess their confidence on communicating with patients before and after the training. They also underwent a simulated patient interaction pre‐ and postlecture. Their performance during these was evaluated by both the simulated patient actors and the participants themselves using a rubric. Each data set was paired and analyzed for significance using a Wilcoxon rank‐sum test with an alpha of 0.05. Participants reported significantly higher confidence in their feeling of preparedness to interact with patients (mean = 2.38 vs. 3.88, p = 0.008), comfort interacting independently (mean = 2.00 vs. 4.00, p = 0.002), comfort showing patients they are actively listening (mean = 3.50 vs. 4.50, p = 0.005), and confidence handling challenging patient interactions (mean = 1.88 vs. 3.38, p = 0.01), after the training. Their encounter scores, as evaluated by the simulated patient actors, significantly increased (mean = 77% vs. 91%, p = 0.022). Self‐evaluation scores increased, but not significantly (mean = 62% vs. 68%, p = 0.184). The difference between the simulated patient and self‐evaluation scores for the postinstruction encounter was statistically significant (p = 0.0014). This patient communication training for medical physics graduate students is effective at increasing both the confidence and the competence of the participants in the subject. We propose that similar trainings be incorporated into medical physics graduate training programs prior to students entering into residency.

Integrating Radiation Oncology Into Undergraduate Medical Education

Cancer is one of the most important public health problems. However, medical education has not advanced at the same rate when it comes to cancer education. Currently, the United States Medical Licensing Examination subject examinations do not cover radiation oncology, prevention, and survivorship planning in its assessment model. Incorporating medical oncology and radiation oncology training into the undergraduate medical education curriculum can have a significant benefit in training future physicians. In this paper, we review current literature and propose some ideas that can help incorporate oncology, and specifically radiation oncology, into undergraduate medical education.

Why an Increasing Number of Unmatched Residency Positions in Radiation Oncology? A Survey of Fourth-Year Medical Students

Purpose

The number of US fourth-year medical students applying to radiation oncology has decreased during the past few years. We conducted a survey of fourth-year medical students to examine factors that may be influencing the decision to pursue radiation oncology.

Methods and Materials

An anonymous online survey was sent to medical students at 9 participating US medical schools.

Results

A total of 232 medical students completed the survey. Of the 153 students who stated they were never interested in radiation oncology, 77 (50%) reported never having been exposed to the specialty as their reason for not pursuing radiation oncology. The job market was the most commonly cited factor among students who said they were once interested in but ultimately chose not to pursue radiation oncology. Conversely, the recent low pass rates for board examinations and a perception of a lack of diversity within radiation oncology had the least influence.

Conclusions

Despite discussion of potential measures to address this disquieting trend, there have been minimal formal attempts to characterize and address potential causes of a decreasing interest in radiation oncology. This study's data are consistent with previous research regarding the trend of decreased medical student interest in radiation oncology and may be used as part of ongoing introspective assessment to inform future change within radiation oncology.

Interprofessional Image Verification Workshop for Physician and Physics Residents: A Multi-Institutional Experience

PURPOSE

Verification of patient position through pretreatment setup imaging is crucial in modern radiation therapy. As treatment complexity increases and technology evolves, physicist-physician collaboration becomes imperative for safe and successful radiation delivery. Despite the importance of both, residency programs lack formal interprofessional education (IPE) activities or structured training for image verification. Here we show the impact of an interprofessional image verification workshop for residents in a multi-institutional setting.

METHODS

The workshop included a lecture by the attending physicist and physician, and hands-on image registration practice by learners (medical physics residents, MP; and radiation oncology residents, RO). All participants filled out pre- and postactivity surveys and rated their comfort from 1 to 10 in (A) selecting what type of imaging to order for a given case and (B) independently assessing the setup quality based on imaging. A paired 1-tailed t test (α = 0.05) was used to evaluate significance; Spearman rank correlation coefficient was used to assess correlation of ratings and RO postgraduate year (PGY). Surveys had free-response questions about IPE and image verification activities in residency.

RESULTS

A total of 71 residents from 7 institutions participated between 2018 and 2020. Pre- and postsurveys were completed by 50 residents (38RO, 12MP) and showed an increase in (A) from 5.5 ± 2.2 to 7.1 ± 1.6 (P < .001) and in (B) from 5.1 ± 2.3 to 6.8 ± 1.5 (P < .001), with significant increases per subgroup (A_{Δ, RO} = 1.8 ± 1.7, P < .001; B_{Δ, RO} = 1.9 ± 1.8, P <. 001; A_{Δ, MP} = 1.1 ± 1.4, P = .012; B_{Δ, MP} = 1.2 ± 1.6, P = .016). RO confidence scores moderately correlated with PGY. Survey responses indicated that image verification training is mostly unstructured, with extent of exposure varying by program and attending; most with little-to-no training. Time constraints were identified as the main barrier. IPE was noted as a useful way to incorporate different perspectives into the process.

CONCLUSIONS

Formal image verification training increases resident comfort with setup imaging review and provides opportunities for interprofessional collaboration in radiation oncology residency programs.

The Radiation Oncology Education Collaborative Study Group 2020 Spring Symposium: Is Virtual the New Reality?

PURPOSE

Because of the COVID-19 pandemic, the Radiation Oncology Education Collaborative Study Group (ROECSG) hosted its annual international symposium using a virtual format in May 2020. This report details the experience of hosting a virtual meeting and presents attendee feedback on the platform.

METHODS AND MATERIALS

The ROECSG symposium was hosted virtually on May 15, 2020. A postsymposium survey was distributed electronically to assess attendee demographics, participation, and experience. Attendee preference and experience were queried using 3-point and 5-point Likert-type scales, respectively. Symplur LLC was used to generate analytics for the conference hashtag (#ROECSG).

RESULTS

The survey was distributed to all 286 registrants, with a response rate of 67% (191 responses). Seventeen nonattendee responses were omitted from this analysis, for a total of 174 included respondents. Eighty-two attendees (47%) were present for the entire symposium. A preference for a virtual symposium was expressed by 78 respondents (45%), whereas 44 (25%) had no preference and 52 (30%) preferred an in-person meeting. A total of 150 respondents (86%) rated the symposium as "extremely" well organized. Respondents who had not attended a prior in-person ROECSG symposium were more likely to prefer the virtual format (P = .03). Seventy-eight respondents (45%) reported a preference for the virtual platform for reviewing scholarly work, and 103 (59%) reported a preference for an in-person platform for networking. On the day of the symposium, #ROECSG had 408 tweets and 432,504 impressions.

CONCLUSIONS

The 2020 ROECSG symposium was well received and can serve as a framework for future virtual meetings. Although the virtual setting may facilitate sharing research, networking aspects are more limited. Effort is needed to develop hybrid virtual and in-person meetings that meet the needs of participants in both settings. Social media is a significant avenue for dissemination and discussion of information and may be valuable in the virtual setting.

A new development in ultrasound-compatible gynecologic brachytherapy simulators

PURPOSE

Gynecologic brachytherapy is an essential component in the curative treatment of cervical cancer. With the decline in brachytherapy utilization, gynecologic brachytherapy simulators are being used to provide a mechanism to enhance proficiency-based resident training. However, most models that have been used lack procedural fidelity as they are either repurposed from OB/GYN basic models or from physics phantoms. Therefore, we set out to develop a high-fidelity, ultrasound- and CT-compatible gynecologic brachytherapy training simulator.

METHODS AND MATERIALS

Based on prior experience with gynecologic training simulators on the market, we developed a wish list for an ultrasound-compatible brachytherapy training model. A custom simulator was developed based on an existing pelvic ultrasound trainer. Features included a cervical os and endometrial canal as well as a palpable and hypoechoic cervical tumor.

RESULTS

The model took about 3 months from the initial meeting with the developer to completion. The properties of the material were equivalent to water for ultrasound, CT, and also MRI and the model did not show signs of degradation after multiple tandem insertions.

CONCLUSIONS

A high-fidelity ultrasound-compatible simulator was effectively developed and utilized to improve resident training to perform brachytherapy implants with a derivative benefit in the long term of improving survival for women with advanced gynecologic malignancies through having access to more proficient brachytherapists. Future directions include enhancing the model to allow for repetitive needle insertion and suturing for interstitial training as well as creating variations in anatomy (e.g., retroverted uterus, bulky tumors, etc.) for more advanced technical training.

Acute extraperitoneal spontaneous bladder rupture in cervical cancer patient undergoing chemoradiation: A case report and review of the literature

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Spontaneous bladder ruptures have only been reported intraperitoneally, and years after the cessation of therapy.

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Extraperitoneal bladder rupture can occur with radiation therapy in treatment of cervical cancer.

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Improved reporting of toxicity is needed to identify types of genitourinary toxicity seen with modern chemoradiation.

The standard of care for locally advanced cervical cancer is pelvic radiotherapy with sensitizing cisplatin, and intracavitary brachytherapy. This standard of care treatment paradigm has best survival outcomes, however is associated with genitourinary toxicities. Spontaneous bladder rupture (SBR) is a rare complication of chemoradiation that has only been reported in literature as an intraperitoneal rupture occurring years after the cessation of treatment. We herein present a novel case of extraperitoneal SBR in a 27-year-old female with FIGO Stage IIIC cervical cancer and no prior surgical history who was undergoing chemoradiation with sensitizing cisplatin. During her final planned brachytherapy treatment upon instilling the bladder under ultrasound guidance, an anterior midline extraperitoneal rupture was noted. She was managed conservatively for several weeks and during this time was ultimately able to complete her external beam therapy and last cycle of cisplatin. After approximately ten weeks of conservative management, imaging demonstrated complete resolution of the rupture. A review of the literature suggests this complication tends to occur as an intraperitoneal rupture years after the cessation of therapy. Late genitourinary complications and types of complications are rarely reported in clinical trials, so it is difficult to determine the true incidence of rare complications and identify patients that may be at risk.

Increasing Medical Student Engagement Through Virtual Rotations in Radiation Oncology

Corona virus disease 2019 (COVID-19) affected medical student clerkships and education around the country. A virtual medical student clerkship was created to integrate didactic education with disease specific lectures for medical students, contouring, and hands on learning with telehealth. Twelve medical students in their 3rd and 4th year were enrolled in this 2 week elective from April 27, 2020 to June 5, 2020. There was significant improvement of overall knowledge about the field of radiation oncology from pre elective to post elective (P < .001). Feedback included enjoying direct exposure to contouring, telehealth, and time with residents. Overall this 2 week rotation was successful in integrating radiation oncology virtually for medical students. This is now being expanded to multiple institutions as an educational resource and future rotations for medical students.

Image-Guided Gynecologic Brachytherapy for Cervical Cancer

The incorporation of magnetic resonance imaging in brachytherapy has resulted in an increased use of interstitial catheters in order to create a comprehensive treatment plan that covers the visualized tumor. However, the insertion with passive, image-guidance requires estimating the location of the tumor during the insertion process, rather than visualizing and inserting the catheters directly to the desired location under active tracking. In order to treat residual disease, multiparametric MR sequences can enhance the information available to the clinician. The precision availed by MR-guided brachytherapy results in substantial improvements in needle positioning, and resulting treatment plans.

The vaginal cylinder: Misunderstood, misused, or trivial? An in-depth dosimetric and multiinstitutional outcome investigation

PURPOSE

The purpose of the study was to investigate the impact on dose distribution and radiobiological metrics of common high-dose-rate vaginal brachytherapy treatment parameters and to analyze multiinstitutional data for clinically significant impact on outcomes in early-stage endometrial cancer.

METHODS AND MATERIALS

Treatment plans were created for all combinations of prescription parameters and used to quantify the dosimetric impact of each parameter and to estimate the dose delivered using common voxel-integrated radiobiological metrics. A rating system, based on risk grouping from GOG and PORTEC trials, was used to consolidate staging information into a cancer "aggressiveness" measure. Correlations between the rating, toxicity, disease recurrence, and plan parameters were investigated.

RESULTS

When prescribing to 5 mm depth, the variation caused by the diameter was very large across all dose metrics, ranging from 51% to 175% increase with the most divergence in BED_max. For surface prescription, changing the cylinder diameter from 4 cm to 2 cm caused the dose metrics of BED_min, D_min, and gBEUD (a = -3) to increase by 117%, 67%, and 52%, respectively. Prescription to 5-mm depth caused changes across all dose metrics of 260% compared with surface prescription for a 2-cm cylinder. Deeper prescription point (p = 0.005) and longer treatment length (p = 0.01) were correlated with increased stenosis rates. No correlation between recurrence and any plan parameter was found.

CONCLUSIONS

Dramatic differences in dose distributions arise by small variations of plan parameters, with large impact on rates of vaginal stenosis, but no clear relation with local recurrence. To help radiation oncologists interpret the magnitude of these effects for their patients, we created a tool that allows comparison between dose and fractionation parameters.

Co-occurring substance use disorder: The impact on treatment adherence in women with locally advanced cervical cancer

The purpose of this study was to identify the prevalence of substance use disorder and its association with adherence to treatment and survival in locally advanced cervical cancer patients treated with primary radiation therapy. This is a retrospective case series of locally advanced cervical cancer patients with substance use disorder in a single academic institution treated with radiation therapy between 2005 and 2016. Substance use disorder was identified through chart review. Those with substance use disorder were compared to those without in regards to demographics, Charlson comorbidity index, treatment details and outcomes. Of the 129 patients with locally advanced cervical cancer, 16 (12.4%) were identified as having substance use disorder. Patients with substance use disorder were younger (42.1 years vs 51.5 years, p = .013) and more likely to be smokers (81.3% vs 42.5%, p = .004). The majority of patients with substance use disorder received concurrent chemotherapy (93.8%) and brachytherapy in addition to external beam radiation therapy (81.3%). There was no significant difference in days to completion of radiation therapy between patients with and without substance use disorder. Radiation dose received, toxicities and survival were similar between groups. Among cervical cancer patients receiving treatment with radiation therapy, substance use disorder was not associated with poorer adherence, longer radiation treatment times or a difference in total dose of radiation received. Our experience demonstrates that patients with substance use disorder are able to adhere to complex, multimodal treatment plans resulting in similar cancer specific outcomes compared to patients without substance use disorder.

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Substance abuse disorder is common among locally advanced cervical cancer patients.

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Treatment adherence is similar in patients with and without substance use disorder.

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Treatment plan should not be altered based on a substance use disorder comorbidity.

Adjuvant radiation therapy for T4 non-rectal colon adenocarcinoma provides a cause-specific survival advantage: A SEER database analysis

PURPOSE

While there is no level 1 evidence supporting the use of adjuvant radiotherapy (RT) for non-rectal colon cancer in the modern chemotherapy era, there are studies that suggest a local control benefit. This treatment modality is not part of standard treatment recommendations, and we hypothesized that adjuvant RT provides a benefit in locally advanced disease. Due to the limited number who receive post-operative RT, a national database was searched to provide sufficient power.

MATERIALS AND METHODS

A retrospective analysis using the Surveillance, Epidemiology, and End Results (SEER) database was performed. Inclusion criteria were: non-rectal colon cancer, AJCC 6th or 7th edition T4 and M0, oncologic resection, and 1st cancer site. Patients were excluded for RT prior to or during surgery, or if the sequence of RT was unknown. Using a Cox proportional hazard model, the relative risk of cause-specific mortality for "RT after surgery" versus "No RT" was calculated.

RESULTS

21,789 patients were identified who met the inclusion criteria. Of these, only 1001 received adjuvant RT, and 64% were node-positive (53% RT vs. 65% no RT). When comparing RT vs. no RT, after adjusting for sex, age, N stage, and grade, we determined the relative risk of death from cancer was 0.8849 (95% CI: 0.8008-0.9779; p = 0.0165), suggesting that only 14 patients with T4 disease need receive adjuvant radiation to spare a cancer-related death.

CONCLUSIONS

Adjuvant RT is not routinely utilized for definitive treatment of T4 non-rectal colon cancer, but this analysis shows a significant cause-specific survival benefit.

The long-lasting relationship of distress on radiation oncology-specific clinical outcomes

Purpose

The diagnosis and treatment of cancer can have significant mental health ramifications. The National Comprehensive Cancer Network currently recommends using a distress screening tool to screen patients for distress and facilitate referrals to social service resources. Its association with radiation oncology–specific clinical outcomes has remained relatively unexplored.

Methods and materials

With institutional review board approval, National Comprehensive Cancer Network distress scores were collected for patients presenting to our institution for external beam radiation therapy during a 1-year period from 2015 to 2016. The association between distress scores (and associated problem list items and process-related outcomes) and radiation oncology–related outcomes, including inpatient admissions during treatment, missed treatment appointments, duration of time between consultation and treatment, and weight loss during treatment, was considered.

Results

A total of 61 patients who received either definitive (49 patients) or palliative (12 patients) treatment at our institution and completed a screening questionnaire were included in this analysis. There was a significant association between an elevated distress score (7+) and having an admission during treatment (36% vs 11%; P = .04). Among the patients treated with definitive intent, missing at least 1 appointment (71% vs 26%; P = .03) and having an admission during treatment (57% vs 10%; P = .009) were significantly associated with our institutional definition of elevated distress. We found no correlation between distress score and weight loss during treatment or a prolonged time between initial consult and treatment start.

Conclusions

High rates of distress are common for patients preparing to receive radiation therapy. These levels may affect treatment compliance and increase rates of hospital admissions. There remains equipoise in the best method to address distress in the oncology patient population. These results may raise awareness of the consequences of distress among radiation oncology patients. Specific interventions to improve distress need further study, but we suggest a more proactive approach by radiation oncologists in addressing distress.