A Phase I Trial of a Methionine Restricted Diet with Concurrent Radiation Therapy

Methionine is an essential amino acid critical for cell growth and survival. Preclinical evidence suggests a methionine restricted diet (MRD) sensitizes cancer to radiation therapy (RT), without significant adverse effects. However, this has never been evaluated in humans. The purpose of this pilot study was to evaluate the safety and feasibility of concurrent MRD with standard-of-care definitive RT in adults with any non-skin cancer malignancy. The MRD extended from 2 wk before RT initiation, through 2 wk beyond RT completion. The primary endpoint of safety was assessed as rate of grade 3 or higher acute and late toxicities. Feasibility was assessed with quantitative plasma amino acid panel every 2 wk during the MRD (target plasma methionine 13 μM). Nine patients were accrued over a two-year period, with five able to complete the treatment course. The trial was closed due to slow accrual and subjects' difficulty maintaining the diet. No grade 3 or higher adverse events were observed. Subjects' average methionine level was 18.8 μM during treatment, with average nadir 16.8 μM. These findings suggest the safety of concurrent MRD with RT, with toxicities comparable to those expected with RT alone. However, the diet was challenging, and unacceptable to most patients.

Assessment of Student Perceptions of Aspects of a Career in Radiation Oncology

PURPOSE

To determine medical students' views of various aspects of a career in radiation oncology (RO) to identify areas that may benefit from reform and to guide initiatives to stimulate broader and more diverse student interest in the specialty.

METHODS AND MATERIALS

An electronic survey was sent to student oncology interest group members at seven US medical schools. The survey asked students to rate 19 aspects of RO on a 5-point bipolar Likert-type scale. Descriptive statistics are reported, along with subgroup analyses based on participants' demographics.

RESULTS

The response rate was 51.1% (n = 275 of 538). The most favorably rated aspects of RO were outpatient working hours (mean ± SD Likert-type rating of 4.51 ± 0.82), routinely working with other physicians (4.45 ± 0.76), and use of advanced technology to treat patients. The most unfavorably rated aspects of RO were less geographic flexibility for residency or employment (1.98 ± 1.04), spending a lot of time on a computer doing treatment planning (2.80 ± 1.21), and having a job that is not well understood by most doctors and the general public (2.89 ± 1.02). Gender was associated with significant differences in 8 of 19 questions in how each aspect of RO was viewed. Few differences were observed based on race or ethnicity, though Asian participants had a significantly more favorable view of RO being a more science-oriented specialty compared with White or underrepresented students, respectively (3.50 versus 3.21 versus 2.84, P = .01).

CONCLUSIONS

These findings inform the RO community in the development of more effective initiatives to encourage students to fully explore the specialty.

Assessment of Medical Student Research Mentorship in Radiation Oncology

Purpose

Mentored medical student (MS) research opportunities in radiation oncology (RO) provide in-depth exposure to the specialty and may promote greater interest in a career in RO. Many radiation oncologists conduct research; however, the extent to which they directly engage MSs in their research is unknown. The purpose of this study was to characterize MS authorship in American Society for Radiation Oncology (ASTRO) journals.

Methods and Materials

The byline and abstract of all scientific articles (ie, clinical, basic science, training/education) and case reports published from 2019 to 2021 in the International Journal of Radiation Oncology, Biology, and Physics; Practical Radiation Oncology; and Advances in Radiation Oncology were reviewed. Characteristics of MSs and senior authors are reported.

Results

A total of 105 of 1785 articles (5.8%) included an MS author, among which 72 (68.6%) were clinical, 13 training/education (12.4%), 12 case reports (11.4%), and 8 basic science (7.6%). MS authors were more common for publications in Advances in Radiation Oncology (9.0%) than Practical Radiation Oncology (6.4%) or the International Journal of Radiation Oncology, Biology, and Physics (4.2%; P = .002). There were 125 unique MS authors from 72 institutions, among which 40 were first author (32.0%), 28 second author (22.4%), and 57 third (or higher) author (45.6%). There were 88 unique senior authors from 55 institutions, among which 10 (11.3%) were on 2 or more MS publications, and 57 (64.7%) shared the same institution as the MS. The median number of articles per mentor institution was 1 (interquartile range, 1-2), and the mentor institutions in the upper quartile in terms of number of MS publications accounted for 53 (50.5%) of all MS publications.

Conclusions

Few publications in American Society for Radiation Oncology journals include MS authors with mentorship disproportionately from a small number of academic faculty at select institutions. These findings suggest that there is great potential for radiation oncologists to proactively engage more students in their work.

Evaluation of a Radiation Oncology Microclerkship as a Component of Medical Student Education

Compared to most oncologic subspecialties, radiation oncology (RO) lacks a natural pathway for incorporation into the clinical clerkships, and few students ever complete a formal rotation in RO. The feasibility, and perceived value, of a 1-day "microclerkship" exposure in RO during other related clerkships was evaluated in this study. At a single institution, the RO clerkship director partnered with clerkship directors in medical oncology, palliative care, and radiology so that every 3rd or 4th year student would spend 1 day in RO during those clerkships. Afterwards, students completed an electronic survey containing multiple choice and 5-point Likert-type questions describing their experience. Descriptive statistics are reported. Ninety-seven students completed the RO microclerkship over 2 years, and 81 completed the survey (response rate 84%). Only 8 students (10%) had ever been in a RO department previously. During the microclerkship, 73 students (90%) saw at least one new patient consultation; 77 (95%) were involved in contouring or treatment planning; 76 (94%) saw treatment delivery; and 38 (47%) saw a brachytherapy procedure. Seventy-nine students (98%) felt that the microclerkship was at least moderately valuable (mean Likert-type rating 4.01, SD 0.73). Forty students (49%) were either somewhat or much more interested in participating in a longer (2-4 week) rotation in radiation oncology (mean Likert-type rating 3.59, SD 0.83). This study demonstrated the feasibility of incorporating a 1-day RO microclerkship into other related elective clerkships. Students viewed the experience favorably and found it valuable in their education.

Oncology Physician Workforce Diversity: Rationale, Trends, Barriers, and Solutions

ABSTRACT

This chapter will discuss (1) the rationale for physician workforce diversity and inclusion in oncology; (2) current and historical physician workforce demographic trends in oncology, including workforce data at various training and career levels, such as graduate medical education and as academic faculty or practicing physicians; (3) reported barriers and challenges to diversity and inclusion in oncology, such as exposure, access, preparation, mentorship, socioeconomic burdens, and interpersonal, structural, systemic bias; and (4) potential interventions and evidence-based solutions to increase diversity, equity, and inclusion and mitigate bias in the oncology physician workforce.

Pilot Study Assessing Student Interest in Combined Residency Training Pathways with Radiation Oncology

PURPOSE/OBJECTIVE(S)

Radiation oncology (RO) is a small, highly specialized field, which most medical students have limited exposure to before having to decide what specialty to apply to for their graduate medical education (GME). This may ultimately limit the number and diversity of RO applicants. The purpose of this pilot study was to determine students' views on a combined pathway program between RO with internal medicine (IM), as well as other related medical specialties, as a potential means of overcoming some of these barriers to student interest in RO and the early decision point to solo training in RO.

MATERIALS/METHODS

An electronic survey was sent to 299 United States student members of the American Society for Radiation Oncology (ASTRO) between July-August 2022. Multiple choice and Likert-type questions were used to assess students' views on the potential advantages and disadvantages of a combined IM/RO training pathway, and interest in this potential combined pathway as well as other combined pathway programs with RO and other related subspecialties. The Mann-Whitney U and Kruskal-Wallis tests were used to compare the responses of subgroups of students stratified according to their gender identity, race, or ethnicity. The Wilcoxon signed rank test was used to compare all participants' interest in different combined pathway programs compared to RO/IM.

RESULTS

Eighty participants completed the survey (response rate 27%). Thirty-four participants (43%) were either very or extremely interested in pursuing a combined IM/RO residency (median Likert-type rating 3, IQR 2-4). The duration of a combined IM/RO training considered most preferable or ideal was five years (n = 57, 71%) or six years (n = 21, 26%). The most important potential advantages of a combined IM/RO pathway included greater flexibility in employment options (n = 51, 64%), enhanced general medical knowledge to facilitate ambitions in other career pathways (n = 46, 58%), improved patient care (n = 43, 54%), and having a pathway for combined hematologic/oncology and RO board certification (n = 46, 58%). In comparison to IM/RO, participants were significantly more interested in a combined RO and hematology/oncology program (median Likert-type rating 5, IQR 5-5, p = 0.005). Among the subgroup of 26 students who believed that it was less likely that they would be applying for RO residency, 18 (69%) believed that the availability of an IM/RO pathway would increase their interest in applying to RO (median Likert-type rating 4, IQR 3-5). Interest in IM/RO did not differ by gender, race, or ethnicity.

CONCLUSION

Combined training pathways involving RO were viewed positively by most survey respondents, comprised of student members of ASTRO. Such programs may be particularly appealing to those students who are interested, but less committed to pursuing, a career in RO. Further research will help guide recommendations for the creation of these programs.

Pilot Study Evaluating Cross-Disciplinary Educational Material to Improve Patients' Knowledge of Palliative Radiation Therapy

Palliative radiation therapy (PRT) is underutilized, partially due to misconceptions about its risks, benefits, and indications. The objective of this pilot study was to determine if patients with metastatic cancer would gain knowledge from educational material describing PRT and perceive it as useful in their care. A one-page handout conveying information about the purpose, logistics, benefits, risks, and common indications for PRT was offered to patients undergoing treatment for incurable, metastatic solid tumors in one palliative care clinic and four medical oncology clinics. Participants read the handout, then completed a questionnaire assessing its perceived value. Seventy patients participated between June and December 2021. Sixty-five patients (93%) felt they learned from the handout (40% learned "lots"), and 69 (99%) felt the information was useful (53% "very useful"). Twenty-one patients (30%) were previously unaware that PRT can relieve symptoms, 55 (79%) were unaware that PRT can be delivered in five treatments or less, and 43 (61%) were unaware that PRT usually has few side effects. Sixteen patients (23%) felt they currently had symptoms not being treated well enough, and 34 (49%) felt they had symptoms that radiation might help with. Afterwards, most patients felt more comfortable bringing symptoms to a medical oncologist's (n = 57, 78%) or radiation oncologist's (n = 51, 70%) attention. Patient-directed educational material about PRT, provided outside of a radiation oncology department, was perceived by patients as improving their knowledge and adding value in their care, independent of prior exposure to a radiation oncologist.

Characterizing Wellness Leadership in Academic Radiation Oncology Departments in the United States

PURPOSE/OBJECTIVE(S)

Burnout is prevalent in radiation oncology (RO), with 56% of respondents in a 2020 survey reporting symptoms of burnout. This has led to an increased effort to promote physician wellness via formal wellness-directed initiatives in recent years. However, little is known about the specifics of wellness activities and their impact. We aim to characterize current wellness leadership positions and efforts within academic RO departments.

MATERIALS/METHODS

A total of 120 US academic RO department chairs were contacted to inquire whether they had a departmental wellness leader, with a request for leader contact information, if applicable. Wellness leaders were invited to complete an anonymous survey in January and February 2023 via a survey platform. Questions assessed leader demographics, role structure, resources, current initiatives, and impacts to date. Descriptive statistics and summaries of free text responses are reported.

RESULTS

Seventy-one chairs (59%) responded, among which 43 (61%) reported having departmental wellness leaders. On interim analysis, 11 (26%) responded to the survey. 82% were female and 73% were physician faculty. Leaders spanned career stages, and respondent ages ranged from 32-66. Wellness leaders were commonly in formal departmental committees (n = 4) or implemented hospital initiatives without independent departmental programming (n = 5). Committees had all been started since 2020. 5 respondents stated departmental wellness leadership was required by their institution. Some leaders were provided with administrative support (n = 4) and/or departmental program funding (n = 4), however only 1 had protected time for wellness work. Challenges included limited bandwidth (n = 7), lack of departmental interest (n = 4), and limited funding (n = 4). The most commonly completed initiatives include programming and education (n = 4) and improved support for caregivers (n = 3). No departments had hired physician coaches or created a peer support network. Of 14 initiatives, departments had, on average, implemented 2. 36% and 27% of respondents agree that because of wellness initiatives the department is more aware of the importance of wellness and wellness-promoting strategies, respectively. Only 9% and 18% felt initiatives changed a culture of constant availability and encouraged use of full PTO and limiting work off hours, respectively. Leaders highlight the importance of a dedicated individual to tangibly implement changes and the unique opportunity of someone within RO to understand the specific challenges faced by those in our field.

CONCLUSION

Wellness leadership roles exist in many RO departments. However, these roles are new and evolving, with a limited number of fully implemented initiatives to date. Longitudinal data collection and follow-up will help establish the impact of these roles on bringing positive change to departments. Full results will be presented at ASTRO 23.

Safety and Feasibility of the Addition of a Radiosensitizing Methionine-Restricted Diet to Radiation Therapy

PURPOSE/OBJECTIVE(S)

Methionine is an amino acid necessary for numerous processes critical for cell growth and survival. While normal cells can tolerate methionine deficiency, most cancer cells are methionine auxotrophs, requiring dietary intake since they cannot synthesize it. In vitro, methionine deficiency causes cancer cells to undergo cell cycle arrest and cell death, and in vivo a methionine restricted diet (MRD) enhances radiosensitization without significant adverse effects. Combining a MRD and radiation therapy (RT) to treat human malignancies has never been evaluated. The hypothesis of this Phase I study was that a MRD would be safe, and feasible to administer concurrently with curative-intent RT.

MATERIALS/METHODS

Eligible patients included adults with any non-skin cancer malignancy undergoing standard radiation therapy without concurrent cytotoxic chemotherapy. The MRD consisted of low-protein cereals, grains, and breads; fruits; vegetables; margarines and oils; and simple carbohydrates. A clinical dietician developed a personalized meal plan with each subject to reduce methionine consumption to 5-10 mg/kg body weight/day, while maintaining adequate protein and caloric intake. An unlimited supply of a commercially available methionine-free protein supplement was provided to minimize hunger and weight loss. The MRD extended from 2 weeks before initiation of RT, through 2 weeks beyond completion of RT. The primary endpoint for safety was the rate of grade 3 or higher acute and late toxicities per CTCAE, over 12 months follow-up. Feasibility was assessed with a biweekly quantitative plasma amino acid panel during the MRD. The target accrual was 15 subjects.

RESULTS

Over two years, 53 patients were offered enrollment, 9 subjects enrolled, 5 completed the MRD and RT, and 4 withdrew during the MRD. The table summarizes subjects' characteristics and outcomes. There was no grade 3 or higher adverse events attributable to the MRD. Methionine plasma levels varied over the course of treatment, and while no subject achieved the target of 13 μM, two nadired at 14 μM. The trial was closed early due to slow accrual and subjects' difficulty maintaining the diet.

CONCLUSION

This study suggests a MRD is safe with thoracic or abdominopelvic RT, with toxicities comparable to those expected with RT alone. However, the diet was challenging, and unacceptable to most patients with cancer.

The Current State of Departmental Diversity, Equity, and Inclusion Efforts Within US Academic Radiation Oncology Departments

PURPOSE

Promoting a diverse workforce of health care professionals that delivers equitable patient care is an important goal in oncology, as in all of medicine. Although most medical schools have a diversity office and associated initiatives, little is known about radiation oncology (RO) department-level efforts to promote diversity, equity, and inclusion (DEI). We describe the current state of DEI leadership and initiatives in RO departments in the US to guide future policies and programs.

METHODS AND MATERIALS

A total of 124 US RO departments affiliated with a medical school were contacted to identify departmental DEI leadership. Identified DEI leaders were asked to complete an anonymous survey assessing characteristics of their departmental DEI leadership, committee/organizational structure, activities, and perceived barriers to, and effect of, their work. Descriptive statistics are reported.

RESULTS

Among 85 RO departments that responded (68.5% response rate), 48 (56.5%) reported having a departmental DEI leader. Thirty-four DEI leaders completed the survey (70.8%). Of those who answered each survey question, most DEI leaders were assistant or associate professors (n = 24, 82.8%), women (n = 19, 73.1%), and identified with at least one non-White race or Hispanic ethnicity (n = 15, 53.6%). Nineteen (57.6%) had an associated departmental DEI committee; with 10 of these starting in 2020 or later. Few DEI leaders had administrative support (38.2%), funding (29.4%), protected time (23.5%), or increased compensation for added duties Fifteen (50.0%) believed their DEI-focused efforts were considered for promotion. The most reported initiatives included offering programming/education, supporting students from backgrounds underrepresented in medicine, improving recruitment practices/hiring, and implementing pipeline/pathway projects. The perceived impact of DEI initiatives included an increased culture of respect (89.7%), improved health care disparity awareness (75.9%), and improved systemic/structural racism awareness (79.3%).

CONCLUSIONS

Departmental DEI efforts are increasingly common within RO, however, the structure, resources, and recognition associated with DEI work are variable. Additional dedicated resources and recognition for these efforts will help ensure a culture of inclusive excellence for the RO workforce and patients.

Predictors of Interest in Radiation Oncology: The Effect of Race, Ethnicity, Gender, and Other Diversity Measures

Purpose

The presence of women and people underrepresented in medicine (URiM) continues to be lower in radiation oncology (RO) than within the United States population, medical school graduates, and oncology fellowship applicants. The objective of this study was to identify demographics of matriculating medical students who are inclined to consider pursuing a residency in RO and identify barriers to entry that students may perceive before medical school training.

Methods and Materials

A survey of incoming medical students at New York Medical College was distributed via e-mail and assessed demographic background information, interest in and awareness of oncologic subspecialties, and perceived barriers to RO.

Results

Students of the incoming class of 2026 had a complete response rate of 72% (155 complete responses and 8 incomplete responses of 214 class members). Two-thirds of participants had prior awareness of RO, and half have considered pursuing an oncologic subspecialty, but less than one-fourth have ever previously considered a career in RO. Students responded that they need more education, clinical exposure, and mentorship to increase their chance of choosing RO. Male participants had 3.4 times the odds of having an acquaintance in the community tell them about the specialty and also had significantly greater interest in using advanced technologies. There were no URiM participants who had personal relationships with an RO physician compared with 6 (4.5%) non-URiM participants. The average response to "What is the likelihood that you will pursue a career in RO?" showed no significant difference between genders.

Conclusions

All races and ethnicities scored a similar likelihood of pursuing a career in RO, which differs greatly from the current RO workforce. Responses emphasized the importance of education, mentorship, and exposure to RO. This study demonstrates the need for support of female and URiM students during medical school.

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.

The American Society for Radiation Oncology Workforce Taskforce Review of the United States Radiation Oncology Workforce Analysis

Over the past decade, concerns have arisen in radiation oncology regarding potential workforce supply and demand imbalance. The American Society for Radiation Oncology commissioned an independent analysis in 2022, looking at supply and demand in the United States radiation oncology workforce and projecting future trends for 2025 and 2030. The final report entitled, "Projected Supply and Demand for Radiation Oncologists in the U.S. in 2025 and 2030" is now available. The analysis included evaluating radiation oncologist supply (new graduates, exits from the specialty), potential changes in demand (growth of Medicare beneficiaries, hypofractionation, loss of indications, new indications) as well as radiation oncologist productivity (growth of work RVUs produced) and demand per beneficiary. The results demonstrated a relative balance between radiation oncology supply and demand for radiation services; the growth in radiation oncologists was balanced by the rapid growth of Medicare beneficiaries over the same time period. The primary factors driving the model were found to be growth of Medicare beneficiaries, and change in work RVU productivity with hypofractionation and loss of indication having only a moderate impact; while the most likely scenario was a balance of workforce supply and demand, scenarios did demonstrate the possibility of over and under supply. Oversupply may become a concern if radiation oncologist wRVU productivity reaches the highest region; beyond 2030, this is also possible if growth in radiation oncologist supply does not parallel Medicare beneficiary growth. Limitations of the analysis included the lack of inclusion of most technical reimbursement and its impact as well as failing to account for SBRT. A modeling tool is available to allow individuals to evaluate different scenarios. Moving forward, continued study will be needed to evaluate trends (particularly work RVU productivity and Medicare beneficiary growth) to allow for continued assessment of workforce supply and demand in radiation oncology.

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.

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.

Demographics of ASTRO Student Members and Potential Implications for Future U.S. Radiation Oncology Workforce Diversity

Purpose

The radiation oncology workforce in the United States is comparatively less diverse than the U.S. population and U.S. medical school graduates. Workforce diversity correlates with higher quality care and outcomes. The purpose of this study was to determine whether student members of the American Society for Radiation Oncology (ASTRO) are any more diverse than resident members-in-training using the recently established medical student membership category.

Methods and Materials

Self-reported sex, race and Hispanic ethnicity, medical school, and degree(s) earned for all medical students (n = 268) and members-in-training (n = 713) were collected from the ASTRO membership database. International members were excluded. The χ² test was used to assess for differences between subgroups.

Results

Compared with members-in-training, student members were more likely to be female (40.0% vs 31.5%, P = .032), black or African American (10.7% vs 4.8%, P = .009), candidates for or holders of a DO rather than MD degree (5.2% vs 1.5%, P = .002), and from a U.S. medical school that is not affiliated with a radiation oncology residency program (30.5% vs 20.9%, P = .001). There was no significant difference in self-reported Hispanic ethnicity (7.3% vs 5.4%, P = .356). There were no indigenous members in either category assessed.

Conclusions

Medical student members of ASTRO are more diverse in terms of black race, female sex, and osteopathic training, though not in terms of Hispanic ethnicity or nonmultiracial indigenous background, than the members-in-training. Longitudinal engagement with these students and assessment of the factors leading to specialty retention versus attrition may increase diversity, equity, and inclusion in radiation oncology.

A Survey to Assess and Delineate Approaches to Medical Student Outreach to Promote Diversity at Academic Radiation Oncology Programs

PURPOSE/OBJECTIVE(S)

To assess how academic radiation oncology departments engage medical students who are either female and/or from racial and ethnic demographic groups that are underrepresented in medicine (URiM).

MATERIALS/METHODS

An electronic survey was sent to all 83 radiation oncology residency program directors (or if applicable medical student directors) whose department is affiliated with an on-site medical school. Questions assessed whether any faculty in the participants' department offer exposure in radiation oncology specifically to medical and premedical student groups whose members are typically female or URiM, or promote the American Society for Radiation Oncology (ASTRO) Minority Summer Fellowship (MSF) Award. Barriers to these types of involvement were also assessed.

RESULTS

A representative from 54/83 programs responded (response rate 65%). Faculty from 83% of departments had given a presentation to an oncology or radiation oncology medical student interest group. However, faculty from only 18% of departments had given a presentation to a Student National Medical Association chapter, 9% to a Latino Medical Student Association chapter, and 11% to an American Medical Women's Association chapter. Faculty from 15% of departments actively promote the MSF to the general student body, and 24% promote it to any minority students who express interest in radiation oncology. Faculty from 22% of departments had given a presentation to a premedical student group, 10% to an undergraduate student group focused on minority or female students, and 20% to a pipeline program for high school (or younger) female or URiM students. Lack of awareness of the existence of such programs, or not being invited, were the most common barriers to participation.

CONCLUSIONS

Most academic radiation oncology departments do not offer educational outreach specifically targeting women or minority students or promote the MSF. Further efforts are needed to break from the status quo and attract a more diverse workforce.

Therapy of Angiosarcoma with Thalidomide and Lenalidomide

Angiosarcoma is an uncommon malignancy with a poor prognosis. Systemic therapy options for patients with metastatic disease generally have limited effectiveness. In this case study, a 73-year-old male with metastatic angiosarcoma who previously declined chemotherapy and developed progressive disease after checkpoint inhibitor immunotherapy elected to try thalidomide based on 6 case reports describing its effectiveness. Thalidomide resulted in stable disease for 9 months, but due to severe neuropathy as a side effect, lenalidomide was then substituted for thalidomide. The patient continued to have stable disease on lenalidomide for an additional 16 months and ongoing. This is the first case study to report on effective treatment of angiosarcoma with lenalidomide. Further investigation of lenalidomide in the management of angiosarcoma is warranted.

Factors Predictive of Publication Among Medical Students Participating in School-Sponsored Research Programs

Introduction: Publishing research is an important component of medical students’ career development and becoming a more competitive residency applicant. Many medical schools offer structured programs to enable students to participate in research during their preclinical and clinical years, but the majority of student-mentor partnerships do not culminate in publication across a variety of institutions and medical specialties. The primary objective of this study is to determine if any factors associated with mentee-mentor partnerships are predictive of publication from two school-sponsored research programs at a single US medical school.

Methods: The PubMed-indexed publications of all student-mentor pairings from a summer internship (after year 1 of medical school) or research elective (during year 4 of medical school) at a single institution from 2008 to 2018 were retrospectively reviewed. Student/mentor demographic information was associated with the probability of publication.

Results: A total of 124 students participated in the summer internship with 32 (26%) achieving publication. The publication was significantly more likely for students that were from highly ranked undergraduate institutions (p = 0.04; likelihood ratio (LR) = 5.788), were future Alpha Omega Alpha (AOA) members (p = 0.03; LR = 4.597), or worked with a mentor focused on clinical rather than basic science research (p = 0.02; LR = 5.662). Forty-four students participated in the fourth-year elective with 11 (25%) achieving publication. The publication was more likely if the student worked with a mentor without a Doctor of Medicine (MD)/Doctor of Osteopathic Medicine (DO) degree (p = 0.001; LR = 7.051), with a PhD degree (p = 0.002; LR = 7.820), or a mentor with prior publication(s) with prior mentee(s) (p = 0.03; LR = 5.368).

Conclusion: Only one-quarter of mentor-mentee research pairings resulted in publication, with student-related factors more predictive for publication from the internship and mentor-related factors more predictive of publication from the elective. Approaches to promote successful completion of medical student research projects should be considered to yield the greatest value from students’ work and strengthen the development of future physician-scientists.

Overcoming Barriers to Radiation Oncology Access in Low-Resource Settings in the United States

Providing high-quality radiation therapy in medically underserved, low-resource environments can be challenging in the United States. During the American Society of Radiation Oncology 2020 Annual Meeting, the American Society for Radiation Oncology Committee on Health Equity, Diversity, and Inclusion hosted 4 radiation oncologists from both academic and community practices in an educational session. Speakers discussed creative ways to overcome barriers to equitable cancer care and outcomes for their vulnerable patient populations in both rural and urban settings. Successful tactics have included applying for state-sponsored grants, lobbying hospital leadership for equipment upgrades, implementing quality improvement programs specifically targeting the needs of the patient population, studying novel hypofractionation schedules, monitoring toxicities using wearable devices, and expanding transportation options.

Impact of the Coronavirus Disease of 2019 Pandemic on Radiation Oncology Clinical Decision Making in a High-Prevalence Environment

PURPOSE

This study aimed to define how the coronavirus disease of 2019 (COVID-19) pandemic affected the role, timing, and delivery of radiation therapy (RT) in a high-prevalence region at the height of the initial U.S. outbreak.

METHODS AND MATERIALS

We performed a retrospective review of all patients seen at 3 radiation oncology departments within the Rutgers Robert Wood Johnson Barnabas Health system in New Jersey during the initial COVID-19 surge. The primary endpoints were to define and quantify COVID-related, radiation-specific care changes, and identify predictive factors of experiencing COVID-related care changes.

RESULTS

A total of 545 patients with cancer were seen during the study period, 99 of whom (18.1%) experienced ≥1 COVID-related care change. RT delays were the most common, accounting for 51.5% of all care changes. Physician-directed delays accounted for 41.2% of RT delays, and patient fears, COVID testing, and access barriers were responsible for 27.5%, 17.6%, and 13.7%, respectively. Patient age (P = .040), intent of treatment (P = .047), and cancer type (P < .001) were significantly associated with experiencing a COVID-related care change, as we found that older, curative intent and patients with rectal cancer were more likely to experience care changes. On multivariate analysis, patient age remained significant when controlling for treatment intent and cancer type.

CONCLUSIONS

Our study provides a perspective on how care was adapted to protect patients with cancer during a pandemic while maximizing disease control. The positive correlation between age and likelihood of care changes may reflect extra precaution taken with older patients given their vulnerability to severe COVID illness. The lower observed likelihood of COVID-related care changes among patients undergoing palliative RT may reflect either the more urgent needs addressed by palliative RT or simply be logistical, because palliative radiation is often delivered in short courses with less exposure risk. Assessing adaptations others have implemented and monitoring how they affect patient outcomes will be crucial.

Effect of Terminology Used to Describe Medical Oncologists on Perceptions of Radiation Oncologists as Equal Partners in Cancer Care

Purpose

Our purpose was to assess the terminology used to describe the different oncologic subspecialties at academic institutions in the United States and determine whether the use of the term “oncologist” to describe a medical oncologist (MO) may affect the multidisciplinary care of patients with cancer.

Methods and Materials

An electronic survey was sent to chairs and program directors at all 94 academic radiation oncology departments in the United States. Questions assessed the terminology used to describe the oncologic subspecialties in their hospital’s electronic medical record system, their views on how that terminology may affect referral patterns, and the perception of radiation oncologists’ (ROs) role in patient care.

Results

Responses were received from 40 institutions (response rate, 42.6%). Fifteen percent of hospital electronic medical record systems used the term “oncology” instead of “medical oncology” (51%) or “hematology/oncology” (28%). Describing MOs simply as “oncologists” was thought to more likely affect patient views of MOs as the primary decision maker in their cancer care (mean Likert-type rating, 3.43) than it would affect the probability of up-front multidisciplinary referrals (mean Likert-type rating, 2.69). Patient perceptions of ROs as equal partners in care were thought to be less associated with the terminology used to describe MOs (mean Likert-type rating, 3.15) than the behavior of ROs in patient care (mean Likert-type rating, 4.65; P < .001), the attitude of MOs toward ROs (mean Likert-type rating, 4.59; P < .001), and the involvement of ROs in the initial new patient visits rather than a downstream referral (mean Likert-type rating, 3.95; P < .001).

Conclusions

The terminology used to describe MOs was thought to affect patient and provider perceptions of RO, but less so than other patient-provider interaction factors.

Comfort Level of US Radiation Oncology Graduates: Assessment of Transition to Independent Clinical Practice

Radiation training programs are designed to prepare graduates for independent practice, with metrics in place to assess appropriateness of clinical decision-making. Here, we investigated the self-assessed preparedness of US graduates during the transition to independent practice.An anonymous, Internet-based survey was distributed to recent graduates of radiation oncology residencies (2016-2017). A Likert scale was used to assess comfort with various aspects of practice, as well as "time" to development of comfort in independent practice.Responses were obtained from 70/210 (33%), the majority reported training in programs with 5-8 residents (n = 35). Most (77%) reported designing between 500 and 900 treatment plans during training (n = 54). Only 41% of respondents reported the opportunity to review treatment plans and make decisions about safety/adequacy without attending input > 50% of the time (n = 29). Thirty percent of residents reported being responsible for seeing/managing on-treatment visits (OTVs) ≤ 75% of the time. Aspects with which practitioners reported the least comfort were understanding of billing/application to practice (2.43, IQR 2-3), orthovoltage (superficial radiation) setup and field design (2.57, IQR 1-4), and planning/delivery of prostate implants (2.82, IQR 2-4). Increased mean comfort levels were reported by those designing > 700 treatment plans in training as well as those reporting an opportunity to evaluate plans and make clinical decisions prior to attending input > 50% of the time during residency. Comfort with the delivery of stereotactic body radiation (SBRT) correlated with caseload for liver, spine, prostate, and CNS disease sites but not lung.Variations in training experiences exist across institutions. Here, a lower than expected number of residents reported seeing/managing OTVs as well as reviewing treatment plans prior to attending input during training. Overall comfort was correlated with case volume and opportunities to independently review treatment plans prior to attending input. These data highlight areas of opportunity for improving resident education with implications for ease of transition to independent clinical practice.

The Impact of COVID-19 on Brachytherapy During the Pandemic: A Rutgers-Robert Wood Johnson Barnabas Health Multisite Experience

PURPOSE

This study aimed to evaluate whether the coronavirus disease of 2019 (COVID-19) pandemic resulted in treatment delays in patients scheduled for or undergoing brachytherapy.

METHODS AND MATERIALS

A retrospective cohort study was conducted across 4 affiliated sites after local institutional review board approval. The eligibility criteria were defined as all patients with cancer whose treatment plan included brachytherapy during the COVID-19 pandemic from February 24, 2020 to June 30, 2020. Treatment delays, cancellations, alterations of fractionation regimens, and treatment paradigm changes were evaluated.

RESULTS

A total of 47 patients were eligible for the analysis. Median patient age at the time of treatment was 62 years (interquartile range, 56-70 years). Endometrial, cervical, and prostate cancers were the most common sites included in this analysis. Three patients (6.4%) with cervical cancer were diagnosed with COVID-19 during the course of their treatment. Interruptions of external beam radiation therapy (EBRT), cancellations of EBRT, cancellations of brachytherapy, and treatment delays due to COVID occurred in 5 (10.6%), 3 (6.4%), 8 (17%), and 9 (19%) patients, respectively. The mean and median number of days delayed for patients who experienced treatment interruptions were 16.3 days (standard deviation: 13.9 days) and 14 days (interquartile range, 5.75-23.75 days), respectively. For patients with cervical cancer, the mean and median overall treatment times defined as the time from the start of EBRT to the end of brachytherapy were 56 and 49 days, respectively.

CONCLUSIONS

Despite the challenges the health care system faced during the pandemic, most patients with cancer were safely treated with minor treatment delays and interruptions. Long-term follow up is needed to assess the impact of COVID-19 and treatment interruptions on oncologic outcomes.

Impact of Systemic Therapy Type and Timing on Intracranial Tumor Control in Patients with Brain Metastasis from Non-Small-Cell Lung Cancer Treated With Stereotactic Radiosurgery

OBJECTIVE

Stereotactic radiosurgery (SRS) can effectively control brain metastasis (BRM) from non-small-cell lung cancer (NSCLC), although intracranial recurrence from untreated micrometastatic tumor deposits is common without whole-brain radiotherapy. Our goal was to determine if immunotherapy improves distant intracranial progression-free survival (DI-PFS) compared with other systemic therapies in patients treated with SRS.

METHODS

All patients from 2011 to 2019 treated with SRS without previous whole-brain radiotherapy for NSCLC BRM were reviewed. DI-PFS for the entire cohort, and subgroups of patients, was estimated and compared using the Kaplan-Meier/log-rank method.

RESULTS

One hundred and thirty-six SRS sessions used to treat 99 patients were reviewed; 98 (72%) for previously untreated BRM and 38 (28%) for recurrent BRM. 35% received immunotherapy (77% concurrent with SRS), 46% received chemotherapy (75% concurrent), and 18% received epidermal growth factor receptor/anaplastic lymphoma kinase (ALK) targeted therapy (85% concurrent). At median follow-up of 13.7 months, 49% developed distant intracranial recurrence. One-year DI-PFS was improved with any use of immunotherapy (58% vs. 39%; P = 0.03) and concurrent immunotherapy versus chemotherapy or targeted therapy (67% vs. 37% vs. 39%, respectively; P = 0.01). In the immunotherapy cohort, 1-year DI-PFS was improved for programmed death-ligand 1 expression ≥50% versus 1%-49% versus 0% (80% vs. 49% vs. 19%, respectively; P < 0.01), and Lung Immune Prognostic Index 0-1 versus 2 (63% vs. 34%; P = 0.03).

CONCLUSIONS

Immunotherapy concurrent with SRS, particularly in patients with high programmed death-ligand 1 expression or low Lung Immune Prognostic Index, is associated with improved DI-PFS and no increased risk of radiation necrosis compared with other systemic therapies for NSCLC.

Patterns of palliative care consultation among patients with brain metastasis: an opportunity for radiation oncologists to facilitate earlier referral

BACKGROUND

Early palliative care (PC) physician involvement alongside standard oncologic care has been recommended by the American Society of Clinical Oncology (ASCO) guidelines for all advanced cancer patients, although adherence to these guidelines is variable. Radiation oncologists (ROs) could help facilitate early PC referral for patients treated with palliative radiation, particularly those with brain metastasis (BRM), and the aim of this study was to evaluate the circumstances of PC referral at our institution to better understand the multidisciplinary approaches to facilitate it.

METHODS

Patients diagnosed with BRM from non-small cell lung cancer (NSCLC) from 2012 to 2018 whose primary RO and MO were at our institution were reviewed. Overall survival and time to PC consultation from the first oncologic visit following BRM diagnosis was determined using the KaplanMeier method. Mann-Whitney U and Chi-Squared assessed for predictive factors for shorter time to PC consultation. For these factors, the overall survival, rate of PC consultation, and PC setting was used to determine utilization of early PC.

RESULTS

Among 103 eligible patients, only 48% underwent a PC consultation in their lifetime, with the initial evaluation being as an outpatient for 37%, and within 1 month of death for 35%. Median survival from BRM diagnosis was 9.0 months. The median time from oncologic appointment to PC referral was 2.8 months, and from initial PC consultation to death was 1.6 months. Only more recent BRM diagnosis (2016-2018 vs. 2012-2015) was associated with shorter time to PC consultation (1.0 vs. 5.6 months, P=0.013), increased PC consult rate (60% vs. 42%, P=0.105), and increased outpatient PC consultation (56% vs. 26%, P=0.037).

CONCLUSIONS

The majority of patients did not undergo early PC consultation, though utilization has improved over time. As ROs are commonly involved in BRM management, they may be in a position to proactively support early PC consultations in this patient population.

Patterns of disease progression to checkpoint inhibitor immunotherapy in patients with stage IV non-small cell lung cancer

INTRODUCTION

The purpose of this study was to assess patterns of disease progression for patients with metastatic non-small cell lung cancer (NSCLC) on checkpoint inhibitor immunotherapy.

METHODS

This single centre, retrospective study included all patients diagnosed with Stage IV NSCLC from 2015 to 2019 who received at least 2 cycles of immunotherapy, with or without concurrent chemotherapy. Immune RECIST criteria were used to assess patterns of disease progression, and progression-free survival (PFS), excluding irradiated tumours. The chi-square and log-rank tests assessed for associations between baseline clinical characteristics and progressive disease in initial sites only (vs. new or combined sites), and PFS, respectively.

RESULTS

Among 143 eligible patients with a median follow-up of 11 months, 97 (68%) developed disease progression. Of these, 67 patients (69.1%) progressed only at initial disease site(s), 10 patients (10.3%) progressed only at new disease site(s), and 20 patients (20.6%) progressed in both initial and new sites. Rates of disease progression based on tumour location were higher for liver (64%) and lung metastases (61%) than for other metastatic sites (33-36%) or the primary tumour (24%). Only higher PD-L1 expression (P = 0.002) and absence of lung metastasis (P = 0.048) at baseline were associated with improved PFS. No baseline characteristics significantly impacted the probability of initial disease site-only progression, though a trend was observed for untreated primary tumour (72% vs. 56%, P = 0.169).

CONCLUSIONS

The dominant pattern of disease progression is in the initial sites of disease alone, suggesting a potential role for local radiation therapy as a complementary treatment modality to immunotherapy.

Quality Improvement Initiative to Enhance Multidisciplinary Management of Malignant Extradural Spinal Cord Compression

PURPOSE

To determine if a quality improvement (QI) initiative could enhance multidisciplinary management of acute malignant extradural spinal cord compression (ESCC) at our institution.

METHODS

The medical records of all 40 patients who received palliative radiotherapy for malignant ESCC from 2015 to 2017 were reviewed to determine the time course of key National Comprehensive Cancer Network guideline-supported workup and management steps. On the basis of the findings, a multidisciplinary group of physician stakeholders developed a clinical pathway to facilitate expedited care. The efficacy of this clinical pathway and the educational content provided to all relevant departments were then evaluated by comparing outcomes with data from a similarly reviewed follow-up cohort of 25 patients from 2018 to 2019.

RESULTS

Patients treated for malignant ESCC after our QI intervention were more likely to undergo magnetic resonance imaging (MRI) of the entire spine (64% v 44%; P = .013) and have a radiation oncology (RO) consultation before surgery (100% v 27%; P = .002). Median time from MRI to RO consultation decreased from 3 to 1 days (P = .03). On subgroup analysis, initial trends toward delays in RO consultation for patients planning for surgery (median, 3 days) or for lack of prior cancer diagnosis (median, 4 days) were reduced to delays of 0 and 1 day, respectively, after the QI intervention. No significant differences were observed in time to surgical consultation or surgery itself.

CONCLUSION

This QI study was able to stimulate better use of diagnostic imaging and earlier involvement of RO in multidisciplinary decision making, suggesting an effective approach to improving multidisciplinary care in other scenarios as well.

Impact of Incident Cancer on Short-Term Coronary Artery Disease-Related Healthcare Expenditures Among Medicare Beneficiaries

Background: Healthcare spending for coronary artery disease (CAD)-related services is higher than for other chronic conditions. Diagnosis of incident cancer may impede management of CAD, thereby increasing the risk of CAD-related complications and associated healthcare expenditures. This study examined the relationship between incident cancer and CAD-related expenditures among elderly Medicare beneficiaries. Patients and Methods: A retrospective longitudinal study was conducted using the SEER-Medicare linked registries and a 5% noncancer random sample of Medicare beneficiaries. Elderly fee-for-service Medicare beneficiaries with preexisting CAD and with incident breast, colorectal, or prostate cancer (N=12,095) or no cancer (N=34,237) were included. CAD-related healthcare expenditures comprised Medicare payments for inpatient, home healthcare, and outpatient services. Expenditures were measured every 120 days during the 1-year preindex and 1-year postindex periods. Adjusted relationship between incident cancer and expenditures was analyzed using the generalized linear mixed models. Results: Overall, CAD-related mean healthcare expenditures in the preindex period accounted for approximately 32.6% to 39.5% of total expenditures among women and 41.5% to 46.8% among men. All incident cancer groups had significantly higher CAD-related expenditures compared with noncancer groups (P<.0001). Men and women with colorectal cancer (CRC) had 166% and 153% higher expenditures, respectively, compared with their noncancer counterparts. Furthermore, men and women with CRC had 57% and 55% higher expenditures compared with those with prostate or breast cancer, respectively. Conclusions: CAD-related expenditures were higher for elderly Medicare beneficiaries with incident cancer, specifically for those with CRC. This warrants the need for effective programs and policies to reduce CAD-related expenditures. Close monitoring of patients with a cancer diagnosis and preexisting CAD may prevent CAD-related events and expenditures.

Associations of multimorbidity and patient-reported experiences of care with conservative management among elderly patients with localized prostate cancer

Background

Many elderly localized prostate cancer patients could benefit from conservative management (CM). This retrospective cohort study examined the associations of patient‐reported access to care and multimorbidity on CM use patterns among Medicare Fee‐for‐Service (FFS) beneficiaries with localized prostate cancer.

Methods

We used linked Surveillance, Epidemiology, and End Results cancer Registry, Medicare Claims, and the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) survey files. We identified FFS Medicare Beneficiaries (age ≥ 66; continuous enrollment in Parts A & B) with incident localized prostate cancer from 2003 to 2013 and a completed MCAHPS survey measuring patient‐reported experiences of care within 24 months after diagnosis (n = 496). We used multivariable models to examine MCAHPS measures (getting needed care, timeliness of care, and doctor communication) and multimorbidity on CM use.

Results

Localized prostate cancer patients with multimorbidity were less likely to use CM (adjusted odds ratio (AOR)=0.42 (0.27‐ 0.66), P < .001); those with higher scores on timeliness of care (AOR = 1.21 (1.09, 1.35), P < .001), higher education attainment (3.21 = AOR (1.50,6.89), P = .003), and impaired mental health status (4.32 = AOR (1.86, 10.1) P < .001) were more likely to use CM.

Conclusion(s)

Patient‐reported experience with timely care was significantly and positively associated with CM use. Multimorbidity was significantly and inversely associated with CM use. Addressing specific modifiable barriers to timely care along the cancer continuum for elderly localized prostate cancer patients with limited life expectancy could reduce the adverse effects of overtreatment on health outcomes and costs.

Opening large-conductance potassium channels selectively induced cell death of triple-negative breast cancer

Background

Unlike other breast cancer subtypes that may be treated with a variety of hormonal or targeted therapies, there is a need to identify new, effective targets for triple-negative breast cancer (TNBC). It has recently been recognized that membrane potential is depolarized in breast cancer cells. The primary objective of the study is to explore whether hyperpolarization induced by opening potassium channels may provide a new strategy for treatment of TNBC.

Methods

Breast cancer datasets in cBioPortal for cancer genomics was used to search for ion channel gene expression. Immunoblots and immunohistochemistry were used for protein expression in culture cells and in the patient tissues. Electrophysiological patch clamp techniques were used to study properties of BK channels in culture cells. Flow cytometry and fluorescence microscope were used for cell viability and cell cycle studies. Ultrasound imaging was used to study xenograft in female NSG mice.

Results

In large datasets of breast cancer patients, we identified a gene, KCNMA1 (encoding for a voltage- and calcium-dependent large-conductance potassium channel, called BK channel), overexpressed in triple-negative breast cancer patients. Although overexpressed, 99% of channels are closed in TNBC cells. Opening BK channels hyperpolarized membrane potential, which induced cell cycle arrest in G2 phase and apoptosis via caspase-3 activation. In a TNBC cell induced xenograft model, treatment with a BK channel opener significantly slowed tumor growth without cardiac toxicity.

Conclusions

Our results support the idea that hyperpolarization induced by opening BK channel in TNBC cells can become a new strategy for development of a targeted therapy in TNBC.

Assessment of the Medical Schools From Which Radiation Oncology Residents Graduate and Implications for Diversifying the Workforce

PURPOSE

To identify factors predictive of a medical school graduating a high volume of future radiation oncology (RO) residents to better understand potential pathways to effectively recruit women and underrepresented minority (URM) students into RO.

METHODS AND MATERIALS

Demographics for US allopathic medical schools and affiliated RO departments were collected from web resources and correlated with the percentage of graduates from each school currently enrolled in RO residency in 2019, and the probability of at least 1 female or URM student from each school pursuing RO.

RESULTS

The median percentage of students per medical school who pursued RO residency was 0.37% (interquartile range, 0.16%-0.66%). A total of 79.7% of schools graduated at least 1 RO resident, whereas 51.7% graduated at least 1 female RO resident and 14.0% graduated at least 1 URM RO resident. The 30 schools graduating the highest percentage of RO residents accounted for 52.1% of current RO residents, only 4 of which were in the top quartile for URM enrollment. Medical students were significantly more likely to pursue RO when there was an affiliated RO department (0.42% vs 0.18%, P < .001) or RO residency program (0.51% vs 0.18%, P < .001), more total RO faculty (r_s = 0.521, P < .001), female RO faculty (r_s = 0.481, P < .001), and URM RO faculty (r_s = 0.197, P < .001). The probability of at least 1 female student pursuing RO was also correlated with the number of female faculty in the affiliated RO department (r_pb = 0.348, P = .001), and a similar correlation was observed between URM students and URM faculty (r_pb = 0.312, P = .011).

CONCLUSIONS

Most RO residents graduate from medical schools with larger affiliated RO departments but fewer URM students. To promote greater RO diversity, outreach should be considered among schools with greater URM enrollment but fewer affiliated radiation oncologists, and among female and URM students in schools that graduate many RO residents.

Radiation-Association Hypertension in Patients Undergoing Treatment for Prostate Cancer

OBJECTIVE

Patients undergoing prostate radiation therapy were observed to have elevated blood pressures in clinic. Therefore, we sought to further characterise this phenomenon.

METHODS

The charts of 76 patients who received radiotherapy for prostate cancer between 2014 and 2017 were examined. Blood pressure (BP) readings were obtained at initial consultation, on treatment visits, and subsequent follow-up appointments. To describe this effect, we defined radiation-associated hypertension (RAH) as an increase ≥15 mmHg systolic BP, 10 mmHg diastolic BP, or 5 mmHg mean arterial pressure.

RESULTS

Within this cohort, 36 patients developed RAH, with 75% developing RAH while on treatment, and 25% developing RAH at post-treatment visits. Two-thirds of patients remained hypertensive during post-treatment visits, and 27% were prescribed additional anti-hypertensives. There was no association between neoadjuvant/concurrent androgen deprivation therapy and RAH.

CONCLUSION

A significant number of patients undergoing prostate radiotherapy developed RAH, necessitating additional medication in some.

Pathways for Recruiting and Retaining Women and Underrepresented Minority Clinicians and Physician Scientists Into the Radiation Oncology Workforce: A Summary of the 2019 ASTRO/NCI Diversity Symposium Session at the ASTRO Annual Meeting

Diversifying the radiation oncology workforce is an urgent and unmet need. During the American Society of Radiation Oncology (ASTRO) 2019 Annual Meeting, ASTRO's Committee on Health Equity, Diversity, and Inclusion (CHEDI) and the National Cancer Institute (NCI) collaborated on the ASTRO-NCI Diversity Symposium, entitled "Pathways for Recruiting and Retaining Women and Underrepresented Minority Clinicians and Physician Scientists Into the Radiation Oncology Workforce." Herein, we summarize the presented data and personal anecdotes with the goal of raising awareness of ongoing and future initiatives to improve recruitment and retention of underrepesented groups to radiation oncology. Common themes include the pivotal role of mentorship and standardized institutional practices – such as protected time and pay parity – as critical to achieving a more diverse and inclusive workplace.

A targeted needs assessment to improve referral patterns for palliative radiation therapy

Radiation therapy (RT) can effectively palliate a variety of symptoms in patients with metastatic cancer, using relatively low doses that infrequently cause major side effects. However, palliative radiation is often underutilized and sub-optimally implemented. In this study, we surveyed the Society of Palliative Radiation Oncology (SPRO) membership to identify barriers to appropriate referral for palliative RT that they encounter in their practice, and identify specific groups of physicians who radiation oncologists believed would benefit most from further education on when to refer patients. A total of 28 radiation oncologists responded to the survey with a response rate of 20.5%. On average, participants felt that referrals for palliative RT were inappropriately delayed 46.5% [standard deviation (STD) 20.2%] of the time. The most common barrier to referral for medical oncologists was thought to be potential interference with systemic therapy (33%); for primary care physicians and surgeons it was a lack of knowledge about the benefit (42%), and for palliative care physicians it was concern for patient convenience (25%). For brain metastases and spinal cord compression radiation oncology was felt to be part of the initial referral sequence more than 50% of the time, but less so for thoracic airway obstruction/bleeding (38%), esophageal obstruction (16%), or urinary obstruction/bleeding (8%), where another subspecialist was more often consulted first. Primary care, geriatric medicine, and emergency medicine were considered among the least knowledgeable specialties about palliative radiation. These hypothesis-generating findings can guide approaches to improve referral patterns for this important aspect of supportive care.

The Journey of an EGFR-Mutant Lung Adenocarcinoma through Erlotinib, Osimertinib and ABCP Immunotherapy Regimens: Sensitivity and Resistance

Patients with epidermal growth factor receptor (EGFR) mutation positive non-small cell lung cancer (NSCLC) have several EGFR targeting tyrosine kinase inhibitors (TKIs) available in frontline management. However, the disease will inevitably progress over time due to acquired resistance. Longitudinal tumor profiling for genomics guided therapy is indicated upon disease progression. It is a common scenario yet, when after failure of EGFR-TKIs, potentially actionable genomic alterations are lacking. Management of such patient is challenging with very limited options available. Combination of chemotherapy, anti-vascular/anti-angiogenic and immune-checkpoint inhibitors may become a salvage option for such patients. Here we describe a case of TKI refractory EGFR-mutant NSCLC successfully treated with carboplatin, paclitaxel, atezolizumab and bevacizumab combination with remarkable prompt tumor response.

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

PURPOSE

Radiation oncology is often overlooked in US medical school curricula, with few opportunities for most students to learn about the specialty or the value of radiation therapy in cancer care. Tumor boards represent a potential avenue not only to increase students' exposure to radiation oncologists but also to provide a fundamental understanding of the multidisciplinary nature of cancer care and effective collaboration in clinical practice.

METHODS AND MATERIALS

In this study, we evaluated a novel radiation oncologist-driven tumor board shadowing experience at 3 medical schools in the United States and Canada. A total of 323 first- and second-year medical students participated, of whom 77.4% completed a follow-up survey assessing the effectiveness of the program as a learning tool.

RESULTS

Compared with traditional clinical shadowing, students were more likely to believe that tumor board shadowing provided a similar or better experience in terms of educational content (85%), exposure to a new field (96%), and overall experience (89%). Forty-eight percent of students perceived a greater amount of multidisciplinary collaboration in oncologic care than they thought existed prior to attending. Forty-eight percent of students also felt more competent interacting with oncologists after participating, whereas 21% felt more competent interacting with patients with cancer. Students' perception of increased competence was correlated with the amount of time their assigned physician mentor spent answering their questions after the tumor board (P < .01). Second-year medical students also had a more favorable overall experience than first-year medical students did (P = .04).

CONCLUSIONS

Multidisciplinary tumor boards can be used effectively as a unique immersive learning opportunity that can be feasibly implemented to improve knowledge of clinical oncology and multidisciplinary care in medical schools and expose students to physicians in smaller fields such as radiation oncology.

Student Perspectives on Oncology Curricula at United States Medical Schools

Delivering a cohesive oncology curriculum to medical students is challenging due to oncology's multidisciplinary nature, predominantly outpatient clinical setting, and lack of data describing effective approaches to teaching it. We sought to better characterize approaches to oncology education at US medical schools by surveying third and fourth year medical students who serve on their institution's curriculum committee. We received responses from students at 19 schools (15.2% response rate). Key findings included the following: (1) an under-emphasis of cancer in the curriculum relative to other common diseases; (2) imbalanced involvement of different clinical subspecialists as educators; (3) infrequent requirements for students to rotate through non-surgical oncologic clerkships; and (4) students are less confident in their knowledge of cancer treatment compared to basic science/natural history or workup/diagnosis. Based on these findings, we provide several recommendations to achieve robust multidisciplinary curriculum design and implementation that better balances the clinical and classroom aspects of oncology education.

The dosimetric effects of limited elective nodal irradiation in volumetric modulated arc therapy treatment planning for locally advanced non-small cell lung cancer

Objective

Contemporary radiotherapy guidelines for locally advanced non-small cell lung carcinoma (LA-NSCLC) recommend omitting elective nodal irradiation, despite the fact that evidence supporting this came primarily from older reports assessing comprehensive nodal coverage using 3D conformal techniques. Herein, we evaluated the dosimetric implications of the addition of limited elective nodal irradiation (LENI) to standard involved field irradiation (IFI) using volumetric modulated arc therapy (VMAT) planning.

Method

Target volumes and organs-at-risk (OARs) were delineated on CT simulation images of 20 patients with LA-NSCLC. Two VMAT plans (IFI and LENI) were generated for each patient. Involved sites were treated to 60 Gy in 30 fractions for both IFI and LENI plans. Adjacent uninvolved nodal regions, considered high risk based on the primary tumor site and extent of nodal involvement, were treated to 51 Gy in 30 fractions in LENI plans using a simultaneous integrated boost approach.

Results

All planning objectives for PTVs and OARs were achieved for both IFI and LENI plans. LENI resulted in significantly higher esophagus D_mean (15.3 vs. 22.5 Gy, p < 0.01), spinal cord D_max (34.9 vs. 42.4 Gy, p = 0.02) and lung D_mean (13.5 vs. 15.9 Gy, p = 0.02), V₂₀ (23.0 vs. 27.9%, p = 0.03), and V₅ (52.6 vs. 59.4%, p = 0.02). No differences were observed in heart parameters. On average, only 32.2% of the high-risk nodal volume received an incidental dose of 51 Gy when untargeted in IFI plans.

Conclusion

The addition of LENI to VMAT plans for LA-NSCLC is feasible, with only modestly increased doses to OARs and marginal expected increase in associated toxicity.