The Inpatient Consultation Experience in Radiation Oncology: A Contemporary Evaluation of a Single Academic Institution

PURPOSE/OBJECTIVE(S)

Participating in an inpatient consultation service is an essential aspect of radiation oncology residency training. However, there are no reports in the literature describing the inpatient on-call experience. To better describe the clinical burden and define the learning opportunities associated with inpatient consultation service participation, inpatient on-call data were tracked and assessed.

MATERIALS/METHODS

From July 1, 2022, through Dec. 31, 2022, radiation oncology residents covering the on-call pager for the inpatient consultation service spanning two hospitals at a single academic institution prospectively self-reported the total number of pages, new consultations, inpatient treatment starts, and treatment indications. Patient billing records and paging logs were reviewed to confirm self-reported cases and track the number of business days between simulation and the first fraction of treatment. A new inpatient consultation was defined as a novel encounter requiring independent evaluation; as such, patients admitted during an ongoing course of radiotherapy who continued the planned course while inpatient were not included.

RESULTS

During the initial six months of tracking, on-call residents received a total of 607 pages with an average of 23.1 pages per week (range: 14-38). Of these pages, 212 were for new inpatient consultations with an average of 8.1 consultations per week (range: 2-15). Out of these 212 new consultations, 75 patients (35%) were treated on an inpatient basis. Nine patients (12%) received their first fraction of treatment on the same day as simulation, 13 (17%) on the next day, 11 (15%) two days after, 22 (29%) three days after, and 20 (27%) four or more days after simulation. The most common indications for urgent treatment were malignant spinal cord compression (27%), brain metastases (24%), tumor-related bleeding (8%), malignant obstruction of the airway or vasculature (8%), painful bone metastases (7%), and heterotopic ossification prophylaxis (7%). The most common primary sites of disease were leukemia/lymphoma (16%), gastrointestinal (13%), breast (11%), lung (9%), gynecologic (9%), sarcoma (9%), and benign (9%). Each individual resident's caseload differed greatly in quantity, indication, treatment site, and primary site over this six-month time period.

CONCLUSION

In this longitudinal analysis at a single academic institution, the radiation oncology inpatient consultation service experience was highly variable and diverse in clinical volume and treatment indication on a week-to-week and resident-to-resident basis. Exposure to radiation oncology emergencies is a vital component of residency training. However, the unpredictable nature of inpatient on-call scenarios can lead to variable educational experiences. Tracking inpatient on-call cases during residency may help identify areas needing improvement to enhance both patient care and residency training.

Abstract OT2-04-01: Phase III trial to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to whole breast RT post breast-conserving surgery (BCS) reduces invasive breast cancer recurrence-free interval (IBCR-FI) in patients (pts) with pathologically positive axillary (PPAx) nodes who are ypN0 after neoadjuvant chemotherapy (NC): NRG Oncology/NSABP B-51/RTOG 1304

This phase III post-NC trial evaluates if CWRNRT post-Mx or whole breast irradiation (WBI) with RNRT after BCS significantly reduces the IBCR-FI rate in pts with PPAx nodes that are pathologically negative after NC. Secondary aims are OS, LRR-FI, DR-FI, DFS-DCIS, second primary cancer, and comparison of RT effect on cosmesis in reconstructed Mx pts. Correlative science examines RT effect by tumor subtype, molecular outcome predictors for residual disease, and predictors for the degree of reduction in loco-regional recurrence.

Methods: Clinical T1-3, N1 IBC PPAx nodes (FNA or core needle biopsy) pts complete ≥8 weeks of NC (anthracycline and/or taxane). HER2+ pts receive anti-HER2 therapy. Following NC, BCS or Mx, sentinel node biopsy (≥2 nodes) and/or Ax dissection with histologically negative nodes is performed. ER/PR and HER-2neu status before NC is required. Pts may receive appropriate adjuvant systemic therapy. Radiation credentialing with a facility questionnaire/case benchmark is required. Random assignment for Mx pts is to no CWRNRT or CWRNRT and for BCS pts to WBI or WBI+RNRT.

Statistics: 1,636 pts are to be enrolled over 5 yrs (definitive analysis at 7.5 yrs). Study is powered at 80% to test that RT reduces the annual hazard rate of events for IBCR-FI by 35% for an absolute risk reduction of 4.6% (5-yr cumulative rate). Intent-to-treat analysis with 3 interim analyses (43, 86, and 129 events) and a 4th/final analysis at 172 events. Pt-reported outcomes focusing on RT effect will be provided by 736 pts before random assignment and at 3, 6, 12, and 24 mos. Accrual as of 6-21-18 is 967 (59.11%).

Contacts: Protocol: CTSU member website https://www.ctsu.org. Questions: NRG Oncology Pgh Clin Coord Dpt: 1-800-477-7227 or ccd@nsabp.org. Pt entry: OPEN at https://open.ctsu.org or the OPEN tab on CTSU member website.

NCT01872975

Support: U10 CA-2166; -180868, -180822; 189867; Elekta

Citation Format: Mamounas EP, Bandos H, White JR, Julian TB, Khan AJ, Shaitelman SF, Torres MA, Vicini FA, Ganz PA, McCloskey SA, Paik S, Gupta N, Li XA, DiCostanzo DJ, Curran WJ, Wolmark N. Phase III trial to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to whole breast RT post breast-conserving surgery (BCS) reduces invasive breast cancer recurrence-free interval (IBCR-FI) in patients (pts) with pathologically positive axillary (PPAx) nodes who are ypN0 after neoadjuvant chemotherapy (NC): NRG Oncology/NSABP B-51/RTOG 1304 [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-04-01.

Abstract P3-02-07: Predictors associated with MRI surveillance screening in women with a personal history of unilateral breast cancer but without a genetic predisposition for future contralateral breast cancer

Purpose

Women with a personal history of breast cancer (BC), in the absence of genetic predisposition or significant family history, are generally categorized as having an intermediate (15-20%) risk of developing future BC. Screening MRI is recommended as a supplement to mammography for women with a ≥20% lifetime risk. However, models available to calculate risk exclude women with a personal history of BC. Thus, there has existed no reliable mechanism to calculate future risk in these women to refine MRI surveillance recommendations. The Manchester score was recently developed and intended to inform contralateral breast cancer (CBC) risk for surgical decision making. We hypothesized that the score could be informative to guide follow-up imaging recommendations among women with a personal history of BC.

Patients & Methods

322 women with newly-diagnosed, non-metastatic, unilateral BC were seen in multidisciplinary breast clinic and underwent unilateral surgery (either breast conserving surgery or mastectomy) at our institution between June 2012 and November 2015. Using life expectancy, family history, genetic mutation status, and endocrine therapy use, we calculated the Manchester score, i.e. CBC risk, for all women. Patients were categorized as low- (<10% CBC lifetime risk), above average- (10-20%), moderate- (20-30%), and high-risk (>30%). We also reviewed the rationale that treating physicians noted for recommending MRI surveillance. Univariate logistic regression analysis (UVA) was used to assess if Manchester score was predictive of MRI surveillance in addition to other known factors.

Results

In the entire cohort, 75.8% (n=244) were low-risk for CBC, 18.6% (n=60) were above average-risk, 4.3% (n=14) were moderate-risk, and 1.2% (n=4) were high-risk. Using a 20% CBC risk as a threshold for MRI justification, 5.6% (n=18) met indications for MRI surveillance. Among the 21.7% (n=70) undergoing MRI surveillance, 57.1% (n=40) were low-risk, 32.9% (n=23) were above average-risk, 7.1% (n=5) were moderate-risk, and 2.9% (n=2) were high-risk. There was a significant trend for higher rates of MRI surveillance as the risk score increased (odds ratio, OR 1.1, p<0.0001). On UVA, the highest odds for MRI surveillance were in women with a mammographically-occult BC history (OR 9.35, p<0.0001), pre-operative breast MRI use (OR 8.41, p<0.0001), and dense breast tissue (OR 4.88, p<0.0001). The top clinician-endorsed reasons for MRI surveillance were dense breast tissue (61.4%), young age at diagnosis (28.6%), and mammographically-occult BC history (25.7%).

Conclusions

Although Manchester score was significantly predictive for MRI surveillance, we identified a large subset of women with <20% calculated CBC risk who underwent MRI surveillance (90.0% of the cohort undergoing MRI) and a small subset with >20% CBC risk who continue with mammography alone (4.4%). Overall, concern about poor detection of a future CBC appeared to dominate the selection of surveillance MRI use, even within a largely low-risk population. We believe this calculation could be informative prospectively to select surveillance strategies in women at a high future risk of CBC.

Citation Format: Hegde JV, Wang P-C, Kusske A, Hoyt AC, Hurvitz S, McCloskey SA. Predictors associated with MRI surveillance screening in women with a personal history of unilateral breast cancer but without a genetic predisposition for future contralateral breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-02-07.

Abstract OT2-03-01: NRG oncology/NSABP B-51/RTOG 1304: A phase III superiority clinical trial designed to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to breast RT post breast-conserving surgery (BCS) will reduce invasive cancer events in patients (pts) with positive axillary (Ax) nodes and convert to ypN0 after neoadjuvant chemotherapy (NC)

Background:

This phase III post-NC trial evaluates if CWRNRT post Mx or whole breast irradiation (WBI) with RNRT after BCS significantly reduces the invasive breast cancer recurrence-free interval (IBC-RFI) rate in pts presenting with positive Ax nodes that are pathologically negative after NC. Secondary aims are OS, LRRFI, DRFI, DFS-DCIS, and second primary cancer, as well as comparing RT effect on cosmesis in reconstructed Mx pts.

Correlative science studies examine RT effect by tumor subtype, molecular outcome predictors for residual disease pts, and predictors for the degree of reduction in loco-regional recurrence.

Methods:

Clinical T1-3, N1 IBC pts with positive Ax nodes (FNA or core needle biopsy) complete ≥8 wks of NC (anthracycline and/or taxane). HER2-positive pts receive anti-HER2 therapy (tx). After NC, BCS or Mx is performed with a sentinel node biopsy (≥2 nodes) and/or Ax dissection with histologically negative nodes. ER/PR and HER2 neu status before NC is required. Pts receive required systemic tx. Radiation credentialing with a facility questionnaire and a case benchmark is required. Randomization for Mx pts is to no CWRNRT or CWRNRT and for BCS pts to WBI or WBI+RNRT.

Statistics:

1636 pts to be enrolled over 5 yrs with definitive analysis at 7.5 yrs. Study is powered at 80% to test that RT reduces the annual hazard rate of events for IBCR-FI by 35% for an absolute risk reduction in the 5-yr cumulative rate of 4.6%. Intent-to-treat analysis with 3 interim analyses at 43, 86, and 129 events, with a 4th/final analysis at 172 events will occur. Accrual as of 6/13/16 is 356. Pt-reported outcomes focusing on RT effect will be obtained from 736 pts before randomization and at 3, 6, 12, and 24 months.

Contacts:

Protocol: CTSU member website https://www.ctsu.org. Questions: NRG Oncology Pgh Clin Coord Dpt: 1-800-477-7227 or ccd@nsabp.org. Pt entry: OPEN at https://open.ctsu.org or the OPEN tab on CTSU member website.

Support: U10 CA-2166; -180868, -180822; -189867; Elekta.

Citation Format: Mamounas EP, Bandos H, White JR, Julian TB, Khan AJ, Shaitelman SF, Torres MA, Vicini FA, Ganz PA, McCloskey SA, Paik S, Gupta N, Li XA, DiCostanzo DJ, Curran, Jr WJ, Wolmark N. NRG oncology/NSABP B-51/RTOG 1304: A phase III superiority clinical trial designed to determine if chest wall and regional nodal radiotherapy (CWRNRT) post mastectomy (Mx) or the addition of RNRT to breast RT post breast-conserving surgery (BCS) will reduce invasive cancer events in patients (pts) with positive axillary (Ax) nodes and convert to ypN0 after neoadjuvant chemotherapy (NC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-03-01.

Yersinia pseudotuberculosis aortitis in a patient with diverticulosis and polycystic kidney disease

An 81-year-old gentleman with chronic kidney disease presented with pyrexia and a new systolic cardiac murmur. Investigations revealed infective aortitis of a pre-existing aortic aneurysm graft repair. Peripheral blood cultures were positive for Yersinia pseudotuberculosis and the patient was successfully treated with an extended course of antibiotics. Abdominal imaging also revealed progressive bilateral polycystic kidney disease with associated diverticular disease, which was postulated as the source of the Y. pseudotuberculosis. An autosomal dominant polycystic kidney disease may present late in life and extra-renal manifestations of this disease are an important cause of morbidity.

Evidence-based indications for post-mastectomy radiation after neoadjuvant chemotherapy for stage II-III breast cancer

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Background: There are no established guidelines to define the role of post-mastectomy radiation therapy after neoadjuvant chemotherapy. We sought to identify a cohort of women with stage II-III breast cancer in whom radiation may be omitted based on the risk of local-regional failure (LRF).

Methods: Seven breast cancer physicians participating in the multi-campus University of California (UC) Athena Breast Health Network identified, reviewed and abstracted the available literature (from MEDLINE and Cochrane databases), formulated evidence tables (endpoints LRF, disease-free, and overall survival) and developed a risk assessment table of women undergoing mastectomy after neoadjuvant chemotherapy. We created 18 hypothetical clinical case scenarios, and using the American College of Radiology appropriateness criteria methodology, assigned appropriateness ratings for post-mastectomy radiation for each scenario based on our literature review.

Results: 23 of 24 studies identified were retrospective from single institutions. Consensus (80% agreement in a category) in the appropriateness rating was achieved for 78% of the clinical scenarios. Distinct LRF risk categories emerged. Patients who presented with clinical stage II (T1-2N0-1) ER(+) disease with age at diagnosis ≥35-40 years who had either a pathologic complete response (pCR) or 0-3 positive nodes without LVI or ECE were identified as having ≤10% risk of LRF without radiation. Limited data support pCR stage IIIA patients as being low risk.

Conclusions: In the absence of randomized trial data, we identified existing data to guide the use of PMRT in the neoadjuvant chemotherapy setting. Using this data and the appropriateness ratings, we found a high concordance of treatment recommendations for PMRT in our clinical scenarios and were able to identify a cohort of women with a low risk of LRF without radiation. These women will form the basis for future clinical studies in the UC Athena Breast Health Network.