Depression and Anxiety Among English- and Spanish-Speaking Patients With Breast Cancer Receiving Radiation Therapy

PURPOSE

An estimated 30% and 40% of patients with breast cancer experience depression and anxiety, respectively. However, distress experienced by patients with breast cancer receiving radiation therapy may vary among patients and vary at different time points. This study sought to describe the changes in levels of depression and anxiety experienced by English- and Spanish-speaking patients throughout a course of radiation therapy for breast cancer, along with the effect of different variables to better understand potential gaps.

METHODS AND MATERIALS

Eligibility criteria included English- and Spanish-speaking females, aged 18 or older, undergoing radiation therapy treatment for breast cancer at 2 institutions. Pre- and posttreatment surveys were completed before and after delivery of radiation therapy. Sociodemographic characteristics collected included race, ethnicity, marital status, education level, longest residency location, religion, housing, and food insecurity. The survey ended with the standardized PHQ-4 questionnaire to assess anxiety and depression. Results were analyzed using the analysis of covariance procedure.

RESULTS

A total of 160 participants completed pre- and posttreatment surveys, with an initial response rate of 100% (169 patients), though 9 were lost to follow-up. Most of the participants were nonwhite (50%), primarily married (42.5%), and had a high school or associate's level education (46.9%). The total baseline distress mean (BDM) was 2.96 and the final distress mean was 2.78. English-speaking patients comprised 82.5% (n = 132) of the sample and had a BDM of 2.91 with an adjusted change mean decrease of 0.45. Spanish-speaking patients comprised 17.5% (n = 28) of the sample, with a baseline distress mean of 3.21 and an adjusted change mean increase of 1.03 (P = .002). Housing (P = .017) and food insecurity (P = .0002) also showed increasing distress with increased insecurity at baseline.

CONCLUSIONS

Patients who speak Spanish, identify as Hispanic, or are experiencing food and housing insecurity are at an increased risk for depression and anxiety, and could benefit from more support during their course of radiation therapy to minimize distress.

Assessment of medical students' knowledge of primary limb sarcomas

INTRODUCTION

Typically, oncology is not a structured part of the curriculum in Brazilian medical schools. Furthermore, sarcomas, which are uncommon tumors, are seldom covered in depth. A lack of comprehensive education on sarcomas might result in medical professionals being ill-equipped to care for patients with this condition.

OBJECTIVES

To assess medical students' understanding and awareness of sarcomas and the specific principles related to these tumors.

MATERIALS AND METHODS

A quantitative, cross-sectional study was conducted using a questionnaire, applied to medical students, focusing on the epidemiology, pathophysiology, and treatments of bone and soft tissue sarcomas. In all tests, the significance level adopted was 5%. The SPSS version 25.0 software was used.

RESULTS

Of the 825 questionnaires distributed, 325 were returned. Educational sessions on sarcomas did not appear to significantly improve the student's knowledge. Only 29.5% of students identified the lack of pain as an indicator of potential malignancy in soft tissue sarcomas, while 73.8% correctly recognized pain as a symptom of bone sarcomas. Limb amputation as the optimal surgical method for patient recovery was incorrectly reported by 39.1% of the sample.

CONCLUSION

A great part of the surveyed population does not have adequate knowledge about the basic concepts associated with limb sarcomas. The minority of them are satisfied with the knowledge gained during their medical education about these tumors. Inadequate medical academic training may initially lead to the wrong clinical management of patients with bone and soft tissue tumor lesions. An educational effort is needed to enhance oncology education for medical students, especially concerning sarcomas.

Assessing Depression and Anxiety Levels in English and Spanish-Speaking Patients throughout a Course of Radiation Therapy

PURPOSE/OBJECTIVE(S)

An estimated 32.2% and 41.9% of breast cancer patients experience depression and anxiety, respectively. However, distress experienced by patients with breast cancer receiving radiation therapy may vary at different time points and differ in comparison to other patients with breast cancer, potentially due to differences in the understanding of radiotherapy and variability in the severity of side effects. This study sought to describe the changes in levels of depression and anxiety experienced by English and Spanish-speaking patients throughout a course of radiation therapy for breast cancer, along with the impact of different variables on these levels of distress to better understand and quantify potential gaps.

MATERIALS/METHODS

Eligibility criteria included English and Spanish-speaking females, ages 18 or older, undergoing radiation therapy treatment for breast cancer at two institutions, including a safety-net hospital. Pre- and post-treatment surveys were completed before and after delivery of radiation therapy. Sociodemographic characteristics collected included: race, ethnicity, marital status, education level, longest residency location, housing, and food security. The survey ended with the standardized PHQ-4 questionnaire, which uses a maximum total score of 12 to assess anxiety and depression. Results were analyzed using the Analysis of Covariance procedure.

RESULTS

A total of 160 participants completed pre- and post-treatment surveys. Half of the participants were non-white (50%), primarily married (42.5%), and had a high school or associate's level education (46.9%). The total baseline distress mean (BDM) was 2.96 (Standard deviation, SD = 3.11), and the final distress mean (FDM) was 2.78 (SD = 3.78). English-speaking patients comprised 82.5% (n = 132) of the sample and had a BDM of 2.91 with an adjusted change mean (ACM) decrease of 0.45. Spanish-speaking patients comprised 17.5% (n = 28) of the sample, with a BDM of 3.21 and an ACM increase of 1.03 (P = 0.002). Housing (P = 0.021) and food insecurity (P = 0.002) also showed increasing distress with increased insecurity at baseline.

CONCLUSION

Our study shows that Spanish-speaking patients present with higher levels of distress than their English-speaking counterparts and their distress increased throughout treatment as opposed to English speakers. Other factors, such as housing and food insecurity, are also significantly associated with increased distress. As the number of Spanish speakers in the US continues to increase, it will be important to continue assessing potential differences in cancer care. In addition, understanding the distress changes throughout radiation treatment could help inform future interventions that address these disparities.

Development and Assessment of a Multi-Purpose Knowledge-Based Planning Model (RapidPlan) for Prostate Radiation

PURPOSE/OBJECTIVE(S)

RapidPlan (RP) is a knowledge-based planning (KBP) tool to improve plan quality, planning speed, and reduce inter-patient plan variability. For small to medium institutions, it is difficult to find sufficient patient numbers to configure a reliable KBP-RP model. This study aimed to build a multi-purpose KBP-RP model for prostate cancers.

MATERIALS/METHODS

A total of 124 prostate plans from 2018-2022 at our institution were selected to configure the initial RP model. After model training, outliers were removed. 77 patients were used for the final RP model. Three fine-tuned RP sub-models with different optimized constraints corresponding to prostate bed, prostate + seminal vesicles (SV), and prostate boost plans were generated. RP models were validated by comparing plan quality with the original manually optimized plans (MP). 54 independent plans were selected to validate the RP models. Validation included: dose to 99% and 2% of PTV (D99%, D2%), PTV conformity index (CI); for organs at risk (OARs), volume receiving >70Gy and >60Gy (V70Gy, V60Gy) to bladder and rectum, maximum dose (Dmax) to femur heads (FHs) and small bowel. Statistical t-test analysis was performed with a significance of p<0.05.

RESULTS

A total of 48/54 model-based plans were clinically approved after single RP optimization. 6/54 failed plans were prostate bed plans and were deemed acceptable after additional minor constraint adjustments. For PTV, D99%, D2%, and CI were comparable (p>0.05) to MP. Bladder and rectum V70Gy were comparable (p>0.05), and V60Gy were significantly lower to MP (p<0.05), with an average Dmean of 23.21±14.58Gy and 16.41±10.63Gy vs 26.36±16.89Gy and 18.24±12.81Gy for RP and MP. RP significantly reduced Dmax to FHs and small bowel (p<0.05), with average Dmax of 34.95±6.06Gy and 35.62±18.99Gy vs 36.81±7.05Gy and 38.14±17.81Gy, respectively.

CONCLUSION

Multi-purpose prostate RP model was configured and approved plans were generated after single optimization. Prostate RP plans had equivalent PTV coverage with better or comparable OAR constraints.

Axillary Lymph Node Dissection is Associated with Improved Survival Among Men with Invasive Breast Cancer and Sentinel Node Metastasis

BACKGROUND

Male breast cancer (MBC) is rare, and management is extrapolated from trials that enroll only women. It is unclear whether contemporary axillary management based on data from landmark trials in women may also apply to men with breast cancer. This study aimed to compare survival in men with positive sentinel lymph nodes after sentinel lymph node biopsy (SLNB) alone versus complete axillary dissection (ALND).

PATIENTS AND METHODS

Using the National Cancer Database, men with clinically node-negative, T1 and T2 breast cancer and 1-2 positive sentinel nodes who underwent SLNB or ALND were identified from 2010 to 2020. Both 1:1 propensity score matching and multivariate regression were used to identify patient and disease variables associated with ALND versus SLNB. Survival between ALND and SLNB were compared using Kaplan-Meier methods.

RESULTS

A total of 1203 patients were identified: 61.1% underwent SLNB alone and 38.9% underwent ALND. Treatment in academic centers (36.1 vs. 27.7%; p < 0.0001), 2 positive lymph nodes on SLNB (32.9 vs. 17.3%, p < 0.0001) and receipt or recommendation of chemotherapy (66.5 vs. 52.2%, p < 0.0001) were associated with higher likelihood of ALND. After propensity score matching, ALND was associated with superior survival compared with SLNB (5-year overall survival of 83.8 vs. 76.0%; log-rank p = 0.0104).

DISCUSSION

The results of this study suggest that among patients with early-stage MBC with limited sentinel lymph node metastasis, ALND is associated with superior survival compared with SLNB alone. These findings indicate that it may be inappropriate to extrapolate the results of the ACOSOG Z0011 and EORTC AMAROS trials to MBC.

Exploring the Perceived Educational Impact of COVID-19 on Postgraduate Training in Oncology

This study sought to report the degree to which postgraduate trainees in radiation oncology perceive their education has been impacted by the COVID-19 pandemic. A cross-sectional online survey was administered from June to July 2020 to trainee members of the Canadian Association of Radiation Oncology (CARO) (n = 203). Thirty-four trainees responded with a 17% response rate. Just under half of participants indicated that COVID-19 had a negative/very negative impact on training (n = 15; 46%). The majority agreed/strongly agreed that they feared family/loved ones would contract COVID-19 (n = 29, 88%), felt socially isolated from friends and family because of COVID-19 (n = 23, 70%), and had difficulty concentrating on tasks because of concerns about COVID-19 (n = 17, 52%). Changes that had a negative/very negative impact on learning included limitations to travel and networking (n = 31; 91%) and limited patient contact (n = 19; 58%). Virtual follow-ups (n = 25: 76%) and in-patient care activities (n = 12; 36%) increased. Electives were cancelled in province (n = 10; 30%), out-of-province (n = 16; 49%), and internationally (n = 15; 46%). Teaching from staff was moderately reduced to completely suppressed (n = 23, 70%) and teaching to medical students was moderately reduced to completely suppressed (n = 27, 82%). Significant changes to radiation oncology training were wrought by the pandemic, and roughly half of trainees perceive that these changes had a negative impact on training. Innovations in training delivery are needed to adapt to these new changes.

Mitigating disparities in breast cancer treatment at an academic safety-net hospital

PURPOSE

Among women with non-metastatic breast cancer, marked disparities in stage at presentation, receipt of guideline-concordant treatment and stage-specific survival have been shown in national cohorts based on race, ethnicity, insurance and language. Little is published on the performance of safety-net hospitals to achieve equitable care. We evaluate differences in treatment and survival by race, ethnicity, language and insurance status among women with non-metastatic invasive breast cancer at a single, urban academic safety-net hospital.

METHODS

We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2014 at an urban, academic safety-net hospital. Demographic, tumor and treatment characteristics were obtained. Stage at presentation, stage-specific overall survival, and receipt of guideline-concordant surgical and adjuvant therapies were analyzed. Chi-square analysis and ANOVA were used for statistical analysis. Unadjusted survival analysis was conducted by Kaplan-Meier method using log-rank test; adjusted 5 year survival analysis was completed stratified by early and late stage, using flexible parametric survival models incorporating age, race, primary language and insurance status.

RESULTS

520 women with stage 1-3 invasive breast cancer were identified. Median age was 58.5 years, 56.1% were non-white, 31.7% were non-English-speaking, 16.4% were Hispanic, and 50.1% were Medicaid/uninsured patients. There were no statistically significant differences in stage at presentation between age group, race, ethnicity, language or insurance. The rate of breast conserving surgery (BCS) among stage 1-2 patients did not vary by race, insurance or language. Among patients indicated for adjuvant therapies, the rates of recommendation and completion of therapy did not vary by race, ethnicity, insurance or language. Unadjusted survival at 5 years was 93.7% for stage 1-2 and 73.5% for stage 3. Adjusting for age, race, insurance status and primary language, overall survival at 5 years was 93.8% (95% CI 86.3-97.2%) for stage 1-2 and 83.4% (95% CI 35.5-96.9%) for stage 3 disease. Independently, for patients with early- and late-stage disease, age, race, language and insurance were not associated with survival at 5-years.

CONCLUSION

Among patients diagnosed and treated at an academic safety-net hospital, there were no differences in the stage at presentation or receipt of guideline-concordant treatment by race, ethnicity, insurance or language. Overall survival did not vary by race, insurance or language. Additional research is needed to assess how hospitals and healthcare systems mitigate breast cancer disparities.

Correlation between research productivity during medical school and radiation oncology residency

Purpose

This analysis investigates whether research productivity during medical school predicts future research productivity during radiation oncology residency.

Methods and Materials

At our institution, there have been 20 medical students who graduated between 2005 and 2015 and subsequently completed their residency training in radiation oncology. We built a database of all PubMed-indexed publications in which these former students were the first author or coauthor. Mean publication rates with 95% confidence intervals (95% CI) were computed. The paired t test and McNemar-Bowker test of symmetry were used to examine differences in first-author and coauthor publications between the medical school and residency periods. An ordinal logistic regression model was employed to measure the odds ratio of publishing during residency versus during medical school. A Spearman correlation coefficient was calculated for the relationship between the number of publications during medical school and the number during residency.

Results

A total of 14 and 60 first-author publications (46 and 117 coauthor publications) were identified for 20 individuals during medical school and residency, respectively. There was an average of 0.7 (95% CI, 0.17-1.23) first-author publications during medical school and 3.08 (95% CI, 1.56-4.44) first-author publications during residency (P = .003). Only 15% (3/20) had ≥2 publications during medical school, and 50% (10/20) had ≥2 publications during residency (P = .012). The Spearman correlation coefficient between research publications before and during residency was .457 (P = .043). The mean number of coauthor publications during medical school and residency was 2.3 (95% CI, 0.92-3.68) and 5.85 (95% CI, 3.50-8.20), respectively (P = .004).

Conclusions

Based on this retrospective analysis from our institution, student research productivity during medical school, as defined by the number of first-author publications, does correlate with future research productivity during radiation oncology residency.

Inequalities in Cancer Stage at Diagnosis Among Incarcerated Individuals Undergoing Radiation Therapy at a Large Safety-Net Hospital

INTRODUCTION

There is a dearth of data on cancer care in the incarcerated population, despite being the leading cause of illness-related death in United states' prisons. We retrospectively reviewed the demographic and clinicopathologic characteristics of incarcerated individuals who received radiation therapy at a large safety-net hospital.

METHODS

Following IRB approval, we identified 80 incarcerated patients who presented for radiation therapy between January 2003 and May 2019. Descriptive statistics on the patients, tumor types and stage, treatment factors, and follow-up rates were analyzed.

RESULTS

80 individuals with 82 cancer diagnoses presented for radiation oncology consultation over the study period. The median age was 54 years (range, 46-64). Patients of White, Black, and "other" races comprised 61.3% (n=49), 28.8% (n=23), and 10% (n=8), respectively. Most patients were male (n=75, 93.8%) and English speakers (n=76, 95%). Moreover, 50% (n=40) had a substance use disorder history and 75% (n=60) had a smoking history. The three most common cancer types were prostate (n=12, 14.6%), gastrointestinal (n=14, 17.1%), thoracic (n=17, 20.7%), and head and neck (n=21, 25.6%). The distribution of tumor stage (AJCC) was I (n=12, 14.6%), II (n=12, 14.6%), III (n=14, 17.1%), IV (n=38, 46.3%), and unknown/unavailable (n=6, 7.3%). Of the cohort, 65 patients with 66 cancers (80.5%) received radiation. Among them, the 6-month, 1-year, and 5-year follow-up rates were 41.5%, 27.7%, and 3.1%, respectively. Subset analysis limited to stage I-III patients (n=30) revealed 6-month, 1-year and 5-year follow-up rates of 41.9%, 22.6%, and 3.2%, respectively.

CONCLUSIONS

This study highlights inequalities in cancer stage at diagnosis among a vulnerable patient population that is largely excluded from clinical research. Majority of the incarcerated patients presented with stage III & IV cancers and have poor follow up rates even among those with early-stage disease. Efforts to understand and mitigate persistent health inequalities among incarcerated patients are warranted.

Longitudinal Outcomes of Medical Student Research Mentorship: a 15-Year Analysis of the Radiation Oncology Mentorship Initiative

At our institution, students can be mentored by radiation oncology faculty through structured research programs, such as the Medical Student Summer Research Program (MSSRP). The purpose of this study is to report the research productivity of students who engaged in radiation oncology research mentorship, whether through the MSSRP or other avenues of research mentorship. We compiled a database of abstracts and manuscripts co-authored by 58 students who conducted research with radiation oncology faculty from 2005 to 2020. The means, medians, ranges, and interquartile ranges (IQR) of co-authorships and first authorships were calculated for the overall cohort and compared for MSSRP and non-MSSRP students, who matched into radiation oncology and those who did not, and male versus female students. Among all 58 students, 106 abstracts and 70 manuscripts were identified. Of those students, 54 (93.1%) published at least one abstract or manuscript. The mean number of abstract co-authorships per student was 3.07 (median 2, range 0-25, IQR 0-4), and the mean number of manuscript co-authorships per student was 2.22 (median 1, range 0-18, IQR 1-3). There were no significant differences in research output between MSSRP and non-MSSRP students or male and female students. However, the students who matched into radiation oncology published more co-author (3.67 vs. 1.63, p = 0.01) and first-author (1.62 vs. 0.53, p = 0.006) manuscripts than those who did not. Further research is warranted to assess whether skills gained from student-directed research translate into residency and beyond.

Medical Student Leadership in the Student Oncology Society: Evaluation of a Student-Run Interest Group

At our institution, we aim to foster interest in oncology through the Student Oncology Society (SOS). The SOS was formed in 2010 and since then has hosted numerous oncology-related events, such as career panels, patient survivorship celebrations, and movie screenings. The purpose of this study is to report the experiences from former student leaders of the SOS, particularly how their participation informed their career choice. Complete survey responses were obtained from 26 of 32 former SOS student leaders (response rate 81.3%). Out of the 26 respondents, 19 (73.1%) are pursuing an oncology-related specialty. The three most common competencies that were affected by participation in SOS, noted by 21 (80.8%) respondents, were learning about pathways to careers in oncology, understanding the multidisciplinary approach to cancer care, and coordinating events. By mean Likert score, the most important factors in career choice for respondents who eventually pursued an oncology field were having a mentor in oncology (4.44), a clinical rotation in oncology (4.31), research involvement (4.22), and SOS involvement (3.17). While SOS involvement played a role in career choice among our student leaders, having a mentor was cited to be the most important factor for choosing an oncology career. Thus, implementation of formal mentorship initiatives within the framework of oncology interest groups should be explored.

Radiation Oncology AcaDemic Mentorship Program (ROADMAP) for Junior Faculty: One-Year Results of a Prospective Single Institution Initiative

PURPOSE

Although mentorship has been associated with promotion, job satisfaction, and retention, data are limited on the mentorship experience of clinical- versus research-track physicians as well as feasibility and relative priority of formal program components.

METHODS AND MATERIALS

Within a single-institution, multi-site, academic network, we implemented a Radiation Oncology AcaDemic Mentorship Program (ROADMAP) for junior faculty. Validated surveys assessing mentee satisfaction were distributed at baseline and 1 year. The statistical analysis included Wilcoxon rank sum and signed tests. Mentees assessed the likelihood to recommend each program component (10-point Likert-type scale), and means with standard error (SE) are reported.

RESULTS

Among 42 eligible junior faculty, 36 (86%) opted into the program. The median time since residency was 2.5 years (interquartile range, 1.75-5.25) on the clinical track (n = 12) and 3 years (interquartile range, 2.75-5.00) on the research track (n = 24). At baseline, research-track physicians reported higher satisfaction with mentoring than physicians on the clinical track (2.92 vs 2.16; P = .02). Among 32 physicians completing 1 year, overall satisfaction with mentoring increased compared with baseline (2.72 vs 3.87; P < .001), which persisted on subset analysis for both clinical- (2.16 vs 4.03; P < .001) and research-track physicians (2.99 vs 3.77; P = .005). At 1 year, 28 mentees (88%) opted to continue the program. Program components were rated 8.25 (SE, 0.37) for mentor-mentee pairings, 7.22 (SE, 0.39) for goal setting, 6.84 (SE, 0.47) for administrative support, 6.69 (SE, 0.44) for peer mentoring, and 6.53 (SE, 0.45) for steering committee oversight. Ratings of peer mentoring were not associated with track (P = .59) or years in practice (P = .29).

CONCLUSIONS

Clinical-track physicians may be less satisfied with mentorship than research-track faculty. However, all junior faculty, regardless of track, appeared to benefit from formalizing dyadic mentor-mentee relationships, goal setting, and peer mentoring. Further work is needed to determine the role of mentorship in addressing physician burnout.

Effect of Radiation Treatment at a High-Volume Center on Outcomes in Intermediate-Risk Prostate Cancer: An Analysis of the National Cancer Database

OBJECTIVE

To investigate the effect of radiation treatment at a high-volume center on overall survival in men with intermediate-risk prostate cancer.

METHODS

From 2004-2015, 430,347 patients with intermediate-risk prostate cancer were identified in the NCDB. Radiation case volume (RCV) of each hospital was calculated based on number of patients treated. After excluding certain patients including those with metastatic disease, our final analysis population included 116,091 intermediate-risk prostate cancer patients receiving radiation therapy (RT) or radiation with androgen deprivation therapy (RT+ADT). Characteristics analyzed include age, race, distance to treatment facility, Charlson-Deyo Score (CDS), and socioeconomic factors. Primary outcome was overall survival (OS). 5-year survival rates were estimated using the Kaplan-Meier method. Adjusted hazard ratios (HR) with 95% confidence intervals (CI) were computed using multivariate analysis (MVA). Cox regression and propensity score-matched (PSM) analysis was performed.

RESULTS

Median follow up was 63.5 months and estimated 5-year OS was 90.1% at high RCV centers and 88.2% at low RCV centers (p<0.0001). Treatment at high RCV facility was associated with significantly lower mortality compared to treatment at a low RCV facility on MVA and PSM analysis. The survival benefit of treatment at a high RCV facility remained when high RCV facilities were defined as those above the 80^th, 90^th, and 95^th percentile in patient volume (p<0.05).

CONCLUSIONS

Treatment at a high radiation case volume facility is associated with improved OS in patients with radiation-treated intermediate-risk prostate cancer. This survival benefit is important to consider when choosing a treatment center for radiation therapy.

Mentorship Initiatives in Radiation Oncology: A Scoping Review of the Literature

PURPOSE

Although mentorship is described extensively in academic medical literature, there are few descriptions of mentorship specific to radiation oncology. The goal of the current study was to investigate the state of mentorship in radiation oncology through a scoping review of the literature.

METHODS AND MATERIALS

A search protocol was defined according to Preferred Reporting Items for Systematic Reviews and Meta Analyses extension for scoping reviews (PRISMA-ScR) guidelines. Predefined search terms and medical subject headings were used to search PubMed for English language articles published after January 1, 1990, on mentorship in radiation oncology. Additionally, in-press articles from major radiation oncology and medical education journals were searched. Three reviewers determined article eligibility. Included articles were classified based on predefined evaluation criteria.

RESULTS

Fourteen publications from 2008 to 2019 met inclusion criteria. The most commonly described form of mentorship was the dyad (64.3%), followed by team (14.3%) and peer (7.1%); 2 articles did not specify mentorship type (14.3%). The most commonly mentored participants were residents (35.7%), followed by medical students (35.7%) and attendings (21.4%); 1 study included participants of all levels (7.1%). Thirteen studies (92.9%) identified an experimental study design, most of which were cross-sectional (42.9%), followed by cohort studies (28.6%) and before/after (21.4%). Median sample size, reported in 12 of 13 experimental studies, was 132 (coefficient of variation, 1.06). Although outcomes varied widely, the majority described successful implementation of mentorship initiatives with high levels of participant satisfaction.

CONCLUSIONS

Although few initiatives are currently reported, the present study suggests that these initiatives are successful in promoting career development and increasing professional satisfaction. The interventions overwhelmingly described mentorship dyads; other forms of mentorship are either less common or understudied. Limitations included interventions not being evaluated in a controlled setting, and many were assessed using surveys with low response rates. This review highlights rich opportunities for future scholarship to develop, evaluate, and disseminate radiation oncology mentorship initiatives.

Effect of Medical Student Contributions on Academic Productivity: Analysis of Student Authorship Over Time

INTRODUCTION

Understanding the trend of student authorship is crucial in determining its correlation to scholarly impact for corresponding authors. Our objective is to investigate student authorship rates over time in articles published in JAMA Internal Medicine (IM), as well as to examine potential effects student authors have on scholarly impact scores of corresponding authors via H-index measures.

METHODS

Authorship data including student authors (SA), first student authors, and corresponding authors (CA) from prior JAMA IM publications between 2010 and 2018 were collected, with a total of 701 studies. Analysis of variance (ANOVA) and independent sample t-tests were performed to assess for differences in the mean by publishing year and student authorship, respectively.

RESULTS

Of 4591 total authors, 683 (14.9%) were considered student authors. The percentage of student authorship increased from 46.3% to 58.0% between 2010 and 2018, respectively. No difference in average H-indices of CA between SA and non-SA groups (overall NSA H_i mean: 30.2, vs SA H_i mean: 32.1, p=0.371) was noted.

DISCUSSION

Student participation in research is not a disadvantage to scholarly impact for corresponding authors. Increased student authorship reflects a promising trend towards greater student participation in research within the field of medicine.

Knowledge-based planning in robotic intracranial stereotactic radiosurgery treatments

Purpose

To develop a knowledge‐based planning (KBP) model that predicts dosimetric indices and facilitates planning in CyberKnife intracranial stereotactic radiosurgery/radiotherapy (SRS/SRT).

Methods

Forty CyberKnife SRS/SRT plans were retrospectively used to build a linear KBP model which correlated the equivalent radius of the PTV (r_{eq_PTV}) and the equivalent radius of volume that receives a set of prescription dose (r_{eq_Vi}, where V_i = V_10%, V_20% … V_120%). To evaluate the model’s predictability, a fourfold cross‐validation was performed for dosimetric indices such as gradient measure (GM) and brain V_50%. The accuracy of the prediction was quantified by the mean and the standard deviation of the difference between planned and predicted values, (i.e., ΔGM = GM_pred − GM_clin and fractional ΔV_50% = (V_50%pred − V_50%clin)/V_50%clin) and a coefficient of determination, R². Then, the KBP model was incorporated into the planning for another 22 clinical cases. The training plans and the KBP test plans were compared in terms of the new conformity index (nCI) as well as the planning efficiency.

Results

Our KBP model showed desirable predictability. For the 40 training plans, the average prediction error from cross‐validation was only 0.36 ± 0.06 mm for ΔGM, and 0.12 ± 0.08 for ΔV_50%. The R² for the linear fit between r_{eq_PTV} and r_{eq_vi} was 0.985 ± 0.019 for isodose volumes ranging from V_10% to V_120%; particularly, R² = 0.995 for V_50% and R² = 0.997 for V_100%. Compared to the training plans, our KBP test plan nCI was improved from 1.31 ± 0.15 to 1.15 ± 0.08 (P < 0.0001). The efficient automatic generation of the optimization constraints by using our model requested no or little planner’s intervention.

Conclusion

We demonstrated a linear KBP based on PTV volumes that accurately predicts CyberKnife SRS/SRT planning dosimetric indices and greatly helps achieve superior plan quality and planning efficiency.

Disparities in Laryngeal Cancer Treatment and Outcomes: An Analysis by Hospital Safety-Net Burden

OBJECTIVES/HYPOTHESIS

To analyze the impact of hospital safety-net burden on survival outcomes for laryngeal squamous cell carcinoma (LSCC) patients.

STUDY DESIGN

Retrospective cohort study.

METHODS

From 2004 to 2015, 59,733 LSCC patients treated with curative intent were identified using the National Cancer Database. Low (LBH) <25th, medium (MBH) 25th-75th, and high (HBH) >75th safety-net burden hospitals were defined by the percentage quartiles (%) of uninsured/Medicaid-insured patients treated. Social and clinicopathologic characteristics and overall survival (using Kaplan-Meier survival analysis) were evaluated. Crude and adjusted hazard ratios (HR) with 95% confidence intervals (CI) were computed using Cox regression modeling.

RESULTS

There were 324, 647, and 323 hospitals that met the criteria as LBH, MBH, and HBH, respectively. The median follow-up was 38.6 months. A total of 27,629 deaths were reported, with a median survival of 75.8 months (a 5-year survival rate of 56.6%). Median survival was 83.2, 77.8, and 69.3 months for patients from LBH, MBH, and HBH, respectively (P < .0001). The median % of uninsured/Medicaid-insured patients treated among LBH, MBH, and HBH were 3.6%, 14.0%, and 27.0%, respectively. Patients treated at HBH were significantly more likely to be young, Black, Hispanic, of low income, and present with more advanced disease compared to LBH and MBH. Survival was comparable for LBH and MBH (HR = 1.02; 95% CI = 0.97-1.07, P = .408) on multivariate analysis. HBH, compared to LBH patients, had inferior survival (HR = 1.07; 95% CI = 1.01-1.13, P = .023).

CONCLUSIONS

High burden safety-net hospitals receive disproportionately more patients with advanced-stage and low socioeconomic status, yielding inferior survival compared to low burden hospitals.

LEVEL OF EVIDENCE

3 (individual cohort study) Laryngoscope, 131:E1987-E1997, 2021.

The Radiation Oncology Mentorship Initiative: Analysis of a Formal Mentoring Initiative for Medical Students Interested in Radiation Oncology

The importance of mentorship in medicine and its impact on academic and professional development has been widely studied. However, mentorship for medical students in the field of radiation oncology is limited. Our radiation oncology department developed a formal medical student mentorship program in 2004. This program included both clinical and research mentoring pathways. Our study aims to gain feedback and perspective from former medical student participants who subsequently entered into a radiation oncology residency program. An anonymous survey was sent to 22 former students in the mentorship program from 2005 to 2016 who entered a radiation oncology residency program. The survey included Likert scales (1-5), multiple choice, strength category rankings, and free responses. Data was compiled and analyzed with Qualtrics data software. The survey response rate was 100%. Seventeen (77.3%) participants reported that the mentorship program strongly affected their career choice and a majority reported that their research experience strongly (45.5%) or moderately affected (31.8%) their career choice. Fourteen (63.6%) respondents reported that the mentorship program was very effective and 8 (36.4%) reported it as being effective. Eighteen (81.8%) respondents reported that mentorship was extremely important to their career. Students participating in the research pathway also reported improvement in valuable skills such as presentations, abstract writing, manuscript writing, statistical analysis, and coordination with colleagues. A total of 66.7% of attending radiation oncologists who previously participated in this program now practice in an academic setting. Our institution successfully developed a formalized mentorship program for medical students interested in radiation oncology. Participants in this program reported high levels of satisfaction and emphasized the importance of mentorship in the development of valuable research competencies and on their overall career path. This program can serve as a model for future mentorship initiative in medical school.

Improving Diversity and Inclusion in the Post-Coronavirus Disease 2019 Era Through a Radiation Oncology Intensive Shadowing Experience (RISE)

Purpose

In response to the coronavirus disease 2019 pandemic, current Association of American Medical Colleges guidelines discourage away rotations, posing significant challenges for attracting students to radiation oncology (RO). This is particularly concerning for medical students underrepresented in medicine (UIM) due to the potential of widening existing disparities in applicant and workforce composition. To proactively address this, we created a Radiation Oncology Intensive Shadowing Experience (RISE) to expose UIM students to the field of RO.

Methods and Materials

Key stakeholders within the residency program, including both UIM faculty and residents with experience in health disparities and medical education, designed a 1-week virtual RISE intended for fourth year UIM students recruited through established national organizations serving UIM medical students. A 1-week disease-specific curriculum was developed using 4 components: (1) foundational exposure to RO, (2) didactic teaching, (3) mentorship opportunities, and (4) a capstone experience. Mentorship was continuously weaved through the experience by attendings, peer resident mentors, and a UIM resident panel to optimize exposure.

Results

RISE was successfully initiated at 2 academic medical centers with 12 UIM students enrolled through August. Anonymized pre- and postclerkship surveys were developed for students, residents, and faculty involved in RISE to evaluate participants’ satisfaction, resident and attending time burden, and perceptions of program effectiveness.

Conclusions

We created a unique virtual RO shadowing experience for UIM students to address a critical gap in exposure to RO, heightened by the corona virus disease 2019 pandemic, with the goal of improving diversity, equity, and inclusion in our field.

Placard in Hand: A Simple, Inexpensive Intervention to Improve On-Treatment Visit Compliance in a Safety Net Radiation Oncology Patient Population

PURPOSE

On-treatment visits (OTVs) for patients undergoing radiotherapy (RT) should occur every five fractions. Compliance with OTVs was identified as a potential issue in a safety-net patient population. This study determined if brightly colored placards given to patients improved OTV compliance.

MATERIALS AND METHODS

A retrospective analysis of all patients with lung cancer receiving RT from October 1, 2015 to September 30, 2017 evaluated OTV compliance before (No Placard) and after (Placard) the placard was introduced in the clinic. Analysis of variance, χ² tests, and Fisher's exact tests were performed to assess differences in continuous and categorical patient and treatment variables, respectively.

RESULTS

The No Placard group included 48 patients who were scheduled for 151 OTVs. The Placard group included 50 patients who were scheduled for 187 OTVs. The percentage of missed OTVs in the No Placard group was 9.3% (14/151), versus 2.1% (4/187) in the Placard group (P = .004). Patients in the No Placard group were more likely to speak English (97.9% v 86.0%; P = .060), were less likely to have stage I-III disease (75% v 88%; P = .097), and received lower mean RT doses (48.2 Gy v 55.6 Gy; P = .007). On multivariate analysis adjusting for language, stage, and RT dose, the adjusted mean rate of missed OTVs in the No Placard group was 7.1%, versus 1.4% in the Placard group (P = .019).

CONCLUSION

A significant increase in compliance of OTVs was observed with the introduction of brightly colored placards. This represents a simple, inexpensive method to improve OTV compliance in a safety-net setting and may be applicable to other patient populations.

Abstract B124: Breast cancer treatment delays at an urban safety net hospital among women experiencing homelessness

Abstract Disparities in outcomes for vulnerable women is a persistent, ongoing problem. Timely treatment improves breast cancer outcomes and efforts to improve delays among underserved patients is needed. Specifically, homelessness and breast cancer treatment outcomes are understudied. This is a novel and descriptive study exploring types of homelessness and treatment delays at an urban safety net hospital providing care to a vulnerable patient population. Experimental Procedures This study is a retrospective chart review of homeless female patients diagnosed with breast cancer between January 1, 2000 and December 31, 2014. Data for this study were acquired from the hospital cancer registry and electronic medical record. Homelessness was categorized as transitionally, episodically or chronically homeless. Other variables collected included demographic characteristics and time to treatment. A detailed chart review was conducted to identify delays to breast cancer treatment and the potential reasons for delay between diagnosis and first treatment. All demographic characteristics, time to treatment and factors related to delays to treatment were analyzed descriptively, reporting frequencies and proportions. Delay to treatment was calculated as date of pathologically confirmed biopsy of breast cancer to date of first treatment (surgery or chemotherapy). Summary of Data The total number of individuals analyzed was 24. All except two subjects were delayed to treatment (&gt; 30 days from diagnosis to treatment). Most women in this cohort were categorized as chronically homeless (46%) with the rest categorized as transitionally (29%) or episodically (12%) homeless. The majority of subjects (70%) were Black, non-Hispanic. Most women identified as single (58%) or divorced (21%) at the time of breast cancer diagnosis. All except one subject were publicly insured (71% Medicaid; 12% Medicare) or uninsured (8%). Regardless of type of homelessness, most subjects were either 30-60 or 60-90 days delayed. Those who were chronically homeless experienced significantly more delays to first treatment (56% of those who were delayed 30-60 days and 57% of those who were delayed 60-90 days; p-value 0.006) than those who were episodically or transitionally homeless. Conclusions Significant delays and barriers to breast cancer treatment exist among women experiencing homelessness. Further studies and focused efforts to improve timely breast cancer care for homeless women is warranted.

Citation Format: Kate Festa, Ariel E Hirsch, Michael R Cassidy, Lauren Oshry, Kathryn Quinn, Margaret M Sullivan, Naomi Y Ko. Breast cancer treatment delays at an urban safety net hospital among women experiencing homelessness [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B124.

Abstract P5-12-03: Socio-demographic differences in utilization of genomic testing and receipt of endocrine therapy in the National Cancer Database

Background & Objectives Breast cancer outcome disparities for racial and ethnic minorities continues to be a problem in the United States. Genomic testing in early stage hormone positive breast cancer is the current standard of care given the useful predictive and prognostic value of testing. However, chemotherapy treatment decisions based on genomic testing results are predicated on the assumption that patient adhere to adjuvant endocrine treatment. Factors that could contribute to ongoing disparities for racial and ethnic minorities include both the utilization of genomic testing and adherence to hormonal therapy. Understanding these patterns of care across the United States with a large dataset has not yet been done. Methods We analyzed a cohort from the National Cancer Database (NCDB) of 387,008 female patients diagnosed with Stage I-II, ER+ breast cancer between 2010 and 2014. Demographic variables included age, race, ethnicity, insurance status, income, education, Charlson-Deyo comorbidity score. Clinicopathologic and treatment variables included tumor grade, histology, receptor status, facility type, delivery of treatment at &gt;1 facility and receipt of genomic testing. Descriptive statistics using chi-square testing were computed to describe patient, tumor and treatment characteristics. Logistic regression analysis was used to calculate odds of genomic testing and receipt of hormone therapy among patients who did or did not receive genomic testing.

Results Among a total sample size of 387,008, median age was 63 years old, majority white (87%), non-Hispanic (95.4%), without co-morbidities (88%). A total of 147,863 (38.2%) patients underwent genomic testing. Compared to patients with ages 18-&lt;50, older age (≥70 years) was associated with a lower adjusted odds of genomic testing (OR=0.33; 95% CI=0.32-0.34, p=&lt;0.0001). Blacks had a lower odds of receiving genomic testing on multivariate analysis compared to whites (OR=0.82; 95% CI=0.80-0.85, p=&lt;0.0001). Hispanic ethnicity, non-private insurance, increasing percentage of no high school degree in area of residence, CDS score of 2 or more, stage II disease, community or comprehensive community facility setting, and borderline HER2 status were also factors associated with a lower odds of receiving a genomic test. Odds of getting genomic testing improved over the years with patients diagnosed in 2014 reporting an odds ratio of 1.57 (95% CI=1.53-1.60, p=&lt;0.0001) compared to those diagnosed in 2010. Compared to whites, blacks had a lower odds of receiving hormone therapy irrespective of genomic testing status (OR=0.86; 95% CI=0.83-0.88, p=&lt;0.0001). Age ≥70 (OR=0.53; 95% CI=0.51-0.55, p=&lt;0.0001), Hispanic ethnicity (OR=0.89; 95% CI=0.85-0.93, p=&lt;0.0001), non-private insurance and non-academic treatment facilities were associated with lower odds of getting hormone therapy. Among patients undergoing a genomic test, age ≥70, black race, and non-academic treatment facilities had lower odds of receiving hormone therapy. Conclusion In a national cohort of breast cancer patients, Black women consistently were less likely to get genomic testing and less likely to receive hormonal therapy. Ensuring that all women with early stage ER+ breast cancer eligible for genomic testing and hormone therapy receive appropriate testing and hormonal treatment is a priority to addressing breast cancer disparities.

Citation Format: Naomi Y Ko, Mustafa Q Muhammad, Michael R Cassidy, Lauren Oshry, Ariel E Hirsch. Socio-demographic differences in utilization of genomic testing and receipt of endocrine therapy in the National Cancer Database [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-12-03.

The Impact of Locoregional Treatment on Survival in Patients With Metastatic Breast Cancer: A National Cancer Database Analysis

BACKGROUND

Although systemic therapy is the standard treatment for metastatic breast cancer, the value of locoregional treatment (LRT) of the primary tumor and its impact on survival is controversial. This study evaluates survival outcomes in patients with metastatic breast cancer after receiving LRT (surgery and/or radiation therapy) of the primary tumor.

MATERIALS AND METHODS

The National Cancer Database was used to identify 16,128 qualifying cases of metastatic breast cancer who received systemic therapy with or without LRT from 2004 to 2013. Treatment modality was divided into surgery (Sx), radiation therapy (RT), surgery followed by RT (Sx + RT), and no LRT. The median survival and 3-year actuarial survival rates (OS) were analyzed for each treatment group. On multivariate analyses, adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were computed using Cox regression modeling to adjust for patient and clinicopathologic characteristics.

RESULTS

Overall, the median follow-up was 28.3 months, and the median survival for all patients was 37.2 months. With 9761 deaths reported, the estimated 3-year OS was 51.3%. The Sx + RT group (n = 2166) had the highest 3-year OS of 69.4%, followed by the Sx group (n = 4293) with 57.6%, the no LRT group (n = 8955) with 44.3%, and the RT group (n = 714) with 41.5% (P < .0001). On multivariate analysis, compared with the no LRT group, a decreased HR was noted in patients receiving Sx (adjusted HR, 0.68; 95% CI, 0.65-0.71; P < .0001) and Sx + RT (adjusted HR, 0.46; 95% CI, 0.43-0.49; P < .0001).

CONCLUSION

LRT, especially surgery followed by RT, in addition to systemic therapy, was associated with improved survival in patients with metastatic breast cancer.

A Thorough Analysis of the Current State of Cancer Education in Medical Schools and Application of Experimental Teaching Techniques and Their Efficacy

Newly diagnosed cases of cancer are expected to double by the year 2040. Although many different oncology teaching initiatives have been implemented, many students continue to report uncertainty when dealing with patients with cancer. Through this review, we aim to find the most effective teaching methods to better prepare future physicians. Papers studying different methods of teaching oncology were identified through a thorough review of specific electronic databases. Each study was analyzed and sorted into one of ten unique categories created by the authors specifically for this review. If portions of the study fit into multiple categories, relevant results would be analyzed in all applicable areas. Additionally, papers were separated and analyzed by country of origin, preclinical or clinical interventional basis, and quantitative versus qualitative form of statistical analysis. A total of 115 papers from 26 different countries and regions were included in the final analysis. 91.4% of papers analyzing Lecture and Small Group Discussions indicated a positive impact. 97.1% of papers analyzing Clinical Practice and Simulation indicated a positive impact. 100% of papers analyzing Early Experience and Mentorship, Summer Programs and Voluntary Electives, use of Multidisciplinary Teams, and Role Play stated that these methods had a positive impact. 50% of papers analyzing Computer/Web Based Programs indicated a positive impact. Clinical Practice and Simulation, Role Play, Summer/Elective Programs and interventions involving Multidisciplinary Team Work all appeared to be most effective. Intensive Block Programs, Didactic Lectures/Small Group Discussions, and Computer/Web Based Education tools as a whole were variable. General Review papers showed continued variability in domestic and international oncology curricula. Incorporation of effective teaching interventions should be highly considered in the future creation of standardized oncology curricula in order to best prepare the next generation of physicians. Future studies could explore the differing efficacies of teaching interventions in the postgraduate versus graduate realms.

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 Impact of a Radiation Oncologist led Oncology Curriculum on Medical Student Knowledge

Medical students at our institution all take a pre-clinical oncology course as well as a clinical radiation oncology didactic session during their clinical curriculum. The objective of this analysis is to demonstrate the impact of the radiation oncology didactic on medical student knowledge of core oncology concepts. All students received a standardized didactic lecture introducing students to core concepts of general oncology and radiation. We administered an 18-question pretest and a posttest examining student knowledge between 2012 and 2015. Changes in student responses between pre-test and post-tests were analyzed to evaluate the effectiveness of the didactic session. Over the course of three years, 319 (64.4%) of 495 students who completed the Radiology block completed both the pre-test and post-test. The average student test grade improved from 62.0% on the pretest to 69.6% on the posttest (p < 0.001). By category, students increased their score from 81.4% to 89.8% (p < 0.001) in general oncology, from 59.9% to 69.9% (p < 0.001) in breast oncology, from 43.0% to 51.0% (p < 0.001) in prostate oncology, and from 71.3% to 75.7% (p = 0.003) in radiation oncology. Students showed increases in knowledge across general oncology, prostate oncology, breast oncology, and radiation oncology.

A 3D-Printed Patient-Specific Phantom for External Beam Radiation Therapy of Prostate Cancer

This paper presents the design evolution, fabrication, and testing of a novel patient and organ-specific, 3D printed phantom for external beam radiation therapy of prostate cancer. In contrast to those found in current practice, this phantom can be used to plan and validate treatment tailored to an individual patient. It contains a model of the prostate gland with a dominant intraprostatic lesion, seminal vesicles, urethra, ejaculatory duct, neurovascular bundles, rectal wall, and penile bulb generated from a series of combined T2-weighted/dynamic contrast-enhanced magnetic resonance images. The iterative process for designing the phantom based on user interaction and evaluation is described. Using the CyberKnife System at Boston Medical Center a treatment plan was successfully created and delivered. Dosage delivery results were validated through gamma index calculations based on radiochromic film measurements which yielded a 99.8% passing rate. This phantom is a demonstration of a methodology for incorporating high-contrast magnetic resonance imaging into computed-tomography-based radiotherapy treatment planning; moreover, it can be used to perform quality assurance.

Scholarly Impact of Student Participation in Radiation Oncology Research

PURPOSE

To evaluate the rate of non-doctoral student authors publishing in an academic journal over time and to analyze the effects student authors have on the scholarly impact of corresponding authors (CAs) by comparing their respective H-index (H_i).

METHODS AND MATERIALS

A database was created of authors who published articles in the International Journal of Radiation Oncology, Biology, Physics in 2006, 2010, and 2014 that included CA, degree, and student author designations. Corresponding authors' H_is were obtained from Scopus (scopus.com). Student authorship rates were compared between the sampled years. The data were divided into 2 groups: CAs publishing with student authors (SA) and those without (nSA). The CAs' median and mean H_is with standard deviation and a 95% confidence interval were compared between SA and nSA.

RESULTS

A total of 1728 published articles were identified with 1477 unique CAs. The percentage of published articles with student authors increased from 44.4% in 2006, to 52.9% in 2010, to 55.9% in 2014 (P = .0003). In overall analysis, mean H_i was higher for SA as compared with nSA (24.3 vs 22.9), although this did not achieve statistical significance (P = .094). Mean H_i (standard deviation) in 2006, 2010, and 2014 was 27.9 (16.6), 23.6 (16.7), and 18.5 (14.6), respectively. Mean H_i was significantly higher for SA compared with nSA in the years 2006 (29.5 vs 26.6, P = .048) and 2010 (24.9 vs 21.9, P = .038) but not in 2014 (18.5 vs 18.4, P = .963).

CONCLUSION

Student authorship rates in the International Journal of Radiation Oncology, Biology, Physics are increasing. The data suggest that student participation in research may benefit both corresponding and student authors. Creating and expanding research programs to integrate research into medical education may enhance students' experience and encourage interest in radiation oncology.

Introductory Radiation Oncology Curriculum: Report of a National Needs Assessment and Multi-institutional Pilot Implementation

PURPOSE

To assess the optimal structure of an introductory curriculum (IC) for radiation oncology residents, including the perceived utility of a 2-day off-site "boot camp," and evaluate the success of a pilot introductory radiation oncology curriculum (IROC) based on these initial data.

METHODS AND MATERIALS

In the first phase, anonymous, web-based surveys were sent to US radiation oncology program directors and residents. Likert-type scores (1, not at all; 5, extremely) are reported as the median and interquartile range. Using the phase 1 results, IROC was developed, piloted, and evaluated.

RESULTS

Of the 89 program directors and 697 residents, 47 (53%) and 165 (24%) responded, respectively. Of the 89 program directors, 37 (79%) reported offering a formal IC. However, only 83 residents (50%) reported having a formal IC. Program directors reported resident preparation for clinical training as "moderate" (median 3, interquartile range 2-3) on entering residency and "moderate" (median 3, interquartile range 3-4) after IC completion (P = .03). However, residents only believed they were "slightly" prepared (median 2, interquartile range 1-2) on entering residency and "moderately" (median 3, interquartile range 2-3) prepared after IC completion (P < .01). Program directors believed an off-site boot camp would be of "moderate" utility (median 3, interquartile range 3-4) with participation limited by funding (57%). Residents without an IC reported that having an IC would be "quite" beneficial (median 4, interquartile range 3-5). Residents preferred instruction before the clinical training (49%) and over 1 week (40%). Both program directors and residents rated lectures on radiation emergencies and simulation highly. Using these data, IROC was developed and piloted with incoming residents at 4 institutions. After IROC, residents reported improvement in overall preparedness for clinical training (before: median 1, interquartile range 1-2; vs after: median 3, interquartile range 2-3; P < .01) and among specific practice domains.

CONCLUSIONS

Beginning radiation oncology residents frequently lack structured introductory curricula but desire instruction before the clinical training with a focus on practical aspects (emergency management, contouring). Program directors recognize the value of both off-site and on-site boot camps. An on-site IC could mitigate funding barriers. A standardized IC, IROC, piloted at 4 programs, showed promising outcomes.

Risk factors involved in treatment delays and differences in treatment type for patients with prostate cancer by risk category in an academic safety net hospital

OBJECTIVES

Understanding the drivers of delays from diagnosis to treatment can elucidate how to reduce the time to treatment (TTT) in patients with prostate cancer. In addition, the available treatments depending on the stage of cancer can vary widely for many reasons. This study investigated the relationship of TTT and treatment choice with sociodemographic factors in patients with prostate cancer who underwent external beam radiation therapy (RT), radical prostatectomy (RP), androgen deprivation therapy (ADT), or active surveillance (AS) at a safety-net academic medical center.

METHODS AND MATERIALS

A retrospective review was performed on 1088 patients who were diagnosed with nonmetastatic prostate cancer between January 2005 and December 2013. Demographic data as well as data on TTT, initial treatment choice, American Joint Committee on Cancer stage, and National Comprehensive Cancer Network risk categories were collected. Analyses of variance and multivariable logistic regression models were performed to analyze the relationship of these factors with treatment choice and TTT.

RESULTS

Age, race, and marital status were significantly related to treatment choice. Patients who were nonwhite and older than 60 years were less likely to undergo RP. Black patients were 3.8 times more likely to undergo RT compared with white patients. The median TTT was 75 days. Longer time delays were significant in patients of older age, nonwhite race/ethnicity, non-English speakers, those with noncommercial insurance, and those with non-married status. The average TTT of high-risk patients was 25 days longer than that of low-risk patients. Patients who underwent RT had an average TTT that was 34 days longer than that of RP patients.

CONCLUSIONS

The treatment choice and TTT of patients with prostate cancer are affected by demographic factors such as age, race, marital status, and insurance, as well as clinical factors including stage and risk category of disease.

Impact of patient demographics, tumor characteristics, and treatment type on treatment delay throughout breast cancer care at a diverse academic medical center

Purpose and objective

The aim of this study was to examine the impact of patient demographics, tumor characteristics, and treatment type on time to treatment (TTT) in patients with breast cancer treated at a safety net medical center with a diverse patient population.

Patients and methods

A total of 1,130 patients were diagnosed and treated for breast cancer between 2004 and 2014 at our institution. We retrospectively collected data on patient age at diagnosis, race/ethnicity, primary language spoken, marital status, insurance coverage, American Joint Committee on Cancer (AJCC) stage, hormone receptor status, and treatment dates. TTT was determined from the date of breast cancer biopsy to treatment start date. Nonparametric Mann-Whitney U-test (or Kruskal-Wallis test when appropriate) and multivariable quantile regression models were employed to assess for significant differences in TTT associated with each factor.

Results

Longer median TTT was noted for Black (P=0.002) and single (P=0.002) patients. AJCC stage IV patients had shorter TTT (27.5 days) compared to earlier AJCC patients (36, 35, 37, 37 days for stage 0, I, II, III, respectively), P=0.028. Age, primary language spoken, insurance coverage, and hormone receptor status had no significant impact on TTT. On multivariate analysis, race/ethnicity remained the only significant factor with Black reporting longer TTT, P=0.025. However, race was not a significant factor for time from first to second treatment. More Black patients were noted to be single (P<0.0001) and received chemotherapy as first treatment (P=0.008) compared to White, Hispanic, or other race/ethnicity patients.

Conclusion

In this retrospective analysis, Black patients had longer TTT, were more likely to receive chemotherapy as first treatment, and have a single marital status. These patient factors will help identify vulnerable patients and guide further research to understand the barriers to care and the impact of treatment delays on outcomes.

Dosimetric impacts of endorectal balloon in CyberKnife stereotactic body radiation therapy (SBRT) for early-stage prostate cancer

PURPOSE

In SBRT for prostate cancer, higher fractional dose to the rectum is a major toxicity concern due to using smaller PTV margin and hypofractionation. We investigate the dosimetric impact on rectum using endorectal balloon (ERB) in prostate SBRT.

MATERIALS AND METHODS

Twenty prostate cancer patients were included in a retrospective study, ten with ERB and 10 without ERB. Optimized SBRT plans were generated on CyberKnife MultiPlan for 5 × 7.25 Gy to PTV under RTOG-0938 protocol for early-stage prostate cancer. For the rectum and the anterior half rectum, mean dose and percentage of volumes receiving 50%, 80%, 90%, and 100% prescription dose were compared.

RESULTS

Using ERB, mean dose to the rectum was 62 cGy (P = 0.001) lower per fraction, and 50 cGy (P = 0.024) lower per fraction for the anterior half rectum. The average V_50% , V_80% , V_90% , and V_100% were lower by 9.9% (P = 0.001), 5.3% (P = 0.0002), 3.4% (P = 0.0002), and 1.2% (P = 0.005) for the rectum, and lower by 10.4% (P = 0.009), 8.3% (P = 0.0004), 5.4% (P = 0.0003), and 2.1% (P = 0.003) for the anterior half rectum.

CONCLUSIONS

Significant reductions of dose to the rectum using ERB were observed. This may lead to improvement of the rectal toxicity profiles in prostate SBRT.

Cultivating Interest in Oncology Through a Medical Student Oncology Society

The purpose of this descriptive analysis is to describe a formal method to foster interest in oncology among medical students through a Student Oncology Society (SOS). The SOS is a student-run multidisciplinary interest group that offers oncology-related events to interested medical students at the Boston University School of Medicine (BUSM). We employed a student survey to document the impact of the SOS on student interest in careers in oncology and students' perceived accessibility of mentors in oncology at our institution. All 35 students who attended the event reported that they found the discussion panels "valuable" or "somewhat valuable." A minority of students reported that student and faculty were "somewhat accessible" or "very accessible." At the end of the survey, 37 % of the students reported that a discussion of career paths of various physicians or a student/resident panel on oncology would be beneficial. By giving students an opportunity to learn about the different medical and surgical specialties within oncology, the SOS is able to cultivate early interest and understanding of the field of oncology among pre-clinical medical students. Further work must be done to connect medical students to faculty mentors in oncology. Although this short report provides a model for other medical schools to begin their own student oncology interest groups, further rigorous evaluation of pre-clinical oncology education initiatives are necessary in order to document their long-term impact on medical education.

A Nationwide Medical Student Assessment of Oncology Education

Cancer is the second leading cause of death in the USA, but there is minimal data on how oncology is taught to medical students. The purpose of this study is to characterize oncology education at US medical schools. An electronic survey was sent between December 2014 and February 2015 to a convenience sample of medical students who either attended the American Society for Radiation Oncology annual meeting or serve as delegates to the American Association of Medical Colleges. Information on various aspects of oncology instruction at participants' medical schools was collected. Seventy-six responses from students in 28 states were received. Among the six most common causes of death in the USA, cancer reportedly received the fourth most curricular time. During the first, second, and third years of medical school, participants most commonly reported 6-10, 16-20, and 6-10 h of oncology teaching, respectively. Participants were less confident in their understanding of cancer treatment than workup/diagnosis or basic science/natural history of cancer (p < 0.01). During the preclinical years, pathologists, scientists/Ph.D.'s, and medical oncologists reportedly performed the majority of teaching, whereas during the clinical clerkships, medical and surgical oncologists reportedly performed the majority of teaching. Radiation oncologists were significantly less involved during both periods (p < 0.01). Most schools did not require any oncology-oriented clerkship. During each mandatory rotation, <20 % of patients had a primary diagnosis of cancer. Oncology education is often underemphasized and fragmented with wide variability in content and structure between medical schools, suggesting a need for reform.

Daily patient setup error in prostate image guided radiation therapy with fiducial-based kilovoltage onboard imaging and conebeam computed tomography

BACKGROUND

This study examined the interfraction setup error in patients undergoing prostate radiotherapy using fiducial markers and on-board imaging.

METHODS

Patients (n=53) were aligned to the treatment isocenter by laser followed by orthogonal kilovoltage (kV) radiographs to visualize bony anatomy and implanted fiducial markers. The magnitude and direction of couch shifts for isocenter correction required was determined by image registration for bony anatomy and fiducial markers. Twice weekly, 25 of the 53 patients also underwent conebeam computed tomography (CBCT) to measure any residual error in patient positioning. Based on individual coordinate shifts from CBCT, a net three-dimensional (3D) residual shift magnitude vector R was calculated.

RESULTS

The average couch shifts were 0.26 and 0.40 cm in inferior direction and 0.25 and 0.33 cm in superior direction for alignments made with bony anatomy and fiducial markers, respectively (P<0.0001). There were no significant differences noted in the vertical or lateral planes between the two image registration methods. In subset of 25 patients, no residual shift from fiducial plain film set up was required with CBCT matching in 66.5%, 52.4% and 57.9% of fractions for longitudinal, vertical and lateral planes, respectively, with majority (79%) of patients having a net residual 3D shifts of <0.3 cm. The use of CBCT increased average treatment time by approximately 6 min compared to kV radiographs alone.

CONCLUSIONS

The residual setup errors following daily kV image guided localization, as determined by CBCT, were small, which demonstrates high accuracy of kV localization when fiducial markers are present.

Effect of Patient Demographic Characteristics and Radiation Timing on PSA Reduction in Patients Treated With Definitive Radiation Therapy for Prostate Cancer

INTRODUCTION

The purpose of this study was to assess how demographic characteristics and temporal factors including time to treatment (TTT) and elapsed time of treatment (ETT) affect prostate-specific antigen (PSA) levels during and after radiation treatment for low- and intermediate-risk prostate cancer.

PATIENTS AND METHODS

A retrospective review of 1584 patients was conducted on patients diagnosed with prostate cancer between 2005 and 2013, from which 147 patients were found to have completed definitive external beam radiation therapy (EBRT) monotherapy. Demographic data, TTT (days between diagnosis and EBRT start date), ETT (days between EBRT start and stop date), and Gleason score were collected on these patients and analysis of variance was performed to analyze the relationship of these factors with PSA changes. PSA changes were calculated during treatment as the difference between pre- and posttreatment PSA levels and after treatment as 3-year and overall PSA velocities.

RESULTS

Patients who spoke Haitian Creole (P = .039) and those with a longer ETT (P = .029) had significantly greater PSA decline during treatment, primarily as a result of higher pretreatment PSA levels. Patients with Gleason score 4+3 disease had significantly greater 3-year (P = .033) and overall (P = .019) PSA velocities. Race and/or ethnicity, insurance type, marital status, and age were not associated with any PSA variable.

CONCLUSION

Disparities in prostate cancer are not reflected in PSA dynamics during or after radiation treatment, but are evident in PSA level at presentation. Timeliness of treatment was not found to affect true PSA change due to EBRT in low- and intermediate-risk prostate cancer patients.

Medical Student--Reported Outcomes of a Radiation Oncologist--Led Preclinical Course in Oncology: A Five-Year Analysis

PURPOSE

There is a recognized need for more robust training in oncology for medical students. At our institution, we have offered a core dedicated oncology block, led by a radiation oncologist course director, during the second year of the medical school curriculum since the 2008-2009 academic year. Herein, we report the outcomes of the oncology block over the past 5 years through an analysis of student perceptions of the course, both immediately after completion of the block and in the third year.

METHODS AND MATERIALS

We analyzed 2 separate surveys. The first assessed student impressions of how well the course met each of the course's learning objectives through a survey that was administered to students immediately after the oncology block in 2012. The second was administered after students completed the oncology block during the required radiology clerkship in the third year. All questions used a 5-level Likert scale and were analyzed by use of a Wilcoxon signed-rank test.

RESULTS

Of the 169 students who took the oncology course in 2012, 127 (75.1%) completed the course feedback survey. Over 73% of students agreed or strongly agreed that the course met its 3 learning objectives. Of the 699 medical students who took the required radiology clerkship between 2010 and 2013, 538 participated in the second survey, for a total response rate of 77%. Of these students, 368 (68.4%) agreed or strongly agreed that the course was effective in contributing to their overall medical education.

CONCLUSION

Student perceptions of the oncology block are favorable and have improved across multiple categories since the inception of the course. Students self-reported that a dedicated preclinical oncology block was effective in helping identify the basics of cancer therapy and laying the foundation for clinical electives in oncology, including radiation oncology.

Elective courses for medical students during the preclinical curriculum: a systematic review and evaluation

OBJECTIVE

Preclinical medical student electives are prevalent at medical schools across the United States, but the range of electives available and their impact on medical student education are not well described in the literature. The objective of this article is to review the literature relating to preclinical medical student electives and their impact on medical student educational outcomes.

METHODS

We reviewed studies that met the following criteria: English-language articles describing preclinical US-based medical electives. We used PubMed journal databases and limited our search for the time period 1999-2014. We excluded electives based in other countries or electives designed for third or fourth year students. Data abstracted included the topic of the elective, qualitative descriptions of the electives, and any associated surveys or exam data associated with the electives. Data were synthesized using descriptive tables sorting electives by broad topic. Reported outcomes and statistical methods were analyzed to assess study quality.

RESULTS

We found a wide range of subjects taught in the form of preclinical medical school electives. We identified electives in clinical skills, the humanities, student lifestyle, specialty-specific electives, and an assortment of other miscellaneous electives. Surveys and exams administered to students showed that the electives were universally well received by students. Of the 37 electives identified, 15 electives used quantitative objective assessments, such as knowledge exams, while the remaining tended to use student self-reported results.

CONCLUSIONS

Preclinical medical student electives are prevalent at medical schools across the United States and have a significant impact on medical student education.