Burnout Rates in Clinical Radiation Oncology and Variations across Professional Subgroups

PURPOSE/OBJECTIVE(S)

Physician and medical professional burnout has emerged as an important issue in clinical medicine and has been shown to negatively affect patient outcomes. The aim of this study is to determine how rates of burnout vary between different radiation oncology professional subgroups.

MATERIALS/METHODS

Participants were selected from those employed in one of the professional subgroups (radiation therapists, nurses, physicists, dosimetrists, and physicians) at two institutions that cover a total of seven sites. 126 individuals were recruited to participate. In addition to demographics, participants were asked to respond to questions regarding professional burnout utilizing the Maslach Burnout Inventory (MBI). Responses were on a seven-point Likert scale with subcategories of Exhaustion, Depersonalization, and Personal Achievement. Each participant's score per subcategory was categorized as either low, moderate, or high. For our primary outcome, frequencies and proportions were reported and Fisher's Exact Test was used to evaluate whether there was a statistically significant difference in proportions in categorized burnout scores across professional subgroups. Secondary analyses were performed comparing burnout across sex, age, and categorized years in position. An alpha level of 0.05 was used for all analyses.

RESULTS

In total, 55 participants responded to the survey: 12 nurses, 8 dosimetrists, 12 physicians, 5 physicists, and 18 radiation therapists for a response rate of 43.6%. Demographics were consistent across professional subgroups with the exception of participant sex (p = .0397), which had a greater proportion of females (72.22%) in the Radiation Therapist subgroup. Among the three subcategories, only Exhaustion had a significant difference between groups (p = .0494) with Dosimetrists (62.50%) and Physicists (40.00%) experiencing the highest level of burnout. For Depersonalization, at least one individual in each subgroup identified high burnout with higher rates among the Dosimetrists (25.00%) and Physicists (40.00%). Similarly, at least one person in each subgroup reported high burnout in Personal Achievement, but the highest response was among Dosimetrists (37.50%). In total, at least 12.75% of participants reported high burnout in at least one subcategory. No statistically significant differences in burnout were detected in our secondary analyses across sex, age, and years in position.

CONCLUSION

Our study showed that burnout rates are moderate in members of the radiation oncology team, with dosimetrists and physicists displaying the highest levels of burnout. In order to better estimate professional burnout, larger studies should be conducted to determine causes of burnout. Furthermore, wellness programs should be encouraged and incentivized to help reduce burnout and improve workplace morale, occupational fulfillment, and effective patient care.

Outcomes of a Single Isocenter Brain Multi-Metastases Linear Accelerator Delivered Stereotactic Radiosurgery (SRS)

PURPOSE/OBJECTIVE(S)

The management of brain metastases has evolved from using 2D whole brain radiotherapy (WBRT) to more complex techniques like stereotactic radiosurgery (SRS) for patients with limited disease. Long-term control of lesions is challenging with WBRT techniques but treating multiple lesions with traditional SRS, where each lesion is treated on its own isocenter, can be time-consuming and difficult on patients, especially those with claustrophobia. Single Isocenter Multiple Metastases (SIMM) SRS has emerged as an option to deliver ablative SRS doses simultaneously to multiple brain metastases using a single isocenter, thereby limiting the duration of treatments for patients. Though appealing, SIMM SRS adds technical complexity and could potentially lead to worse outcomes or more complications relative to traditional SRS treatments. Given the current paucity of clinical evidence supporting SIMM SRS, we sought to retrospectively review our institution's outcomes and complications for patients treated with SIMM SRS to determine the efficacy and safety of this approach in our hands.

MATERIALS/METHODS

Patients treated at our institution with SIMM SRS with at least one post-treatment brain MRI were identified. Date on patient clinical characteristics, planning, and treatment characteristics, and outcomes were retrospectively collected. Post-treatment tumor control was evaluated with follow-up MRI imaging based on RANO criteria. Correlation between tumor control and toxicity was done by assessing radiation doses, PTV coverage, and normal brain V12 constraints.

RESULTS

A total of 27 patients received SIMM SRS from January 2015 to February 2022. The median age at first SIMM SRS was 61 (range: 38-87). The most common disease sites were lung (63.0%), breast (18.5%), and GI (7.4%). The 27 patients had 47 SIMM SRS treatments of 163 lesions total. The median number of lesions treated per isocenter was 3 (range: 2-9). 5 patients had 2 SIMM SRS isocenters treated on the same day, treating clusters of lesions (ranging from 5-11 lesions treated on that day). The most common locations involved were frontal, cerebellar, and parietal lobes (32.52%, 21.47%, and 15.34%). The modal dose was 22 Gy (range: 18-24 Gy). Median OS from initial primary diagnosis was 23.23 months, and 9.92 months after the first SIMM SRS treatment. The median imaging follow-up was 9.8 months per lesion, and the local control rate was 95.03%. 2 lesions (1.23%) developed radiation necrosis and the median time to RT necrosis among those lesions was 5.7 months after treatment.

CONCLUSION

The utilization of SIMM SRS demonstrates acceptable efficacy and safety as it has been implemented at our institution. Further studies to evaluate this planning modality are warranted to establish suitable candidates for SIMM SRS as well as evaluate the long-term outcomes for these patients.

Technology Usage and Impacts by COVID-19 among Patients in a Radiation Oncology Clinic

Purpose/Objective(s)

Mobile devices provide platforms for consistent and real time symptom tracking for cancer patients, allowing for better symptom reporting and more timely interventions. There is limited research investigating barriers to adoption within the oncology setting and COVID-19 impacts on patent willingness to use health technology. Understanding these issues is key to successful development and implementation. We designed a survey to assess patient willingness and barriers to using mobile devices to report/track symptoms (e-report).

Materials/Methods

Two cohorts of adult patients completed a 21-question anonymized survey. The survey was administered to clinic patients before (PRE) and 18mo after (POST) the start of the COVID pandemic. Three additional questions were added to POST survey to investigate impacts from COVID. Demographics, technology usage, willingness to report data, barriers to utilization, and changes due to COVID were evaluated using descriptive statistics. Predictors of willingness to e-report, barriers to use, and changes due to the COVID-19 pandemic were analyzed using univariate and multivariate logistic regression (MVA).

Results

318 patients completed the survey (PRE= 144 patients; POST= 174 patients) with mean age 65y, 75% Caucasian, 55% male. Altogether, 75% used a smart phone (PRE=66.7%; POST=81.3%; p 0.003), 90% reported home internet access (PRE=87.5%; POST=91.4%; p 0.259), 86% used a computer (PRE=79.2%; POST=90.8%; p 0.004), and 26% used a wearable health tracker (PRE 25.7%; POST 26.4%; p 0.881). On MVA, age>65 (OR 0.32; p 0.001), annual income>50K (OR 2.16; p 0.032), smart phone ownership (OR 4.07; p 0.000), and new/current patient status (OR 2.15; p 0.020) were all significant factors impacting willingness to e- report. Limited tech literacy (p 0.024) and time commitment (p 0.048) were the only significant barriers. Privacy as a barrier was greater in PRE vs POST cohort (OR 2.3 vs OR 1.1) trending toward significance. Nearly all modes of tech usage were greater in POST vs PRE cohort. POST cohort was significantly more willing to e- report (81.1% vs 69.1%; OR 1.91; p 0.016). This remained significant on MVA after adjusting for age, concern for privacy, tech literacy, and patient status (OR 1.88; p 0.026). Furthermore, 51% of POST cohort reported the pandemic directly influenced their willingness to e-report (40% more, 11% less).

Conclusion

Radiation oncology patients are willing to use mobile technology to report symptoms. Willingness increases with decreasing age, increasing annual income, smartphone ownership, and new/current patient status. Significant barriers include tech literacy and time commitment. Post-pandemic patients are more willing to e-report and list fewer barriers. The COVID-19 pandemic appears to have had a positive impact on technology usage by patients. Efforts to develop and test mobile applications for this population are justified.

Serum Vascular Endothelial Growth Factor Concentrations in Hepatocellular Cancer Patients Undergoing Percutaneously Radiofrequency Thermal Ablation

Vascular endothelial growth factor (VEGF) is known to play a central role in tumour angiogenesis. However, no data have been published with regard to the clinical-biological significance of serum (S)-VEGF in hepatocellular cancer (HCC) patients undergoing to percutaneously radiofrequency thermal ablation (PRFA). The aim of this study was to assess the modifications of S-VEGF levels in a series of 28 HCC patients in hepatitis C virus-positive cirrhosis before and after PRFA, respectively. Samples of S were taken before, 2 and 5 days after PRFA respectively and VEGF levels were assessed by ELISA. No significant difference was found between pre- and post-VEGF levels (p= n.s.; by Wilcoxon test). We suggest that S-VEGF level is not useful as early predictive marker of response to PRFA.

Attitude towards genetic testing for breast cancer susceptibility: a comparison of affected and unaffected women

The objective of this study is to evaluate women's awareness and interest in genetic testing for breast cancer risk, to identify socio-demographic factors, to analyse the reasons for wanting or not wanting to be tested and finally to determine whether breast cancer patients and healthy women have different attitudes towards genetic testing. Consecutive series of 879 women without and with breast cancer participated in a 20-item self-completing questionnaire. Among breast cancer patients, 57% answered that they would definitely or probably accept being tested, compared with 84% of women without breast cancer. At the multiple logistic regression analysis only to have a diagnosis of breast cancer conditioned significantly the interest to have genetic testing. Surprisingly, a family history of breast cancer was found to have no significant impact. The most frequently cited reason for being interested in genetic testing was 'to learn about your children's risk'. Although women's awareness about breast cancer genes is inadequate, the interest in genetic testing is substantial and higher both in healthy women and in women with breast cancer. These results provide important indications for the development of educational strategies.

Efaproxiral red blood cell concentration predicts efficacy in patients with brain metastases

Efaproxiral (Efaproxyn™, RSR13), a synthetic allosteric modifier of haemoglobin (Hb), decreases Hb-oxygen (O₂) binding affinity and enhances oxygenation of hypoxic tumours during radiation therapy. This analysis evaluated the Phase 3, Radiation Enhancing Allosteric Compound for Hypoxic Brain Metastases; RT-009 (REACH) study efficacy results in relation to efaproxiral exposure (efaproxiral red blood cell concentration (E-RBC) and number of doses). Recursive partitioning analysis Class I or II patients with brain metastases from solid tumours received standard whole-brain radiation therapy (3 Gy/fraction × 10 days), plus supplemental O₂ (4 l/min), either with efaproxiral (75 or 100 mg/kg daily) or without (control). Efaproxiral red blood cell concentrations were linearly extrapolated to all efaproxiral doses received. Three patient populations were analysed: (1) all eligible, (2) non-small-cell lung cancer (NSCLC) as primary cancer, and (3) breast cancer primary. Efficacy endpoints were survival and response rate. Brain metastases patients achieving sufficient E-RBC (⩾483 μg/ml) and receiving at least seven of 10 efaproxiral doses were most likely to experience survival and response benefits. Patients with breast cancer primary tumours generally achieved the target efaproxiral exposure and therefore gained greater benefit from efaproxiral treatment than NSCLC patients. This analysis defined the efaproxiral concentration-dependence in survival and response rate improvement, and provided a clearer understanding of efaproxiral dosing requirements.

Awareness of breast cancer genetics and interest in predictive genetic testing: a survey of a southern Italian population

BACKGROUND

Before starting a molecular screening program for breast cancer risk and in order to develop ad hoc educational strategies, a population survey in Apulia, Italy, was performed to gather information on women's awareness of breast cancer genetics and their attitude toward genetic testing for breast cancer risk.

PATIENTS AND METHODS

A consecutive series of 677 healthy women with or without a family history of breast cancer, who attended the outpatient clinics of Lega Italiana per la Lotta contro i Tumori in Bari, Italy, for preventive visits, were asked to complete a 20-item questionnaire on socio-demographics, risk perception, psychological characteristics and interest in genetic testing for breast cancer predisposing genes.

RESULTS

Most women (77%) reported knowing something about the genetics of breast cancer; only 7% of the women were not interested at all in genetic testing. These figures were not significantly different for women with or without a family history of breast cancer. The two most frequently cited reasons for being interested in genetic testing, accounting for more than 50% of collected responses, were 'to learn about your children's risk' and 'to help advance research'. On multiple logistic regression analysis, only older age [odds ratio (OR) 1.9; 95% confidence interval (CI) 1.3-2.9] was associated with women's knowledge of genetic testing. Moreover, marital status (OR 4.0; 95% CI 1.1-14.6) and thinking of cancer (OR 2.2; 95% CI 1.0-4.7) independently predicted the interest in having genetic testing.

CONCLUSIONS

Southern Italian women seem highly interested in genetic testing for breast cancer risk. However, their expectations mainly regard their concerns about their children or their altruistic need to help research rather than the idea of a direct clinical benefit. The great interest of the women in genetic testing probably reflects their inappropriate knowledge of the information that genetic testing can provide for breast cancer risk analysis.

Limb volume reduction after physical treatment by compression and/or massage in a rodent model of peripheral lymphedema

Lack of a standardized experimental counterpart of peripheral lymphedema (LE) in a small animal has hampered research into treatment of this debilitating condition. We recently refined a rodent model consisting of radical unilateral lymphatic/nodal groin excision in conjunction with a circumferential integumental gap, followed by regional irradiation of the groin to reproduce stable unilateral hindlimb LE (1). In the current study, Wistar-Fuzzy rats with established right hindlimb LE, were subdivided into five groups and subjected to one of the following daily physical regimens over a 5-day period: pneumatic compression pumping at 30 torr (PCP); low-stretch multi-layered compressive bandaging using Coban (CB); manual lymphedema drainage (MLD) or a light massage consisting of stationary circular motions using the fingertips; combined physiotherapy (CPT consisting of MLD + CB); and a no treatment or control group (CTRL). Hindlimb and LE volumes were serially measured before and after treatment. Whereas CTRL showed progressive worsening of hindlimb swelling, PCP, CB, CPT and MLD each produced similar and substantial edema reduction over the 5 day interval, PCP, CB and CPT induced vacillating edema reduction which, however, exceeded rebound swelling on a daily basis. MLD, on the other hand, showed a steady gradual daily decline in LE volume.

External beam radiotherapy and hyperthermia in the treatment of patients with locally advanced prostate carcinoma

BACKGROUND

The current study was conducted to evaluate the combination of external beam radiation therapy and hyperthermia in the treatment of patients with locally advanced prostate carcinoma.

METHODS

Twenty-six patients were treated on a Phase I/II protocol between June 1990 and April 1993. The median age of the patients was 69 years. Nine patients had well differentiated adenocarcinoma, ten patients had moderately differentiated adenocarcinoma, and six patients had poorly differentiated adenocarcinoma. All patients had American Urologic Society Stage C2-D1 adenocarcinoma. The median pretreatment prostate specific antigen (PSA) level was 29 ng/mL (range, 6-104 ng/mL). All patients received external beam radiation therapy using a four-field technique. The median radiation dose was 6,800 centigrays (cGy) given in 200-cGy fractions. Hyperthermia was administered concurrently with radiation therapy to temperatures of 42.5 degrees C for 30 minutes using a transrectal ultrasound applicator with 3 thermometry probes, given as either a single treatment (9 patients) or as two treatments (17 patients). Overall survival (OS) and biochemical no evidence of disease (bNED) status were calculated using Kaplan-Meier analysis. A consensus conference definition of PSA failure was used. The Cox proportional hazards model was used for multivariate analysis. The median follow-up for all patients was 71 months.

RESULTS

The median time to PSA nadir was 15 months with a median PSA nadir value of 1.0 ng/mL. The median and 5-year OS was 88 months and 73%, respectively, and the median and 5-year bNED survival was 36 months and 35%, respectively. Multivariate analysis revealed only the pretreatment PSA level (P = 0.03) and the PSA nadir reached (P < 0.01) to be significant predictors of bNED survival. The duration of hyperthermia therapy showed a trend toward significance for OS (P = 0.06).

CONCLUSIONS

The current Phase I/II protocol evaluating the combination of prostate hyperthermia and external beam radiation therapy for the treatment of patients with locally advanced prostate carcinoma suggests prostate hyperthermia to be feasible with no apparent significant increased toxicity, although there was no significant improvement in treatment outcome when compared with other studies reported in the literature evaluating external beam radiation therapy with or without androgen suppression. However, further investigation into the duration as well as the temperature of the hyperthermia with a greater number of patients is warranted.

High-dose-rate postoperative vaginal cuff irradiation alone for stage IB and IC endometrial cancer

PURPOSE

To evaluate the effectiveness of postoperative high-dose-rate (HDR) vaginal cuff irradiation alone (1500 cGy in 3 fractions) in patients with Stage Ib and Ic endometrial cancer.

METHODS AND MATERIALS

This is a retrospective review of 102 patients with Stage Ib and Ic endometrial cancer treated with a hysterectomy and postoperative HDR intracavitary therapy alone during the period of 1/1/90-12/31/96. Each patient received 1500 cGy in 3 weekly treatments, dosed to a depth of 0.5 cm. Pathologic features such as depth of invasion, tumor grade, lower uterine segment (LUS) involvement, and lymphvascular invasion (LVI) were evaluated for their impact on recommended postoperative treatment. All survival curves were generated utilizing Kaplan-Meier methods and all statistical comparisons were via a Wilcoxon rank sum test.

RESULTS

The 5-year actuarial overall survival (OS) is 84% and the 5-year disease-free survival (DFS) is 93%. Locoregional disease control (pelvic control) was excellent with 97% of the patients free of pelvic disease at 5 years. Of the three pelvic failures only one was in the vaginal cuff. LVI, LUS involvement, Grade 3 and/or outer third myometrial involvement were identified in 41 patients. Thirty-one of these patients underwent a lymphadenectomy and there were two regional failures within this increased-risk group.

CONCLUSIONS

We obtained an excellent level of locoregional control with minimal morbidity and minimal time commitment for treatment with vaginal HDR brachytherapy alone. Our dose per fraction and total dose is lower than most reported series and there is no apparent loss in locoregional control. In addition, intermediate-risk patients and patients with an increased risk of recurrence (Grade 3, outer third myometrial involvement, LVI, LUS) may be treated with cuff irradiation alone, after surgical staging and a negative lymphadenectomy.

Refinement of a rodent model of peripheral lymphedema

A reliable, inexpensive experimental counterpart of peripheral lymphedema has been notoriously difficult to reproduce thereby stifling basic and clinical research into this frustrating clinical condition. Accordingly, in 45 adult Wistar-Fuzzy rats, we attempted to produce sustained hindlimb lymphedema by either groin nodal/lymphatic microsurgical ablation (S) (guided by visual blue dye lymphography) or limited field-groin irradiation (R) alone (4500 rads) or combined S followed by R or R followed by S with an additional non-manipulated group serving as controls. Observations were made for 30-100 days thereafter. Hindlimb volumes were determined serially using the truncated cone formula based on multiple circumferential measurements at standardized intervals along the affected hindlimb and the findings compared with similar measurements in the contralateral non-manipulated hindlimb. In randomly selected rats from each group, lymphatic drainage was assessed by lymphangioscintigraphy (LAS), soft tissue swelling by magnetic resonance imaging (MRI), and edema fluid total protein content by refractometry. Whereas S or R alone produced only transient or mild hindlimb edema without associated morbidity or mortality, S-R or R-S induced moderate to severe sustained protein-rich hindlimb lymphedema associated with 9-13% early mortality and notable late local limb morbidity. Lymphatic obstruction was documented by sustained maintenance of increased hindlimb volume, subcutaneous fluid accumulation (MRI), and impaired lymphatic drainage (LAS). This reproducible rodent model of secondary lymphedema reliably simulates a stable clinical condition for a window of up to 100 days and should thereby facilitate standardized testing of therapeutic/preventive protocols and basic research into lymphatic dynamics in secondary lymphedema.

Timing of breast cancer surgery within the menstrual cycle: tumor proliferative activity, receptor status and short-term clinical outcome

We verified the variations of primary tumour steroid receptor status and proliferative activity at different times and phases (follicular vs luteal) of the menstrual cycle and their relationship with short clinical outcome in a cohort of 248 N- breast cancer patients. Steroid receptor content (ER and PgR) was evaluated by DCC assay and proliferative activity by 3H-Thymidine autoradiographic assay (TLI). Median age was 44 years, 60% of tumors were T1, and cytohistological grade was G1-2 in 54% of cases. At surgery, 57% were in the luteal phase while 43% were in the follicular phase. No significant variations were found in mean TLI or ER and PgR characteristics of the primary tumors surgically treated in different periods of the menstrual cycle; however, the ER level resulted significantly higher in 4th with respect to the 3rd week of menstrual cycle, while PgR level was higher in PgR+ cases treated during the 3rd week. The number of relapses and disease-free survival curves after 36 months median follow-up did not differ significantly for patients treated in different periods of the menstrual cycle (12% and 9% of disease relapses in luteal and follicular phases; p=n.s.). We can conclude, therefore, that TLI, ER and PgR expressions could vary significantly during menstrual cycle only in certain specific tumor subgroups.