An Exploration of the Pillars of Leadership in Cancer Education

Leadership plays a key role in cancer education (CE) and the success of its practices. Leaders in CE must effectively use their leadership skills to be able to communicate, collaborate, and educate their team members. There is a lack of formalized and standardized curriculums for institutions in developing leadership programs, including what themes to focus on in CE. In this article, the authors describe key pillars of leadership in CE that have presented themselves throughout their experience and within the literature. A search was conducted using the Ovid MEDLINE® database and articles were reviewed for eligibility. In this review, thirty articles were selected for their relevance to CE. With this literature search and the authors' reflections, four pillars of leadership in CE were identified: (1) leadership development, (2) collaboration, (3) diversity and equity, and (4) implementation. Within these themes, key areas of importance were discussed further, and barriers to CE leadership were identified. By reflecting upon pillars of leadership in CE, this article may be helpful for developing future leadership programs within CE. It is vital that initiatives continue to be held and barriers are addressed to increase leadership effectiveness within CE.

Radiation enhancement using focussed ultrasound-stimulated microbubbles for breast cancer: A Phase 1 clinical trial

BACKGROUND

Preclinical studies have demonstrated that tumour cell death can be enhanced 10- to 40-fold when radiotherapy is combined with focussed ultrasound-stimulated microbubble (FUS-MB) treatment. The acoustic exposure of microbubbles (intravascular gas microspheres) within the target volume causes bubble cavitation, which induces perturbation of tumour vasculature and activates endothelial cell apoptotic pathways responsible for the ablative effect of stereotactic body radiotherapy. Subsequent irradiation of a microbubble-sensitised tumour causes rapid increased tumour death. The study here presents the mature safety and efficacy outcomes of magnetic resonance (MR)-guided FUS-MB (MRgFUS-MB) treatment, a radioenhancement therapy for breast cancer.

METHODS AND FINDINGS

This prospective, single-center, single-arm Phase 1 clinical trial included patients with stages I-IV breast cancer with in situ tumours for whom breast or chest wall radiotherapy was deemed adequate by a multidisciplinary team (clinicaltrials.gov identifier: NCT04431674). Patients were excluded if they had contraindications for contrast-enhanced MR or microbubble administration. Patients underwent 2 to 3 MRgFUS-MB treatments throughout radiotherapy. An MR-coupled focussed ultrasound device operating at 800 kHz and 570 kPa peak negative pressure was used to sonicate intravenously administrated microbubbles within the MR-guided target volume. The primary outcome was acute toxicity per Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Secondary outcomes were tumour response at 3 months and local control (LC). A total of 21 female patients presenting with 23 primary breast tumours were enrolled and allocated to intervention between August/2020 and November/2022. Three patients subsequently withdrew consent and, therefore, 18 patients with 20 tumours were included in the safety and LC analyses. Two patients died due to progressive metastatic disease before 3 months following treatment completion and were excluded from the tumour response analysis. The prescribed radiation doses were 20 Gy/5 fractions (40%, n = 8/20), 30 to 35 Gy/5 fractions (35%, n = 7/20), 30 to 40 Gy/10 fractions (15%, n = 3/20), and 66 Gy/33 fractions (10%, n = 2/20). The median follow-up was 9 months (range, 0.3 to 29). Radiation dermatitis was the most common acute toxicity (Grade 1 in 16/20, Grade 2 in 1/20, and Grade 3 in 2/20). One patient developed grade 1 allergic reaction possibly related to microbubbles administration. At 3 months, 18 tumours were evaluated for response: 9 exhibited complete response (50%, n = 9/18), 6 partial response (33%, n = 6/18), 2 stable disease (11%, n = 2/18), and 1 progressive disease (6%, n = 1/18). Further follow-up of responses indicated that the 6-, 12-, and 24-month LC rates were 94% (95% confidence interval [CI] [84%, 100%]), 88% (95% CI [75%, 100%]), and 76% (95% CI [54%, 100%]), respectively. The study's limitations include variable tumour sizes and dose fractionation regimens and the anticipated small sample size typical for a Phase 1 clinical trial.

CONCLUSIONS

MRgFUS-MB is an innovative radioenhancement therapy associated with a safe profile, potentially promising responses, and durable LC. These results warrant validation in Phase 2 clinical trials.

TRIAL REGISTRATION

clinicaltrials.gov, identifier NCT04431674.

Randomized Trial of Concomitant Hypofractionated Intensity Modulated Radiation Therapy Boost Versus Conventionally Fractionated Intensity Modulated Radiation Therapy Boost for Localized High-Risk Prostate Cancer (pHART2-RCT)

PURPOSE

The aim of this work is to report on the results of a phase 2 randomized trial of moderately hypofractionated (MH) versus conventionally fractionated (CF) radiation therapy to the prostate with elective nodal irradiation.

METHODS AND MATERIALS

This was a single-center, prospective, phase 2 randomized study. Patients with high-risk disease (cT3, prostate-specific antigen level >20 ng/mL, or Gleason score 8-10) were eligible. Patients were randomized to either MH using a simultaneous integrated boost (68 Gy in 25 fractions to prostate; 48 Gy to pelvis) or CF (46 Gy in 23 fractions with a sequential boost to the prostate of 32 Gy in 16 fractions), with long-term androgen deprivation therapy. The primary endpoint was grade ≥2 acute gastrointestinal (GI) and genitourinary (GU) toxicity (Common Terminology Criteria for Adverse Events version 3.0). Secondary endpoints included late GI and GU toxicity, quality of life, and oncologic outcomes.

RESULTS

One-hundred eighty patients were enrolled; 90 were randomized to and received MH and 90 to CF. The median follow-up was 67.4 months. Seventy-five patients (41.7%) experienced a grade ≥2 acute GI and/or GU toxicity, including 34 (37.8%) in the MH and 41 (45.6%) in the CF arms, respectively (P = .29). Late grade ≥2 GI (P = .07) and GU (P = .25) toxicity was not significantly different between arms; however, late grade ≥3 GI toxicity was worse in the MH group (P = .01). There were no statistically significant quality-of-life differences between the 2 treatments. There were no statistically significant differences observed in cumulative incidence of biochemical failure (P = .71) or distant metastasis (P = .31) and overall survival (P = .46).

CONCLUSIONS

MH to the prostate and pelvis with androgen deprivation therapy for men with high-risk localized prostate cancer was not significantly different than CF with regard to acute toxicity, quality of life, and oncologic efficacy. However, late grade ≥3 GI toxicity was more common in the MH arm.

To Boost or Not to Boost: Pooled Analyses From 2-Fraction SABR Trials for Localized Prostate Cancer

PURPOSE

Focal boost to dominant intraprostatic lesion (DIL) is an approach for dose escalation in prostate radiation therapy. In this study, we aimed to report the outcomes of 2-fraction SABR ± DIL boost.

METHODS AND MATERIALS

We included 60 patients with low- to intermediate-risk prostate cancer enrolled in 2 phase 2 trials (30 patients in each trial). In the 2STAR trial (NCT02031328), 26 Gy (equivalent dose in 2-Gy fractions = 105.4 Gy) was delivered to the prostate. In the 2SMART trial (NCT03588819), 26 Gy was delivered to the prostate, with up to 32 Gy boost to magnetic resonance imaging-defined DIL (equivalent dose in 2-Gy fractions = 156.4 Gy). The reported outcomes included prostate-specific antigen (PSA) response (ie, <0.4 ng/mL) at 4 years (4yrPSARR), biochemical failure (BF), acute and late toxicities, and quality of life (QOL).

RESULTS

In 2SMART, median DIL D99% of 32.3 Gy was delivered. Median follow-up was 72.7 months (range, 69.1-75.) in 2STAR and 43.6 months (range, 38.7-49.5) in 2SMART. The 4yrPSARR was 57% (17/30) in 2STAR and 63% (15/24) in 2SMART (P = 0.7). The 4-year cumulative BF was 0% in 2STAR and 8.3% in 2SMART (P = 0.1). The 6-year BF in 2STAR was 3.5%. For genitourinary toxicities, there were differences in grade ≥1 urinary urgency in the acute (0% vs 47%; P < .001) and late settings (10% vs 67%; P < .001) favoring 2STAR. For urinary QOL, no difference was observed in the acute setting, but lower proportion in 2STAR had minimal clinically important changes in urinary QOL score in the late setting (21% vs 50%; P = .03). There were no significant differences in gastrointestinal and sexual toxicities and QOL in both acute and late settings between the 2 trials.

CONCLUSIONS

This study presents the first prospective data comparing 2-fraction prostate SABR ± DIL boost. The addition of DIL boost resulted in similar medium-term efficacy (in 4yrPSARR and BF), with impact on late urinary QOL outcomes.

Patient engagement in CPD in radiation oncology and radiation therapy across Canada: A national survey

BACKGROUND

The aim of this study was to investigate patient engagement (PE) in the development and delivery of Continuing Professional Development (CPD) programs for health care providers within radiation oncology, radiation therapy and medical physics across Canada. This study looked at the current state of PE in CPD programs across Canada and how to address the benefits and barriers to PE to advance these programs.

METHODS

A quantitative, exploratory survey was conducted among radiation oncologists, radiation therapists and medical physicists across Canada. The questionnaire was developed by a multi-disciplinary team and piloted among interprofessional (IP) faculty with a special interest in patient education. The survey was web-based and disseminated through the Canadian Association of Medical Radiation Technologists (CAMRT) and Canadian Radiation Oncologists (CARO) professional associations.

RESULTS

A total of 97 responses were obtained, 43.3% (n = 41) were radiation oncologists 64% (n = 54) were radiation therapists and 2(2%) were medical physicists. There was representation from all provinces, except Newfoundland, with the majority 36% (n = 35) from Ontario. 57% (n = 46) of participants agreed that patients should be involved in CPD, and 11% (n = 9) disagreed. The most agreed-upon barriers are financial costs for patients and clinician bias when selecting patients. The most agreed-upon solutions were improving patient resources and creating training programs for patients. Radiation therapists agreed significantly more (p<0.05) with the potential benefits of PE in CPD, compared to radiation oncologists.

DISCUSSION

PE in CPD programs is a novel and controversial topic but is still highly rated and important. We intend to advocate for patients to take an active role in our CPD programs. Further research is warranted.

Dosimetric correlates of toxicities and quality of life following two-fraction stereotactic ablative radiotherapy (SABR) for prostate cancer

PURPOSE

There is no evidence-based data to guide dose constraints in two-fraction prostate stereotactic ablative radiotherapy (SABR). Using individual patient-data from two prospective trials, we aimed to correlate dosimetric parameters with toxicities and quality of life (QoL) outcomes.

MATERIALS AND METHODS

We included 60 patients who had two-fraction prostate SABR in the 2STAR (NCT02031328) and 2SMART (NCT03588819) trials. The prescribed dose was 26 Gy to the prostate+/-32 Gy boost to the dominant intraprostatic lesions. Toxicities and QoL data were prospectively collected using CTCAEv4 and EPIC-26 questionnaire. The outcomes evaluated were acute and late grade ≥ 2 toxicities, and late minimal clinical important changes (MCIC) in QoL domains. Dosimetric parameters for bladder, urethra, rectum, and penile bulb were evaluated.

RESULTS

The median follow-up was 56 months (range: 39-78 months). The cumulative incidence of grade ≥ 2 genitourinary (GU), gastrointestinal (GI), and sexual toxicities were 62%, 3%, and 17% respectively in the acute setting (<3 months), and 57%, 15%, and 52% respectively in late setting (>6 months). There were 36%, 28%, and 29% patients who had late MCIC in urinary, bowel and sexual QoL outcomes respectively. Bladder 0.5 cc was significant predictor for late grade ≥ 2 GU toxicities, with optimal cut-off of 25.5 Gy. Penile bulb D5cc was associated of late grade ≥ 2 sexual toxicities (no optimal cut-off was identified). No dosimetric parameters were identified to be associated with other outcomes.

CONCLUSION

Using real-life patient data from prospective trials with medium-term follow-up, we identified additional dose constraints that may mitigate the risk of late treatment-related toxicities for two-fraction prostate SABR.

A Novel Strategy to Enhance Radiotherapy Efficacy: Results from the Prospective Phase I Clinical Trial of MR-Guided Focused Ultrasound-Stimulated Microbubbles (MRgFUS+MB) Treatment for Breast Cancer

PURPOSE/OBJECTIVE(S)

Preclinical in vitro and in vivo studies have demonstrated that tumor cell death can be enhanced 10- to 40-fold when radiotherapy (RT) is combined with focused-ultrasound (FUS)-stimulated microbubbles (MB) treatment. MBs are gas microspheres used as intravascular contrast agents. The acoustic exposure of MBs within the target volume causes bubbles cavitation that induces perturbation of tumor vasculature. This activates apoptotic pathways responsible for the ablative effect of stereotactic body radiotherapy, which would otherwise require high-dose radiotherapy (>8-10 Gy/fraction) to be activated. Subsequent irradiation of an MB-sensitized tumor causes increased anoxic tumor killing, which occurs in addition to canonical RT-induced DNA damage. Given the compelling results of preclinical data, we conducted a phase I clinical trial of magnetic resonance (MR)-guided FUS-stimulated MBs (MRgFUS+MB) treatment for breast cancer patients (pts). We report the safety and efficacy results of this new radio enhancement treatment.

MATERIALS/METHODS

This is a single-center, single-arm, investigator-initiated phase 1 clinical trial (NCT04431674). We included pts with stage I-IV breast cancer with tumor in situ for whom breast or chest wall RT was deemed adequate by a multidisciplinary team. Pts were excluded if they had contraindications for contrast-enhanced MR or MB administration. Pts underwent 2-3 MRgFUS+MB treatments throughout the RT course. We used an MR-coupled FUS-device operating at 500 KHz and 540 kPa peak negative pressure to deliver the treatment. The FUS sonicated intravenously administrated MB within the MR-guided target volume. Pts were monitored for 30-min post-procedure and subsequently treated with RT. The primary outcome was acute toxicity per Common Terminology for Adverse Events V5.0. Secondary outcomes were radiological response at 3 months and local control (LC) at 1 year. Kaplan-Meier method was used to estimate local control. All pts signed a written consent form before study participation.

RESULTS

We enrolled 18 females with 20 primary breast cancer treated with MRgFUS+MB therapy. The median age was 60 years (range, 44-90). The molecular subtypes consisted of basal-like (n = 3/20), luminal (n = 11/20), and HER2-enriched (n = 6/20). The prescribed dose was 20 Gy/5 fractions (n = 8/20), 30-35 Gy/5 fractions (n = 7/20), 30-40 Gy/10 fractions (n = 3/20), and 66 Gy/33 fractions (n = 2/20). The median follow-up was 9 months (range, 0.3-29). All pts completed the planned MRgFUS+MB treatments. The only MRgFUS+MB treatment-related toxicity consisted of Grade 1 allergic reaction (mild cough) 30 minutes after the last MB injection. All worst acute toxicities were radiation dermatitis (Grade 3 = 2/20, Grade 2 = 2/20, Grade 1 = 14/20). At 3 months, 75% had partial (n = 6/20) or complete (n = 9/20) response, with a single progression. The LC rate at 1 year was 86%.

CONCLUSION

MRgFUS+MB was a safe and efficient treatment that provided durable responses.

Dosimetric Parameters Predictive of Treatment-Related Toxicity in High Dose-Rate Brachytherapy as Monotherapy for Prostate Cancer

PURPOSE/OBJECTIVE(S)

High dose-rate (HDR) brachytherapy as monotherapy is an effective treatment for patients with low- and intermediate-risk prostate cancer and is increasingly being offered as a 2-fraction protocol. There is a lack of consensus on the optimal dosimetric planning parameters to use, or whether there is any benefit summating dosimetric parameters from more than one implant. Our goal is to determine planning parameters associated with disease control, toxicity and health-related quality of life (HRQOL).

MATERIALS/METHODS

Data were collected on 83 patients with low- and intermediate-risk prostate cancer who received 2 fractions of 13.5 Gy HDR brachytherapy without androgen-deprivation therapy as part of a randomized phase II clinical trial. An in-house deformable, registration algorithm was used to co-register and dose-summate the plans from both implants for each patient. Acute and late GU and GI toxicities were measured using CTCAE 4.0 and HRQOL was measured in urinary, bowel, sexual and hormonal domains using the EPIC scores. Treatment efficacy was assessed through PSA measurement and imaging with or without biopsy where indicated. Covariates included baseline clinical factors, disease characteristics and treatment dosimetric parameters. Cox proportional hazards was performed to evaluate covariates impact on treatment toxicity and efficacy, and logistic regression analysis evaluated covariates impact on HRQOL.

RESULTS

Among the 83 patients, median prostate volume was 46.7cm3. Median summated planning target volume receiving 100% prescription dose (PTV V100%) was 97.4%, median PTV V150% 42.4% and median PTV V200% 15.5%. Median highest dose to the 1cm3 rectum (D1cc) was 66.9% of the prescription dose and median rectum V80% was 0.008cm3. Median urethral D1cc was 99.0% of the prescription dose, median urethral Dmax 121.7% and median urethral D10% 116.2%. Grade ≥2 GI toxicity was uncommon (3.7% acute and 8.5% late), but grade ≥2 GU toxicity was reported in 73.2% (acute) and 46.3% (late) patients. Rectum D1cc and V80% were found to be significantly associated with grade 2 or higher acute GI toxicity, while use of a-blocker at baseline was associated with grade ≥2 acute GU toxicity. Similarly, use of a-blocker was associated with late grade ≥2 GU toxicity, but with no dosimetric associations. No other variables were associated with treatment-related toxicities. Only rectum D1cc was significantly associated with changes in bowel EPIC scores. Estimated 5-year biochemical disease-free survival was 93.9% and 5-year cumulative incidence of local failure was 3.8%.

CONCLUSION

HDR monotherapy with 27 Gy delivered in 2 fractions in treatment of prostate cancer is well tolerated with high rates of disease control and minimal toxicity. Dose summation between 2 fractions of HDR brachytherapy is feasible, with rectal dose predicting acute GI toxicity. The lack of association between dose metrics and urinary toxicity raises the potential for further dose escalation.

Dosimetric Predictors of Toxicities and Quality of Life Following Two-Fraction Stereotactic Body Radiotherapy for Prostate Cancer

PURPOSE/OBJECTIVE(S)

There is emerging interest in two-fraction stereotactic body radiotherapy (2#SBRT) for localized prostate cancer. However, there is limited data to guide organs at risk (OAR) dose constraints in 2#SBRT. We aim to identify dosimetric predictors of toxicities and quality of life (QoL) using real life patient data from two prospective 2#SBRT trials.

MATERIALS/METHODS

We included 60 patients who had 2#SBRT in the 2STAR (NCT02031328) and 2SMART (NCT03588819) phase 2 trials. The prescribed dose was 26Gy to the prostate +/- focal boost of 32Gy to the dominant intraprostatic lesions. Toxicities and QoL data were prospectively collected using CTCAEv4 and EPIC26 questionnaires. For QoL, we reported the minimal clinical important changes (MCIC), defined as changes in QoL score of >0.5 standard deviation from baseline QoL score. We evaluated the bladder, urethra, rectum, and penile bulb dosimetry (urethra dosimetry only available in 30 patients in 2SMART trial). Some of the dosimetric parameters were log-transformed to normalize the distribution. Cox regression was used to identify dosimetric predictors for acute and late grade ≥2 GU toxicities. Logistic regression was used to identify dosimetric predictors for late MCIC in urinary, bowel and sexual QoL domains. Backward stepwise selection was used to identify significant dosimetric parameters. For GU toxicities and urinary QoL, three additional clinical factors (age, prostate volume and IPSS) were included in the final model as confounding factors. Receiver operating characteristics curve was used to identify cut-off for significant dosimetric parameters.

RESULTS

The median follow-up for the cohort was 56 months (range: 39-78 months). The cumulative acute and late grade ³2 GU toxicities were 62% (37/60) and 57% (34/60) respectively. No bladder or urethra dosimetric parameter was associated with acute grade ≥2 GU toxicities. Bladder D0.5cc was significant predictor of late grade ≥2 GU toxicities in univariate model (P = 0.05), but not in multivariate model. Baseline IPSS score was the single strongest predictor for late grade ≥2 GU toxicities (HR = 1.9; 95% CI = 1.1-3.4; P = 0.03). For late QoL outcomes, there were 36% (21/58), 28% (16/58), and 29% (17/58) of patients with MCIC in urinary, bowel and sexual QoL domains respectively. Bladder V10Gy was associated with late urinary MCIC in multivariate model after adjusting for clinical confounders (HR = 2.6, 95% CI = 1.1-6.6; P = 0.04). 48% (14/29) and 24% (7/29) of patients with bladder V10Gy>13.9% and V10Gy≤13.9% respectively had late urinary MCIC. No rectum and penile bulb dosimetry parameters was identified to be associated with late bowel or sexual QoL.

CONCLUSION

Using real life patient data from prospective clinical trials with medium term follow-up, we identified statistically significant bladder dosimetry parameter predictive of late urinary QoL. This finding could be useful to guide OAR dose constraints in prostate 2#SBRT trials.

Implementing geriatric assessment and management for older Canadians with cancer: Adherence to and satisfaction with the intervention, results of the 5C study

INTRODUCTION

Geriatric assessment and management (GAM) is recommended by professional organizations and recently several randomized controlled trials (RCTs) demonstrated benefits in multiple health outcomes. GAM typically leads to one or more recommendations for the older adult on how to optimize their health. However, little is known about how well recommendations are adhered to. Understanding these issues is vital to designing GAM trials and clinical programs. Therefore, the aim of this study was to examine the number of GAM recommendations made and adherence to and satisfaction with the intervention in a multicentre RCT of GAM for older adults with cancer.

MATERIALS AND METHODS

The 5C study was a two-group parallel RCT conducted in eight hospitals across Canada. Each centre kept a detailed recruitment and retention log. The intervention teams documented adherence to their recommendations. Medical records were also reviewed to assess which recommendations were adhered to. Twenty-three semi-structured interviews were conducted with 12 members of the intervention teams and 11 oncology team members to assess implementation of the study and the intervention.

RESULTS

Of the 350 participants who were enrolled, 173 were randomized to the intervention arm. Median number of recommendations was seven. Mean adherence to recommendations based on the GAM was 69%, but it varied by type of recommendation, ranging from 98% for laboratory tests to 28% for psychosocial/psychiatry oncology referrals. There was no difference in the number of recommendations or non-adherence to recommendations by sex, level of frailty, or functional status. Oncologists and intervention team members were satisfied with the study implementation and intervention delivery.

DISCUSSION

Adherence to recommendations was variable. Adherence to laboratory investigations and further imaging were generally high but much lower for recommendations regarding psychosocial support. Further collaborative work with older adults with cancer is needed to understand how to optimize the intervention to be consistent with patient goals, priorities, and values to ensure maximal impact on health outcomes.

Predictors and effects of toxicity experienced by older adults with cancer receiving systemic therapy in a randomized clinical trial of geriatric assessment

INTRODUCTION

Older adults represent a large segment of the oncology population, however, they remain underrepresented in clinical research. Treatment of older adults is often extrapolated using data from younger and fitter patients, which may not be appropriate. Furthermore the implications of toxicity from treatment can be greater for this population. Predicting toxicity from treatment and its effect on quality of life and functional status for older adults therefore is important.

MATERIALS AND METHODS

We analyzed data from a clinical trial of geriatric assessment and management for Canadian elders with cancer (5C study). We assessed whether the baseline Cancer and Aging Research Group (CARG) toxicity score, G8 score, and Eastern Cooperative Oncology Group (ECOG) performance predicted grade 3-5 toxicity using logistic regression and pattern mixture models. We also assessed the impact of toxicity on quality of life and functional decline. Patients were followed for six months.

RESULTS

Three hundred sixteen patients were included. Mean age was 76 years old and 40% of patients were female. One hundred nineteen patients (38%) experienced at least one grade 3-5 toxicity. Neither the CARG toxicity score, G8, or ECOG were predictive of grade 3-5 toxicity. Patients who experienced grade 3-5 toxicity were more likely to have functional impairments over time (odds ratio 3.71, p = 0.03). However, they maintained their quality of life.

DISCUSSION

In this secondary analysis of a randomized controlled trial of geriatric assessment and management we did not find any predictors of grade 3-5 toxicity. Patients who did experience toxicity were more likely to report functional decline over time. Older adults who do experience treatment related toxicity may benefit from increased supports.

CLINICAL TRIAL INFORMATION

NCT0315467.

Functional decline and resilience in older adults over the age of 70 receiving radiotherapy for breast cancer: A pilot study

INTRODUCTION

Radiotherapy (RT) as an adjuvant, post-lumpectomy treatment has been shown to improve local control and survival in people with breast cancer. While adverse events because of cancer treatments are common, many older adults have demonstrated the ability to return to their baseline levels of physical functioning. There are limited reports on the functional decline and recovery of older patients undergoing RT. The primary objective of this study was to investigate physical function at various time points during RT in people with breast cancer over age 70 and their ability to recover post-decline.

MATERIALS AND METHODS

Seventy-nine patients with breast cancer aged 70+ undergoing adjuvant RT at Sunnybrook Health Science Centre, Toronto, Ontario, Canada were enrolled for a prospective observational study. Participants completed the EORTC QLQ-C30 quality of life questionnaire before their first RT, after their final RT, and at three- and six-months post-RT to assess changes in physical function. Descriptive statistics were utilized to evaluate EORTC QLQ-C30 scores. A higher score was indicative of poorer physical function. Physical decline was a 10+ point increase in EORTC QLQ-C30 score from baseline to the last RT, and resilience was a return to <10 points from the baseline score within six months post-RT. Resistance was a post-RT change from the baseline score by fewer than 10 points.

RESULTS

Nine patients (11%) experienced physical decline following their last RT, and two of them (22%) displayed resilience within six months. There were no demographic or symptom variables associated with functional decline from the baseline to post-RT, nor with resilience. Nausea, pain, and diarrhea post-RT were associated with functional decline at six months post-RT (P = 0.0185, P = 0.0449, P = 0.0007, respectively). Nausea and diarrhea at baseline were associated with resistance to decline (P = 0.0055, P = 0.019, respectively), and with decline at the six-month follow-up (P ≤0.0001, P = 0.0235, respectively).

DISCUSSION

This study highlights the incidence of physical decline in patients over age 70 receiving RT for breast cancer and identifies risk factors for decline. Future research with a larger sample, longer follow-up period, and incorporating geriatric assessments pre-RT is warranted to better understand functional decline and resilience in this population.

Leadership, Leading, and Influencing Change in Cancer Education: Development and Assessment of a Pilot Leadership Workshop in Cancer Education for Interdisciplinary Healthcare Staff

Effective leaders in healthcare settings create a motivating work environment, initiate changes in practice, and facilitate interdisciplinary collaboration to advance patient-centered care. Health professionals in cancer education need leadership development to meet the continued rise in cancer cases and to keep up with the rapid biomedical and technological advances in global cancer care. In addition, leadership development in cancer education supports interprofessional collaboration, optimizes patient engagement, and provides mentorship opportunities necessary for career advancement and skill development. The identified benefits from leadership development in cancer education led to the creation of an interactive pilot leadership workshop titled "Essential Skills in Cancer Education: Leadership, Leading, and Influencing Change in Cancer Education," held at the International Cancer Education Conference in October 2020. The workshop was led by global leaders in cancer education and utilized lectures, mentorship opportunities, interactive case studies, and individual learning projects to develop leadership skills in multidisciplinary oncology professionals. Fifteen attendees from diverse educational backgrounds and levels of experience participated in the virtual leadership workshop and mentorship program. Following the workshop, participants reported an increase in knowledge regarding how to use different leadership styles, initiate changes in practice, and apply leadership skills in their career development and at their institutions. The feedback received from participants through post-workshop evaluations was overall positive and demonstrated an interest for more leadership development opportunities in cancer education. This pilot workshop shows that leadership is a valuable and teachable skill that will benefit both healthcare professionals and patients in the field of cancer education.

Mepitel Film for the Prevention of Acute Radiation Dermatitis in Breast Cancer: A Randomized Multicenter Open-Label Phase III Trial

PURPOSE

Radiation dermatitis (RD) is common in patients undergoing breast radiotherapy. Mepitel film (MF) can reduce RD, but the results from two randomized controlled trials are conflicting. We aimed to conduct a confirmatory randomized controlled trial in patients at risk of RD.

METHODS

Patients were randomly assigned to receive MF or standard care (2:1 ratio). Patients with large breasts after lumpectomy (bra size ≥ 36 inches or cup size ≥ C) or after mastectomy were eligible. Stratification factors included surgery type, dose fractionation, and administration of boost/bolus. The primary end point was grade (G) 2 or 3 RD using the Common Terminology Criteria for Adverse Events v5.0. Secondary end points included patient- and clinician-reported outcomes.

RESULTS

Between January 2020 and May 2022, 376 patients were included in the modified intention-to-treat analysis. The incidence of G2 or 3 RD was significantly lower in MF patients compared with standard care (n = 39/251, 15.5%; 95% CI, 11.3 to 20.6% v n = 57/125, 45.6%; 95% CI, 36.7 to 54.8% respectively, odds ratio (OR): 0.20, P < .0001). Benefits of MF remained significant in patients who developed G 3 RD (n = 7, 2.8%; 95% CI, 1.1 to 5.7% v n = 17, 13.6%; 95% CI, 8.1 to 20.9%, OR: 0.19) and moist desquamation (n = 20, 8.0%; 95% CI, 4.9 to 12.0% v n = 24, 19.2%; 95% CI, 12.7 to 27.1%, OR: 0.36). When evaluating the combined patient and health care provider score using Radiation-Induced Skin Reaction Assessment Scale, the MF arm had significantly lower scores (P < .0001). Individual items on the Radiation-Induced Skin Reaction Assessment Scale also favored the MF for both patient- and clinician-reported outcomes. Blistering/peeling, erythema, pigmentation, and edema were significantly reduced in the MF arm. Three patients removed the film prematurely because of rash (n = 2) and excessive pruritus (n = 1).

CONCLUSION

MF significantly reduces RD in patients undergoing breast radiotherapy.

Two-fraction stereotactic MRI-guided ablative radiotherapy with simultaneous boost to dominant intraprostatic lesion: Results from the 2SMART phase 2 trial

349

Background: Prostate stereotactic ablative radiotherapy (SABR) for localised prostate cancer is commonly delivered over 5 fractions. Focal boost to the dominant intraprostatic lesion (DIL) seen on multiparametric magnetic resonance imaging (mpMRI) is an approach for dose-escalation in prostate SABR. This is the first report of the outcomes of the 2SMART trial, a phase 2 single-arm study using 2-fraction prostate SABR with DIL boost. Methods: Men with low to intermediate risk prostate cancer were enrolled in the study. Three gold fiducial markers were inserted for image guidance. The clinical target volume (CTV) included the prostate gland, and the planning target volume (PTV) was a 2mm expansion antero-posterior and laterally, and 2.5mm supero-inferiorly. The DIL was contoured on fused mpMRI. The prescribed dose was 26Gy in 2 fractions (EQD2 110Gy, α/β of 1.4) to the CTV, and up to 32Gy in 2 fractions (EQD2 164Gy) to the DIL as long as the dose constraints for the organs at risks were not exceeded. Each fraction was delivered 1 week apart. Daily image guidance with cone-beam computed tomography was used pre- and post-treatment. The primary endpoint was acute (≤3 months) changes in quality of life (QOL), assessed using the EPIC questionnaire. Minimal clinically important change (MCIC) in QOL was defined as an EPIC score decrease of >0.5 standard deviation of the baseline EPIC score for each domain. Secondary endpoints were acute and late toxicities (assessed using CTCAEv4), and biochemical failure (based on Phoenix criteria). Results: 30 men were enrolled in the study, of which 2 (7%) had low risk and 28 (93%) had intermediate risk prostate cancer. The median follow-up was 44 months (range: 39-49 months). The median PSA nadir was 0.2ng/mL, with median time to nadir of 37 months. One patient (3%) had biochemical failure at 44 months post-treatment. 1 (3%) and 17 (57%) had acute Grade 2 GU and GI toxicities, while 3 (10%) and 15 (50%) had late (>6 months) Grade 2 GU and GI toxicities. No acute or late Grade ≥3 GU or GI was reported. 10 (33%), 6 (20%), and 3 (10%) men had acute MCIC in urinary, bowel and sexual domains respectively. 15 (50%), 9 (30%) and 13 (43%) had late MCIC in urinary, bowel and sexual domain respectively. Conclusions: Two-fraction prostate SABR with DIL boost is a safe approach for dose-escalation for localised prostate cancer, with minimal impact on acute QOL, and no grade 3-4 toxicities. Clinical trial information: NCT03588819 .

Impact of Geriatric Assessment and Management on Quality of Life, Unplanned Hospitalizations, Toxicity, and Survival for Older Adults With Cancer: The Randomized 5C Trial

PURPOSE

American Society of Clinical Oncology recommends that older adults with cancer being considered for chemotherapy receive geriatric assessment (GA) and management (GAM), but few randomized controlled trials have examined its impact on quality of life (QOL).

PATIENTS AND METHODS

The 5C study was a two-group parallel 1:1 single-blind multicenter randomized controlled trial of GAM for 6 months versus usual oncologic care. Eligible patients were age 70+ years, diagnosed with a solid tumor, lymphoma, or myeloma, referred for first-/second-line chemotherapy or immunotherapy or targeted therapy, and had an Eastern Cooperative Oncology Group performance status of 0-2. The primary outcome QOL was measured with the global health scale of the European Organisation for the Research and Treatment of Cancer QOL questionnaire and analyzed with a pattern mixture model using an intent-to-treat approach (at 6 and 12 months). Secondary outcomes included functional status, grade 3-5 treatment toxicity; health care use; satisfaction; cancer treatment plan modification; and overall survival.

RESULTS

From March 2018 to March 2020, 350 participants were enrolled. Mean age was 76 years and 40.3% were female. Fifty-four percent started treatment with palliative intent. Eighty-one (23.1%) patients died. GAM did not improve QOL (global QOL of 4.4 points [95% CI, 0.9 to 8.0] favoring the control arm). There was also no difference in survival, change in treatment plan, unplanned hospitalization/emergency department visits, and treatment toxicity between groups.

CONCLUSION

GAM did not improve QOL. Most intervention group participants received GA on or after treatment initiation per patient request. Considering recent completed trials, GA may have benefit if completed before treatment selection. The COVID-19 pandemic may have affected our QOL outcome and intervention delivery for some participants.

Success of targeted transperineal biopsy in patients on surveillance for grade group 1 prostate cancer

Introduction: We aimed to determine the minimum cross-sectional ellipsoid area on magnetic resonance (MR) of intraprostatic nodules that best predicts for subsequent targeted biopsies revealing ≥ grade group (GG) 2 disease. Methods: Forty-six patients previously diagnosed with GG 1 prostate adenocarcinoma who received cognitively fused, MR-guided, transperineal targeted biopsies in addition to six random biopsies were included in this analysis. A Youden cutpoint analysis was used to determine the ellipsoid area in the axial plane best predicting for ≥GG 2 disease within the targeted biopsy cores and logistic regression used to assess the result. Results: Median time from MR imaging to targeted biopsy was 2.4 (1.4–5.5) months. Forty of 46 (87%) patients had one nodule and 6/46 (13%) had two separate nodules on MR that received targeted biopsy. Of the 52 nodules, five (10%), 33 (63%), and 14 (27%) were Prostate Imaging–Reporting and Data System (PI-RADS) 3, 4, and 5. Thirteen (25%), six (12%), and 33 (64%) were in the anterior, medial, and posterior regions of the prostate. Median area was 0.72 (0.49–1.29) cm2 (average diameter 9.5 mm). Fifteen of 46 (33%) patients had ≥1 random biopsy and 20/52 (38%) nodules had ≥1 targeted biopsy revealing ≥GG 2 disease. The optimal area cutpoint was ≥0.7cm2, with an area under the curve of 0.671 (0.510–0.832). On logistic regression, areas ≥0.7 cm2 was solely predictive of targeted biopsy revealing ≥GG 2 disease (odds ratio 6.5, 1.3–32.4, p=0.022). Conclusions: Nodule area ≥0.7 cm2 may predict for transperineal-based targeted biopsies being positive for ≥GG 2 disease when 1–2 cores are taken.

Abstract P5-14-11: Retrospective analysis of VES13 questionnaire prior oncology consultation in the Senior Women’s Breast Cancer Clinic at tertiary care center, what have we learned?

Purpose/Objectives: - Breast cancer mortality is the highest among older women due to co morbidities, increased frailty. Geriatric assessment with focus on frailty is important and several validated tools available to assist this. The Vulnerable Elders Survey 13 (VES-13) screening tool validated in community populations aged 70 and older is a self-reported tool developed to identify older patients at risk of further health decline, showed 4.2 time risk of functional decline over two year in high scorer. We introduced VES-13 screening tool in Senior Women’s Breast Cancer Clinic (SWBCC), prior patient’s visits with medical, radiation or surgical oncology consultations. The aim was to identify feasibility of using VES 13 as a screening tool and its impact on clinical decisions and treatment recommendations. Materials/Methods: - this is descriptive retrospective study, we reviewed VES-13 questionnaires collected SWBCC in patients above the age of 70. We reviewed electronic medical records, variables included ECOG, disease stage, number of comorbidities, and referral to geriatrician or other supportive services, presence of basic social supports, modifications in oncology treatment. We also investigated if the oncologists in the breast centre reviewed VES-13 scores and requested additional services or referral the patients to a geriatrician or other allied health services in the patients who scored higher on the VES-13 instrument. Descriptive statistics were used analyze the data. Results: - 701 patients completed VES-13 questionnaires in the SWBCC between October 2019 and January 2020. 235(33.5%) patient had a documented VES-13 score of 3 or greater. Analysis was focused on patients with a VES13 score of 3 or greater. Mean VES13 score was 6 ± 3.86 with a mean ECOG score of 1.09 ± 1.19.There was no statistically significant association between referrals for geriatric assessment and VES13 score (p=0.20) or ECOG (p=0.33. However, while referral to additional allied health services was not significantly associated with VES13 score (0.6114), it was significantly associated with patient ECOG status (p&lt;0.0001). Higher VES13 scores, increased patient age and higher ECOG scores were significantly associated with modification of oncological treatment and recommendations (p&lt;0.0001). Conclusions: - Our study demonstrates that clinicians do not frequently use the VES13 in their clinical assessment, as opposed to the patients’ ECOG status, which results in missed opportunities for referral of frail patients for additional supportive services. Lack of review by oncologists of the VES13 questionnaires due to time constrain in a busy oncology clinic, further complicate it. Proper Utilizing of VES-13 screening can help in more optimal assessment of older breast cancer patients, individualize treatment approaches and reduce the possibility of frailty related adverse treatment outcomes in older population. Proper infrastructure of introducing VES-13 screening and collection of the VES-13 instrument in a busy academic Breast Cancer Centre is recommended

Citation Format: Benazir Mir Khan, Arman Zereshkian, Xingshan Cao, Rajin Mehta, Bonnie Bristow, Maureen Trudeau, Nayanee Henry-Noel, Matthew Neve, Mireille Norris, Mark Pasetka, Katie Rice, Fiona McCullock, Frances Wright, Ines Menjak, Ewa Szumacher. Retrospective analysis of VES13 questionnaire prior oncology consultation in the Senior Women’s Breast Cancer Clinic at tertiary care center, what have we learned? [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-14-11.

Elective pelvic nodal irradiation with a simultaneous hypofractionated integrated prostate boost for localized high risk prostate cancer: Long term results from a prospective clinical trial

BACKGROUND

To report on long-term results of elective pelvic nodal irradiation (EPNI) and a simultaneous hypofractionated prostate boost for high-risk prostate cancer.

MATERIALS AND METHODS

This was a prospective single-arm study. Patients with high-risk disease (cT3, PSA >20 ng/mL, or Gleason score 8-10) were eligible. Patients received 45 Gy in 25 fractions to the prostate and pelvic lymph nodes with a simultaneous intensity-modulated radiotherapy boost of 22.5 Gy to the prostate (total dose 67.5 Gy in 25 fractions), with androgen deprivation therapy (ADT) for 2-3 years. The primary endpoint was biochemical failure. Secondary endpoints included distant metastases and overall survival. Multivariable analysis was performed to look for predictive factors. Late toxicity was assessed using CTCAE v3.0.

RESULTS

230 patients enrolled. Median follow-up was 11.2 years (IQR 8.1-12.9). At 10 years, cumulative incidence of biochemical failure was 33.4%, distant metastasis was 16.5%, and overall survival was 76.3%. On multivariable analysis, PSA nadir ≥0.05 ng/mL was associated with biochemical failure (HR 6.8, 95% CI 4-11.8, p < 0.001) and distant metastases (HR 7.5, 95% CI 3.9-14.5, p < 0.0001). PSA nadir ≥0.1 ng/mL (HR 5.2, 95% 2.2-12, p = 0.0001) and ADT use ≤12 months (versus >24 months) (HR 2.3, 95% CI 1.3-3.9, p = 0.004) were associated with worse survival. The 5-year cumulative incidence of any late grade ≥3 gastrointestinal and genitourinary toxicity was 2.3% and 7.5%, respectively.

CONCLUSION

EPNI and a simultaneous hypofractionated prostate boost combined with long-term ADT for high-risk prostate cancer resulted in acceptable 10-year biochemical control and survival with low grade ≥3 toxicity.

Comprehensive geriatric assessment and management for Canadian elders with Cancer: The 5C study

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Background: Comprehensive Geriatric Assessment (CGA) is recommended by ASCO for older adults with cancer undergoing chemotherapy to identify issues that can interfere with treatment delivery and optimize functional status and quality of life. However, few randomized controlled trials have been completed so far. Our objective is to evaluate the effectiveness of CGA on improving quality of life for older adults receiving cancer treatment. Methods: Eligible patients were aged 70+, diagnosed with a solid tumour, lymphoma or myeloma, referred for first/second line chemotherapy, speaking English/French, and with an Eastern Collaborative Oncology Group Performance Status 0–2. The CGA was done by a nurse and geriatrician followed by monthly phone calls by the study nurse for 6 months. Patients were randomly assigned (1:1) to receive either the intervention (CGA plus follow-up by geriatric trained team in addition to usual oncology care) or usual care alone. All participants received a monthly healthy aging booklet for attention control. Randomization was stratified by center and treatment intent (curative/adjuvant versus palliative). Our primary outcome was health-related quality of life (HRQOL) assessed with the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 global health scale (items 29 and 30). Secondary outcomes include functional status (Instrumental Activities of Daily Living). Outcome data collection was completed monthly for the first 6 months, then at 9 and 12 months. For the primary outcome we used a pattern mixture model using an intent-to-treat approach (at 0, 3, and 6 months). The last data collection took place March 8 2021. Results: From May 2017 to March 2020, 351 participants from 8 hospitals across Canada were enrolled. All patients were seen on or after day 1 of treatment for the intervention per patient request. Patient characteristics at baseline were similar in both arms. The average age was 75.7 (SD = 4.8), 60.4% was male and 54.3% had treatment with palliative intent. Change in HRQOL scores did not differ by arm (p =.80). Neither group exceeded the MCID of 10 points. There was also no difference in IADL between the groups (p = 0.82). Conclusion: CGA was not effective in improving quality of life for older adults receiving cancer treatment in this study. CGA may need to be performed prior to treatment initiation to achieve benefits. Clinical trial information: NCT03154671.

How do patient-reported outcomes compare with clinician assessments? A prospective study of radiation dermatitis in breast cancer

BACKGROUND AND PURPOSE

Breast cancer patients frequently develop radiation dermatitis (RD) when undergoing post-operative radiation therapy (RT). Traditional RD assessment methods measure clinician-reported outcomes (CROs), but patient-reported outcomes (PROs) have gained recent popularity. The purpose of this prospective analysis was to compare PROs with CROs of breast RD.

MATERIALS AND METHODS

Demographic and treatment characteristics were prospectively collected for patients receiving post-operative RT between February 2018 to September 2020. Patients and clinicians completed a skin symptom assessment at baseline, weekly during RT, and at a one- to three-month follow-up visit. Skin treatments used by patients were collected. Concordance between each PRO and CRO was determined using percent concordance and concordance index (C-statistic) by logistic regression analysis.

RESULTS

A total of 777 patients were included in the present study. All skin symptom assessment items were significantly underreported by clinicians in comparison to patients (p < 0.0001), with a low to moderate level of concordance (C-statistic range: 0.58-0.70; percent concordance range: 29-50%). The majority of patients used moisturizing creams as a prophylactic measure (65.1%), as per institutional guidelines.

CONCLUSION

There were significant discrepancies between PROs and CROs when assessing breast RD. CROs alone are insufficient in measuring RD as they fail to capture the impact on patient quality of life. The study findings highlight the need for improved RD symptom assessment and support the development of a new tool with both patient and clinician components.

Clinical research mentorship programme (CRMP) for radiation oncology residents in Africa-building capacity through mentoring

Research skills are mandatory for all oncology residency training programmes. Creating the environment to foster skills and passion can be a challenge in all settings, and a unique challenge in low and middle income countries (LMICs). Tremendous clinical workload places exceptional demand on clinician teachers, research infrastructure and access to research collaborators with diverse methodological skill sets can be limited. International collaborations, and in particular relationship partnerships (Whitehead et al ((2018) Acad Med 93 1760-1763)) can be a useful approach to bridge resource gaps and enrich the support available to trainees (Research EoH ((2014) TDR/ESSENCE/2.14)). The Clinical Research Mentorship Programme (CRMP) is a collaborative initiative created by the University of Toronto Department of Radiation Oncology, Princess Margaret Cancer Centre, delivered in collaboration with LMIC radiation oncology residency programmes with the primary goal of enriching the research experience of LMIC oncology trainees. It was inspired by observing a need, an enthusiasm to collaborate and some seed funding that supported the idea. At the heart of the programme is a formalised relationship, a triad, between a LMIC oncology trainee, their local supervisor and a mentor from Toronto. Within the collaborative environment created between the LMIC and high income country (HIC) institutions, enabled by remote learning technologies, a 12-week research methods seminar kick starts a year-long mentorship for the trainee on their research question. The goal is to enrich the quality of the research experience for the trainee, resulting in dissemination of research findings in international conferences and publications. A standard evaluation package is used (Vuple et al ((2021) 6 919-928)). In this paper, through a description of our collaboration, we will highlight how a distant mentorship programme was used to enhance clinical research mentorship skills for radiation oncology trainees in Africa. We hope the format we have chosen will continue to demonstrate effectiveness for our trainees, sustainability for our faculty and institutions and will serve as one mechanism to build radiation capacity for LMIC through collaboration, mentorship and research.

Methods for frailty screening and geriatric assessment in older adults with cancer

PURPOSE OF REVIEW

This review highlights the latest development in the use of geriatric assessment(GA) and frailty assessment for older adults with cancer.

RECENT FINDINGS

From 2019, there were six large randomized controlled trials (RCTs) completed of GA for older adults with cancer, as well as several studies of frailty screening tools.

SUMMARY

The findings in this review highlight the benefits of implementing GA, followed by interventions to address the identified issues (GA -guided interventions). Four of six RCTs that implemented GA for older adults with cancer showed positive impact on various outcomes, including treatment toxicity and quality of life. GA implementation varied significantly between studies, from oncologist acting on GA summary, geriatrician comanagement, to full GA by a multidisciplinary team. However, there were several barriers reported to implementing GA for all older adults with cancer, such as access to geriatrics and resource issues. Future research needs to elucidate how to best operationalize GA in various cancer settings. The authors also reviewed frailty screening tools and latest evidence on their use and impact.

Continuing Professional Development Needs Amongst University of Toronto's Department of Radiation Oncology Faculty

Continuing professional development (CPD) and lifelong learning are core tenets of most healthcare disciplines. Where undergraduate coursework lays the foundation for entry into practice, CPD courses and offerings are designed to aid clinicians in maintaining these competencies. CPD offerings need to be frequently revised and updated to ensure their continued utility. The purpose of this qualitative study was to better understand the CPD needs of members of the University of Toronto's Department of Radiation Oncology (UTDRO) and determine how these needs could be generalized to other CPD programs. Given that UTDRO consists of members of various health disciplines (radiation therapist, medical physicists, radiation oncologists, etc.), eleven semi-structured interviews were conducted with various health professionals from UTDRO. Inductive thematic analysis using qualitative data processing with NVivo® was undertaken. The data was coded, sorted into categories, and subsequently reviewed for emergent themes. Participants noted that a general lack of awareness and lack of access made participation in CPD programs difficult. Members also noted that topics were often impractical, irrelevant, or not inclusive of different professions. Some participants did not feel motivated to engage in CPD offerings due to a general lack of time and lack of incentive. To address the deficiencies of CPD programs, a formal needs assessment that engages stakeholders from different centers and health professions is required. Needs assessments of CPD programs should include analyzing elements related to access, how to utilize technology-enhanced learning (TEL), determine barriers to participation, and understand how to better engage members.

Perceptions of Canadian radiation oncologists, radiation physicists, radiation therapists and radiation trainees about the impact of artificial intelligence in radiation oncology - national survey

BACKGROUND

Artificial Intelligence (AI) is making a continuous progression into the field of Radiation Oncology in Canada and globally. While this field continues to evolve, there is no clear understanding about how radiation oncologists, radiation therapists, medical physicists and radiation trainees perceive AI and its' impact on radiation oncology as a discipline. The purpose of this study was to investigate the perception of these four Canadian professional groups about AI. and how AI will affect radiation oncology as a specialty.

METHODS

Following an in-depth scientific review of the existing literature, a 29 Likert-scale questionnaire was developed using Google Survey. The questionnaire was piloted and distributed through national organizations including the Canadian Association for Radiation Oncology (CARO), the Canadian Association of Medical Radiation Therapy (CAMRT) and the Canadian Organization of Medical Physicists (COMP), initially in February, and again between March and June 2020. The results were analyzed using descriptive statistics.

RESULTS

159 responses were received from 10 Canadian provinces. Knowledge about AI was moderate with an average of 5/10, but 91% responded interest in learning more about it. The negative implications of AI were related to fear of losing jobs and shift of practice. The majority of participants agreed AI would positively impact on patient treatment.

CONCLUSION

Radiation oncology professionals believe AI will be an important part of patient treatment in their future practices. The fear about AI may be mitigated with further education programs about AI, which can gain more confidence in the acceptance of AI.

A Feasibility Study of Mepitel Film for the Prevention of Breast Radiation Dermatitis in a Canadian Center

PURPOSE

Severe radiation dermatitis (RD) is distressing and may have adverse long-term effects including fibrosis and telangiectasia. Treatment interruptions due to severe RD may increase the risk of recurrence. Two randomized trials of Mepitel film demonstrated efficacy in preventing severe RD in breast cancer, but this product has not been widely adopted in North America. We aimed to assess the feasibility and efficacy of Mepitel film for prevention of breast RD at a Canadian center.

METHODS AND MATERIALS

Patients were stratified based on breast size and receipt of postmastectomy radiation therapy. The primary outcome was RD grade using the Common Terminology Criteria for Adverse Events. Secondary outcomes included moist desquamation, patient- and clinician-reported symptoms of skin toxicity, and cosmetic outcomes.

RESULTS

Thirty patients receiving external beam radiation therapy to the breast or chest wall were enrolled. Two patients (6.7%) discontinued use of the Mepitel film before completing radiation therapy. No patients developed grade 3 RD or higher. Five patients (17.9%) developed grade 2 RD: 3 (10.7%) had moist desquamation, and 2 (7.1%) had brisk erythema without moist desquamation.

CONCLUSIONS

Mepitel film completely prevented grade 3 RD. Rates of moist desquamation and grade 2 RD were lower with Mepitel film than in studies using aqueous cream, but unlike previous trials of Mepitel film we did not achieve complete prevention of moist desquamation. Further research is needed to confirm the efficacy of Mepitel film versus standard prophylaxis for RD and identify the patients who will benefit the most from the film.

Development and Testing of an Adjuvant Radiotherapy Decision Aid for Older Women Diagnosed with Stage I Breast Cancer: A Pilot Study

Background Whole breast irradiation therapy (WBRT), accelerated partial breast irradiation (APBI), and omission of radiotherapy (ORT) are options for women aged 65 years and older with low-risk breast cancer post lumpectomy. Aim The aim of the study was to develop and pilot a decision aid pamphlet (DA), among women aged 65 years and older with low-risk breast cancer and who were undergoing or had undergone WBRT, to ensure they were fully informed about the different options for radiation treatment following lumpectomy. Methods We piloted the decision aid with 40 participants, women aged 65-86 years with low-risk breast cancer and who had undergone or were undergoing WBRT. The women completed a pre-DA Decisional Conflict Scale (DCS) and post-DA DCS, Knowledge, Preparation for Decision-Making and Acceptability questionnaires. We then used descriptive statistics to compare the DCS scores before and after distributing the decision aid. Results The median age of the 40 participants was 72 years (range, 65-86 years), 38% less than 70, 48% between 70 and 80 and 15% over 80. Ethnicity included 53% Caucasians and the remaining 48% African-Americans, Asians, Europeans, and others. Thirty-three percent completed high school, 25% college/university, and 7.5% elementary education. Seventy-eight percent had T1 and 23% T2 breast cancer. Thirty-three percent completed RT less than one year prior to the study, 30% between one to two years, and 38% greater than two years. The median pre-DA DCS score was 31.2 (31.2-90.6), and the median post-DA DCS score was 23.4 (0-75.0). Six (6/40) patients scored 0 on the DCS post intervention, while 13 (13/40) scored less than 15.6. The median knowledge score was 70%. Preparation for decision-making median score was 90%. Ninety-nine percent stated that the DA was useful for future patients.  Conclusion We piloted a DA that aimed to provide the necessary information for women aged 65 years and older with low-risk breast cancer, to understand radiation treatment options post lumpectomy. The results obtained from the study highlighted the utility of the DA in increasing patient comprehension about the different treatment options, reducing decisional conflict in terms of perceptions of uncertainty and preparing patients to engage with their radiation oncologist during the treatment decision-making process. Ultimately, this study promoted the importance of patient-centered care in geriatric oncology by piloting this DA to see its effectiveness while also being responsive to patient's thoughts regarding the tool, so as to have their values guide its further development.

Prostate high dose-rate brachytherapy as monotherapy for low and intermediate risk prostate cancer: Efficacy results from a randomized phase II clinical trial of one fraction of 19 Gy or two fractions of 13.5 Gy

BACKGROUND AND PURPOSE

High dose-rate (HDR) brachytherapy as monotherapy is a treatment option for localized prostate cancer, but optimal dose and fractionation is unknown. We report efficacy results of a randomized phase II trial of HDR monotherapy delivered as either one or two fractions.

MATERIALS AND METHODS

Eligible patients had low or intermediate risk prostate cancer, prostate volume <60 cc, and no androgen deprivation use. 170 patients were randomized to receive HDR as either a single fraction of 19 Gy or as two fractions of 13.5 Gy one week apart. Median age was 65 years, median PSA was 6.33 ng/ml, and Grade Group 1, 2 and 3 was present in 28%, 60%, and 12%, respectively. There was no difference in baseline factors between arms and 19%, 51% and 30% had low risk, favourable intermediate and unfavourable intermediate risk disease, respectively. The Phoenix definition was used to define biochemical failure, all local failures were confirmed by biopsy and toxicity was assessed using CTCAE v.4.

RESULTS

Median follow-up was 60 months. PSA decreased more quickly in the 2-fraction arm (p = 0.009). Median PSA at 5-years was 0.65 ng/ml in the single fraction and 0.16 ng/ml in the 2-fraction arm. The 5-year biochemical disease-free survival and cumulative incidence of local failure was 73.5% and 29% in the single fraction arm and 95% (p = 0.001) and 3% (p < 0.001) in the 2-fraction arm, respectively. Recurrence was not associated with initial stage, grade group, or risk group. Grade 2 late rectal toxicity occurred in 1% while the incidence of grade 2 and 3 urinary toxicity was 45% and 1%, respectively, with no difference between arms.

CONCLUSIONS

HDR monotherapy delivered as two fraction of 13.5 Gy is well tolerated with a high cancer control rate at 5 years. Single fraction monotherapy is inferior and should not be used.

Gait Speed vs. VES-13: A Pilot Study Comparing Screening Tools to Determine the Need for a Comprehensive Geriatric Assessment in Senior Women with Breast Cancer

BACKGROUND/OBJECTIVES

Patients aged 70 years and older may be suboptimally treated with cancer therapy because of the lack of clinical trial data in this population. The Comprehensive Geriatric Assessment can be time consuming, and access to geriatricians is limited. This study aims to determine whether gait speed (GS) analysis is equivalent to the widely accepted Vulnerable Elders Survey 13 (VES-13) in identifying vulnerable or frail patients in need of a Comprehensive Geriatric Assessment.

METHODS

A pilot prospective cohort study was carried out at a tertiary cancer centre in Toronto, Canada, in a radiation oncology breast follow-up clinic. GS analysis and VES-13 were completed by each patient at the same clinic visit. GS of <1 meter/second (m/s) and VES-13 score ≥3 were considered abnormal. Sensitivity, specificity, positive and negative predictive values, and Kappa characteristic were calculated for GS compared with VES-13.

RESULTS AND DISCUSSION

Twenty-nine participants aged 70 years and older with any stage of breast cancer were included. The GS was 67% sensitive and 95% specific for abnormal VES-13 scores. The GS had an 86% positive predictive value and 86% negative predictive value for abnormal scores on VES-13. Overall, the GS showed a substantial strength of agreement with the VES-13 (kappa 0.66, P < .0001).

CONCLUSION

The GS analysis compared very well with VES-13 scores, and this may be a reasonable alternative to VES-13 screening. This pilot data warrant further study in a larger group of patients.

Results of 15 Gy HDR-BT boost plus EBRT in intermediate-risk prostate cancer: Analysis of over 500 patients

PURPOSE/OBJECTIVE

To report biochemical control associated with single fraction 15 Gy high-dose-rate brachytherapy (HDR-BT) boost followed by external beam radiation (EBRT) in patients with intermediate-risk prostate cancer.

MATERIALS AND METHODS

A retrospective chart review of all patients with intermediate-risk disease treated with a real-time ultrasound-based 15 Gy HDR-BT boost followed by EBRT between 2009 and 2016 at a single quaternary cancer center was performed. Freedom from biochemical failure (FFBF), cumulative incidence of androgen deprivation therapy use for biochemical or clinical failure post-treatment (CI of ADT) and metastasis-free survival (MFS) outcomes were measured.

RESULTS

518 patients met the inclusion criteria for this study. Median age at HDR-BT was 67 years (IQR 61-72). 506 (98%) had complete pathologic information available. Of these, 146 (28%) had favorable (FIR) and 360 (69%) had unfavorable (UIR) intermediate-risk disease. 83 (16%) received short course hormones with EBRT + HDR. Median overall follow-up was 5.2 years. FFBF was 91 (88-94)% at 5 years. Five-year FFBF was 94 (89-99)% and 89 (85-94)% in FIR and UIR patients, respectively (p = 0.045). CI of ADT was 4 (2-6)% at 5 years. Five-year CI of ADT was 1 (0-3)% and 5 (2-8)% in FIR and UIR patients, respectively (p = 0.085). MFS was 97 (95-98)% at 5 years. Five-year MFS was 100 (N/A-100)% and 95 (92-98)% in FIR and UIR patients, respectively (p = 0.020).

CONCLUSION

In this large cohort of intermediate-risk prostate cancer patients, 15 Gy HDR-BT boost plus EBRT results in durable biochemical control and low rates of ADT use for biochemical failure.

Mentorship in Medicine and Other Health Professions

Mentoring skills are valuable assets for academic medicine and allied health faculty, who influence and help shape the careers of the next generation of healthcare providers. Mentors are role models who also act as guides for students' personal and professional development over time. Mentors can be instrumental in conveying explicit academic knowledge required to master curriculum content. Importantly, they can enhance implicit knowledge about the "hidden curriculum" of professionalism, ethics, values, and the art of medicine not learned from texts. In many cases, mentors also provide emotional support and encouragement. It must be noted that to be an effective mentor, one must engage in ongoing learning in order to strengthen and further mentoring skills. Thus, learning communities can provide support, education, and personal development for the mentor. The relationship benefits mentors as well through greater productivity, career satisfaction, and personal gratification. Maximizing the satisfaction and productivity of such relationships entails self-awareness, focus, mutual respect, and explicit communication about the relationship. In this article, the authors describe the development of optimal mentoring relationships, emphasizing the importance of different approaches to mentorship, roles of the mentors and mentees, mentor and mentee benefits, interprofessional mentorships for teams, gender and mentorship, and culture and mentorship.

Clinical and Cost-effectiveness of a Comprehensive geriatric assessment and management for Canadian elders with Cancer-the 5C study: a study protocol for a randomised controlled phase III trial

INTRODUCTION

Geriatric assessment and management is recommended for older adults with cancer referred for chemotherapy but no randomised controlled trial has been completed of this intervention in the oncology setting.

TRIAL DESIGN

A two-group parallel single blind multi-centre randomised trial with a companion trial-based economic evaluation from both payer and societal perspectives with process evaluation.

PARTICIPANTS

A total of 350 participants aged 70+, diagnosed with a solid tumour, lymphoma or myeloma, referred for first/second line chemotherapy, who speak English/French, have an Eastern Collaborative Oncology Group Performance Status 0-2 will be recruited. All participants will be followed for 12 months.

INTERVENTION

Geriatric assessment and management for 6 months. The control group will receive usual oncologic care. All participants will receive a monthly healthy ageing booklet for 6 months.

OBJECTIVE

To study the clinical and cost-effectiveness of geriatric assessment and management in optimising outcomes compared with usual oncology care.

RANDOMISATION

Participants will be allocated to one of the two arms in a 1:1 ratio. The randomisation will be stratified by centre and treatment intent (palliative vs other).

OUTCOME

Quality of life.

SECONDARY OUTCOMES

(1) Cost-effectiveness, (2) functional status, (3) number of geriatric issues successfully addressed, (4) grades3-5 treatment toxicity, (5) healthcare use, (6) satisfaction, (7) cancer treatment plan modification and (8) overall survival.

PLANNED ANALYSIS

For the primary outcome we will use a pattern mixture model using an intent-to-treat approach (at 3, 6 and12 months). We will conduct a cost-utility analysis alongside this clinical trial. For secondary outcomes 2-4, we will use a variety of methods.

ETHICS AND DISSEMINATION

Our study has been approved by all required REBs. We will disseminate our findings to stakeholders locally, nationally and internationally and by publishing the findings.

TRIAL REGISTRATION NUMBER

NCT03154671.

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