Conventional four-field pelvic radiotherapy technique without computed tomography-treatment planning in cancer of the cervix: potential geographic miss and its impact on pelvic control

PURPOSE

To evaluate the impact of inadequate margins on pelvic control using the conventional four-field pelvic portals without computed tomography (CT)-treatment planning.

METHODS AND MATERIALS

Between 1986 and 1991, 34 patients with invasive cancer of the cervix were eligible for outcome study of conventional four-field radiation therapy (10 Stage I, 16 Stage II, 8 Stage III). The eligibility for this study includes four-field pelvic technique, definitive radiation therapy, and diagnostic CT scan of the pelvis. For this study, an inadequate margin is arbitrarily defined as < or = 1.0 cm of normal tissue around the CT-defined tumor volume.

RESULTS

All 34 patients had adequate margins for anterio-posterior/posterio-anterior portals. However, 19 patients had an inadequate margin at the posterior border (S2-S3 interspace) and/or custom-shaped rectal block for lateral pelvic portals. Two patients had inadequate margins at the anterior border (level of symphysis pubis) due to an enlarged uterus. With a median follow-up of 36 months, pelvic control for adequate margins and inadequate margins was 100% and 71% for Stage IB disease and 88% and 50% for Stage IIB disease, respectively. However, pelvic control for Stage IIIB disease was 50% for both groups. There was no difference in total dose to point A or point B between the two groups.

CONCLUSION

Our preliminary data show higher local failure in patients with an inadequate margin. For four-field pelvic radiation therapy, we strongly recommend CT-treatment planning. Otherwise, anterio-posterior/posterio-anterior pelvic therapy is the most reliable treatment for cancer of the uterine cervix.

Gamma knife treatment of refractory cluster headache

Four men and two women were treated for refractory cluster headache by gamma knife radiosurgery of the trigeminal nerve root entry zone. The maximum dose of radiation was 70 Gy to the isocenter. Of five patients treated who had refractory chronic cluster headache and one with refractory episodic cluster headache, four had relief judged excellent. Of the two remaining patients with refractory chronic cluster headache, one had relief judged good and the other fair. Five of the six patients treated had relief within a few days to a week following gamma knife radiosurgery. Three with chronic cluster headache had remissions allowing cessation of all preventive and abortive medication. Although one patient experienced complete relief of chronic cluster headache, he continued to have migraine requiring medication. None of the patients treated developed significant postradiation side effects during a follow-up period of 8 to 14 months. The authors conclude that gamma knife radiosurgery of the trigeminal nerve affords great promise in the management of chronic and refractory cluster headache. The technique seemingly carries negligible short- and long- term risk.

Major geometric variations between multiple high-dose-rate applications of brachytherapy in cancer of the cervix: frequency and types of variation

PURPOSE

To evaluate major geometric variations in multiple intracavitary applications for carcinoma of the cervix.

MATERIALS AND METHODS

Orthogonal radiographs were reviewed of 17 consecutive patients with carcinoma of the cervix treated with 70 applications of high-dose-rate brachytherapy. In seven patients, conscious sedation was used for all applications. In 10 patients, general anesthesia was used for the first application and conscious sedation for subsequent applications. Major geometric variation between applications in axis, length, and slippage in tandem placement and separation, packing, and slippage in colpostats placement were reviewed. A major variation was defined as more than 1.0-cm deviation.

RESULTS

Major variations between applications occurred more commonly in colpostats placement than in tandem placement. For tandems, the rates of variation were 5.7% in axis, 4.3% in length, and 1.4% in slippage. For colpostats, rates of variation were 7.1% in separation, 25.7% in vaginal packing, and 7.1% in slippage. No consistent pattern of variation was found between applications except in vaginal packing.

CONCLUSION

Awareness of geometric variations should improve proper placement of intracavitary applicators for brachytherapy.

Outcomes of choroidal melanomas treated with eye physics plaques: A 25-year review

PURPOSE

To review long-term outcomes of the University of Southern California Plaque Simulator (PS) software and Eye Physics (EP) plaques. We hypothesize that the PS/EP system delivers lower doses to critical ocular structures, resulting in lower rates of radiation toxicity and favorable visual outcomes compared to Collaborative Ocular Melanoma Study plaques, while maintaining adequate local tumor control.

METHODS AND MATERIALS

Retrospective review of 133 patients treated for choroidal melanoma with ¹²⁵I brachytherapy, using PS software and EP plaques, from 1990 through 2015. A dose of 85 Gy at a rate of 0.6 Gy/h was prescribed to the tumor apex (with a typical margin of 2 mm) over 7 days. Primary outcomes were local tumor recurrence, globe salvage, and metastasis. Secondary outcomes were changes in visual acuity and radiation complications.

RESULTS

With median followup of 42 months, 5-year Kaplan-Meier estimated rates for tumor control, globe salvage, and metastatic-free survival were 98.3%, 96.4%, and 88.2%, respectively. Median doses to the macula and optic nerve were 39.9 Gy and 30.0 Gy, respectively. Forty-three percent of patients developed radiation retinopathy, and 20% developed optic neuropathy; 39% lost ≥6 Snellen lines of vision.

CONCLUSIONS

The PS/EP system is designed to improve the accuracy and conformality of the radiation dose, creating a steep dose gradient outside the melanoma to decrease radiation to surrounding ocular structures. We report favorable rates of local tumor control, globe salvage, metastases, and radiation complications when compared to the Collaborative Ocular Melanoma Study and other studies. Overall, the PS/EP system results in excellent tumor control and appears to optimize long-term visual and radiation-related outcomes after brachytherapy.

Conventional four-field pelvic radiotherapy technique without CT treatment planning in cancer of the cervix: potential geographic miss

The advantage of 4-field radiation to the pelvis is the use of lateral ports which spare the small bowel anteriorly and a portion of the rectum posteriorly from radiation. However, guidelines for the lateral pelvic ports are poorly defined. This is a comparative analysis to determine adequate margins by correlating conventional lateral pelvic treatment portals with CT defined tumor volume. The study included 52 patients treated definitively for carcinoma of the uterine cervix between 1986 and 1991. The most common site of inadequate margin (< or = 1.0 cm) was at the rectal block. The incidence of inadequate margin ranged from 39% to 50% and was independent of the stage of the disease except non-bulky stage IB disease. The next most common site was at the posterior border where frequency of inadequate margin for cervical tumor depended on stage with 8% of stage IB, 27% of stage IIB and 22% of stage IIIB/IVA disease. For the anterior border, an enlarged uterus was the only reason for inadequate margin rather than cervical tumor in 8% of stage IB, 18% of stage IIB, and 27% of stage IIIB/IVA disease. Without knowledge of precise tumor volume, the 4-field pelvic technique is potentially dangerous, risking underdosing of the tumor volume. For 4-field pelvic radiotherapy, we strongly recommend CT treatment planning.

Phase 1 Trial of SBRT to the Prostate Fossa After Prostatectomy

PURPOSE

The primary objective was to evaluate the maximum tolerated dose (within 10 weeks after treatment) associated with increasing hypofractionation to the prostate fossa (PF). We hypothesized that escalating the dose per fraction (fx) to the PF would have acceptable toxicity.

MATERIALS AND METHODS

Tested dose levels (DLs) were 3.6 Gy × 15 fx (DL1); 4.7 Gy × 10 fx (DL2); and 7.1 Gy × 5 fx (DL3). Escalation followed a 6 + 6 rules-based design with 12 patients required at the maximum tolerated dose. Dose-limiting toxicity was defined as grade (G) ≥3, gastrointestinal (GI) or genitourinary (GU) toxicity by National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.03). Patients completed quality-of-life questionnaires.

RESULTS

Twenty-four patients with indications for adjuvant or salvage radiation therapy (RT) enrolled (6 at DL1 and 2; 12 at DL3). All patients had at least 6 months of follow-up (median follow-up, 14.1 months). Four patients received concurrent androgen deprivation therapy. No G ≥ 3 GI or GU toxicity was seen at any DL; 2 of 6 patients in the DL1 group, 3 of 6 in DL2, and 7 of 12 in DL3 experienced G2 GI toxicity during RT. Except in 1 patient, all acute G2 GI toxicity resolved by 10 weeks. Three of 12 patients reported an increase to G1 and G2 GU toxicity in the 2 weeks after RT in groups DL1 and DL2 and 1 of 12 patients in DL3. At week 2 after RT, decline in the 26-item Expanded Prostate Cancer Index Composite bowel domain met criteria for a minimally important difference in 71% of patients. At week 10, 1 of 6, 2 of 6, and 7 of 11 patients at DLs 1, 2, and 3, respectively, still met minimally important difference criteria. International Prostate Symptom Scores worsened 2 weeks after treatment but improved by 6 to 10 weeks.

CONCLUSIONS

Dose escalation up to 7.1 Gy × 5 fx to the PF was completed without acute G ≥ 3 toxicity. There was transient G2 rectal toxicity at all DLs during and immediately after RT. We must perform long-term follow-up and assessment of late toxicity of SBRT to the PF.

Quality assurance system to correct for errors arising from couch rotation in linac-based stereotactic radiosurgery

PURPOSE

The purpose of this project was the development of a quality assurance (QA) system that would provide geographically accurate targeting for linac-based stereotactic radiosurgery (LBSR).

METHODS AND MATERIALS

The key component of our QA system is a novel device (Alignment Tool) for expedient measurement of gantry and treatment table excursions (wobble) during rotation. The Alignment Tool replaces the familiar pencil-shaped pointers with a ball pointer that is used with the field light of the accelerator to indicate alignment of beam and target. Wobble is measured prior to each patient treatment and analyzed together with the BRW coordinates of the target by a spreadsheet. The corrections required to compensate for any imprecisions are identified, and a printout generated indicating the floor stand coordinates for each couch angle used to place the target at isocenter.

RESULTS

The Alignment Tool has an inherent accuracy of measurement better than 0.1 mm. The overall targeting error of our QA method, found by evaluating 177 target simulator films of 55 foci in 40 randomly selected patients, was 0.47 +/- 0.23 mm. The Alignment Tool was also valuable during installation of the floor stand and a supplemental collimator for the accelerator.

CONCLUSIONS

The QA procedure described allows accurate targeting in LBSR, even when couch rotation is imprecise. The Alignment Tool can facilitate the installation of any stereotactic irradiation system, and can be useful for annual QA checks as well as in the installation and commissioning of new accelerators.

Outcomes of medium choroidal melanomas treated with ruthenium brachytherapy guided by three-dimensional pretreatment modeling

PURPOSE

The Collaborative Ocular Melanoma Study (COMS) established iodine-125 (I-125) plaque brachytherapy for eye preserving treatment of medium-sized choroidal melanomas in the United States. Eye Physics I-125 plaque treatment modeled with Plaque Simulator (PS) software yields similar results to COMS. Herein, we report results from a series of 15 patients treated with ruthenium-106 (Ru-106) plaque brachytherapy using PS pretreatment modeling for plaque localization and dosimetry.

METHODS AND MATERIALS

Fifteen patients with medium-sized choroidal melanomas (2.84-5.5 mm in apical height and a basal diameter of 7.8-12.6 mm) treated with ruthenium brachytherapy from 2003 to 2005 were evaluated retrospectively. Baseline and followup data were evaluated for tumor height, best corrected visual acuity, radiation retinopathy, radiation optic neuropathy, postradiation cataract formation, diplopia, and ptosis. Tumor response for both Ru-106 and I-125 plaques planned using the same PS pretreatment modeling was evaluated and compared.

RESULTS

Isotope-specific radiation profiles were compared, and rates of local treatment failure (0%), optic neuropathy (6.7%), retinopathy (20%), and cataracts (33%) were evaluated. Five year-treated tumor heights were approximately 0.61 ± 0.29 (I-125, n = 16) and 0.53 ± 0.17 (Ru-106, n = 6) of their heights at diagnosis.

CONCLUSIONS

This patient subset had background characteristics very similar to those of the COMS and patients treated at our institution with I-125 plaques. Treatment response was equivalent although radiation complications occurred slightly less frequently in the Ru-106 group compared with those treated with I-125. Image-guided three-dimensional pretreatment modeling for plaque localization and dosimetry seems to work equally as well for Ru as for I-125 plaques and justifies more extensive investigation.

Resection of multiple pulmonary metastases from a recurrent intracranial meningioma

Surgical resection of multiple pulmonary metastases from a recurrent intracranial meningioma in a 53-year-old woman is presented. The primary tumor was diagnosed in 1984 and partially excised in early 1985. The tumor recurred and was re-excised in 1989 and 1992. A fourth intracranial recurrence was noted in 1993, accompanied by multiple bilateral pulmonary metastases. The metastases were excised using staged thoracotomies in July and September 1994. The patient is surviving with cranial tumor residual.

Safety-net versus private hospital setting for brain metastasis patients treated with radiosurgery alone: Disparities in follow-up care and outcomes

BACKGROUND

Stereotactic radiosurgery (SRS) alone is an increasingly accepted treatment for brain metastases, but it requires adherence to frequently scheduled follow-up neuroimaging because of the risk of distant brain metastasis. The effect of disparities in access to follow-up care on outcomes after SRS alone is unknown.

METHODS

This retrospective study included 153 brain metastasis patients treated consecutively with SRS alone from 2010 through 2016 at an academic medical center and a safety-net hospital (SNH) located in Los Angeles, California. Outcomes included neurologic symptoms, hospitalization, steroid use and dependency, salvage SRS, salvage whole-brain radiotherapy, salvage neurosurgery, and overall survival.

RESULTS

Ninety-three of the 153 patients were private hospital (PH) patients, and 60 were SNH patients. The median follow-up time was 7.7 months. SNH patients received fewer follow-up neuroimaging studies (1.5 vs 3; P = .008). In a multivariate analysis, the SNH setting was a significant risk factor for salvage neurosurgery (hazard ratio [HR], 13.65; P < .001), neurologic symptoms (HR, 3.74; P = .002), and hospitalization due to brain metastases (HR, 6.25; P < .001). More clinical visits were protective against hospitalizations due to brain metastases (HR, 0.75; P = .002), whereas more neuroimaging studies were protective against death (HR, 0.65; P < .001).

CONCLUSIONS

SNH patients with brain metastases treated with SRS alone had fewer follow-up neuroimaging studies and were at higher risk for neurologic symptoms, hospitalization for brain metastases, and salvage neurosurgery in comparison with PH patients. Clinicians should consider the practice setting and patient access to follow-up care when they are deciding on the optimal strategy for the treatment of brain metastases. Cancer 2018;124:167-75. © 2017 American Cancer Society.

Quantifying Subclinical and Longitudinal Microvascular Changes Following Episcleral Plaque Brachytherapy Using Spectral Domain-Optical Coherence Tomography Angiography

PURPOSE

To assess longitudinal microvascular changes in eyes treated with I-125 episcleral plaque brachytherapy (EPB).

METHODS

High resolution OCT angiograms of the central 3×3mm macula were obtained from I-125 episcleral plaque brachytherapy treated and untreated fellow eyes of 61 patients. Capillary density (vessel skeleton density, VSD) and caliber (vessel diameter index, VDI) were quantified using previously validated semi-automated algorithms. Nonperfusion was also quantified as flow impairment regions (FIR). Exams from treated and fellow eyes obtained pre-treatment and at 6-month, 1-year, and 2-year intervals were compared using generalized estimating equation linear models. Dosimetry maps were used to evaluate spatial correlation between radiation dose and microvascular metrics.

RESULTS

At 6 months, treated eyes had significantly lower VSD (0.145 ± 0.003 vs 0.155 ± 0.002; p = 0.009) and higher FIR (2.01 ± 0.199 vs 1.46 ± 0.104; p = 0.010) compared to fellow eyes. There was a significant decrease in VSD and a corresponding increase in FIR even for treated eyes without clinically identifiable retinopathy at 6 months. VDI was significantly higher in treated eyes than in fellow eyes at 2 years (2.92 ± 0.025 vs 2.84 ± 0.018; p < 0.001). When our cohort was categorized into low dose radiation (<15Gy) and high dose radiation (>45Gy) to the fovea, there were significant differences in VSD and FIR between groups.

CONCLUSIONS

OCTA can be used to quantify and monitor EPB induced retinopathy, and can detect vascular abnormalities even in the absence of clinically observable retinopathy. OCTA may therefore be useful in investigating treatment interventions that aim to delay EPB-induced radiation retinopathy.

Paradoxical labeling of radiosurgically treated quiescent tumors with Ki67, a marker of cellular proliferation

Ki67 (also known as MIB) is a monoclonal antibody staining agent, which is routinely used as a marker of cellular proliferation. It is used to evaluate the proliferative potential of malignant tumors, since it is thought to stain only those cells undergoing active division. The paradoxical elevation of the Ki67 labeling index observed in radiosurgically treated benign and malignant tumors is reported. Ten patients, who had previously undergone either linac or Gamma Knife radiosurgery, underwent surgical resection for a radiographically quiescent tumor. One patient underwent autopsy after dying from complications of radiosurgery. All were thought to be suffering from adverse radiation effect (ARE) and were refractory to conservative management. None were thought to have a recurrent tumor. All of the resected tumors were subjected to analysis with Ki67 staining. Despite the radiographic stability of the tumors, all manifested significantly elevated populations of cells exhibiting positivity for Ki67 antigen. This staining pattern would suggest a significant proliferative potential, which did not match the observed clinical course. The literature is reviewed and possible mechanisms to explain the paradoxical findings are presented.

Postsurgical recurrent carcinoma of the cervix: reassessment and results of radiation therapy options

PURPOSE

To evaluate outcome and reassess the radiation therapy options in pelvic recurrences of cervical cancer treated initially with surgery.

MATERIALS AND METHODS

In 30 patients, the prognostic factors analyzed for local control included site of recurrence (central, pelvic wall), tumor size, modality of radiation therapy, and radiation dose. Mean follow-up in survivors was 111.5 months.

RESULTS

Local control was attained in (a) nine of 20 patients with central recurrence and in two of 10 with pelvic wall recurrence (p = .25); (b) none of four who received less than 50 Gy, five of nine who received 50-60 Gy, and six of 17 who received greater than 60 Gy (p = .27); and (c) five of 11 with tumor smaller than 3 cm, five of nine with tumor size 3-6 cm, and one of 10 with tumor larger than 6 cm. Multivariate analysis revealed a significant benefit of local control on survival (P = .05). Median survival for patients with central recurrence was 14.5 months compared with 9 months for those with pelvic wall recurrence.

CONCLUSION

Local pelvic control depends on site and size of recurrence and radiation therapy modality and dose. Appropriate choice of brachytherapy modality is important. To improve local control and survival, more aggressive treatment is indicated, but attendant higher complications may be expected.

Use of the Toric Surgical Marker to Aid in Intraoperative Plaque Placement for the USC Eye Physics Plaques to Treat Uveal Melanoma: A New Surgical Technique

BACKGROUND AND OBJECTIVE

To describe a new surgical technique for intraoperative placement of Eye Physics (EP) plaques for uveal melanoma using a toric marker.

PATIENTS AND METHODS

A toric marker is designed for cataract surgery to align the axis of astigmatism; its use was modified in this protocol to mark the axis of suture coordinates as calculated by Plaque Simulator (PS) software.

RESULTS

The toric marker can be used to localize suture coordinates, in degrees, during intraoperative plaque placement. Linear marking using the toric marker decreases potential inaccuracies associated with the surgeon estimating 'clock-hours' by dot placement.

CONCLUSION

Use of the toric marker aided surgical placement of EP plaques. The EP planning protocol is now designed to display the suture coordinates either by clock-hours or degrees, per surgeon preference. Future research is necessary to determine whether routine use of the toric marker improves operative efficiency. [Ophthalmic Surg Lasers Imaging Retina. 2015;46:866-870.].

Identifying Disparities in Care in Treating Glioblastoma: A Retrospective Cohort Study of Patients Treated at a Safety-net Versus Private Hospital Setting

BACKGROUND

Patients of lower socioeconomic status (SES) may experience barriers to their oncologic care, but current data conflict over whether SES affects the prognosis of patients with glioblastoma (GB).

OBJECTIVE

We sought to determine whether SES disparities impaired delivery of neuro-oncologic care and affected the prognosis of GB patients.

METHODS

The records of GB patients treated from 2010 to 2014 at a safety-net hospital (SNH) or private hospital (PH), both served by 1 academic medical institution, were retrospectively reviewed and compared. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method.

RESULTS

A total of 55 SNH and 39 PH GB patients were analyzed with median 11-month follow-up. SNH patients were predominantly Hispanic, low income, enrolled in Medicaid, were less likely to receive radiation (89% vs. 100%), took longer to start radiation (41 vs. 29 days), and were less likely to complete radiation treatment (80% vs. 95%). Concurrent and adjuvant temozolomide use were also lower (85% vs. 94% and 60% vs. 71%, respectively). OS and PFS were not significantly different (15 vs. 16 months and 8 vs. 11 months, respectively). On multivariate analysis, adjuvant chemotherapy and RT completion predicted for better OS, whereas hospital type, income, and insurance did not.

CONCLUSION

Although GB patients at our SNH received less adjuvant treatment compared with PH, outcomes were similar. Access to multidisciplinary care staffed by academic physicians may play an important role in overcoming socioeconomic barriers to treatment availability and quality at SNHs.

Computerized tomography-based radiotherapy improves heterotopic ossification outcomes

PURPOSE

To report the impact of computerized tomography (CT) based radiotherapy (RT) on heterotopic ossification (HO) outcomes.

METHODS

This is a single institution, retrospective study of 532 patients who were treated for traumatic acetabular fractures (TAF). All patients underwent open-reduction internal-fixation (ORIF) of the TAF followed by RT for HO prophylaxis. Postoperative RT was delivered within 72h, in a single fraction of 7Gy. The patients were divided into 2 groups based on RT planning: CT (A) vs. clinical setup (B).

RESULTS

At a median follow up of 8years the incidence of HO was 21.6%. Multivariate regression analysis revealed that group (A) vs. (B) had HO incidence of 6.6% vs. 24.6% (p<0.001), respectively. Furthermore, HO Brooker grade ≥3 was observed in 2.2% vs. 10.8% (p=0.007) in group (A) vs. (B), respectively. Thus, the odds of developing HO and Brooker grades ≥3 were 4.7 and 4.5 times higher, respectively, in patients who underwent clinical setup.

CONCLUSION

Our data suggest that using CT based RT allowed more accurate delineation of the tissues and better clinical outcomes. Although CT-based RT is associated with additional cost the efficacy of CT-based RT reduces the risk of HO, thereby decreasing the need for additional surgical interventions.

Trends in Radiation Practices for Female Ocular Oncologists in North America: A Collaborative Study of the International Society of Ocular Oncology

Background

The aim of this study was to determine the known radiation exposure, attitudes, and consequent risk modifications among female ocular oncologists in North America who routinely administer radioactive plaque brachytherapy treatment and are members of the International Society of Ocular Oncology.

Methods

Nineteen female ocular oncologists completed an anonymous 17-question radiation exposure survey.

Results

Eleven of the participants chose to routinely wear lead protection during surgery; 8 did not. Fifteen of 19 participants reported using an unloaded "nonactive" template to prepare for plaque implantation. During pregnancy, 11 of 13 participants continued to perform plaque brachytherapy. Eight of these 11 undertook measures to decrease radiation exposure self-reported as lead wear and other. The average reported anxiety regarding fertility was 2.1 (SD, 2.2) on a scale from 1 to 10.

Conclusion

This study corroborates prior literature that surgeons' exposure to radiation during plaque brachytherapy is minimal. Nonetheless, there remains some anxiety regarding exposure risk to women, due to potential effects on fertility and fetal health. We found variability in exposure monitoring, required training, and precautions during pregnancy amongst this group of surgeons. Improved education and clearer pregnancy guidelines may equip female ocular oncologists with optimal knowledge regarding risk of radiation exposure.

Residency Match Trends, Racial Disparity, and Matching Amid a Pandemic

PURPOSE

Radiation oncology has been facing an evolving crisis in recruitment for several years, and the events of 2020 to 2021 will certainly add to that crisis with the urgency of addressing systemic racial injustice amid a global pandemic. The purpose of this study is to examine applicant data to gain insight on residency match trends and evaluate these findings within the backdrop of a novel match year.

METHODS AND MATERIALS

National Residency Matching Program (NRMP) data between 2009 and 2020 were assessed for the number of applicants, programs, and positions available, number of ranked applicants needed to fill positions, and successfully matched applicant data. Additionally, Electronic Residency Application Service data were evaluated for race/ethnicity identification among applicants.

RESULTS

The number of applicants who ranked radiation oncology as their preferred specialty has declined for 3 consecutive years from 223 in 2017 to 155 in 2020. In 2020 the applicant-to-position ratio was at an all-time low at 0.82, and the unmatched position rate increased to 18.5%. The percentage of Black or African American applicants applying to radiation oncology has also declined to 4.9%, and this population represents 7.2% of all applicants. The number of ranked applicants needed to fill the available radiation oncology PGY2 positions increased from 4.0 in 2010 to 6.0 in 2020.

CONCLUSION

Declining interest in radiation oncology among applicants, and an even further decline of black applicants, along with the challenges of interview and travel restrictions during the pandemic provide heightened concern for this year's match. Innovative efforts to expand the reach of radiation oncology to prospective applicants is needed to engage diverse, bright, and committed students for the continued progress of radiation oncology and most importantly, our patients.

Active surveillance: Do low-income patients adhere to the protocol?

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Background: Use of active surveillance (AS) in low-risk prostate cancer (PC) is up from 10% in 2006 to 40% in 2013 according to the CaPSURE registry. The data that provides evidence for the use of AS were among patients adhering to follow-up schedules. There are no data illustrating if patients not on a study follow through with their AS. Based on our experience at a large safety-net hospital with a multi-ethnic, low-income population and a nearby university-based hospital, we hypothesize that AS patients at a safety-net hospital fail to follow-up more frequently than those at a university-based hospital. Methods: We performed a retrospective chart review of patients with non-metastatic prostate cancer who initiated AS at Los Angeles County Hospital (LAC) and Norris Cancer Center (NCC) between 1/1/2008-1/1/2015. Competing-risks regression analyses were used to examine the difference in the rates of AS patients being lost to follow-up (LTFU) between the two institutions, as well as the association between LTFU and patient characteristics, with patients who ended AS due to any reasons treated as competing risks. Results: We found 116 patients at LAC and 90 patients at NCC who met the AS criteria of this study. Patients at both hospitals had similar tumor characteristics. Patients at LAC and NCC differed, however, in median income, race, primary language spoken, median miles residing from hospital, and mean percent that graduated from high school in their zip code. There was a statistically significant difference between the rates of AS patients being LTFU at the two institutions. After two years, 48% of patients at LAC were LTFU vs. 16% of AS patients at NCC. Patients stay on AS for a median of 7.4 months at LAC vs. 22.8 months at NCC. On multivariable analysis (MVA), patients at NCC were more likely to be LTFU if they had a lower household income. At LAC, the MVA found that patients that lived further from LAC were significantly more likely to adhere to AS. Conclusions: Patients undergoing AS at LAC were LTFU at a high rate. AS can only be an effective strategy if patients actually undergo surveillance. We need further investigation to evaluate whether we should recommend AS at safety-net hospitals.

The influence of pregnancy on heterotopic ossification post-displaced acetabular fractures surgical repair

Pregnancy is associated with maternal bone mineral density loss and modulation of calcium metabolism. We hypothesized that pregnancy may decrease the risk of heterotopic ossification (HO) after trauma. This is a single-institution, University of Mississippi Medical Center, retrospective study investigating the effect of pregnancy on the incidence HO after surgical repair (SR) of displaced acetabular fractures. Between January 1998 and 2010, 257 non-pregnant women (Group A) and 16 pregnant women (Group B) were identified. All the non-pregnant women received radiation therapy (RT) ± indomethacin. None of the pregnant women in group B received any prophylaxis. After a median follow-up of 6.6 years the incidence of HO in all patients was 27% (75/273). In Group A, non-pregnant, women who received RT ± indomethacin, 29% developed HO; HO risk was 0.4. In Group B, 16 pregnant patients, only one developed HO (6%); HO risk was 0.06. Thus, the risk of HO appears to be nearly six-fold higher in non-pregnant women despite prophylactic RT ± indomethacin. Our data suggest that pregnancy may be associated with a reduced risk of HO after SR of displaced acetabular fractures. Further analysis with a larger pregnant patient sample is necessary to confirm this finding.

Accreditation Program for Excellence (APEx): A Catalyst for Quality Improvement

PURPOSE

In 2014 the American Society for Radiation Oncology's Accreditation Program for Excellence (APEx) was created in response to the Target Safely campaign. APEx is a powerful tool to measure and drive quality improvement in radiation oncology practices.

METHODS AND MATERIALS

A task group from the American Society for Radiation Oncology's Practice Accreditation Committee was formed to provide an overview of the APEx accreditation program including analysis from specific program data.

RESULTS

Through initiatives encouraged by the APEx program, participants are able to evaluate teamwork and effectiveness, implement documented procedures aimed at improving quality and safety, and establish quality management at the practice. The program's Self-Assessment measures performance with program requirements and indicates where compliance lacks standardization. Methods to address these deficiencies form part of on-going quality improvement. These quality outcomes promote the delivery of safe, high-quality care.

CONCLUSION

The accreditation process through APEx is a commitment to an ongoing safety culture. Any worthwhile accreditation program should provide a meaningful assessment of practice operations, supply the tools to identify deficiencies and provide the opportunity to showcase growth and development. A commitment to completing APEx is a commitment to excellence for patients and all those who care for them.

The Cancer Bell: Too Much of a Good Thing?

PURPOSE

Patients around the world often ring a bell on the final day of radiation therapy (RT) to celebrate treatment completion. Patients appear to enjoy ringing the bell, but its psychological impact is unexamined. Applying a psychological principle named the "peak-end rule," we hypothesized that ringing the bell would improve patients' perceptions of the overall distress from cancer treatment.

METHODS AND MATERIALS

We enrolled 2 cohorts of patients completing definitive RT in a single-center outpatient radiation oncology clinic. Patients in the control arm completed treatment and filled out the survey mentioned below. A bell was then installed in the clinic, and patients in the intervention arm rang the bell on the final day of RT and filled out the same survey. Patients evaluated their overall distress from cancer treatment using a survey composed of an 11-point numerical rating scale in combination with the Verbal Rating Scale. At follow-up, a shorter survey was completed that asked the same questions about distress from cancer treatment.

RESULTS

Two hundred ten patients were enrolled, 107 in the bell group and 103 in the control group. One hundred sixty-three patients completed follow-up surveys, n = 86 (80%) and n = 77 (75%) in the bell and control groups, respectively. Demographics and treatment characteristics were well balanced. The bell group reported worse overall distress scores than those not ringing the bell (mean [standard deviation] 5.6 [2.8] vs 4.7 [2.7], P = .045). This difference worsened further at follow-up (6.4 [2.9] vs 5.1 [3.0], P = .009; mean 103 vs 130 days, P = .056).

CONCLUSIONS

Counter to our hypothesis, ringing the bell on the final day of RT worsens patients' evaluation of overall distress from cancer treatment, and this distress persists and even worsens in the months after treatment. Emotional arousal created by ringing the bell may magnify the distress from cancer treatment and subsequently worsen the perception of distress from treatment.