National Survey of Oncologists' Knowledge, Attitudes, and Practice Behaviors: Caring for Cancer Patients Experiencing Incarceration

Cancer is the leading cause of illness-related death in state prisons in the United States. The experiences of physicians providing oncological care to individuals experiencing incarceration are underexplored. The study aims were to evaluate knowledge, attitudes, and practices of oncologists caring for cancer patients who are incarcerated. An online survey was distributed to a random sample of 150 oncologists from the American Society of Clinical Oncology and the American Society for Radiation Oncology from July 2020 to December 2021. Statistical analyses included two proportion Z-test, Fisher's exact test, Kruskal-Wallis test, and Cramer's V to estimate factors associated with attitudes and barriers to care. Of the 55 respondents (36.7% response rate), 21 were medical oncologists and 34 were radiation oncologists. Academic center oncologists were more likely to report caring for incarcerated patients than community or private practice oncologists (p = .04). Most (53%) incorrectly reported "heart disease" as the leading cause of death, as opposed to "cancer" (15% identified correctly). Oncologists practicing at both academic and community centers were more likely to report care coordination barriers than oncologists at academic or community centers (p < .01). We identified potential barriers in caring for incarcerated cancer patients. Future studies should explore ways to improve care coordination between oncology teams and prisons.

Palliative Care among Incarcerated Populations: A National Survey of Radiation Oncologists' Perspectives and Experiences

PURPOSE/OBJECTIVE(S)

Incarcerated individuals carry a high disease burden, including cancer which is now the leading cause of illness-related deaths. Disparities in access to screening, care coordination, timely treatment, and comorbidities have been identified as contributors to late-stage diagnosis and poor cancer-related outcomes. As the first of its kind, we assessed oncologists' knowledge, attitudes, and practices (KAP) in providing cancer care to incarcerated patients.

MATERIALS/METHODS

A KAP survey on incarcerated patients with cancer was developed and piloted with volunteer radiation oncologists. Following IRB approval, the KAP survey questionnaire included physicians' demographics and Likert scale questions on practice patterns and experiences caring for incarcerated patients. The survey was distributed to 150 medical and radiation oncologists randomly selected from national societies' membership directories (ASTRO and ASCO). Data collection took place from 7/2020-12/2021, and descriptive statistics were used for analysis.

RESULTS

Of the 75 surveyed radiation oncologists (RO), 34 responded with a response rate of 45% among the specialty cohort. Most RO (59%) incorrectly identified "heart disease" as the leading cause of death among incarcerated patients, followed by "substance use disorder" (19%); only 9% correctly reported "cancer" as the leading cause of death. Most RO reported caring for a patient who underwent cancer treatment while incarcerated (70%) or recently incarcerated (within 6 months of release; 63%). 38% (n = 10/26) indicated incarcerated patients presented with delayed diagnosis at consultation. 58% (n = 14/24) reported that ≥50% of their patients who were incarcerated presented with cancer-related pain, and 82% (n = 18/22) indicated that ≥50% of their patients had a history of opioid use disorder. Yet 38% (n = 9/24) reported their clinic adequately treated cancer-related pain for incarcerated patients, while 54% (n = 13/24) reported their clinic needed improvement.

CONCLUSION

Most radiation oncologists have experience providing cancer care for incarcerated patients and acknowledge disparities in later-stage disease presentation in this patient population. Interventions are needed to ensure cancer-related pain is appropriately managed among patients experiencing incarceration. Further studies are required to understand practice patterns and ensure equitable cancer treatment for carceral populations.

Radiation Oncology residency training program integration of diversity, equity, and inclusion: An Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee (ARRO EISC) inaugural program director survey

PURPOSE

To investigate United States (US) radiation oncology (RO) program directors' (PDs) attitudes and practices regarding racial/ethnic diversity, equity, and inclusion (DEI) to better understand potential impact on underrepresented in medicine (UIM) residents in RO.

METHODS AND MATERIALS

A 28-item survey was developed using the validated Ethnic Harassment Experiences Scale and the Daily Life Experiences subscale, as well as input from DEI leaders in RO. The survey was IRB-approved and administered to RO PDs. PDs were provided with the American Association of Medical Colleges (AAMC) definition of underrepresented in medicine (UIM), that is "Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population." Descriptive statistics were used in analysis.

RESULTS

The response rate was 71% (64/90). Institutional Culture and Beliefs: 42% responded that they had a department DEI director. A minority (17%, N=11) agreed "I believe that people from UIM backgrounds have equal access to quality tertiary education in the US." The majority (97%, N=62) agreed "My program values residents from UIM backgrounds." Support and Resources: Majority (78%, N=50) agreed "My program has resources in place to assist/provide support for resident physicians from UIM backgrounds." Interview and Recruitment: Most PDs (53%) had not taken part in activities aimed at recruiting UIM residents and 17% had interviewed no UIM applicants in the past 5 years for residency. Resident experiences of Racism: 17% (N=11) agreed "UIM residents in my program have reported incidents of racism to me," and 28% (N=18) agreed "I believe that UIM residents in my program have been treated differently because of their race/ethnicity by faculty, staff, co-residents or patients.".

CONCLUSION

Most PDs reported that they did not believe that UIM residents were treated differently in their department because of their race/ethnicity, and only a minority had received reports of racial discrimination experienced by residents. These data are in contrast to resident experiences, and suggest a disconnect between DEI perceptions and resident experiences among US RO PDs that should be addressed through increased programmatic action and evaluation.

Tailored Mentorship for the Underrepresented and Allies in Radiation Oncology: The Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee Mentorship Experience

PURPOSE

There are limited opportunities for mentorship for underrepresented in medicine (URM) trainees and physicians in radiation oncology (RO). The purpose of this study was to create and evaluate a formal mentorship program open to URMs and allies with interests in diversity, equity, and inclusion.

METHODS AND MATERIALS

A mentorship program incorporating a virtual platform was designed by the Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee. It was structured to include 6 sessions over 6 months with matched mentor-mentee pairs based on responses to a publicized online interest form. A compilation of evidence-based guidelines was provided to optimize the mentorship relationship. Linked pre- and postprogram surveys were administered to collect demographic data, define baseline goals and level of support, and evaluate program satisfaction.

RESULTS

Thirty-five mentor-mentee pairs were matched; 31 mentees completed the preprogram survey and 17 completed the postprogram survey. Preprogram, only 3 mentees (9.7%) reported satisfaction with current mentorship and 5 (16%) reported mechanisms or mentorship in place at their program to support URMs. On the postprogram survey, mentees reported high satisfaction with areas of mentorship, mentor attributes, and the program overall. Opportunities for improvement include implementation of mechanisms to enhance communication with mentor-mentee pairs and maintain longitudinal engagement.

CONCLUSIONS

In the first tailored mentorship program in RO for URMs and those with diversity, equity, and inclusion interests, our results demonstrate that there is self-reported interest for better mentorship for URMs in RO, and that a nationwide structured mentorship program can address participants' goals with high satisfaction. Program expansion could provide URMs and allies in RO more opportunities for career development and promote a greater sense of community and inclusion within the field.

Using health insurance claims data to assess long-term disease progression in a prostate cancer cohort

BACKGROUND

Long-term population-based cohort studies of men diagnosed with prostate cancer are limited. However, adverse outcomes can occur many years after treatment. Herein, we aim to assess the utility of using claims data to identify prostate cancer progression 10-15 years after diagnosis.

METHODS

The study population was derived from the North Carolina-Louisiana Prostate Cancer Project (PCaP). PCaP-North Carolina (NC) included 1031 men diagnosed with prostate cancer from 2004 to 2009. An initial follow-up with a survey and manual medical record abstraction occurred from 2008 to 2011 (Follow-up 1). Herein, we extended this follow-up with linkage to healthcare claims data from North Carolina (2011-2017) and a second, supplementary 10-year follow-up survey (2018-2020) (Follow-up 2). Vital statistics data also were utilized. Long-term oncological progression was determined using these data sources in combination with expert clinical input.

RESULTS

Among the 1031 baseline PCaP-NC participants, 652 were linked to medical claims. Forty-two percent of the men had insurance coverage for the entire 72 months of follow-up. In addition, 275 baseline participants completed the supplementary 10-year follow-up survey. Using all sources of follow-up data, we identified a progression event in 259 of 1031 (25%) men with more than 10 years of follow-up data after diagnosis.

CONCLUSIONS

Understanding long-term clinical outcomes is essential for improving the lives of prostate cancer survivors. However, access and utility of long-term clinical outcomes with claims alone remain a challenge due to individualized agreements required with each insurer for data access, lack of detailed clinical information, and gaps in insurance coverage. We were able to utilize claims data to determine long-term progression due to several unique advantages that included the availability of detailed baseline clinical characteristics and treatments, detailed manually abstracted clinical data at 5 years of follow-up, vital statistics data, and a supplementary 10-year follow-up survey.

Cancer in sub-Saharan Africa: a Lancet Oncology Commission

In sub-Saharan Africa (SSA), urgent action is needed to curb a growing crisis in cancer incidence and mortality. Without rapid interventions, data estimates show a major increase in cancer mortality from 520 348 in 2020 to about 1 million deaths per year by 2030. Here, we detail the state of cancer in SSA, recommend key actions on the basis of analysis, and highlight case studies and successful models that can be emulated, adapted, or improved across the region to reduce the growing cancer crises. Recommended actions begin with the need to develop or update national cancer control plans in each country. Plans must include childhood cancer plans, managing comorbidities such as HIV and malnutrition, a reliable and predictable supply of medication, and the provision of psychosocial, supportive, and palliative care. Plans should also engage traditional, complementary, and alternative medical practices employed by more than 80% of SSA populations and pathways to reduce missed diagnoses and late referrals. More substantial investment is needed in developing cancer registries and cancer diagnostics for core cancer tests. We show that investments in, and increased adoption of, some approaches used during the COVID-19 pandemic, such as hypofractionated radiotherapy and telehealth, can substantially increase access to cancer care in Africa, accelerate cancer prevention and control efforts, increase survival, and save billions of US dollars over the next decade. The involvement of African First Ladies in cancer prevention efforts represents one practical approach that should be amplified across SSA. Moreover, investments in workforce training are crucial to prevent millions of avoidable deaths by 2030. We present a framework that can be used to strategically plan cancer research enhancement in SSA, with investments in research that can produce a return on investment and help drive policy and effective collaborations. Expansion of universal health coverage to incorporate cancer into essential benefits packages is also vital. Implementation of the recommended actions in this Commission will be crucial for reducing the growing cancer crises in SSA and achieving political commitments to the UN Sustainable Development Goals to reduce premature mortality from non-communicable diseases by a third by 2030.

Radiotherapy resources in Africa: an International Atomic Energy Agency update and analysis of projected needs

The number of patients with cancer in Africa has been predicted to increase from 844 279 in 2012 to more than 1·5 million in 2030. However, many countries in Africa still lack access to radiotherapy as a part of comprehensive cancer care. The objective of this analysis is to present an updated overview of radiotherapy resources in Africa and to analyse the gaps and needs of the continent for 2030 in the context of the UN Sustainable Development Goals. Data from 54 African countries on teletherapy megavoltage units and brachytherapy afterloaders were extracted from the Directory for Radiotherapy Centres, an electronic, centralised, and continuously updated database of radiotherapy centres. Cancer incidence and future predictions were taken from the GLOBOCAN 2018 database of the International Agency for Research on Cancer. Radiotherapy need was estimated using a 64% radiotherapy utilisation rate, while assuming a machine throughput of 500 patients per year. As of March, 2020, 28 (52%) of 54 countries had access to external beam radiotherapy, 21 (39%) had brachytherapy capacity, and no country had a capacity that matched the estimated treatment need. Median income was an important predictor of the availability of megavoltage machines: US$1883 (IQR 914-3269) in countries without any machines versus $4485 (3079-12480) in countries with at least one megavoltage machine (p=0·0003). If radiotherapy expansion continues at the rate observed over the past 7 years, it is unlikely that the continent will meet its radiotherapy needs. This access gap might impact the ability to achieve the Sustainable Development Goals, particularly the target to reduce preventable, premature mortality by a third, and meet the target of the cervical cancer elimination strategy of 90% with access to treatment. Urgent, novel initiatives in financing and human capacity building are needed to change the trajectory and provide comprehensive cancer care to patients in Africa in the next decade.

A Paradigm Shift in Radiation Oncology Training

The coronavirus disease 2019 pandemic has been intertwined with the movement for racial justice in the United States and has highlighted and risks aggravating educational and workforce disparities within radiation oncology. We discuss wide-ranging changes within radiation oncology training that are essential to developing and maintaining diversity, including utilization of competency-based educational models that allow for streamlining of training and examinations; responsiveness to the needs of residents and medical students of different gender, racial/ethnic, and socioeconomic groups; and technological integration to increase educational efficiency and decrease barriers.

Global Health Perspectives Among Radiation Oncology Residency Program Directors: A Knowledge, Attitudes, and Practices Survey

PURPOSE

Interest in global health has risen among medical students applying to and residents training in radiation oncology, often outpacing available educational offerings. The Association of Residents in Radiation Oncology Global Health Subcommittee sought to determine the perceptions of program directors (PDs) in radiation oncology and their current or planned global health curricular opportunities.

METHODS AND MATERIALS

A standardized, Knowledge-Attitudes-Practices survey composed of 32 binary items was sent to PDs for all Accreditation Council for Graduate Medical Education-accredited radiation oncology programs.

RESULTS

The program response rate was 60% (55 of 91). Responding programs were distributed evenly geographically and included a range of training program sizes. Most PDs (77%) knew that most nations did not meet standard minimum benchmarks for radiation therapy access. Although 89% would support residents in pursuing global health rotations, only 22% would support departmental funding of such rotations. Furthermore, 94% believed that global health was a field worthy of an academic career, but only 39% believed that it had appropriate rigor. Only 8% of programs had dedicated global health rotations.

CONCLUSIONS

Radiation oncology PDs largely expressed favorable views of global health as a pursuit and affirmed a high degree of resident and medical student interest. However, faculty commitment and program offerings currently lag behind the interest level. In particular, a substantial number of PDs do not perceive global health to be a rigorous academic endeavor. Future progress in academic global health in radiation oncology will require strategies to systematically support pathways for the development of experience and scholarship both within and beyond residency.

328. Kaposi Sarcoma in High Population ART Utilization Setting: An Observational Study in Botswana

Background

Despite population antiretroviral treatment (ART) utilization exceeding UNAIDS 90-90-90 targets, Kaposi sarcoma (KS) remains one of the most prevalent malignancies in Botswana. We sought to examine the characteristics and outcomes of KS in the context of high ART utilization.

Methods

Consenting patients at one of four oncology centers for KS treatment were enrolled prospectively (October 2010 to March 2019) and followed quarterly for 5 years. Survival was estimated using Kaplan–Meier estimator and predictors assessed with Cox proportional hazards modeling.

Results

A total of 408 KS patients were enrolled and of those, 396 (97%) were HIV-positive and included in analyses. Median age at diagnosis was 40 years (IQR: 34.1, 46.7) and 247 patients (62%) were male. The median CD4 cell count at the time of KS diagnosis was 253 cells/mL (IQR: 134, 364) and 279 (73%) were receiving ART at the time of KS diagnosis. Among those on ART, the median duration of ART prior to KS diagnosis was 11.9 months (IQR: 2.7, 46.7). The proportion receiving ART prior to KS increased during the surveillance period from 58% to 80% (P < 0.001). Of the 248 (62.6%) patients with recent measurement, 91% had HIV-1 RNA < 1000 copies/mL. Five-year overall survival was 73% (95% CI 68–78%). In multivariable analysis, Female sex and higher income were associated with improved survival, but not age or CD4 cell count. The duration of ART was significantly associated with survival (P = 0.02), with improved survival for individuals on ART < 6 months compared with longer ART (HR 0.54; 95% CI 0.29–0.98). The incidence of KS cases declined by nearly 50%, but has remained relatively stable since 2015.

Conclusion

Survival rates in this cohort were comparable to other KS cohorts. While KS treatment initially declined with ART expansion, KS remains a significant disease burden in Botswana with 80% of cases occurring among individuals receiving ART.

Disclosures

All authors: No reported disclosures.

International Radiotherapy Referrals From Rural Rwanda: Implementation Processes and Early Clinical Outcomes

Purpose

Low- and middle-income countries disproportionately comprise 65% of cancer deaths. Cancer care delivery in resource-limited settings, especially low-income countries in sub-Saharan Africa, is exceedingly complex, requiring multiple modalities of diagnosis and treatment. Given the vast human, technical, and financial resources required, access to radiotherapy remains limited in sub-Saharan Africa. Through 2017, Rwanda has not had in-country radiotherapy services. The aim of this study was to describe the implementation and early outcomes of the radiotherapy referral program at the Butaro Cancer Centre of Excellence and to identify both successful pathways and barriers to care.

Methods

Butaro District Hospital is located in a rural area of the Northern Province and is home to the Butaro Cancer Centre of Excellence. We performed a retrospective study from routinely collected data of all patients with a diagnosis of cervical, head and neck, or rectal cancer between July 2012 and June 2015.

Results

Between 2012 and 2015, 580 patients were identified with these diagnoses and were potential candidates for radiation. Two hundred eight (36%) were referred for radiotherapy treatment in Uganda. Of those referred, 160 (77%) had cervical cancer, 31 (15%) had head and neck cancer, and 17 (8%) had rectal cancer. At the time of data collection, 101 radiotherapy patients (49%) were alive and had completed treatment with no evidence of recurrence, 11 (5%) were alive and continuing treatment, and 12 (6%) were alive and had completed treatment with evidence of recurrence.

Conclusion

This study demonstrates the feasibility of a rural cancer facility to successfully conduct out-of-country radiotherapy referrals with promising early outcomes. The results of this study also highlight the many challenges and lessons learned in providing comprehensive cancer care in resource-limited settings.

Global palliative radiotherapy: a framework to improve access in resource-constrained settings

Radiotherapy is an essential component of cancer therapy. Lack of access to radiotherapy in less-developed countries prevents its use for both cure and symptom relief, resulting in a significant disparity in patient suffering. Several recent initiatives have highlighted the need for expanded access to both palliative medicine and radiotherapy globally. Yet, these efforts have remained largely independent, without attention to overlap and integration. This review provides an update on the progress toward global palliative radiotherapy access and proposes a strategic framework to address further scale-up. Synergies between radiotherapy, palliative medicine, and other global health initiatives will be essential in bringing palliative radiotherapy to patients around the globe.