A. Choflet

Pelvic Radiation and Normal Tissue Toxicity

Radiation is a component of treatment for many pelvic malignancies, most often originating in the gynecologic, gastrointestinal, and genitourinary systems. Therefore, the management of acute and long-term side effects is an important part of practice as a radiation oncologist, and limiting morbidity is a primary goal. Toxicities vary and are dependent on treatment techniques. Advances in radiation delivery, imaging, and knowledge of underlying biologic determinants of radiation-induced normal tissue toxicity can guide treatment of acute and long-term side effects from pelvic radiation.

Evaluation of classification and regression tree (CART) model in weight loss prediction following head and neck cancer radiation therapy

Objective We explore whether a knowledge–discovery approach building a Classification and Regression Tree (CART) prediction model for weight loss (WL) in head and neck cancer (HNC) patients treated with radiation therapy (RT) is feasible. Methods and materials HNC patients from 2007 to 2015 were identified from a prospectively collected database Oncospace. Two prediction models at different time points were developed to predict weight loss ≥5 kg at 3 months post-RT by CART algorithm: (1) during RT planning using patient demographic, delineated dose data, planning target volume–organs at risk shape relationships data and (2) at the end of treatment (EOT) using additional on-treatment toxicities and quality of life data. Results Among 391 patients identified, WL predictors during RT planning were International Classification of Diseases diagnosis; dose to masticatory and superior constrictor muscles, larynx, and parotid; and age. At EOT, patient-reported oral intake, diagnosis, N stage, nausea, pain, dose to larynx, parotid, and low-dose planning target volume–larynx distance were significant predictive factors. The area under the curve during RT and EOT was 0.773 and 0.821, respectively. Conclusions We demonstrate the feasibility and potential value of an informatics infrastructure that has facilitated insight into the prediction of WL using the CART algorithm. The prediction accuracy significantly improved with the inclusion of additional treatment-related data and has the potential to be leveraged as a strategy to develop a learning health system.

Development of an evidence-based strategy to assess and manage substance use in oncology patients

Background This project will empower cancer patients to address their substance use by establishing an evidence-based strategy for identifying and managing substance use during cancer treatment. The question is: Does the proactive identification and management of substance use in oncology patients improve specific patient outcomes such as quality of life, treatment adherence, and reduction in treatment complications? A multidisciplinary team identified substance use as a contributing factor in several adverse patient outcomes. Further research revealed that there are currently no evidence-based standards to guide the care of patients with alcohol and illicit substance use (AISU) who are diagnosed with cancer. AISU during cancer treatment significantly worsens quality of life outcomes, including problems with pain, sleep, dyspnea, total distress, anxiety, coping, shortness of breath, diarrhea, poor emotional functioning, fatigue and poor appetite[1-4]. AISU in cancer patients may also cause significant safety risks in the short and long term[5-9] and increased mortality [10]. After completing a literature review and an exhaustive needs assessment, the team developed a program to implement Screening, Brief Intervention, and Referral to Therapy (SBIRT) in the outpatient radiation oncology department. The implementation plan includes motivational interviewing training, clinical pathways, and risk-based intervention toolkits that will incorporate oncology-specific resources. Conclusions AISU in cancer patients is a threat to safety and quality of life, and patients who use substances during cancer treatment represent an opportunity to improve wellness in a vulnerable population. A program that incorporates the use of SBIRT as part of routine patient care should improve both cancer-specific and all-cause patient outcomes and is critical to patient safety.

Real-time management of incident learning reports in a radiation oncology department

PURPOSE The optimal approach to managing incident learning system (ILS) reports remains unclear. Here, we describe our experience with prospective coding of events reported to the ILS with comparisons of risk scores on the basis of event type and process map location. METHODS AND MATERIALS Reported events were coded by type, origin, and method of discovery. Events were given a risk priority number (RPN) and near-miss risk index (NMRI) score. We compared workflow versus near-miss events with respect to origin and detection in the process map and by risk scores. A χ2 test was used to compare the differences between workflow and near-miss events. A comparison of RPN scores was done by independent t test. RESULTS During 2016, 1351 events were reported. Of these events, 1300 (96.2%) were workflow and 51 (3.8%) near-miss events. Workflow events were more likely to both originate (1041 of 1300 events; 81.2%) compared with near-miss events (31 of 51 events; 62.7%; P = .005) and be detected in pre-treatment (997 of 1300 events; 76.7%) compared with near-miss events (24 of 51 events; 47%; P < .001). Average occurrence (scale: 1-10) was 6.14 for workflow versus 3.33 for near-miss events (P < .001), average severity was 2.94 versus 7.35 (P < .001), and average detectability was 1.33 versus 4.67 (P < .001). Mean overall RPN was 22.4 for workflow versus 108.4 for near-miss events (P = .07) and mean NMRI was 1.16 versus 3.19, respectively. Events that originated and were detected in treatment delivery had the greatest mean overall RPN (38.2 and 32.1, respectively) and NMRI scores (1.62 and 1.6, respectively). CONCLUSIONS Our experience demonstrates that workflow event reports are far more common than near-misses and that near-miss events are more likely to both originate and be discovered in later treatment phases. The frequency of workflow reports highlights the imperative need for safety and operational teams to work collaboratively to maximize the benefit of ILS. We suggest a potential utility of the RPN system to guide mitigation strategies for future near-miss events.

Interventional Radiation Oncology (IRO): Transition of a magnetic resonance simulator to a brachytherapy suite

PURPOSE As a core component of a new gynecologic cancer radiation program, we envisioned, structured, and implemented a novel Interventional Radiation Oncology (IRO) unit and magnetic resonance (MR)-brachytherapy environment in an existing MR simulator. METHODS AND MATERIALS We describe the external and internal processes required over a 6-8 month time frame to develop a clinical and research program for gynecologic brachytherapy and to successfully convert an MR simulator into an IRO unit. RESULTS Support of the institution and department resulted in conversion of an MR simulator to a procedural suite. Development of the MR gynecologic brachytherapy program required novel equipment, staffing, infrastructural development, and cooperative team development with anesthetists, nurses, therapists, physicists, and physicians to ensure a safe and functional environment. Creation of a separate IRO unit permitted a novel billing structure. CONCLUSIONS The creation of an MR-brachytherapy environment in an MR simulator is feasible. Developing infrastructure includes several collaborative elements. Unique to the field of radiation oncology, formalizing the space as an Interventional Radiation Oncology unit permits a sustainable financial structure.

Cancer, Alcohol, and Aging

Since 1988, alcohol has been classified as a carcinogen and has been attributed to almost seven million deaths per year, the majority of which occur in those 65 years of age and older. Adults 65 years of age or older with a history of at-risk alcohol use over their life time, particularly those with a history of tobacco use, should be routinely screened for alcohol-related cancers. Understanding the relationship between the metabolism of alcohol and cancer is essential knowledge for health care providers who care for older adults. In addition, applying appropriate interventions for older adults experiencing alcohol-associated cancers can assist with decreased alcohol use and pain management.

Prevalence of Substance Use in Patients With Cancer Receiving Radiation Therapy

BACKGROUND Individuals with cancer and risky alcohol and illicit substance use (AISU) are more likely to suffer diminished quality of life and subpar treatment outcomes. The prevalence of AISU in patients with cancer is poorly understood. OBJECTIVES This article reports on the results of a needs assessment to quantify AISU in individuals with cancer seeking care in the radiation oncology department of a large, academic medical center. METHODS Medical records were reviewed for all patients seen in the radiation oncology department in a one-week (five-day) period in the fall of 2014 (N = 397). Demographic and prevalence data were analyzed. FINDINGS The prevalence rates of AISU in this sample were slightly lower than estimates for the general population and inconsistency was noted in the documentation of relevant information. Despite the limitations, data analyses suggested that a significant percentage of patients receiving radiation therapy for cancer diagnoses exhibited substance use patterns that placed them at increased risk for negative short- and long-term outcomes. The findings support the need for systematic substance use screening, assessment, and risk-based interventions as an essential component of comprehensive cancer care.