Charles R. Thomas

“Even if I Don’t Remember, I Feel Better”. A Qualitative Study of Patients with Early-Stage Non–Small Cell Lung Cancer Undergoing Stereotactic Body Radiotherapy or Surgery

RATIONALE While surgical resection is recommended for most patients with early stage lung cancer according to the National Comprehensive Cancer Network guidelines, stereotactic body radiotherapy is increasingly being used. Provider-patient communication regarding the risks and benefits of each approach may be a modifiable factor leading to improved patient-centered outcomes. OBJECTIVES To qualitatively describe the experiences of patients undergoing either surgery or stereotactic body radiotherapy for early stage non-small cell lung cancer. METHODS We qualitatively evaluated and used content analysis to describe the experiences of 13 patients with early clinical stage non-small cell lung cancer before undergoing treatment in three health care systems in the Pacific Northwest, with a focus on knowledge obtained, communication, and feelings of distress. MEASUREMENTS AND MAIN RESULTS Although most participants reported rarely having been told about other options for treatment and could not readily recall many details about specific risks of recommended treatment, they were satisfied with their care. The patients paradoxically described clinicians as displaying caring and empathy despite not explicitly addressing their concerns and worries. We found that the communication domains that underlie shared decision making occurred infrequently, but that participants were still pleased with their role in the decision-making process. We did not find substantially different themes based on where the participant received care or the treatment selected. CONCLUSIONS Patients were satisfied with all aspects of their care, despite reporting little knowledge about risks or other treatment options, no direct elicitation of worries from providers, and a lack of shared decision making. While the development of effective communication strategies to address these gaps is warranted, their effect on patient-centered outcomes, such as distress and decisional conflict, is unclear.

Timing of Thoracic Radiation Therapy With Chemotherapy in Limited-stage Small-cell Lung Cancer: Survey of US Radiation Oncologists on Current Practice Patterns

&NA; In this survey of 309 radiation oncologists in the United States on how they treat limited‐stage small‐cell lung cancer, respondents strongly aligned with guidelines, which recommend early concurrent chemoradiotherapy. However, there was disagreement about whether starting thoracic radiotherapy with cycle 1 of chemotherapy improved survival, and over one‐third of respondents treated based on pre‐chemotherapy volume, which might add unnecessary toxicity. Introduction: For limited‐stage small‐cell lung cancer (LS‐SCLC), National Comprehensive Cancer Network guidelines recommend that thoracic radiotherapy (TRT) be delivered concurrently with chemotherapy and early in the regimen, with cycle 1 or 2. Evidence is conflicting regarding the benefit of early timing of TRT. A Korean randomized trial did not see a survival difference between early (cycle 1) and late (cycle 3) TRT. Current United States (US) practice patterns are unknown. Materials and Methods: We surveyed US radiation oncologists using an institutional review board‐approved online questionnaire. Questions covered treatment recommendations, self‐rated knowledge of trials, and demographics. Results: We received 309 responses from radiation oncologists. Ninety‐eight percent recommend concurrent chemoradiotherapy over sequential. Seventy‐one percent recommend starting TRT in cycle 1 of chemotherapy, and 25% recommend starting in cycle 2. In actual practice, TRT is started most commonly in cycle 2 (48%) and cycle 1 (44%). One‐half of respondents (54%) believe starting in cycle 1 improves survival compared with starting in cycle 3. Knowledge of the Korean trial was associated with flexibility in delaying TRT to cycle 2 or 3 (P = .02). Over one‐third (38%) treat based on pre‐chemotherapy volume. Conclusion: US radiation oncologists strongly align with National Comprehensive Cancer Network guidelines, which recommend early concurrent chemoradiotherapy. Nearly three‐quarters of respondents prefer starting TRT with cycle 1 of chemotherapy. However, knowledge of a trial supporting a later start was associated with flexibility in delaying TRT. Treating based on pre‐chemotherapy volume—endorsed by over one‐third of respondents—may add unnecessary toxicity. This survey can inform development of future trials.

Auto-segmentation of the brachial plexus assessed with TaCTICS – A software platform for rapid multiple-metric quantitative evaluation of contours

Segmentation of organs-at-risk (OARs) remains a highly variable yet critical operator-dependent step in radiation planning [1]. With the increased conformality of intensity-modulated radiotherapy (IMRT) delivery, the ability to spare OARs is markedly increased, enabling more targeted treatment with sparing of specific tissues. However, manual segmentation of target volumes and OARs remains highly variable. For this reason, auto-segmentation approaches are attractive mechanisms to potentially reduce inter-observer region of interest (ROI) variation [2,3], allow assessment of OARs that might otherwise be subject to beam path toxicities [3,4] and improve workflow-time parameters [4-6]. Auto-segmentation techniques have been developed that implement a priori atlas libraries of normal tissue ROIs, with deformable image registration to transfer these ROIs from the reference library to a patient DICOM file [7]. While several commercial and in-house auto-segmentation approaches have been presented and show promise, rigorous quality assessment should be performed before clinical implementation [1,6] given the clinical implications of over-or under-contouring [8]. However, individual institutions may have significant difficulty systematically evaluating competing auto-segmentation platforms, as evaluation of registration and segmentation typically requires substantial effort for multi-ROI segmentation assessment [9,10]. Consequently, we surmised that there exists an unmet need for an open-source, web-based software solution for comparison of auto-segmented ROIs with reference manually segmented ROIs. We have previously reported the development of an open-source web-based software called TaCTICS (Target Contour Testing/Instructional Computer Software, https://github.com/kalpathy/tacticsRT) that provides quantitative and qualitative comparison of submitted and reference manually segmented ROIs in order to provide feedback to users about their performance on contouring target volumes and OARs [11,12]. For this reason we sought to investigate the feasibility and utility of TaCTICS in evaluating the quality of auto-segmentation algorithms by comparing their results to composite expert contours using two brachial plexus ROIs as index OARs. The specific aims of the current study were to assess the feasibility of utilizing TaCTICS to report multi-metric analysis of an auto-segmentation algorithm of the brachial plexus relative to a TaCTICS-generated probabilistic multi-expert manual segmentation, define a performance benchmark comparison of an auto-segmentation algorithm of the brachial plexus to that of a set of reference resident contours and finally, to establish a quality-assessment workflow for the future evaluation of commercial/in-house auto-segmentation algorithm performance.

Lower Gastrointestinal Cancers

What percentage of anal canal cancer patients present with extrapelvic visceral metastasis?

Industry Funding Is Correlated With Publication Productivity of US Academic Radiation Oncologists

PURPOSE Industry payments to physicians are financial conflicts of interest and may influence research findings and medical decisions. We aim to (1) characterize industry payments within radiation oncology; and (2) explore the potential correlation between receiving disclosed industry payments and academic productivity. MATERIALS/METHODS CMS database was used to extract 2015 industry payments. For academic radiation oncologists, research productivity was characterized by h- and m-indices, as well as receipt of National Institutes of Health (NIH) funding, which is not an industry payment. Logistic regression models were used to determine whether publication metrics (m-index, h-index) and other study characteristics such as gender, PhD status, NIH institution funding status, were associated with the endpoints, research and general payments. Associations between the amount of payments (if any) and publication metrics were further studied using linear regression models. RESULTS A total of 22,543 individual payments totaling

Radiation Dose and Fractionation for Limited-stage Small-cell Lung Cancer: Survey of US Radiation Oncologists on Practice Patterns

25,532,482 to 2,995 radiation oncologists were included. Among the 1,189 academic radiation oncologists, 75% received less than

Prophylactic Cranial Irradiation for Limited-Stage Small-Cell Lung Cancer: Survey of US Radiation Oncologists on Current Practice Patterns

167; on the other hand, 10 (<1%) individuals received

Comparison of measurement methods with a mixed effects procedure accounting for replicated evaluations (COM3PARE): method comparison algorithm implementation for head and neck IGRT positional verification.

6,425,728 (51%) of payments. On multiple logistic regression, research payments were significantly associated with the m-index, odds ratio 2.86 (95% confidence interval, 1.84-4.45, p-value <0.0001); as well as with the h-index, odds ratio 1.03 (95% confidence interval, 1.01-1.05, p-value <0.0001). The linear regression model shows that both m-index and h-index were significantly positively associated with the amount of general payments (p-values <0.0001). CONCLUSION There is an association between disclosed payment from the industry and increased individual research productivity metrics. Further research to find the cause behind this association is warranted.

Current patterns of care for patients with extensive-stage SCLC: Survey of U.S. radiation oncologists on their recommendations regarding prophylactic cranial irradiation

Background: Thoracic radiotherapy (TRT) with concurrent chemotherapy is standard for limited‐stage small‐cell lung cancer (LS‐SCLC). However, the optimal dosing and fractionation remain unclear. The National Comprehensive Cancer Network guidelines have recommended either 45 Gy delivered twice daily (BID) or 60 to 70 Gy delivered once daily (QD). However, the current practice patterns among US radiation oncologists are unknown. Materials and Methods: We surveyed US radiation oncologists using an institutional review board‐approved questionnaire. The questions covered demographic data, self‐rated knowledge of key trials, and treatment recommendations. Results: We received 309 responses from radiation oncologists. Of the 309 radiation oncologists, 60% preferred TRT QD and 76% acknowledged QD to be more common in their practice. The respondents in academic settings were more likely to endorse BID treatment by both preference (P = .001) and actual practice (P = .009). The concordance between preferring QD and administering QD in practice was 100%. In contrast, 40% of respondents who preferred BID actually administered QD more often. Also, 15% of physicians would be unwilling to switch from QD to BID and 3% would be unwilling to switch from BID to QD, even on patient request. Most respondents (88%) recommended a dose of 45 Gy for BID treatment. For QD treatment, the division was greater, with 54% recommending 60 Gy, 30% recommending 63 to 66 Gy, and 10% recommending 70 Gy. Conclusion: Substantial variation exists in how US radiation oncologists approach TRT dosing and fractionation for LS‐SCLC. Three quarters of our respondents reported administering TRT QD most often. The most common doses were 60 Gy QD and 45 Gy BID. The results of the present survey have provided the most up‐to‐date information on US practice patterns for LS‐SCLC.

Burnout Evaluation of Radiation Residents Nationwide: Results of a Survey of United States Residents

&NA; In this survey of 309 practicing US radiation oncologists, almost all respondents recommended prophylactic cranial irradiation (PCI) and pre‐PCI brain magnetic resonance imaging (MRI)—practices endorsed by national guidelines. Only a third followed their patients with serial brain MRI after PCI, and about one third recommended memantine for patients undergoing PCI. This survey establishes a practice‐pattern baseline for future clinical trials. Purpose: Prophylactic cranial irradiation (PCI) in patients with limited‐stage small‐cell lung cancer (LS‐SCLC) is considered the standard of care. Meta‐analysis of 7 clinical trials indicates a survival benefit to PCI, but all of these trials were conducted in the pre–magnetic resonance imaging (MRI) era. Therefore, routine brain imaging with MRI before PCI—as recommended by National Comprehensive Cancer Network guidelines—is not directly supported by the evidence. Current US practice patterns for patients with LS‐SCLC are unknown. Materials and Methods: We surveyed practicing US radiation oncologists via an institutional review board–approved online questionnaire. Questions covered demographic information and treatment recommendations for LS‐SCLC. Results: We received 309 responses from US radiation oncologists. Ninety‐eight percent recommended PCI for patients with LS‐SCLC, 96% obtained brain MRI before PCI, 33% obtained serial brain imaging with MRI after PCI to detect new metastases, and 35% recommended memantine for patients undergoing PCI. Recommending memantine was associated with fewer years of practice (P < .001), fewer lung cancer patients treated per year (P = .045), and fewer LS‐SCLC patients treated per year (P = .024). Conclusion: Almost all responding radiation oncologists recommended PCI and pre‐PCI brain MRI for LS‐SCLC patients with disease responsive to initial therapy. Only a third of respondents followed these patients with serial brain MRI. Approximately one third provided memantine therapy to try to limit neurocognitive effects of PCI. Further research is warranted to determine the best treatment for patients with LS‐SCLC. This survey can inform the development of future trials that depend on participation from radiation oncologists.