Christina H. Chapman

Detection of brain tumor cells in the peripheral blood by a telomerase promoter-based assay.

Blood tests to detect circulating tumor cells (CTC) offer great potential to monitor disease status, gauge prognosis, and guide treatment decisions for patients with cancer. For patients with brain tumors, such as aggressive glioblastoma multiforme, CTC assays are needed that do not rely on expression of cancer cell surface biomarkers like epithelial cell adhesion molecules that brain tumors tend to lack. Here, we describe a strategy to detect CTC based on telomerase activity, which is elevated in nearly all tumor cells but not normal cells. This strategy uses an adenoviral detection system that is shown to successfully detect CTC in patients with brain tumors. Clinical data suggest that this assay might assist interpretation of treatment response in patients receiving radiotherapy, for example, to differentiate pseudoprogression from true tumor progression. These results support further development of this assay as a generalized method to detect CTC in patients with cancer.

Current Status of Diversity by Race, Hispanic Ethnicity, and Sex in Diagnostic Radiology

PURPOSE To assess the diversity of the U.S. diagnostic radiology physician workforce by race, Hispanic ethnicity, and sex in the context of the available pipeline of medical students. MATERIALS AND METHODS Institutional review board evaluation and exemption were granted for the study, as primary data were obtained from publicly available registry sources, with no identifiable private or protected information. Publicly available American Medical Association, American Association of Medical Colleges, and U.S. census registries were used to assess differences for 2010 among diagnostic radiology practicing physicians, academic faculty, residents, subspecialty trainees, residency applicants, medical school graduates, and U.S. population by using binomial tests; with adjustment for multiple comparisons among different groups, differences with P < .001 were considered significant. Significant differences in diagnostic radiology resident representation were evaluated for academic years 2003-2004 to 2010-2011 and for 2010, compared among the 20 largest residency training programs. RESULTS Females and traditionally underrepresented minorities in medicine (URM)-blacks, Hispanics, American Indians, Alaskan Natives, Native Hawaiians, and Pacific Islanders (AI/AN/NH/PI)-are underrepresented as practicing physicians (23.5% and 6.5%, respectively), faculty (26.1%, 5.9%), and diagnostic radiology residents (27.8%, 8.3%), compared with the U.S. population (50.8%, 30.0%) (all P < .001). Although they are increased in percentage as residents compared with practicing physicians, females and URMs remain underrepresented at the resident trainee level, compared with their proportions as medical school graduates (48.3%, 15.3%, respectively). During the past 8 years, there was no significant increase in female or URM resident (all P > .01) representation, suggesting no dramatic change in future representation as practicing physicians. Moreover, diagnostic radiology ranks 17th in female and 20th in URM representation among the 20 largest residency training specialties. CONCLUSION Females and URM remain underrepresented in the diagnostic radiology physician workforce despite an available medical student pipeline. Given prevalent health care disparities and an increasingly diverse society, future research and training efforts should address increasing resident diversity with program directors and department chairs.

Diversity Based on Race, Ethnicity, and Sex, of the US Radiation Oncology Physician Workforce

PURPOSE To assess the current diversity of the US radiation oncology (RO) physician workforce by race, ethnicity, and sex. METHODS AND MATERIALS Publicly available American Medical Association, American Association of Medical Colleges, and US census registries were used to assess differences by race, ethnicity, and sex for 2010 among RO practicing physicians, academic faculty, residents, and residency applicants. RO resident diversity was compared to medical school graduates and medical oncology (MO) fellows. Significant differences in diversity of RO residents by race, ethnicity, and sex were evaluated between 2003 and 2010 academic years. RESULTS Females and traditionally underrepresented minorities in medicine (URM), blacks, Hispanics, American Indians, Alaska Natives, Native Hawaiian, and Pacific Islanders are underrepresented as RO residents (33.3% and 6.9%, respectively), faculty (23.8%, 8.1%), and practicing physicians (25.5%, 7.2%) levels compared with the US population (50.8%, 30.0%; P<.01). Although females and URMs remain underrepresented at the resident trainee level compared with their proportions as medical school graduates (48.3%, 15.6%) and MO fellows (45.0%, 10.8%; P<.01), females are significantly increased in proportion as RO residents compared with RO practicing physicians (P<.01), whereas representation of individual URM groups as RO residents is no different than current practicing physicians. There is no trend toward increased diversification for female or URM trainees over 8 years, suggesting underrepresentation is not diminishing. CONCLUSIONS Females and URM are underrepresented in the RO physician workforce. Given existing cancer disparities, further research and efforts are needed to ensure that the field is equipped to meet the needs of an increasingly diverse society.

Diversity in Graduate Medical Education in the United States by Race, Ethnicity, and Sex, 2012

Author Contributions: Ms Dierickx had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Cohen and Chambaere contributed equally as last author. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Dierickx, Cohen, Chambaere. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Dierickx, Chambaere. Obtained funding: Deliens, Cohen. Administrative, technical, or material support: Deliens. Study supervision: Deliens, Cohen, Chambaere.

Underrepresentation of Women and Minorities in the United States IR Academic Physician Workforce

PURPOSE To assess the United States interventional radiology (IR) academic physician workforce diversity and comparative specialties. METHODS Public registries were used to assess demographic differences among 2012 IR faculty and fellows, diagnostic radiology (DR) faculty and residents, DR subspecialty fellows (pediatric, abdominal, neuroradiology, and musculoskeletal), vascular surgery and interventional cardiology trainees, and 2010 US medical school graduates and US Census using binomial tests with .001 significance level (Bonferroni adjustment for multiple comparisons). Significant trends in IR physician representation were evaluated from 1992 to 2012. RESULTS Women (15.4%), blacks (2.0%), and Hispanics (6.2%) were significantly underrepresented as IR fellows compared with the US population. Women were underrepresented as IR (7.3%) versus DR (27.8%) faculty and IR fellows (15.4%) versus medical school graduates (48.3%), DR residents (27.8%), pediatric radiology fellows (49.4%), and vascular surgery trainees (27.7%) (all P < .001). IR ranked last in female representation among radiologic subspecialty fellows. Blacks (1.8%, 2.1%, respectively, for IR faculty and fellows); Hispanics (1.8%, 6.2%); and combined American Indians, Alaska Natives, Native Hawaiians, and Pacific Islanders (1.8%, 0) showed no significant differences in representation as IR fellows compared with IR faculty, DR residents, other DR fellows, or interventional cardiology or vascular surgery trainees. Over 20 years, there was no significant increase in female or black representation as IR fellows or faculty. CONCLUSIONS Women, blacks, and Hispanics are underrepresented in the IR academic physician workforce relative to the US population. Given prevalent health care disparities and an increasingly diverse society, research and training efforts should address IR physician workforce diversity.

Diversity by race, Hispanic ethnicity, and sex of the United States medical oncology physician workforce over the past quarter century.

PURPOSE To assess the medical oncology (MO) physician workforce diversity by race, Hispanic ethnicity, and sex, with attention to trainees. METHODS Public registries were used to assess 2010 differences among MO practicing physicians, academic faculty, and fellows; internal medicine (IM) residents; and the US population, using binomial tests with P < .001 significance adjusting for multiple comparisons. Significant changes in fellow representation from 1986 to 2011 were assessed. RESULTS Female representation as MO fellows (45.0%) was significantly increased compared with faculty (22.4%) and practicing physicians (27.4%); was no different than IM residents (44.7%, P = .853); and increased significantly, by 1.0% per year. Women were significantly underrepresented as practicing physicians, faculty, and fellows compared with the US population (50.8%). Traditionally underrepresented minorities in medicine (URM) were significantly underrepresented as practicing physicians (7.8%), faculty (5.7%), and fellows (10.9%), versus US population (30.0%). Hispanic MO fellows (7.5%) were increased compared with faculty (3.9%) and practicing physicians (4.1%); Black fellows (3.1%) were no different than faculty (1.8%, P = .0283) or practicing physicians (3.5%, P = .443). When comparing MO fellows versus IM residents, there were no differences for American Indians/Alaska Natives/Native Hawaiians/Pacific Islanders (0.3%, 0.6%, respectively, P = .137) and Hispanics (7.5%, 8.7%, P = .139), unlike Blacks (3.1%, 5.6%, P < .001). There has been no significant change in URM representation, with negligible changes every 5 years for American Indians/Alaska Natives/Native Hawaiians/Pacific Islanders (-0.1%), Blacks (-0.3%), and Hispanics (0.3%). CONCLUSIONS Female fellow representation increased 1% per year over the quarter century indicating historical gains, whereas URM diversity remains unchanged. For Blacks alone, representation as MO fellows is decreased compared with IM residents, suggesting greater disparity in MO training.

The pervasive crisis of diminishing radiation therapy access for vulnerable populations in the United States, part 1: African-American patients

Introduction African Americans experience the highest burden of cancer incidence and mortality in the United States and have been persistently less likely to receive interventional care, even when such care has been proven superior to conservative management by randomized controlled trials. The presence of disparities in access to radiation therapy (RT) for African American cancer patients has rarely been examined in an expansive fashion. Methods and materials An extensive literature search was performed using the PubMed database to examine studies investigating disparities in RT access for African Americans. Results A total of 55 studies were found, spanning 11 organ systems. Disparities in access to RT for African Americans were most prominently study in cancers of the breast (23 studies), prostate (7 studies), gynecologic system (5 studies), and hematologic system (5 studies). Disparities in RT access for African Americans were prevalent regardless of organ system studied and often occurred independently of socioeconomic status. Fifty of 55 studies (91%) involved analysis of a population-based database such as Surveillance, Epidemiology and End Result (SEER; 26 studies), SEER-Medicare (5 studies), National Cancer Database (3 studies), or a state tumor registry (13 studies). Conclusions African Americans in the United States have diminished access to RT compared with Caucasian patients, independent of but often in concert with low socioeconomic status. These findings underscore the importance of finding systemic and systematic solutions to address these inequalities to reduce the barriers that patient race provides in receipt of optimal cancer care.

A glimpse of the future: Where will new combinations of diagnostics and therapies take us?

The field of radiation oncology has evolved, especially in the past 20 years. Advances in technology, particularly in computing power, software, and imaging, have fueled contributions to cancer care. It is currently fashionable to say that many of these advances have only served to increase costs of care without clear evidence of benefit, and certainly, efforts to evaluate the value of radiation oncology treatments are needed. However, it is undeniable that the future of radiation oncology depends on discovering such advances and to demonstrate that these increase the therapeutic index of treatment. Across the global radiation oncology community, investigations are proceeding in which innovative means are being used to achieve this goal. We review some of these novel methods to improve the therapeutic index of radiation therapy.

In Reply to Thomas

To the Editor: The recent commentary by Chapman and Jagsi (1) highlights challenges to strengthen our subspecialty. To determine possible mechanisms of implicit bias, we conducted a prospective audit study (2). We hypothesized that prospective black (B) male doctoral students would experience greater disparity in responses when seeking access to National Cancer Instituteefunded Principal Investigators (PIs) compared with prospective Caucasian (W) males. The specific aim was to explore response and acceptance rates for B (vs W) men seeking cancer research mentorship. We utilized a modification of the approach of Milkman et al (3). Identical e-mails were sent to 1028 randomly selected PIs affiliated with 65 National Cancer Instituteedesignated cancer centers. The PIs were randomly assigned to receive e-mails from either “Brad Anderson” (W; nZ513) or “Lamar Washington” (B; nZ515). Primary outcomes were: (1) any response within 1 week (yes/no); and (2) type of response if received (agree to meet/not agree to meet). We did not find strong evidence of bias within the experimental design we used. Implicit gender bias in academic medicine includes language attributed to candidates, within critiques of manuscripts and grants as well as letters of recommendation (4-6). Mitigation strategies are summarized in the primer, Avoiding Gender Bias in Reference Writing (7). Finally, leaders must look in the mirror. In my own department, a gender disparity exists for which I am ultimately accountable. It suggests reflecting on the parable, “And why do you look at the speck in your brother’s eye, but do not consider the plank in your own eye?” (Matthew 7:3, New King James Version Bible).

Castration Remains Despite Decreasing Definitive Treatment of Localized Prostate Cancer in the Elderly: A Case for De-Implementation

In their important study, Yang and colleagues used the National Cancer Data Base to examine definitive therapy (prostatectomy or radiotherapy) among 400,000 patients who were diagnosed with intermediate-risk or high-risk prostate cancer between 2004 and 2012. By using multivariable regression to adjust for patient and sociodemographic factors, the investigators observed that patients decreasingly received definitive treatment with increasing age and worsening comorbidity. Indeed, greater than 40% of patients aged >80 years did not receive definitive treatment with radiation or surgery. Moreover, one-half of patients aged 80 years with high-risk prostate cancer who did not receive definitive treatment went on to undergo receive primary androgen-deprivation therapy (ADT) instead. In this editorial, the authors conclude that significant under treatment of unfavorable-risk prostate cancer in the elderly puts them at up to 20% risk of prostate cancer-related death at 10 years. On the 1 hand, less use of definitive prostate cancer treatment among patients who are least likely to benefit (ie, elderly, comorbid patients) argues against the widely held belief that we are overtreating patients with prostate cancer. Indeed, compared with men who received definitive treatment, those who did not receive such treatment were more likely to die within 1 year of diagnosis, regardless of age or prostate cancer disease risk, suggesting that decision making was reasonably aligned with life expectancy. An increasing comorbidity score also was associated with a lower likelihood of receiving definitive treatment, such that men who had 2 or more Charlson-Deyo comorbidity points had approximately one-half the odds of receiving definitive treatment compared with men who had no comorbidities. The finding that sicker patients were less likely to receive definitive treatment for localized prostate cancer after taking into consideration other factors (eg, demographics) was encouraging. Conversely, Yang et al observed overtreatment of elderly patients through a different mechanism—a high rate of chemical castration with ADT as the primary treatment for many elderly patients with localized prostate cancer who were not treated definitively with radiation or surgery. With increasing age, patients were less likely to receive definitive treatment but more likely to be treated with primary ADT. Although receipt of primary ADT was more pronounced among patients with high-risk, localized disease who did not receive definitive prostate cancer treatment (41%), 1 in 5 men with intermediate-risk disease who did not undergo definitive treatment also received primary ADT. Because the benefits of castration are associated primarily with advanced rather than localized disease, and because safer, effective treatment approaches, such as observation (ie, watchful waiting) or radiation therapy exist, the authors point out that these findings are troubling, citing decreased overall survival with primary ADT for localized prostate cancer and its notable harms (eg, metabolic syndrome, fractures, and cognitive, cardiovascular, and sexual dysfunction). In patients who do not undergo definitive treatment for localized disease, the early versus delayed castration dilemma has been studied in randomized trials. For example, European Organization for Research and Treatment