American Society Of Radiation Oncology Research Articles

Academic U.S. Radiation Oncology Department Chairs: Who are They?

Historically, there has been a gender imbalance in the composition of the academic radiation oncology (RO) workforce. Given the increasing diversity of patients treated by academic radiation oncologists across the US, sufficient representation of women in academic RO, especially in leadership, is of paramount importance. In this study, we sought to better understand the characteristics of individuals currently serving as academic RO chairpersons whose departments are affiliated with ACGME-accredited RO residency training programs. We created a comprehensive database of academic RO chairpersons in the US by utilizing information from publicly available sources, including residency training program websites, hospital/institutional websites, Doximity, LinkedIn, the American Society of Radiation Oncology (ASTRO) website, the American College of Radiation Oncology (ACRO) website, and the National Plan and Provider Enumeration System National Provider Identifier Registry. We used the Mann-Whitney U test and two-proportion z tests to evaluate for statistical significance among medians and proportions, respectively. We identified 85/90 chairpersons (94.4%) whose departments are affiliated with an ACGME-accredited RO residency program. 4/85 (4.7%) chairpersons hold interim positions and were excluded from further analyses. Of the remaining 81 chairpersons in permanent positions, 10 (12.3%) are females and 71 (87.7%) are males (p < 0.01). 77 (95.1%) chairpersons are full professors and 19 (23.5%) hold dual MD-PhD degrees. 33 (40.7%) chairpersons hold an official leadership role, such as "director" or "chair," in the cancer institution affiliated with their institution; while such titles are more common among male than female chairpersons, the difference is not statistically significant (43.7% vs 20%, p = 0.15). 74/81 chairpersons secured their current positions a median of 16 years (range 6-33 years) after completing RO residency, with no statistically significant difference between male and female chairpersons (median 16 vs 18 years, respectively; p = 0.38). 36 (44.4%) chairpersons were promoted to chair from another position at their respective institutions (men 70.0% vs females 40.8%, p = 0.08). The majority of chairpersons are ASTRO Fellows (61.7%); notably fewer are ASTRO (3.7%) or ACRO (2.5%) Gold Medalists. There are no statistical differences among male and female chairpersons in the proportion who have received an ASTRO Fellow designation (60.6% vs 70.0%, p = 0.57) or ASTRO (4.2% vs 0.0%, p = 0.51) or ACRO (2.8% vs 0.0%, p = 0.59) Gold Medal. In our benchmark study of the characteristics of current academic US RO chairpersons, we found that significantly more men than women currently serve as RO chairpersons. Future interventions that promote the recruitment, retention, and promotion of talented female academic RO physicians through the academic pipeline are warranted.

Operational Ontology for Radiation Oncology (OORO): A Professional Society-Based, Multi-Stakeholder Consensus Driven Informatics Standard Supporting Clinical and Research Use of Real-World Data

There is a critical need for large-scale, multi-institutional "real-world" data to evaluate patient, diagnosis and treatment factors affecting oncology patient outcomes. However, lack of data standardization undermines the potential for automated learning from the vast amount of information routinely archived in electronic health records (EHRs), Radiation Oncology Information Systems and other cancer care databases. As next step to promote data standardization beyond the American Association of Physicists in Medicine (AAPM)'s TG-263 guidance for radiotherapy (RT) nomenclature, the AAPM's Big Data Subcommittee (BDSC) has led an international RT professional society collaboration to develop the Operational Ontology for Radiation Oncology (OORO). Initiated July 2019 to explore issues that typically compromise formation of large inter- and intra- institutional databases from EHRs, the AAPM's BDSC membership includes representatives from the AAPM, American Society of Radiation Oncology (ASTRO), Canadian Organization of Medical Physicists (COMP), Canadian Association of Radiation Oncology (CARO), European Society of Therapeutic Radiation Oncology (ESTRO) and clinical trials experts from NRG Oncology. Multiple external stakeholders were engaged, including government agencies, vendors and RT community members through the iterative and consensus-driven approach to OORO development. The OORO includes 42 key elements, 359 attributes, 144 value sets, and 155 relationships, ranked for priority of implementation based on clinical significance, likelihood of availability in EHRs, or ability to modify routine clinical processes to permit aggregation. The initial version of OORO includes many disease-site independent concepts common for all cancer patients and a smaller set specific for prostate cancer. The OORO development methodology is currently being applied/adapted to include additional disease site-specific concepts beginning with head and neck cancers. The first of its kind in radiation oncology, the OORO is a professional society-based, multi-stakeholder, consensus driven informatics standard. The iterative and collaborative approach to ontology development and refinement aims to ensure that OORO serves as a « living » guidance document, facilitating incremental expansion of data elements over time, as disease site-specific standards are set and RT concepts evolve. Supporting construction of comprehensive "real-world" datasets and application of advanced analytic techniques, including artificial intelligence (AI), OORO holds the potential to revolutionize patient management and improve outcomes.

Measuring and addressing health equity: an assessment of cancer center designation requirements

PurposeBy requiring specific measures, cancer endorsements (e.g., accreditations, designations, certifications) promote high-quality cancer care. While 'quality' is the defining feature, less is known about how these endorsements consider equity. Given the inequities in access to high-quality cancer care, we assessed the extent to which equity structures, processes, and outcomes were required for cancer center endorsements.MethodsWe performed a content analysis of medical oncology, radiation oncology, surgical oncology, and research hospital endorsements from the American Society of Clinical Oncology (ASCO), American Society of Radiation Oncology (ASTRO), American College of Surgeons Commission on Cancer (CoC), and the National Cancer Institute (NCI), respectively. We analyzed requirements for equity-focused content and compared how each endorsing body included equity as a requirement along three axes: structures, processes, and outcomes.ResultsASCO guidelines centered on processes assessing financial, health literacy, and psychosocial barriers to care. ASTRO guidelines related to language needs and processes to address financial barriers. CoC equity-related guidelines focused on processes addressing financial and psychosocial concerns of survivors, and hospital-identified barriers to care. NCI guidelines considered equity related to cancer disparities research, inclusion of diverse groups in outreach and clinical trials, and diversification of investigators. None of the guidelines explicitly required measures of equitable care delivery or outcomes beyond clinical trial enrollment.ConclusionOverall, equity requirements were limited. Leveraging the influence and infrastructure of cancer quality endorsements could enhance progress toward achieving cancer care equity. We recommend that endorsing organizations 1) require cancer centers to implement processes for measuring and tracking health equity outcomes and 2) engage diverse community stakeholders to develop strategies for addressing discrimination.

High resolution dermal ultrasound (US) combined with superficial radiation therapy (SRT) versus non-image guided SRT or external beam radiotherapy (XRT) in early-stage epithelial cancer: a comparison of studies

BackgroundTo compare the effectiveness of high-resolution dermal ultrasound (US) guided superficial radiotherapy (SRT) to non-image-guided radiotherapy in the treatment of early-stage Non-Melanoma Skin Cancer (NMSC).MethodsA high-resolution dermal ultrasound (US) image guided form of superficial radiation therapy (designated here as US-SRT) was developed in 2013 where the tumor configuration and depth can be visualized prior to, during, and subsequent to treatments, using a 22 megahertz (MHz) dermal ultrasound (US) with a doppler component. We previously published the results using this technology to treat 2917 early-stage epithelial cancers showing a high local control (LC) rate of 99.3%. We compared these results with similar American studies from a comprehensive literature search used in an article/guideline published by American Society of Radiation Oncology (ASTRO) on curative radiation treatment of basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and squamous cell carcinoma in-situ (SCCIS) lesions from 1988 to 2018. Only U.S. based studies with greater than 100 cases with similar patient/lesion characteristics and stages treated by external beam, electron, or superficial/orthovoltage radiation therapy were included in the criteria for selection. The resultant 4 studies had appropriate comparable cases identified and the data analyzed/calculated with regard to local control. Logistic regression analysis was performed comparing each study to US-SRT individually and collectively with stratification by histology (BCC, SCC, and SCCIS).ResultsUS-SRT LC was found to be statistically superior to each of the 4 non-image-guided radiation therapy studies individually and collectively (as well as stratified by histology subtype) with p-values ranging from p < 0.0001 to p = 0.0438.ConclusionsResults of US-SRT in local control were statistically significantly superior across the board versus non-image-guided radiation modalities in treatment of epithelial NMSC and should be considered a new gold standard for treatment of early-stage cutaneous BCC, SCC, and SCCIS.

Local control comparison of early-stage non-melanoma skin Cancer (NMSC) treated by superficial radiotherapy (SRT) and external beam radiotherapy (XRT) with and without dermal image guidance: a meta-analysis

BackgroundVarious treatments exist for non-melanoma skin cancer (NMSC), but the mainstay is surgical removal. Superficial radiotherapy (SRT) is one non-surgical technique that has been used for over a century but fell out of favor due to the advent of Mohs micrographic surgery (MMS). A new technology that combines a 22 megahertz (MHz) dermal ultrasound with SRT (US-SRT) enables tumor visualization before, during, and after treatment, and demonstrates increased cure rates and reduced recurrences.MethodsWe conducted a meta-analysis comparing the local control (LC) of four studies using traditional non-image-guided forms of radiotherapy for NMSC treatment to two seminal studies utilizing high-resolution dermal ultrasound-guided SRT (HRUS-SRT). The four traditional radiotherapy studies were obtained from a comprehensive literature search used in an article published by the American Society of Radiation Oncology (ASTRO) on curative radiation treatment of basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and squamous cell carcinoma in-situ (SCCIS) lesions. The meta-analysis employed a logit as the effect size indicator with Q-statistic to test the null hypothesis.ResultsLC rates for the 2 US-SRT studies were statistically superior to the 4 traditional therapies individually and collectively. When stratified by histology, statistically superior outcomes for US-SRT were observed in all subtypes with p-values ranging from p < 0.0001 to p = 0.0438. These results validated an earlier analysis using a logistic regression statistical method showing the same results.ConclusionUS-SRT is statistically superior to non-image-guided radiotherapies for NMSC treatment. This modality may represent the future standard of non-surgical treatment for early-stage NMSC.

MSPP03 Presentation Time: 4:20 PM: Decline of Complex Brachytherapy Procedures and Providers Despite Ongoing Need: An Analysis of US Brachytherapy Services from 2013-2019 Based on Medicare Data

<h3>Purpose</h3> According to the American Society of Radiation Oncology (ASTRO), there are approximately 5,000 practicing radiation oncologists (RO) in the United States (US). It is unknown, however, how many of these RO practice brachytherapy. We used claims from Center for Medicare and Medicaid services (CMS) to estimate the number of RO who provide brachytherapy and examine trends in the number of patients that receive brachytherapy. <h3>Materials and Methods</h3> Using Medicare Provider Utilization and Payment Data (the Physician and Other Supplier Public Use File (POSPUF) publically available data set), we identified unique procedural codes related to brachytherapy practice in prostate, gynecologic (GYN), breast, and ocular cancers from 2013 to 2019. For each disease site, the total of rendering providers, beneficiaries, and services were identified. The number of patients who received brachytherapy and the number of procedures per 100,000 Medicare enrollees were also calculated. Yearly trends in services and number of providers were then developed. Trends were tested using the Kendall Tau rank correlation using R version 3.6.3. <h3>Results</h3> For prostate brachytherapy, the total number of patients receiving brachytherapy (6145 in 2013 to 5695 in 2019) and procedures performed (8609 to 7862) remained steady over the study period (p=0.76), while the number of providers dropped significantly by 32% (1981 to 1361, p=0.003). The number of providers providing brachytherapy remained steady for intrauterine implants (663 to 625, p=0.37), while the number of patients (4.3 to 3.2 per 100,000 enrollee, p=0.02) and performed procedures decreased (13.4 to 10.4 per 100,000 enrollee, p=0.02) from 2013 to 2019. There was a non-significant trend in decline of total patients (12%) and services (8.6%) over time (p=0.07). For intravaginal implants, total services increased by 45% (p=0.007) and patients increased by 36% (p=0.007). The number of patients and procedures per 100,000 Medicare enrollee (12.7 to 14.7, p=0.035 and 40.8 to 50.1, p=0.007, respectively) as well as the number of providers performing intravaginal implants increased by 31% (1070 to 1403, p=0.007) from 2013-2019. For breast, total providers decreased by 56.4%, as well as patients (-51.4%) and procedures (-52%, p=0.003, for all metrics). For ocular implants, the total number of patients and services remained steady (p=0.37 and p=0.37), while those performing decreased by 13% (p=0.048). <h3>Discussion</h3> There is an overall decline of providers performing brachytherapy for prostate and ocular cancers, although the number of procedures and patients remain the same. There is a decline in the number of RO providing and patients receiving brachytherapy for breast cancer. While the number of providers performing intrauterine implants remains steady, there is an increase in those performing vaginal implants, suggesting more RO are performing less complicated intracavitary vaginal implants. A decrease of patients requiring intrauterine implants may reflect either decreased indications (such as in cervical cancer with decreased incidence due to better screening and vaccination against Human Papillomavirus) or decreased utilization by providers in favor of other methods, such as with stereotactic body radiotherapy (SBRT). A potential limitation of this study includes the inability to identify individual providers who may be included in multiple disease categories and thus, overestimating the total number of providers. These data underlie the need for increased brachytherapy training to ensure that utilization rates for all forms of brachytherapy match the clinical indications.

Associations between Disclosed Conflicts of Interests and Abstract Prestige at the 2021 ASTRO Annual Meeting

<h3>Purpose/Objective(s)</h3> There have been substantial and growing concerns about conflicts of interest (COI) involving clinical research. Using data from the American Society of Radiation Oncology (ASTRO) 2021 annual meeting, we assessed the frequency and type of COI and evaluated associations between COI and opportunity for oral presentation. <h3>Materials/Methods</h3> A web scraping program was used to capture all abstracts, authors, and COI disclosures from ASTRO's 63rd Annual Meeting issue of the Red Journal (11/1/21). COI disclosures were categorized into monetary (advisory board, consulting, honorarium, industry employment, patent, research funding, royalties, stock) or non-monetary (leadership role at professional society) disclosures. Abstracts were stratified based on acceptance as poster, quick pitch oral, or oral scientific presentation. Pearson's X² and independent t-test were used to determine differences across abstract categories. Binary logistic regression was used to determine factors that portended for monetary disclosures. Univariate and multivariate analysis was used to determine the impact of various disclosures on acceptance category. <h3>Results</h3> 1548 abstracts with 7529 authors were analyzed. Oral scientific sessions, quick pitch oral sessions, and poster sessions composed 148 (9.6%), 108 (7.0%), and 1292 (83.5%) abstracts, respectively. The median number of authors per abstract was 8 (range:1-44). 612 (39.5%) abstracts had no disclosures amongst listed authors, and 936 (60.5%) abstracts had at least one author noting a relevant disclosure. The most common types of disclosures were Research Funding, Consulting, and Honoraria (42.1%, 33.4%, and 28.7% of abstracts, respectively). 165 (10.7%) abstracts involved authors disclosing leadership at a professional society. There were 898 (58.0%) monetary disclosures and 165 (10.7%) non-monetary disclosures. Disclosure rates were significantly different (p=.001) between abstracts awarded posters 58.5%, quick pitch oral (67.6%), and oral scientific abstracts (72.3%). Oral scientific and quick pitch oral abstracts had higher rates of monetary disclosures relative to poster abstracts (70.3% and 65.7%, vs. 56.0%, respectively; p=.001). Abstracts that involved professional society leadership were more likely to report a monetary disclosure (91.5% vs. 54.0%; p<.001). On multivariate analysis, monetary disclosures were associated with abstracts written by authors with leadership at professional societies (OR: 7.763, CI 4.421-13.631; p<.0001), abstracts containing ≥5 authors (OR 3.589, CI 2.668-4.827; p<.0001), and abstracts awarded oral presentations (OR 1.306, CI 1.086-1.567; p=.005). <h3>Conclusion</h3> Most abstracts at the 2021 ASTRO annual meeting had COI disclosures, and most disclosures were monetary. Rates of disclosure increased as abstract prestige increased, and monetary disclosures were associated with oral presentations and abstracts written by authors with leadership roles in professional societies.

ACR-ACNM-ASTRO-SNMMI Practice Parameter for Lutetium-177 (Lu-177) DOTATATE Therapy.

This practice parameter (PP) for Lutetium-177 (Lu-177) DOTATATE peptide receptor radionuclide therapy (PRRT) aims to guide authorized users in selection of appropriate adult candidates with gastroeneropancreatic neuroendocrine tumors (GEP-NETs) from foregut, midgut, and hindgut. The essential selection criteria include somatostatin receptor-positive GEP-NETs, which are usually inoperable and progressed despite standard therapy. Lu-177 DOTATATE is a radiopharmaceutical with high avidity for somatostatin receptors that are overexpressed by these tumors. This document ensures safe handling of Lu-177 DOTATATE by the authorized users and safe management of affected patients. The document was developed according to the systematic process developed by the American College of Radiology (ACR) and described on the ACR Web site (https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards). The PP development was led by 2 ACR Committees on Practice Parameters (Nuclear Medicine and Molecular Imaging and Radiation Oncology) collaboratively with the American College of Nuclear Medicine, American Society of Radiation Oncology, and Society of Nuclear Medicine and Molecular Imaging. The Lu-177 DOTATATE PP reviewed pharmacology, indications, adverse effects, personnel qualifications, and required clinical evaluation before starting the treatment, as well as the recommended posttherapy monitoring, quality assurance, documentation, and appropriate radiation safety instructions provided in written form and explained to the patients. Lu-177 DOTATATE is available for therapy of inoperable and/or advanced GEP-NETs when conventional therapy had failed. It can reduce tumor size, improve symptoms, and increase the progression free survival. The PP document provides clinical guidance for authorized users to assure an appropriate, consistent, and safe practice of Lu-177 DOTATATE.

Radiation Therapy for Brain Metastases: ASCO Guideline Endorsement of ASTRO Guideline.

American Society of Radiation Oncology (ASTRO) has developed a guideline on appropriate radiation therapy for brain metastases. ASCO has a policy and set of procedures for endorsing clinical practice guidelines that have been developed by other professional organizations. "Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline"2 was reviewed for developmental rigor by methodologists. An ASCO Endorsement Panel subsequently reviewed the content and the recommendations. The ASCO Endorsement Panel determined that the recommendations from the ASTRO guideline, published May 6, 2022, are clear, thorough, and based upon the most relevant scientific evidence. ASCO endorses "Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline."2. Within the guideline, stereotactic radiosurgery (SRS) is recommended for patients with Eastern Cooperative Oncology Group performance status of 0-2 and up to four intact brain metastases, and conditionally recommended for patients with up to 10 intact brain metastases. The guideline provides detailed dosing and fractionation recommendations on the basis of the size of the metastases. For patients with resected brain metastases, radiation therapy (SRS or whole-brain radiation therapy [WBRT]) is recommended to improve intracranial disease control; if there are limited additional brain metastases, SRS is recommended over WBRT. For patients with favorable prognosis and brain metastases ineligible for surgery and/or SRS, WBRT is recommended with hippocampal avoidance where possible and the addition of memantine is recommended. For patients with brain metastases, limiting the single-fraction V12Gy to brain tissue to ≤ 10 cm3 is conditionally recommended.Additional information is available at www.asco.org/neurooncology-guidelines.

ACR-ACNM-ASTRO-SNMMI Practice Parameter for Lutetium-177 (Lu-177) DOTATATE Therapy.

This practice parameter (PP) for Lutetium-177 (Lu-177) DOTATATE peptide receptor radionuclide therapy (PRRT) aims to guide authorized users in selection of appropriate adult candidates with gastroeneropancreatic neuroendocrine tumors (GEP-NETs) from foregut, midgut, and hindgut. The essential selection criteria include somatostatin receptor-positive GEP-NETs, which are usually inoperable and progressed despite standard therapy. Lu-177 DOTATATE is a radiopharmaceutical with high avidity for somatostatin receptors that are overexpressed by these tumors. This document ensures safe handling of Lu-177 DOTATATE by the authorized users and safe management of affected patients. The document was developed according to the systematic process developed by the American College of Radiology (ACR) and described on the ACR Web site (https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards). The PP development was led by 2 ACR Committees on Practice Parameters (Nuclear Medicine and Molecular Imaging and Radiation Oncology) collaboratively with the American College of Nuclear Medicine, American Society of Radiation Oncology, and Society of Nuclear Medicine and Molecular Imaging. The Lu-177 DOTATATE PP reviewed pharmacology, indications, adverse effects, personnel qualifications, and required clinical evaluation before starting the treatment, as well as the recommended posttherapy monitoring, quality assurance, documentation, and appropriate radiation safety instructions provided in written form and explained to the patients. Lu-177 DOTATATE is available for therapy of inoperable and/or advanced GEP-NETs when conventional therapy had failed. It can reduce tumor size, improve symptoms, and increase the progression free survival. The PP document provides clinical guidance for authorized users to assure an appropriate, consistent, and safe practice of Lu-177 DOTATATE.

Assessment of Proton Beam Therapy Use Among Patients With Newly Diagnosed Cancer in the US, 2004-2018

Proton beam therapy (PBT) is a potentially superior technology to photon radiotherapy for tumors with complex anatomy, those surrounded by sensitive tissues, and childhood cancers. To assess patterns of use of PBT according to the present American Society of Radiation Oncology (ASTRO) clinical indications in the US. Individuals newly diagnosed with cancer between 2004 and 2018 were selected from the National Cancer Database. Data analysis was performed from October 4, 2021, to February 22, 2022. ASTRO's Model Policies (2017) were used to classify patients into group 1, for which health insurance coverage for PBT treatment is recommended, and group 2, for which coverage is recommended only if additional requirements are met. Use of PBT. Of the 5 919 368 patients eligible to receive PBT included in the study, 3 206 902 were female (54.2%), and mean (SD) age at diagnosis was 62.6 (12.3) years. Use of PBT in the US increased from 0.4% in 2004 to 1.2% in 2018 (annual percent change [APC], 8.12%; P < .001) due to increases in group 1 from 0.4% in 2010 to 2.2% in 2018 (APC, 21.97; P < .001) and increases in group 2 from 0.03% in 2014 to 0.1% in 2018 (APC, 30.57; P < .001). From 2010 to 2018, among patients in group 2, PBT targeted to the breast increased from 0.0% to 0.9% (APC, 51.95%), and PBT targeted to the lung increased from 0.1% to 0.7% (APC, 28.06%) (P < .001 for both). Use of PBT targeted to the prostate decreased from 1.4% in 2011 to 0.8% in 2014 (APC, -16.48%; P = .03) then increased to 1.3% in 2018 (APC, 12.45; P < .001). Most patients in group 1 treated with PBT had private insurance coverage in 2018 (1039 [55.4%]); Medicare was the most common insurance type among those in group 2 (1973 [52.5%]). The findings of this study show an increase in the use of PBT in the US between 2004 to 2018; prostate was the only cancer site for which PBT use decreased temporarily between 2011 and 2014, increasing again between 2014 and 2018. These findings may be especially relevant for Medicare radiation oncology coverage policies.

Abstract PO-215: Racial disparities in proton beam therapy use for newly diagnosed cancer patients in the United States

Abstract Background: Black patients are less likely than White patients in the US to receive guideline-concordant cancer care, including radiation therapy. Proton Beam Therapy (PBT) is a potentially superior technology to photon radiotherapy for the treatment of pediatric cancers, where decreasing late effects of radiation treatment is a main concern, and in cancers where pituitary, visual, auditory, and intellectual functions might be disrupted because of radiation therapy. The aim of this study was to conduct a comprehensive evaluation of racial disparities in PBT use in the US. Methods: We identified 4,919,975 Black and White patients diagnosed between 2004 and 2018 in the National Cancer Database (NCDB) based on data collected from Commission on Cancer (CoC) accredited hospitals. Once a patient is diagnosed and/or treated at a CoC accredited facility, the patient is followed and all treatment is reported (including treatment received outside of the reporting facility). Therefore, NCDB captures PBT received both at CoC-accredited hospitals (59.5% of patients who received PBT in this study) and PBT received at hospitals not accredited by CoCs (40.5% of PBT patients in this study). American Society of Radiation Oncology (ASTRO) Model Policies were used to classify patients into Group 1, for which PBT is the recommended radiation therapy modality, and Group 2, for which evidence of PBT efficacy is still under investigation. Propensity score matching was used to ensure comparability of Black and White patients' clinical characteristics and regional availability of PBT. Results: Black cancer patients were less likely to be treated with PBT than White cancer patients with similar characteristics (Odds Ratios [OR]: 0.72; 95% Confidence Interval [CI]: 0.68, 0.76). Racial disparities were greater for Group 1 cancers (OR = 0.61; CI: 0.54, 0.69) than for Group 2 cancers (OR: 0.75; CI: 0.70, 0.81). Disparities were greatest for Group 1 cancers commonly diagnosed in children, such as central nervous system (OR: 0.54; CI: 0.46, 0.63) and rhabdomyosarcoma (OR: 0.47; CI: 0.31, 0.70). Racial disparities in PBT receipt among Group 1 cancers increased during the study period and were greatest in 2018 despite the increase in the number of facilities offering PBT from 4 to 28 during the corresponding period, Conclusion and Relevance: Racial disparities in PBT receipt are greatest for cancers for which PBT is the recommended radiation therapy modality. The racial disparities identified in our study suggest undertreatment of Black patients with the greatest need (e.g. children diagnosed with central nervous system cancers). Future studies are needed to identify modifiable factors contributing to the racial disparity in receipt of PBT as efforts other than increasing the number of facilities providing PBT will be needed to eliminate disparities. Citation Format: Leticia M. Nogueira, Ahmedin Jemal, Jason A. Efstathiou, K. Robin Yabroff. Racial disparities in proton beam therapy use for newly diagnosed cancer patients in the United States [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-215.

High Risk Head and Neck Cutaneous Squamous Cell Carcinoma Treated With Mohs Surgery or Mohs Surgery and Adjuvant Radiation Therapy

<h3>Purpose/Objective(s)</h3> The recurrence risk for head and neck (H&N) cutaneous squamous cell carcinoma (cSCC) is higher than other sites, and current National Cancer Comprehensive Network (NCCN) and American Society of Radiation Oncology (ASTRO) guidelines encourage considering adjuvant radiation therapy (RT) for high-risk patients. Actuarial recurrence rates following R0 Mohs micrographic surgery have to our knowledge not yet been reported for high risk cSCC H&N patients, and we hypothesized that recurrence rates would be low for these patients regardless of the addition of RT. <h3>Materials/Methods</h3> Between 1/2011 and 1/2020, 362 consecutive H&N cSCC tumors in 325 patients underwent R0 Mohs also with eligibility criteria of size > 2 cm, 10 of whom underwent adjuvant RT (median 52.5 Gy/25 fractions & 6 with elective nodal RT). Kaplan-Meier analyses were performed to evaluate recurrence outcomes, and log-rank was used to compare survival distributions of 2 samples with <i>P</i>≤0.05 considered significant. <h3>Results</h3> Median follow-up from Mohs was 33.4 months, and mean pre-operative size was 3.0 cm with scalp the most common site. Median age was 80.0 years, and 3-year overall survival for all patients was 52.2% with only 4 deaths attributable to cSCC. There were 24 cSCC with perineural invasion (PNI), 32 poorly differentiated, 50 with deep invasion defined as > 6 mm or through subcutaneous fat, 72 with immunosuppression, and 109 with high-risk location defined as ear/lip/temple. No patient received adjuvant systemic therapy and none had a distant failure. The hazard ratios and 95% confidence intervals for locoregional recurrence with classic high-risk features were: PNI (2.68; 0.55 – 12.9), deep invasion (3.02; 0.96 – 9.53), poorly differentiated (vs. well/moderately) (2.20; 0.52 – 9.32), immunosuppression (1.36; 0.50 – 3.69), and high-risk location (0.91; 0.39 – 2.14). High risk tumors defined as AJCC T3 (vs. T1-T2) (3.39; 1.49 – 7.75) and BWH classification T2b-T3 (vs. T2a) (3.16; 1.33 – 7.52) had a significantly increased recurrence risk. The Table shows recurrence rates, with only 1 RT patient experiencing an out-of-RT field scalp in-transit metastasis. Of the 25 that recurred, 56% were rendered disease free with salvage therapy. <h3>Conclusion</h3> In the setting of R0 Mohs for high-risk H&N cSCC, although locoregional control was numerically highest in the small group who received adjuvant RT, with the reasonable salvage rate and infrequent cancer-specific deaths routine offering of RT may be unnecessary.

Overcoming Barriers to Radiation Oncology Access in Low-Resource Settings in the United States

Providing high-quality radiation therapy in medically underserved, low-resource environments can be challenging in the United States. During the American Society of Radiation Oncology 2020 Annual Meeting, the American Society for Radiation Oncology Committee on Health Equity, Diversity, and Inclusion hosted 4 radiation oncologists from both academic and community practices in an educational session. Speakers discussed creative ways to overcome barriers to equitable cancer care and outcomes for their vulnerable patient populations in both rural and urban settings. Successful tactics have included applying for state-sponsored grants, lobbying hospital leadership for equipment upgrades, implementing quality improvement programs specifically targeting the needs of the patient population, studying novel hypofractionation schedules, monitoring toxicities using wearable devices, and expanding transportation options.

Mitigating Implicit Bias in Radiation Oncology

Implicit bias is one of the most insidious and least recognizable mechanisms that can cause inequity and disparities. There is increasing evidence that both implicit and explicit biases have a negative effect on patient outcomes and patient-physician relationships. Given the impact of Implicit bias, a joint session between ASTROs Committee on Health Equity, Diversity, and Inclusion and the National Cancer Institute (the ASTRO-National Cancer Institute Diversity Symposium) was held during the American Society of Radiation Oncology (ASTRO) 2020 Annual Meeting, to address the effect of implicit bias in radiation oncology through real life and synthesized hypothetical scenario discussions. Given the value of this session to the radiation oncology community, the scenarios and discussion are summarized in this manuscript. Our goal is to heighten awareness of the multiple settings in which implicit bias can occur as well as discuss resources to address bias.

Cytoreductive stereotactic body radiotherapy (SBRT) and combination SBRT with immune checkpoint inhibitors in metastatic renal cell carcinoma.

Preclinical evidence demonstrates the immunogenic potential of stereotactic body radiotherapy (SBRT). There is growing interest in investigating this interplay with the immune system in metastatic renal cell carcinoma (mRCC). Cytoreduction with SBRT and combination therapy with SBRT and checkpoint inhibitor immuno-oncology agents (IO) are two potential therapeutic strategies in mRCC. In this review, we summarize the current clinical evidence for the use of cytoreductive SBRT to primary kidney and combination SBRT with IO. A literature review for articles and abstracts published between January 2000 and March 2020 was conducted through the PubMed, the American Society of Clinical Oncology (ASCO), and the American Society of Radiation Oncology (ASTRO) databases. Evaluation of studies followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) criteria. A total of three articles for cytoreductive SBRT and one article and three abstracts for combination SBRT and IO in mRCC met inclusion criteria for this review. Evidence for SBRT to primary kidney is limited by small series and pilot studies. Outcomes vary widely due to small patient numbers and study heterogeneity. Local control ranges from 85-100% and one- and two-year overall survival ranges from 38-71% and 19-53%, respectively. Combination SBRT and IO are tolerable for patients with early data, suggesting grade 3-4 adverse event rates of 0-24%. Long-term survival data is not yet available. Cytoreductive SBRT and combination SBRT with IO therapy represent promising treatment strategies in mRCC. The evidence for clinical benefit is currently limited and requires further study with well-designed, randomized controlled trials.

Perceived Burnout from Online Rating Websites May be More Significant in Younger Physicians

Previous research demonstrated that the majority of radiation oncologists perceive online patient reviews to contribute to burnout. The purpose of this study was to analyze if demographic features of physicians were associated with the perception that online reviews contribute to burnout. An international survey was delivered to practicing radiation oncologists who are members of the American Society of Radiation Oncology (ASTRO). The survey evaluated physicians’ perceptions of these rating websites. The association of gender or physician age with burnout was assessed using Fisher's Exact tests and multiple linear regressions. Criteria for statistical significance was p < 0.05. This study was approved by the IRB. A total of 445 survey responses were collected. Two-hundred (45%) respondents agreed that online physician rating websites contribute to burnout, 200 (45%) respondents were neutral, and 45 (10%) respondents disagreed. Of all respondents, 313 were men, 130 were women, and 2 were other gender. Both men and women were more likely to agree than disagree that online reviews contribute to burnout. Forty-one percent of men agreed and 12% disagreed, whereas 55% of women agreed and 7% disagreed (p = 0.03); these findings also indicate that men were more likely to be neutral than women. Of all respondents who agreed online reviews contribute to burnout, 84 (42.0%) were between the ages of 35 and 50 years, 60 (30.0%) were between the ages of 50 and 60 years, and 56 (28.0%) were above the age of 60 years. Of all respondents who disagreed that online reviews contribute to burnout, 14 (31.1%) were between the ages of 35 and 50 years, 11 (24.4%) were between the ages of 50 and 60 years, and 20 (44.4%) were above the age of 60 years. There was a linear trend in the relationship of ordinal burnout categories and age categories (p = 0.033). The relationship between perceived burnout and age did not differ by gender (p = 0.53), although there was some evidence that gender confounds the relationship of age with burnout. Younger physicians and women are more likely to perceive that online patient reviews contribute to burnout than older physicians and men. This suggests that online reviews may have an increasing effect on physician burnout in the future. Future research could investigate potential burnout secondary to online physician reviews and prevention strategies.

A snapshot on radiotherapy for head and neck cancer patients during the COVID-19 pandemic: a survey of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) head and neck working group.

ObjectivesThe objective of the paper was to assess real-life experience in the management of head and neck cancer (HNC) patients during the COVID-19 pandemic in radiotherapy departments and to evaluate the variability in terms of adherence to American Society of Radiation Oncology (ASTRO) and European Society for Radiotherapy and Oncology (ESTRO) recommendations.Materials and methodsIn May 2020, an anonymous 30-question online survey, comparing acute phase of outbreak and pre-COVID-19 period, was conducted. Two sections exploited changes in general management of HNC patients and different HNC primary tumors, addressing specific statements from ASTRO ESTRO consensus statement as well.ResultsEighty-eight questionnaires were included in the demographic/clinical workflow analysis, and 64 were analyzed for treatment management. Forty-eight percent of radiotherapy departments became part of oncologic hubs. First consultations reduced, and patients were addressed to other centers in 33.8 and 18.3% of cases, respectively. Telematic consultations were used in 50% of follow-up visits and 73.9% of multidisciplinary tumor board discussions. There were no practical changes in the management of patients affected by different primitive HNCs. Hypofractionation was not favored over conventional schedules.ConclusionsCompared to pre-COVID era, the clinical workflow was highly re-organized, whereas there were no consistent changes in RT indications and schedules.Electronic supplementary materialThe online version of this article (10.1007/s11547-020-01296-7) contains supplementary material, which is available to authorized users.

Hereditary breast cancer: translation into clinical practice of recent American Society of Clinical Oncology, American Society of Radiation Oncology, and Society of Surgical Oncology recommendations.

Scientific acquisitions concerning the risk of breast cancer in the context of hereditary breast cancer syndrome are constantly evolving: alongside the BRCA1 and BRCA2 mutations, further ones have been identified, also associated with malignancies in different sites. Therefore, management of these clinical conditions requires a multidisciplinary and shared approach, based on constantly updated guidelines. The recent Expert Panel Consensus about management of hereditary breast cancer, chaired by the Society of Surgical Oncology with the American Society of Clinical Oncology and the American Society of Radiation Oncology, based on the evidences obtained by a systematic review of the literature, delineate accurate and novel directions towards an appropriate surgical, radiation, and systemic therapy management of breast cancer patients with specific germline mutations. These recent recommendations will provide to physicians an updated and useful tool in treatment decision making of these patients in daily practice.

Practice recommendations for risk-adapted head and neck cancer radiotherapy during the COVID-19 pandemic: An ASTRO-ESTRO consensus statement

PurposeBecause of the unprecedented disruption of health care services caused by the COVID-19 pandemic, the American Society of Radiation Oncology (ASTRO) and the European Society for Radiotherapy and Oncology (ESTRO) identified an urgent need to issue practice recommendations for radiation oncologists treating head and neck cancer (HNC) in a time of limited resources and heightened risk for patients and staff. Methods and MaterialsA panel of international experts from ASTRO, ESTRO, and select Asia-Pacific countries completed a modified rapid Delphi process. Topics and questions were presented to the group, and subsequent questions were developed from iterative feedback. Each survey was open online for 24 hours, and successive rounds started within 24 hours of the previous round. The chosen cutoffs for strong agreement (≥80%) and agreement (≥66%) were extrapolated from the RAND methodology. Two pandemic scenarios, early (risk mitigation) and late (severely reduced radiation therapy resources), were evaluated. The panel developed treatment recommendations for 5 HNC cases. ResultsIn total, 29 of 31 of those invited (94%) accepted, and after a replacement 30 of 30 completed all 3 surveys (100% response rate). There was agreement or strong agreement across a number of practice areas, including treatment prioritization, whether to delay initiation or interrupt radiation therapy for intercurrent SARS-CoV-2 infection, approaches to treatment (radiation dose-fractionation schedules and use of chemotherapy in each pandemic scenario), management of surgical cases in event of operating room closures, and recommended adjustments to outpatient clinic appointments and supportive care. ConclusionsThis urgent practice recommendation was issued in the knowledge of the very difficult circumstances in which our patients find themselves at present, navigating strained health care systems functioning with limited resources and at heightened risk to their health during the COVID-19 pandemic. The aim of this consensus statement is to ensure high-quality HNC treatments continue, to save lives and for symptomatic benefit.