American Society Of Radiation Oncology Research Articles

Quality Assurance of LINAC by Analyzing the Profile of 6-MV and 10-MV Photon Beams Using Star Track Device

Introduction: According to the American Society of Radiation Oncology, all patients receive radiation therapy during their illness, where radiation is delivered by the medical linear accelerator (Linac). The aim of this study was to evaluate the quality assurance (QA) of the Linac in analyzing the used dose profile in the treatment of cancer tumors. Material and Methods: This experimental study was performed using Linac (synergy device type) at Baghdad Radiotherapy and Nuclear Medicine laboratories, Baghdad, Iraq. The Star Track device was used for the routine quality assurance of the Linac, using photon beam for the reference Dmax and source to surface distance of 100 cm. The Star Track consists of 453 vented parallel plate ionization chambers. Results: The flatness and symmetry of beams for the reference field size did not exceed from ±2%, as they were within the allowed range. Moreover, the penumbra region showed a change in value that did not exceed from ±0.2 cm. using the Star Track method; maximum differences in beam symmetry and beam flatness were measured at 0.76%±2% and 1.17%±2%, respectively. Moreover, the maximum difference in the penumbra region was estimated at 0.12±0.2 cm. Conclusion: The results indicated, the Star Track could successfully calculate the characteristics of dose profile during a time period of 2,500 ms, showing the superiority of this instrument over other verification devices.

Pathways for Recruiting and Retaining Women and Underrepresented Minority Clinicians and Physician Scientists Into the Radiation Oncology Workforce: A Summary of the 2019 ASTRO/NCI Diversity Symposium Session at the ASTRO Annual Meeting

Diversifying the radiation oncology workforce is an urgent and unmet need. During the American Society of Radiation Oncology (ASTRO) 2019 Annual Meeting, ASTRO's Committee on Health Equity, Diversity, and Inclusion (CHEDI) and the National Cancer Institute (NCI) collaborated on the ASTRO-NCI Diversity Symposium, entitled "Pathways for Recruiting and Retaining Women and Underrepresented Minority Clinicians and Physician Scientists Into the Radiation Oncology Workforce." Herein, we summarize the presented data and personal anecdotes with the goal of raising awareness of ongoing and future initiatives to improve recruitment and retention of underrepesented groups to radiation oncology. Common themes include the pivotal role of mentorship and standardized institutional practices – such as protected time and pay parity – as critical to achieving a more diverse and inclusive workplace.

Practice Recommendations for Risk-Adapted Head and Neck Cancer Radiation Therapy 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.

Analysis of Inter-observer Variation From Meningioma eContouring Session

Inter-observer contour reproducibility may represent a surrogate measure of consensus in delineation of the region at risk from the disease process. We sought to quantify the inter-observer variation in delineating both target and organs-at-risk (OAR) for patients with atypical meningioma. Permission was obtained from the American Society of Radiation Oncology (ASTRO) to analyze inter-observer variation in physician attendee contours of atypical meningioma at the 2017 ASTRO eContouring session. Twenty-nine radiation oncologists participated. They were provided a case history of partially resected atypical meningioma abutting the left optic nerve. Pre- and post- operative MR imaging with diagnostic reports were available. Each participant contoured the gross tumor volume (GTV), clinical target volume (CTV), brainstem, optic chiasm, and optic nerves. The data sets were anonymized. Dice statistics to assess the degree of overlap between an individual’s contour against a referenced expert, descriptive statistics, and coefficients of variation (SD/mean) were calculated for the GTV, CTV, and OARs. Zero overlap would yield a Dice coefficient of 0.00, while perfect overlap a coefficient of 1.00. Similar to other studies where Dice coefficients of 0.85-0.90 indicate consistency between observers, we set a Dice coefficient of <0.80 to indicate meaningful variation. The highest mean Dice coefficient and lowest coefficient of variation was observed for the brainstem. While preoperative GTV demonstrated a high degree of agreement between observers, there was poor agreement in postoperative planning GTV and CTV (Table 1). The difference between GTV and CTV mean Dice statistics was not statistically significant (p=0.09). Poorest agreement was observed for the target-approximate optic chiasm. Compared to other primary diseases treated with radiotherapy, there is considerable inter-observer variability in GTV and CTV contours of atypical meningioma. This may represent both inconsistent training for meningioma treatment planning and a deeper lack of agreement regarding delineation of gross and subclinical disease. This variability may result in both under-treatment and OAR overexposure. This has particularly serious implications for meningioma radiosurgery, which is increasingly used in spite of a paucity of long-term follow-up. Evidence-driven guidelines defining optimal target delineation of meningiomas are warranted.Abstract 2144; Table 1StructureDice (mean)SDCoefficient of Variation (SD/mean)Brainstem0.8890.0720.081Chiasm0.4830.2000.414CTV0.6880.1160.169GTV0.7460.1270.170LON0.5900.1620.275Pre-sx tumor0.9100.0140.016RON0.6070.1230.202StructureVolume (median cc)MinMaxGTV5.0900.72018.040 Open table in a new tab

AB003. Stereotactic body radiation therapy vs. pulmonary resection

: Pulmonary resection remains the accepted standard of care for early stage non-small cell lung cancer (NSCLC) in patients with adequate cardiopulmonary reserve. Radiation therapy, and in particular stereotactic body radiation therapy (SBRT), has traditionally been recommended as curative therapy for medically unfit patients who harbor early stage lung cancer. As a consequence of the rising success of SBRT in patients with medically inoperable early stage NSCLC (evidenced by Radiation Therapy Oncology Group trials 0236 and 0915), there has been keen interest in exploring this modality in operable patients. SBRT to lung is often very well tolerated, thus making it very attractive to patients. The risk of series complications in carefully selected patients is low. Equipoise among surgeons and the medical community for the use of SBRT as curative therapy for patients eligible for surgery has been limited, thus contributing to the poor accrual and early closure of 3 randomized trials attempting to directly compare SBRT to surgery in operable patients. These trials included the STARS trial (Study of Anastrozole and Radiotherapy Sequencing), the ROSEL trial [Either Surgery or Stereotactic Radiotherapy for Early-Stage (IA) Lung Cancer] and the American College of Surgeons Oncology Group (ACOSOG) Z4099 trial. No preliminary data is available from the ACOSOG trial. The STARS and ROSEL trial randomized operable patients with tumors <4 cm (cT1–T2a) and required invasive mediastinal staging in patients harboring radiographically suspicious lymph nodes. Sublobar resection was not permitted in these trials. Since patient accrual was limited (n=58 total patients) the two trials were combined in a controversial publication that showed improved overall survival and decreased toxicity with SBRT compared to surgery. This has spawned additional randomized trials including the STABLE-MATES trial comparing sublobar resection and SBRT in patients with stage I NSCLC (NCT02468024) with an estimated enrollment of 258 patients, a Veterans Affairs Lung Cancer or Stereotactic Radiotherapy (VALOR) trial (NCT02984761) with estimated enrollment of 670 patients, and lastly, a phase II United Kingdom sponsored SABRTooth study (NCT02629458) that is enrolling up to 54 patients. The lack of randomized data has stimulated multiple publications that retrospectively examine these modalities in single center case series and more recently in larger data sets derived from the National Cancer Database (NCDB), the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database and the United States Veterans Affairs Health Care System. These retrospective analyses are clearly limited by patient selection bias and different levels of staging accuracy. Propensity matched retrospective series showed that overall survival was no different at 1 year but favored surgery at 3 years. Cancer-specific survival (clearly a better outcome measure particularly in elderly patients receiving SBRT) was no different compared to surgery, nor was local failure, or the risk of developing distant metastases. Collectively, the studies that used large data with statistical matching demonstrated a survival advantage of surgery (namely lobectomy) over SBRT for stage I NSCLC but raised awareness of the increased post procedure morbidity and mortality for surgery compared to SBRT. Interestingly, sublobar resection versus SBRT in these large data sets had mixed results with some showing survival improvement with surgery and some showing no survival difference. Surgery appears superior at later time points. In a phase II ablate and resect human clinical trial (MISSILE-NSCLC, NCT02136355) for early stage (T1–T2) NSCLC, 35 patients underwent neoadjuvant SBRT using 54–60 Gy in 3–8 fractions followed by surgery at an interval of 10 weeks. The authors reported a 60% pathologic complete response rate, invoking many questions about local control of SBRT. Assessment of local control after SBRT remains the single most challenging real-world clinical problem. The lung injury post ablation is heterogenous and requires very careful observation with imaging modalities that lack sensitivity and specificity for recurrence. At present, the American Society of Radiation Oncology does not recommend SBRT for operable patients with early stage NSCLC outside of a clinical trial.

Overemphasis of Step 1 Scores May Affect Application Pool Diversity in Radiation Oncology

PurposeMany radiation oncology programs use Step 1 score metrics as a surrogate for intelligence and success to screen applicants. The impact of this practice on radiation oncology applicant pool diversity is unknown. Methods and MaterialsElectronic Residency Application Service applications submitted to our institution between 2015 and 2018 match cycles were reviewed. Sex, age, race/ethnicity, and Step 1 scores were collected. Groupings by characteristics were sex (female vs male), age ≤30 versus >30 years, and race/ethnicity by underrepresented minority (URM) versus non-URM status. URMs were defined as Black/African American, Hispanic, Native American/Alaskan Native, and Hawaiian/Pacific Islander. Step 1 scores were divided based on scores of 220 and 240. The association between applicant demographics and Step 1 scores was assessed using proportional odds logistic regression for ordinal outcomes. ResultsEight hundred ten applicants with Step 1 scores ranging from 188 to 275 were collected, representing nearly 90% of all applicants during the 2015 to 2018 Electronic Residency Application Service cycles. Twenty-nine percent were female, 29% were >30 years of age, and 10% were URMs. Increasing Step 1 score requirements disproportionately decreased representation of applicants who were female versus male at 240 (–51% vs –31%), >30 versus ≤30 years old at 220 (–28% vs –6%) and 240 (–55% vs –26%), and URMs versus non-URMs at 220 (–34% vs –9%) and 240 (–61% vs –34%). On analysis, Step 1 score requirements had a statistically significantly impact on applicant distributions based on sex, age, and URM status (P < .001). ConclusionsOveremphasis of Step 1 scores may reduce the diversity of the radiation oncology applicant pool. Further evaluation of practices that counter the stated American Society of Clinical Oncology, American Society of Radiation Oncology, and American College of Radiology diversity missions should be pursued to improve understanding of barriers and biases.

Hypofractionated radiation in older women with breast cancer.

American Society of Radiation Oncology Choosing Wisely campaign recommends hypofractionated radiation and against routine use of intensity-modulated radiation therapy (IMRT) in early-stage estrogen receptor-positive breast cancer. We analyzed guideline recommendation adherence and financial implications in a modern Medicare cohort of women treated across the southeastern United States. Our study population comprised Medicare patients over 65years of age with breast cancer diagnosis from 12 cancer centers in the Southeast United States with stage 0-II breast treated with lumpectomy from 2012 to 2015. Hypofractionation was defined as 4 or fewer weeks of radiation treatments. Factors associated with utilization of hypofractionation and IMRT were identified using Poisson regression. Median costs during radiation treatments were compared for hypofractionation and IMRT. In older women (median age 71), 75% were treated with conventional fractionation, and 20% received IMRT. Hypofractionated women were more likely to have a positive estrogen(ER) or progestorone(PR) receptor status, lower comorbidity scores, and be treated at a high volume center (all P<0.05). IMRT was utilized in 20% of patients and was more common in women treated with conventional fractionation (P<0.001). Positive ER/PR status (P<0.001) and utilization of hormonal blockade (P=0.02) were associated with increased utilization of IMRT. In an older cohort of patients with early-stage breast cancer, a majority were treated with conventional fractionated radiation, while approximately 20% were treated with IMRT. Both of which were associated with increased cost relative to hypofractionation.

Trends in the use of proton beam therapy among newly diagnosed cancer patients in the United States.

6551 Background: Proton Beam Therapy (PBT) is a potentially superior radiotherapy technology for tumors with complex anatomy surrounded by sensitive tissues and for childhood cancers where sparing surrounding normal tissue is better achieved than with photon radiotherapy. The first conditions for payment of PBT claims went into effect in 2009. In 2014, the American Society of Radiation Oncology categorized PBT clinical indications into Group 1, for which health insurance coverage is recommended, and Group 2, for which coverage is recommended only if additional requirements are met. Methods: We evaluated 21,920 newly diagnosed patients in the National Cancer Database (NCDB) who received PBT between 2004 and 2016. Joinpoint analyses were used to evaluate the Annual Percent Change (APC) in the number and characteristics of patients treated with PBT. Results: The number of patients treated with PBT in NCDB facilities increased from 1,114 in 2004 to 3,173 in 2016 (APC = 8.78, p &lt; .001), due mainly to increases in Group 1 cancers after 2010 (from 271 patients in 2010 to 1,124 in 2016, APC = 26.4, p &lt; .001). The number of Group 2 patients treated with PBT increased slower (from 937 in 2004 to 2,049 in 2016, APC = 6.1, p &lt; .05). Breast and prostate cancers were most common, although trends varied substantially by cancer site. Between 2010 and 2016, receipt of PBT increased for breast cancer patients from 40 in 2010 to 405 in 2016 (APC = 48.5, p &lt; .001), but decreased for prostate cancer patients from 1,205 in 2011 to 680 in 2016 (APC = -14.06, p &lt; .001). While most of Group 1 patients had private insurance coverage (59.3% of patients treated in 2016), Medicare was the most common primary insurance type among Group 2 patients (50% of patients treated in 2016). Conclusions: The number of newly diagnosed cancer patients treated with PBT has increased between 2004 to 2016 in the US, with a sharp increase for cancers with clinical indications for health insurance coverage since 2010. While most of these patients have private insurance coverage, the steady increase in the number of patients being treated with PBT for cancers with additional requirements for health insurance coverage is primarily in those with Medicare coverage.

Ductal carcinoma in situ and intraoperative partial breast irradiation: Who are the best candidates? Long-term outcome of a single institution series

AimsTo report the long-term outcome of a single institution series of pure ductal carcinoma in situ (DCIS) treated with accelerated partial irradiation using intraoperative electrons (IOERT). MethodsFrom 2000 to 2010, 180 DCIS patients, treated with quadrantectomy and 21 Gy IOERT, were analyzed in terms of ipsilateral breast recurrences (IBRs) and survival outcomes by stratification in two subgroups. The low-risk group included patients who fulfilled the suitable definition according to American Society of Radiation Oncology (ASTRO) Guidelines (size ≤2.5 cm, grade 1–2 and surgical margins ≥3 mm) (Suitable), while the remaining ones formed the high-risk group (Non-Suitable). ResultsEighty-four and 96 patients formed the Suitable and Non-Suitable groups, respectively. In the whole population, the cumulative incidence of IBR at 5, 7 and 10 years was 19%, 21%, and 25%, respectively. In the Suitable group, the cumulative incidence of IBR remained constant at 11% throughout the years, while in the Non-Suitable group increased from 26% at 5 years to 36% at 10 years (p < 0.0001).When hormonal positivity and HER2 absence of expression were added to the selection of the Suitable group, the cumulative incidence of IBR dropped and stabilized at 4% at 10 years. None died of breast cancer. In the whole population, 5-year and 10-year overall survival rate was 98% and 96.5%, respectively, without any difference between the two groups. ConclusionsThe overall and by group IBR rates were high and stricter criteria are required for acceptable local control for Suitable DCIS. Because of the concerns raised, IOERT should not be used in clinical practice.

Analysis of the 2017 American Society for Radiation Oncology (ASTRO) Research Portfolio

Research in radiation oncology (RO) is imperative to support the discovery of new uses of radiation and improvement of current approaches to radiation delivery and to foster the continued evolution of our field. Therefore, in 2016, the American Society of Radiation Oncology performed an evaluation of research grant funding for RO. Members of the Society of Chairs of Academic Radiation Oncology Programs (SCAROP) were asked about funded and unfunded grants that were submitted by their departments between the fiscal years 2014 and 2016. Grants were grouped according to broad categories defined by the 2017 American Society of Radiation Oncology Research Agenda. Additionally, active grants in the National Institutes of Health (NIH) Research Portfolio Online Reporting Tools database were collated using RO faculty names. Overall, there were 816 funded (44%) and 1031 unfunded (56%) SCAROP-reported grants. Total grant funding was over $196 million. The US government funded the plurality (42.2%; 345 of 816) of grants compared with nonprofit and industry funders. Investigators from 10 institutions accounted for >75% of funded grants. Of the funded grants, 43.5% were categorized as "genomic influences and targeted therapies." The proportion of funded to unfunded grants was highest within the category of "tumor microenvironment, normal tissue effects, and reducing toxicity" (53.4% funded). "New clinical trial design and big data" had the smallest share of SCAROP grant applications and the lowest percent funded (38.3% of grants). NIH grants to RO researchers in 2014 to 2016 accounted for $85 million in funding. From the 31 responding SCAROP institutions, there was a 28% average success rate for RO proposals submitted to the NIH during this period. Though RO researchers from responding institutions were relatively successful in obtaining funding, the overall amount awarded remains small. Continued advocacy on behalf of RO is needed, as well as investment to make research careers more attractive areas for emerging faculty.

Barriers to Referral for Palliative Radiotherapy by Physicians: A Systematic Review

AimsPalliative radiotherapy (PRT) can relieve symptoms and improve quality of life, but remains underutilised, possibly due to lack of referrals. We conducted a systematic review to study barriers impeding referral for PRT. Materials and methodsWe searched EMBASE and MEDLINE to identify published studies of physician barriers to PRT referral. Data were synthesised using the percentage of respondents to the surveys in these studies who identified a given factor as a significant barrier to PRT referral. Barriers were categorised using a conceptual framework for radiotherapy access described by Sundaresan et al. (Aust Health Rev 40 (1), 2016, 11–18.) ResultsEMBASE and MEDLINE searches returned 364 distinct papers. Of these, 11 papers (reporting on 12 cohorts of survey respondents) met the study inclusion criteria. All used a cross-sectional survey design. Seven cohorts included mainly family physicians, one surveyed mostly radiation oncologists, one surveyed hospice professionals and one surveyed members of the American Society of Clinical Oncology, the American Society of Radiation Oncology and the American Academy of Hospice Palliative Medicine. Many factors were identified as strongly influencing referral decisions. Only two cohorts of respondents were asked whether patient wishes influence referrals, but most (78–82%) respondents in these cohorts agreed that it was an important influence. Other important barriers included functional status (five cohorts asked, cited as a strong influence by 53–78% of respondents), short life expectancy (three, 44–59%), treatment length (five, 51–58%), inconvenience (six, 24–65%), cancer type (three, 55–80%), uncertainty of benefits (seven, 18–54%) and toxicity concerns (11, 18–43%). Hospice professionals most frequently cited factors related to expense of treatment. ConclusionsPublished high-quality data on barriers to PRT referral are limited to survey studies. Barriers to PRT referral include referrers' unfamiliarity regarding risks and benefits, cumbersome referral processes and perceived inconvenience of treatment. Interventions to increase referrals should be tailored to different professional groups and may include increased expert participation in multidisciplinary palliative care, shortening treatment courses and in-person interprofessional education.

Comparison of Conflict of Interest (COI) Disclosures to Publicly Reported Industry Payments for Presenters at the American Society of Radiation Oncology (ASTRO) Annual Meeting: Can we Do Better?

The ASTRO annual meeting is the largest US academic forum for radiation oncology. Proper conflict of interest (COI) disclosure by speakers is essential to research integrity. We examine presentations at ASTRO annual meetings to evaluate COI disclosure and compare these disclosures to payments reported on the Centers for Medicare and Medicaid Services Open Payments (OP) database. In this abstract, we report on disclosure discrepancies and quantitative monetary thresholds of these discrepancies. The first presentation of each podium, scientific, presidential symposium, educational and panel session from the 2014-2016 ASTRO virtual meetings was arbitrarily selected. Each presentation was examined 1) for the presence of a COI slide and 2) for the disclosures listed. For each presenter, disclosures were cross-referenced with the OP database in the prior year in the categories of consulting, research, and faculty/speaking fees. Disclosures were determined to be discrepancies if a speaker did not list all the companies from which they received a payment as reported on the OP database, or if no COI slide was present. Of the 401 total presentations examined, 264 were US MDs, and 16.4% of US MDs underreported industry funding. When examining individual payments for all US presenters, 96 payments were reported on the OP database in the aforementioned categories: 53 of these payments were not disclosed and 43 payments were accurately disclosed. Of the presentations with discrepancies, 32.6% did not have a COI slide, 39.5% failed to disclose any OP companies, and 27.9% disclosed some but not all OP companies. Mean payment was $34,264 (median: $4,000; range: $96-$488,931), mean discrepancy was $30,300 (median: $2,925; range: $96-$488,931) and mean disclosed payment was $39,151 (median: $5,000; range: $750-$400,000). Research payments were the largest with a mean of $71,167 (median: $13,566; range: $160-$488,931). Among discrepancies, 49.1% were for research, 30.2% for consulting, and 20.8% for faculty/speaking fees. Three-quarters of the lowest third of all payments ($96-$2000) were not disclosed with the majority (75%) of these discrepancies occurring in presentations with COI slides while 45.3% of the upper two thirds of payments were not disclosed with 41.3% occurring in presentations with COI slides. A large minority of presenters underreported COIs. Payments of lower amounts were more often underreported. Limitations of our study include the small sample size and potential errors in reporting on OP. Nearly a third of discrepancies were due to absent COI slides, suggesting inadequate understanding of disclosure protocols. Guidelines should be revised with an emphasis on the dollar amount relevant for disclosing industry payments.

Radiation-Drug Combinations to Improve Clinical Outcomes and Reduce Normal Tissue Toxicities: Current Challenges and New Approaches: Report of the Symposium Held at the 63rd Annual Meeting of the Radiation Research Society, 15-18 October 2017; Cancun, Mexico.

The National Cancer Institute's (NCI) Radiation Research Program (RRP) is endeavoring to increase the relevance of preclinical research to improve outcomes of radiation therapy for cancer patients. These efforts include conducting symposia, workshops and educational sessions at annual meetings of professional societies, including the American Association of Physicists in Medicine, American Society of Radiation Oncology, Radiation Research Society (RRS), Radiosurgery Society, Society of Nuclear Medicine and Molecular Imaging, Society for Immunotherapy of Cancer and the American Association of Immunology. A symposium entitled "Radiation-Drug Combinations to Improve Clinical Outcomes and Reduce Normal Tissue Toxicities" was conducted by the NCI's RRP during the 63rd Annual Meeting of the RRS on October 16, 2017 in Cancun, Mexico. In this symposium, discussions were held to address the challenges in developing radiation-drug combinations, optimal approaches with scientific evidence to replace standard-of-care, approaches to reduce normal tissue toxicities and enhance post-treatment quality-of-life and recent advances in antibody-drug conjugates. The symposium included two broad overview talks followed by two talks illustrating examples of radiation-drug combinations under development. The overview talks identified the essential preclinical infrastructure necessary to accelerate progress in the development of evidence and important challenges in the translation of drug combinations to the clinic from the laboratory. Also addressed, in the example talks (in light of the suggested guidelines and identified challenges), were the development and translation of novel antibody drug conjugates as well as repurposing of drugs to improve efficacy and reduce normal tissue toxicities. Participation among a cross section of clinicians, scientists and scholars-in-training alike who work in this focused area highlighted the importance of continued discussions to identify and address complex challenges in this emerging area in radiation oncology.

Updated ASTRO guidelines on accelerated partial breast irradiation (APBI): to whom can we offer APBI outside a clinical trial?

The American Society of Radiation Oncology has recently updated itsguidelines on the role of accelerated partial breast irradiation in the management of breast cancer. This commentary discusses the new recommendations and how we might advise patients in the light of existing data.

The 2017 American Society of Radiation Oncology (ASTRO) annual meeting: Taking a deeper dive into social media

The 2017 American Society of Radiation Oncology (ASTRO) annual meeting: Taking a deeper dive into social media

Abstract P4-15-08: Association of OncotypeDX® DCIS ScoreTM results with local recurrence in patients with DCIS treated on accelerated partial breast radiotherapy (APBI) protocols

Abstract Background: Ductal carcinoma in situ (DCIS) is a proliferation of malignant epithelial cells of the ducts and terminal lobular units of the breast that do not invade the basement membrane. The incidence of DCIS has increased markedly since the early 1980s, chiefly due to screening mammography. Whole breast radiotherapy has largely been used to treat breast DCIS after lumpectomy. More recently, APBI has increasingly been utilized for breast DCIS. Currently updated American Society of Radiation Oncology (ASTRO) APBI guidelines have included "low risk" DCIS (as defined by RTOG 9804 criteria). The following results further explore clinico-pathologic factors, in addition to the DCIS Score, in order to better define an appropriate DCIS population for APBI. Methods: An exploratory analysis aimed to retrospectively measure the association between clinico-pathologic factors and the DCIS Score result, an optimized 12-gene expression algorithm, and risk of any local failure (in situ or IBC recurrence) in a cohort of women treated with local excision and APBI on prospective phase II (NCT01185145) and phase III (NCT01185132) clinical trials. Multifocal tumors were described only by local pathology and not determined or defined centrally. The DCIS Score assay was performed by quantitative RT-PCR on formalin-fixed paraffin-embedded DCIS tumor specimens by Genomic Health (Redwood City, CA). Descriptive statistics of the cohort and assay results overall and by clinical trial were derived. Univariable Cox proportional hazards regression was used to determine whether there was an association between local failure and categorized DCIS Score group (≥39 vs &amp;lt;39) or other clinico-pathologic factors on the pooled cohort of clinical trial patients. Results: This analysis included 104 evaluable patients (N=18 from NCT01185145 and N=86 from NCT01185132). The median age was 60 (range: 41-80), 79% of patients were postmenopausal, and the median span of DCIS was 6 mm (range 2-25 mm). Over two-thirds of the cohort presented with necrosis (71%). The distribution of DCIS Score results ranged from 0 to 82, with 69% of patients having a DCIS Score result &amp;lt;39. The median follow-up time was longer at 8.2 years in NCT01185145 versus 3.0 years in NCT01185132. There was a total of 6 local recurrences. DCIS Score result was significantly associated with local recurrence in univariable modeling (hazard ratio=10.3 for ≥39 vs &amp;lt;39; p=0.0104). None of the other clinico-pathologic characteristics resulted in any significant correlation with locoregional recurrence. All results were highly variable due to the small number of events. Conclusion: The DCIS Score assay demonstrated risk stratification in this cohort of patients treated with local excision and APBI pooled from two clinical trials. These results are consistent with those recently published by Rakovitch et al (J Natl Cancer Inst 2017). The cohort in this study was dominated by those in the phase III trial. Due to the small number of local recurrence events and limited follow-up time in the phase III trial, caution should be taken when interpreting the results. Further investigations are needed to confirm findings. Citation Format: Leonard CE, Fryman SP, Turner MP, Bennett JP, Carter DL, Sing AP. Association of OncotypeDX® DCIS ScoreTM results with local recurrence in patients with DCIS treated on accelerated partial breast radiotherapy (APBI) protocols [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-08.

Clinical implementation of radiosurgery using the Helical TomoTherapy unit

The American Society of Radiation Oncology has recently recommended the use of radiosurgery to manage brain metastases. For such a recommendation to be implemented in a widespread manner, radiosurgery must be accessible at community radiation therapy facilities. The work presented here describes our clinical experience in the implementation of radiosurgery using a Helical TomoTherapy unit. Helical TomoTherapy is a unique dose-delivery system designed to perform intensity-modulated radiation therapy (IMRT). The system built on the ring-based gantry has the tight machine tolerances required for radiosurgery. A frameless system consisting of a thermoplastic mask and a noninvasive “stereotactic radiosurgery (SRS)-stereotactic radiotherapy (SRT)” fixation device is used for patient immobilization. Treatment planning is performed using the TomoHD treatment planning system designed for IMRT. The image-guidance system on the Helical TomoTherapy is used for patient localization. Our clinical experience demonstrated that the radiosurgery procedure can be streamlined as we do for IMRT patients. The treatment time of about 10 minutes is comparable with that for IMRT patients. The same patient-specific quality assurance for IMRT is used for radiosurgery. As demonstrated, SRS using Helical TomoTherapy is not a whole-day event, unlike SRS using other dose-delivery systems or SRS performed in the past.

Training Neurosurgery and Radiation Oncology Residents in Stereotactic Radiosurgery: Assessment Gathered from Participants in AANS and ASTRO Training Course.

Stereotactic radiosurgery (SRS) represents an expanding approach for neurosurgeons and radiation oncologists. We evaluate educational gaps of senior residents drawn from each specialty as part of a focused SRS course. We also evaluate the strengths and limitations of SRS training in current residency programs of the course residents and faculty. The American Association of Neurological Surgeons and American Society of Radiation Oncology jointly held a senior resident course in SRS. Residents were nominated by program directors from across the United States. Thirty residents were chosen to participate in the course. The residents were surveyed before and after the course. Faculty (n= 14) were also surveyed to ascertain their perspectives on current training in SRS. Most (96.7%) of the residents planned to perform SRS when finished, and 94% anticipated SRS indications to expand. Regarding SRS technique, 47% reported average/above average understanding of intracranial SRS; only 17% expressed similar understanding of spinal SRS. Before the course, 76.6% noted below average/average ability to recognize and manage SRS complications. Twenty-three percent of the faculty indicated that graduating residents from their programs were unprepared to perform radiosurgery. Residents' self-assessed understanding of brain SRS indication (P= 0.000693), SRS techniques (P= 0.000021), spinal SRS indications (P=0.000050), spinal SRS techniques (P= 0.000019), and complication recognition and management (P= 0.00033) significantly improved following the course. Knowledge and training gaps in SRS appear evident to the senior residents and faculty of both specialties. We believe that other educational opportunities for SRS experience are necessary to optimize clinical competency, as well as meet future clinical staffing needs for this expanding, multidisciplinary approach. Further evaluation of gaps in SRS is necessary through a larger, nationwide survey of U.S. neurosurgeons, program directors, and residents.

Survey to Assess the Practice Patterns of Induction Chemotherapy (IC) in Head and Neck Cancer Patients

To investigate practice patterns of use of IC amongst oncologists in treatment of head and neck cancer (HNC) patients. An IRB approved survey was sent using Red Cap software to oncologists registered on the American Society of Radiation Oncology (ASTRO) website. Variables were subjected to analysis with Fisher’s exact test. Data analysis was considered significant at Bonferroni adjusted p=0.05 threshold if the p-value was≤ 0.001 and suggestive if p<0.05.The survey was sent to 6818 unique email addresses. The response rate was 14.9% of US and 4.6% of international practitioners. 371 (98.4%) of participants were radiation oncologists. Participants identified as their practice type as Private Practice (23.9%), Academic (44.6%), Hospital Based (30.8%). Level of experience was “still in training” (15.4%), <1 year after completion of training (3.4%), 1-5 years (17.5%), 6-10 years (13.5%), 11-20 years (17.8%), 20-30 years (19.6%), and >30 years (12.7%). 56.8% participants treated >20 HNC patients yearly. 52.5% felt that there are some scenarios where IC improves cancer control and 57.8% felt that there were some scenarios where IC improves quality of life (QOL) outcomes for patients with locally advanced HNC. There was no difference between type of practice or level of training and feelings regarding IC in improving outcomes. Non US practitioners were more likely to feel that IC improved QOL (p=0.03) and were more likely to use IC (p=0.005). Increased volume of HNC patients treated was correlated with an increased use of IC (p=0.001). HNC patient volume was correlated with use of IC in a borderline laryngeal preservation (p= 0.006), bulky cervical lymph node (p=0.0005), and optic structure impinging tumor (p=0.007) case. Variability in use of IC was high. In a patient with a bulky lymph node, 30.5% of respondents rated their willingness to use IC at 0 of a 5 on a 5 point scale, 10.6% at 1, 8% at 2, 11.9% at 3, 15.1% at 4 and 19.9% at 5. In a case with tumor impinging on the optic structures, 25.2% of respondents rated their willingness to use IC at 0 of 5, 9.5% at 1, 12.7% at 2, 14.6% at 3, 17.5% at 4 and 16.7% at 5. After a complete response to IC, doses recommended were 70 Gy (54.6%), >60 but <70 Gy (34.1%), and 60 Gy (8.9%). For a patient with a partial response to IC with a decreased size of a lymph node mass, participants were divided on the dose to treat the areas that were previously involved with tumor, treating with <60 Gy (1.4%), 60 Gy (18%), >60 but <70 Gy (36.3%), 70 Gy (41.1%) and >70 Gy (3.5%). Practice patterns regarding the use of IC were highly varied. IC was most often recommended in patients with bulky cervical lymph node burden or a tumor impinging on the optic structures. Use of IC correlated with patient volume and country of practice.

ASTRO's Advances in Radiation Oncology: Success to date and future plans

ASTRO's Advances in Radiation Oncology was launched as a new, peer-reviewed scientific journal in December 2015. More than 200 manuscripts have been submitted and 97 accepted for publication as of May 2017. As Advances enters its second year of publication, we have chosen to highlight subjects that will transform the way we practice radiation oncology in special issues or ongoing series: immunotherapy, biomedical analytics, and social media. A teaching case report contest for North American radiation oncology residents will be launched at American Society of Radiation Oncology 2017 to encourage participation in scientific publication by trainees early in their careers. Recognizing our social mission, Advances will also begin a series of articles devoted to highlighting the growing disparities in access to radiation oncology services in vulnerable populations in North America. We wish to encourage the American Society of Radiation Oncology membership to continue its support of the journal through high-quality manuscript submission, participation in the peer review process, and highlighting important manuscripts through sharing on social media.