Association Of Radiation Oncology Research Articles

Art for Advanced Radiation Oncology – Synchronizing the Past and the Future for a Better Patient Care

"Professor Maria Antonietta Gambacorta is a specialist in Radiation Oncology with a PhD in Brachytherapy. She is responsible for the Radiotherapy Oncology hospitalizations and the Interventional Oncology Center and the coordinator of the Multidisciplinary Group for the treatment of rectal tumors within the Comprehensive Cancer Centre of the Fondazione Policlinico Agostino Gemelli, Rome. Due to her level of expertise, she was elected member of the Board of Directors of the Italian Association of Radiation Oncology (AIRO); and member of the board for the drafting of the Guidelines on rectal cancer of the Italian Association of Medical Oncology. Professor Gambacorta is a member of European Society of Radiation Oncology (ESTRO) where she carries out teaching activities in international courses of the ESTRO school. She has published more than 170 scientific publications in peer-reviewed journals, including the International consensus guidelines for Clinical Target Volume delineation in rectal cancer. In this interview, Professor Gambacorta shares some insights about the Art for ART project, implemented in the Radiotherapy department of Policinico Agostino Gemelli, Rome."

Radiotherapy as treatment option in biliary cancer patients: a national survey of AIRO (Italian Association of Radiation Oncology) Gastroenterology Group.

BackgroundThe aim is to find out how many radiation oncology centres treat biliary duct carcinoma (BDC), what treatments they offer and whether they would be interested in developing prospective trials.Materials and methodsA questionnaire was posted to all 220 Italian Radiation Oncology Centres. The survey consisted of 31 eligibility questions in a combination of multiple and forced choice formats addressing the following parameters: characteristics of the centre, numbers of BDC patients treated, treatment options, radiotherapy parameters (target definition, schedule, technique, dose constraints) and interest in developing future randomized trials.ResultsNo major differences emerged in BDC management, whatever the site, and whether it was resectable or not. Discrepancies in routine clinical practice were, however, observed with lack of agreement on expansion margins, dose constraints and treatment schedules for the stereotactic technique and palliative treatments.ConclusionsThe present survey attempted to fill the gaps in the role of radiotherapy in patients with BDC. Since lack of prospective randomized studies and disease rarity have mitigated against an evidence-based approach, patients with BDC should be enrolled in prospective studies. The above-mentioned results should also emphasize the need to combine analysis of treatment results from all Italian centres in order to create predictive models.

11: The Canadian Association of Radiation Oncology 2020 Radiation Oncologist Burnout and Work Engagement Survey

11: The Canadian Association of Radiation Oncology 2020 Radiation Oncologist Burnout and Work Engagement Survey

OC-0075: The Canadian Association of Radiation Oncology 2019 workforce and technology utilization study

OC-0075: The Canadian Association of Radiation Oncology 2019 workforce and technology utilization study

Brachytherapy in Belgium in 2018. A national survey of the brachytherapy study group of the Belgian SocieTy for Radiotherapy and Oncology (BeSTRO)

PurposeTo explore the current practices patterns and evaluate the actual brachytherapy (BT) resources in Belgium. Material and methodsIn 2019, the Brachytherapy Study Group proposed to conduct a survey on behalf of the Belgian SocieTy of Radiation Oncology (BeSTRO) in order to identify current BT practice patterns. An electronic questionnaire was sent to all primary radiotherapy centers in Belgium. This questionnaire was based on the questionnaire that was used by the Italian Association of Radiation Oncology (AIRO) in 2016, asking for: (a) General information on the Radiation Oncology Centre; (b) BT equipment and human resources; (c) BT procedures; (d) BT assessment (number of patients treated annually, treated sites, and different modalities of treatments). ResultsAll 24 radiation oncology centers (100% response rate) answered the questionnaire and gave also information on the performance of brachytherapy in their (eventual) satellite centers. Eighteen (18) BT afterloader units were installed and operational in 2018. Thirteen centers mentioned a prostate seed implant program, one center a prostate and eye plaque program and one center only an eye plaque program. Less than 50% of centers have the infrastructure to offer the full-range of BT in their own department. In 2018, 1486 patients received a BT-treatment, 28% of them were treated by prostate seed implant, 8% were treated by eye-(seed) BT and 64% by high dose rate (HDR)/pulsed dose rate (PDR) BT. Forty-five percent of HDR/PDR patients were treated by vaginal dome BT, 22% by intra-uterine BT, 11% by skin BT, 10% by breast BT (almost exclusively in one centre), 8% for benign pathology (keloid) and the remaining 4% were treated for prostate (as a boost or as salvage in one centre), anal, penile, lung or oesophageal cancer. ConclusionsBelgian radiotherapy departments often perform BT only in a (highly) selected group of pathologies, resulting in a limited number of patients treated by this technique despite the sufficient availability of BT equipment. Modern indications are often not covered, hence patients do not have regular access to recognized treatment options, possibly leading to inferior oncological outcome. BeSTRO will use the results of this survey to stimulate improvements in training, awareness, education, implementation, collaboration and cooperation in the field of brachytherapy.

Re-irradiation for recurrent glioma: outcome evaluation, toxicity and prognostic factors assessment. A multicenter study of the Radiation Oncology Italian Association (AIRO).

The prognosis of glioma is dismal, and almost all patients relapsed. At recurrence time, several treatment options are considered, but to date there is no a standard of care. The Neurooncology Study Group of the Italian Association of Radiation Oncology (AIRO) collected clinical data regarding a large series of recurrent glioma patients who underwent re-irradiation (re-RT) in Italy. Data regarding 300 recurrent glioma patients treated from May 2002 to November 2017, were analyzed. All patients underwent re-RT. Surgical resection, followed by re-RT with concomitant and adjuvant chemotherapy was performed. Clinical outcome was evaluated by neurological examination and brain MRI performed, 1month after radiation therapy and then every 3months. Re-irradiation was performed at a median interval time (IT) of 16months from the first RT. Surgical resection before re-RT was performed in 19% of patients, concomitant temozolomide (TMZ) in 16.3%, and maintenance chemotherapy in 29%. Total doses ranged from 9Gy to 52.5Gy, with a median biological effective dose of 43Gy. The median, 1, 2year OS were 9.7months, 41% and 17.7%. Low grade glioma histology (p ≪ 0.01), IT > 12months (p = 0.001), KPS > 70 (p = 0.004), younger age (p = 0.001), high total doses delivered (p = 0.04), and combined treatment performed (p = 0.0008) were recorded as conditioning survival. our data underline re-RT as a safe and feasible treatment with limited rate of toxicity, and a combined ones as a better option for selected patients. The identification of a BED threshold able to obtain a greater benefit on OS, can help in designing future prospective studies.

Hypofractionated radiation therapy in the management of locally advanced NSCLC: a narrative review of the literature on behalf of the Italian Association of Radiation Oncology (AIRO)-Lung Working Group.

A systematic literature was performed to assess the benefit in terms of effectiveness and feasibility of hypofractionated radiotherapy (HypoRT), with or without chemotherapy (CT), in the treatment of locally advanced non-small cell lung cancer (NSCLC). We have identified all studies, published from 2007 onwards, on patients with locally advanced NSCLC treated with HypoRT with radical intent, with a minimal dose per fraction of 2.4Gy, with or without concurrent chemotherapy. Twenty-nine studies were identified, for a total of 2614 patients. Patients were divided in the concurrent chemo-radiation therapy group (CT-RT) and radiotherapy alone (RT). In RT group, the delivered dose ranged from 45 to 85.5Gy, with a dose/fraction from 2.4 to 4Gy. Actuarial 2-year PFS ranged from 13 to 57.8%, and 1, 2- and 3-year overall survival (OS) ranged from 51.3 to 95%, from 22 to 68.7%, and from 7 to 32%, respectively. Acute Grade ≥ 3 esophagitis occurred in 0-15%, while late esophageal toxicity was 0-16%. Acute pneumonitis occured in 0-44%, whereas late pneumonitis occured in 0-47%, most commonly grade ≤ G3. In CT-RT group, the delivered dose ranged from 52.5 to 75Gy, with a dose/fraction ranging from 2.4 to 3.5Gy. Actuarial 2-year PFS ranged from 19 to 57.8%, and OS at 1, 2 and 3years ranged from 28 to 95%, 38.6 to 68.7%, and 31 to 44%, respectively. Acute Grade 2 and 3 esophagitis occurred in 3-41.7%, while late esophageal toxicity occurred in 0-8.3%. Acute pneumonitis ranged from 0 to 23%, whereas late pneumonitis occured 0-47%. HypoRT seems to be safe in patients with locally advanced NSCLC. The encouraging survival results of several studies analyzed suggest that hypofractionated radiation schemes should be further investigated in the future.

Policies for reirradiation of recurrent high-grade gliomas: a survey among Italian radiation oncologists.

To assess the contribution of Italian radiation oncologists in the current management of recurrent high-grade gliomas (HGG), focusing on a reirradiation (reRT) approach. In 2015, the Reirradiation and the Central Nervous System Study Groups on behalf of the Italian Association of Radiation Oncology (AIRO) proposed a survey. All Italian radiation oncologists were individually invited to complete an online questionnaire regarding their clinical management of recurrent HGG, focusing on a reRT approach. A total of 37 of 210 questionnaires were returned (18% of all centers): 16 (43%) from nonacademic hospitals, 14 (38%) from academic hospitals, 5 (13%) from private institutions, and 2 (6%) from hadron therapy centers. The majority of responding centers (59%) treated ≤5 cases per year. Performance status at the time of recurrence, along with a target diameter <5 cm and an interval from primary radiation ≥6 months, were the prevalent predictive factors considered for reRT. Sixty percent of reirradiated patients had already received a salvage therapy, either chemotherapy (40%) or reoperation (20%). The most common approach for reRT was fractionated stereotactic radiotherapy to a mean (photon) dose of 41.6 Gy. Although there were wide variations in the clinical practice of reRT across the 37 centers, the core activities were reasonably consistent. These findings provide a basis for encouraging a national collaborative study to develop, implement, and monitor the use of reRT in this challenging clinical setting.

A new standardized data collection system for interdisciplinary thyroid cancer management: Thyroid COBRA

The big data approach offers a powerful alternative to Evidence-based medicine. This approach could guide cancer management thanks to machine learning application to large-scale data. Aim of the Thyroid CoBRA (Consortium for Brachytherapy Data Analysis) project is to develop a standardized web data collection system, focused on thyroid cancer.The Metabolic Radiotherapy Working Group of Italian Association of Radiation Oncology (AIRO) endorsed the implementation of a consortium directed to thyroid cancer management and data collection. The agreement conditions, the ontology of the collected data and the related software services were defined by a multicentre ad hoc working-group (WG).Six Italian cancer centres were firstly started the project, defined and signed the Thyroid COBRA consortium agreement. Three data set tiers were identified: Registry, Procedures and Research. The COBRA-Storage System (C-SS) appeared to be not time-consuming and to be privacy respecting, as data can be extracted directly from the single centre's storage platforms through a secured connection that ensures reliable encryption of sensible data. Automatic data archiving could be directly performed from Image Hospital Storage System or the Radiotherapy Treatment Planning Systems.The C-SS architecture will allow “Cloud storage way” or “distributed learning” approaches for predictive model definition and further clinical decision support tools development.The development of the Thyroid COBRA data Storage System C-SS through a multicentre consortium approach appeared to be a feasible tool in the setup of complex and privacy saving data sharing system oriented to the management of thyroid cancer and in the near future every cancer type.

The INTER-ROMA project--a survey among Italian radiation oncologists on their approach to the treatment of bone metastases.

Radiotherapy has an established palliative role for bone metastases but despite the large number of patients treated there is still controversy surrounding the optimal radiotherapy schedule to prescribe. The aim of this survey was to determine the decision patterns of Italian radiation oncologists in four different clinical cases of patients with bone metastases. During the latest national meeting of the Italian Association of Radiation Oncology (AIRO), four clinical cases were presented to attending radiation oncologists. The cases were different with respect to the histology of the primary tumor, performance status, pain before and after analgesics, tumor site, and radiological characteristics of the metastatic lesions. For each clinical case the respondents were asked to give an indication for treatment; prescribe doses, volumes and treatment field arrangements; decide whether to prescribe prophylactic supportive therapy or not; and provide information about factors that particularly influenced prescription. Finally, a descriptive statistical analysis was performed. Three hundred questionnaires were distributed to radiation oncologists attending the congress. One hundred twenty-five questionnaires were returned but only 122 (40.6%) were adequately completed and considered for the analysis. Considerable differences were observed among radiation oncologists in prescribing and delivering radiotherapy for bone metastases. There was also a notable divergence from international guidelines, which will be discussed in this report. Despite the results of clinical trials, Italian radiation oncologists differ considerably in their decisions on treatment doses and volumes. National guidelines are needed in order that patients can be treated uniformly and better data will become available for evidence-based palliative radiotherapy.

A national survey of AIRO (Italian Association of Radiation Oncology) brachytherapy (Interventional Radiotherapy) study group.

PurposeTo review brachytherapy resources and to explore current practice patterns in Italy.Material and methodsIn 2016, on behalf of the Italian Association of Radiation Oncology (AIRO), the Brachytherapy Study Group proposed conducting a survey in order to identify brachytherapy practice patterns. An electronic questionnaire was sent to all radiotherapy centres in Italy, asking for: 1. General information on the Radiation Oncology Centre (affiliation, whether brachytherapy was delivered or not); 2. Brachytherapy equipment and human resources; 3. Brachytherapy procedures; 4. Brachytherapy assessment (number of patients treated annually, treated sites, and different modalities of treatments).ResultsA total of 66 questionnaires were returned (33.5% of all brachytherapy centers in Italy), out of which 48 (74%) from non-academic hospitals, 6 (10%) from academic hospitals, and 12 (16%) from private institutions. Most centers (84%) had only one brachytherapy machine; 44% did not deliver brachytherapy treatments or delivered less than demanded because of the lack of staff or expertise, need of modernization, or other reasons. The majority of treatments were administered to outpatients for gynecological tumors.ConclusionsThis survey illustrates the current status of brachytherapy in Italy and should encourage collaboration to develop, implement, and monitor its use when appropriate.

Re-irradiation with curative intent in patients with squamous cell carcinoma of the head and neck: a national survey of usual practice on behalf of the Italian Association of Radiation Oncology (AIRO).

To report the results of a national survey investigating the pattern of practice of curative re-irradiation (ReRT) for recurrent squamous cell carcinoma of the head and neck. In March 2016, a 22-item, 4-section questionnaire was sent to all Italian Radiation Oncology centers. Sections were focused on assessing the expertise level of each center and collecting specific information on reRT prescription modalities in the adjuvant and definitive settings. Overall, 77 centers completed the survey. The majority (50/77, 64.9%) of participating radiation oncologists were senior consultants (> 10 years of experience). Of the responding centers, 63 (81.8%) performed curative ReRT, while 14 (18.1%) did not, mainly (5/14, 35.7%) due to the avoidance of severe toxicity. The use of adjuvant ReRT was reported by less than half of the interviewed radiation oncologists (36/77, 46.7%). In case of unresectable local recurrence, definitive ReRT was claimed to be adopted in 55/77 (71.4%) for non-nasopharyngeal and 47/77 (61%) for nasopharyngeal cancer. The preferred treatment technique was Intensity Modulated Radiation Therapy (IMRT) followed by Stereotactic Body Radiation Therapy (SBRT). When IMRT was applied, the most common (19/55 responders, 34.5%) selection of treatment volume consisted of the Gross Tumor Volume (GTV) + 0.5 cm margin to account for microscopic disease. Despite the absence of definitive evidence-based recommendations, a possible consideration for ReRT in case of unresectable recurrent head and neck cancer was reported by over 80% of radiation oncologists taking part in the national survey.

Patterns of Care Related to Post-Operative Radiotherapy for Patients with Prostate Cancer among Canadian Radiation Oncologists and Urologists

The American Society for Radiation Oncology (ASTRO) and American Urological Association (AUA) developed post-prostatectomy radiotherapy (RT) guidelines to aid patient counseling on adjuvant (ART) and salvage radiotherapy (SRT). Our study compared how aware and compliant Canadian radiation oncologists and urologists are to these guidelines. Our online survey was distributed through the Canadian Association of Radiation Oncology (CARO) and Canadian Urology Association (CUA) to radiation oncologists and urologists that treat prostate cancer. We used Wilcoxon rank-sum test and Chi-square test to compare radiation oncologists and urologists. P values for significant findings are reported. A total of 128 participants responded the survey, 52 radiation oncologists, and 76 urologists. The majority (82%) of radiation oncologists had read these guidelines, compared to only 49% of urologists (p<0.001). Radiation oncologists were more likely to recommend ART >50% for adverse pathological findings post-radical prostatectomy compared to urologists (76 vs. 51%, p=0.011). Urologists were more likely to monitor their patient's PSA level post-prostatectomy compared to radiation oncologists (93 vs. 77%, p=0.016). Post-thematic analysis of open-ended questions revealed that urologists rarely refer patients to radiation oncologists for ART, with radiation oncologists confirming that they rarely receive referrals. This study demonstrates the low compliance to ASTRO/AUA guidelines. While radiation oncologists were more aware and compliant to guidelines, urologists were significantly more likely to monitor their patient's PSA. This study highlighted the need for better communication between urologists and radiation oncologists, especially in referrals for ART, to facilitate treatment delivery that is concordant with ASTRO/AUA guidelines.

Image-guided radiation therapy (IGRT): practical recommendations of Italian Association of Radiation Oncology (AIRO)

The use of imaging to maximize precision and accuracy throughout the entire process of radiation therapy (RT) delivery has been called "Image-guided RT" (IGRT). RT has long been image guided: in fact, historically, the portal films and later electronic megavoltage images represented an early form of IGRT. A broad range of IGRT modalities is now available and adopted. The target location may be defined for each treatment fraction by several methods by localizing surrogates, including implanted fiducial markers, external surface markers or anatomical features (through planar imaging, fluoroscopy, KV or MV computed tomography, magnetic resonance imaging, ultrasound and X-ray imaging, electromagnetic localization, optical surface imaging, etc.). The aim of the present review is to define practical recommendations for IGRT.

Radiotherapy in the multidisciplinary treatment of liver cancer: a survey on behalf of the Italian Association of Radiation Oncology

To report the results of the first Italian survey investigating the role of liver-directed radiotherapy in the multidisciplinary approach of primary and metastatic liver cancer. A 21-item, two-section questionnaire was sent to all Italian radiotherapy centers on June 2014. The two sections aimed at: (1) evaluating the presence of a multidisciplinary liver tumor board and describing the role of radiation oncologists within the latter, (2) analyzing Radiotherapy treatment details and differences between centers. A total of 37 centers completed the survey. A multidisciplinary liver tumor board was available in most centers (73%), with a radiation oncologist routinely attending the latter in the majority of cases (85%). Most of the respondents considered liver-directed Radiotherapy as the third line choice when other therapies were not indicated or technically suitable. 18 centers reported the use of liver-directed radiotherapy. The majority of centers started liver irradiation after 2010. The most adopted motion management strategy was abdominal compression. The most adopted GTV-CTV expansion was 0 and 5mm for metastases and hepatocellular carcinoma, respectively. Stereotactic body radiotherapy was the technique of choice; several treatment schedules were registered, being 45Gy in three fractions the most reported fractionation scheme. Dose was prescribed at the PTV margin in most cases. Liver-directed radiotherapy represents a new field of interest which is currently adopted by 10% of all Italian Centers. The technical equipment seems adequate. The variations observed in the treatment regimens reflect the lack of a well-established standard schedule.

SP-0320: The Young AIRO (Italian Association of Radiation Oncology) Group

SP-0320: The Young AIRO (Italian Association of Radiation Oncology) Group

Survey on gynecological cancer treatment by Piedmont, Liguria, and Valle d'Aosta group of AIRO (Italian Association of Radiation Oncology).

PurposeWe focused the attention on radiation therapy practices about the gynecological malignancies in Piedmont, Liguria, and Valle d'Aosta to know the current treatment practice and to improve the quality of care.Material and methodsWe proposed a cognitive survey to evaluate the standard practice patterns for gynecological cancer management, adopted from 2012 to 2014 by radiotherapy (RT) centers with a large amount of gynecological cancer cases. There were three topics: 1. Taking care and multidisciplinary approach, 2. Radiotherapy treatment and brachytherapy, 3. Follow-up.ResultsNineteen centers treated gynecological malignancies and 12 of these had a multidisciplinary dedicated team. Radiotherapy option has been used in all clinical setting: definitive, adjuvant, and palliative. In general, 1978 patients were treated. There were 834 brachytherapy (BRT) treatments. The fusion between diagnostic imaging (magnetic resonance imaging – MRI, positron emission tomography – PET) and computed tomography (CT) simulation was used for contouring in all centers. Conformal RT and intensity modulated radiation therapy (IMRT) were the most frequent techniques. The image guided radiation therapy (IGRT) was used in 10/19 centers. There were 8 active BRT centers. Brachytherapy was performed both with radical intent and as boost, mostly by HDR (6/8 centers). The doses for exclusive BRT were between 20 to 30 Gy. The doses for BRT boost were between 10 and 20 Gy. Four centers used CT-MRI compatible applicators but only one used MRI for planning. The BRT plans on vaginal cuff were still performed on traditional radiographies in 2 centers. The plan sum was evaluated in only 1 center. Only 1 center performed in vivo dosimetry.ConclusionsIn the last three years, multidisciplinary approach, contouring, treatment techniques, doses, and control systems were similar in Liguria-Piedmont and Valle d'Aosta. However, the technology implementation didn't translate in a real treatment innovation so far.

Breakthrough pain management in patients undergoing radiotherapy: a national survey on behalf of the Palliative and Supportive Care Study Group.

To assess the contribution of radiation oncologists in Italy in current management of breakthrough pain (BtP). In 2012, the Palliative and Supportive Care Study Group of the Italian Association of Radiation Oncology (AIRO) proposed a survey. All Italian radiation oncologists were individually invited to complete an online questionnaire regarding their management of BtP in patients undergoing radiotherapy treatment. A total of 303 Italian radiation oncologists (of 330 who had access to the Web site) completed the questionnaire over an 8-month period. Some important differences were shown in pain intensity assessment by validated measurement scales, as well as in setting and prescribing analgesic therapy to prevent procedural pain. These differences were also reviewed and discussed related to international guidelines and data available from the literature. Compared to other medical professionals, the involvement of radiation oncologists in cancer pain management remains marginal, at least in Italy. More than 70% of radiation oncologists directly optimized the analgesic therapy during the treatment course and more than 50% implemented specific treatment for BtP. However, the ability of the radiation oncologist to manage BtP could be improved. In order to increase the consciousness of systematic symptom measurement and to spread the knowledge of the best type of analgesic drugs to be used, training events promoted by national associations, such as AIRO, and a collaborative multidisciplinary approach of the management of cancer pain will be promoted.

Technical guidelines for head and neck cancer IMRT on behalf of the Italian association of radiation oncology - head and neck working group.

Performing intensity-modulated radiotherapy (IMRT) on head and neck cancer patients (HNCPs) requires robust training and experience. Thus, in 2011, the Head and Neck Cancer Working Group (HNCWG) of the Italian Association of Radiation Oncology (AIRO) organized a study group with the aim to run a literature review to outline clinical practice recommendations, to suggest technical solutions and to advise target volumes and doses selection for head and neck cancer IMRT. The main purpose was therefore to standardize the technical approach of radiation oncologists in this context. The following paper describes the results of this working group. Volumes, techniques/strategies and dosage were summarized for each head-and-neck site and subsite according to international guidelines or after reaching a consensus in case of weak literature evidence.

The first survey on defensive medicine in radiation oncology.

Defensive Medicine occurs when doctors order tests, procedures, visits or avoid high-risk patients and procedures, primarily to reduce their exposure to malpractice liability. Some medical specialities are at "high-risk" for legal argument, but no data is actually available for radiation oncology. We present here the first survey of radiation oncologists' views regarding malpractice liability and defensive medicine practice. A three-page questionnaire was sent to 611 active radiation oncologists, members of the Italian Association of Radiation Oncology (AIRO), with questions pertaining to the incidence, nature and causes in their practice of defensive medicine. A total of 361 questionnaires were completed (59% feedback). Physicians practise defensive medicine by ordering further imaging studies (39%) or laboratory tests (35%), referring patients to consultants (43%) or prescribing additional medication (35%). Approximately, 70% declared that the climate of opinion that exists towards doctors is one of the major issues for practising defensive medicine. Although radiation oncology is generally considered a "medium/low risk" speciality for defensive medicine, the present survey reflects a widespread use of this behaviour in daily practice. Investigating which radiation oncologist categories are more prone to defensive medical behaviour can be advantageous for implementing programmes aimed at improving awareness of this phenomenon and to increase good clinical practice.