German Radiation Oncology Research Articles

German radiation oncology's next generation: a web-based survey of young biologists, medical physicists, and physicians-from problems to solutions.

Radiation science is of utmost significance not only due to its growing importance for clinical use, but also in everyday life such as in radiation protection questions. The expected increase in cancer incidence due to an aging population combined with technical advancements further implicates this importance and results in ahigher need for sufficient highly educated and motivated personnel. Thus, factors preventing young scientists and medical personnel from entering or remaining in the field need to be identified. Aweb-based questionnaire with one general and three occupation-specific questionnaires for physicians, biologists, and medical physicists working in radiation oncology and research was developed and circulated for 6weeks. While the overall satisfaction of the 218 participants was quite high, there are some points that still need to be addressed in order to ensure acontinuing supply of qualified personnel. Among these were economic pressure, work-life balance, work contracts, protected research time, and ademand for an improved curriculum. Mentoring programs, improved education, and strengthening the value of societies in radiation sciences as well as translational approaches and more flexible working arrangements might ensure ahigh-quality workforce and thus patient care in the future.

Development and psychometric validation of a patient safety assessment tool in German Radiation Oncology: the PaSaGeRO Study protocol

IntroductionEnsuring patient safety in radiation oncology is crucial for delivering high-quality healthcare. Patient safety indicators (PSIs) provide a mechanism for identifying, quantifying and evaluating risks and the effectiveness of safety...

917: Patient Safety in German Radiation Oncology (PaSaGeRO): A Review on Patient Safety Indicators.

917: Patient Safety in German Radiation Oncology (PaSaGeRO): A Review on Patient Safety Indicators.

Knowledge and competences in hematological malignancies amongst radiation oncology residents in Germany-results from anational survey.

Radiation oncology is apivotal modality in the treatment of hematologic malignancies. To enable state-of-the-art patient care, structured education during residency is essential. However, given the lack of detailed data, the scope of educational opportunities available to trainees remains elusive. This prompted our group to perform anational survey amongst radiation oncology residents in Germany assessing the status quo of competences in the treatment of lymphoma and leukemia patients. Furthermore, areas of potential improvement were identified to further the goal of competence-based education for residents. Asurvey-based analysis was conducted to assess the knowledge and competence of radiation oncology residents in Germany regarding hematological malignancies. Adecisive questionnaire covering demographics, self-assessment of competences, and areas for improvement was developed in adaption of asurvey by the Association of Residents in Radiation Oncology and distributed amongst 1439 members of the German Society of Radiation Oncology. Responses were collected anonymously via an online survey tool and analyzed using descriptive statistics and chi-square tests. Atotal of 59complete and 22partial responses were collected, yielding a5.6% response rate. Participants' competence varied, with notable experience gaps in pediatric cases, proton therapy, and large-field techniques like total-skin irradiation or pediatric total body irradiation. While participants felt confident in treatment planning and patient counseling, they showed deficiencies in the definition of the planning target volume for modern involved site radiotherapy. Resources for education included national and international guidelines, scientific reviews, and textbooks. Board-certified radiation oncologists and physicians from specialized lymphoma centers demonstrated higher overall competence levels. This survey highlights the diversity of resident education regarding hematological malignancies in German radiation oncology programs. Knowledge gaps exist in key areas, including pediatric cases and specialized techniques. Competence-based education, interactive teaching formats, and rotations to specialized centers are potential strategies to address these gaps. The study contributes to the understanding of the federal educational landscape, underscoring the need for standardized and comprehensive training to ensure optimal patient care in hematological malignancies within the context of radiation oncology. Further research and collaborations are warranted to enhance training and expertise in this critical domain.

Risk management patterns in radiation oncology—results of a national survey within the framework of the Patient Safety in German Radiation Oncology (PaSaGeRO) project

PurposeRisk management (RM) is a key component of patient safety in radiation oncology (RO). We investigated current approaches on RM in German RO within the framework of the Patient Safety in German Radiation Oncology (PaSaGeRO) project. Aim was not only to evaluate a status quo of RM purposes but furthermore to discover challenges for sustainable RM that should be addressed in future research and recommendations.MethodsAn online survey was conducted from June to August 2021, consisting of 18 items on prospective and reactive RM, protagonists of RM, and self-assessment concerning RM. The survey was designed using LimeSurvey and invitations were sent by e‑mail. Answers were requested once per institution.ResultsIn all, 48 completed questionnaires from university hospitals, general and non-academic hospitals, and private practices were received and considered for evaluation. Prospective and reactive RM was commonly conducted within interprofessional teams; 88% of all institutions performed prospective risk analyses. Most institutions (71%) reported incidents or near-events using multiple reporting systems. Results were presented to the team in 71% for prospective analyses and 85% for analyses of incidents. Risk conferences take place in 46% of institutions. 42% nominated a manager/committee for RM. Knowledge concerning RM was mostly rated “satisfying” (44%). However, 65% of all institutions require more information about RM by professional societies.ConclusionOur results revealed heterogeneous patterns of RM in RO departments, although most departments adhered to common recommendations. Identified mismatches between recommendations and implementation of RM provide baseline data for future research and support definition of teaching content.

PO-0998: Durvalumab treatment after CRT in inoperable stage III NSCLC – a German radiation oncology survey

PO-0998: Durvalumab treatment after CRT in inoperable stage III NSCLC – a German radiation oncology survey

Implementing a new scale for failure mode and effects analysis (FMEA) for risk analysis in a radiation oncology department

Patients and staffs are endangered by different failure modes during clinical routine in radiation oncology and risks are difficult to stratify. We implemented the method of failure mode and effects analysis (FMEA) via questionnaires in our institution and introduced an adapted scale applicable for radiation oncology. Failure modes in physical treatment planning and daily routine were detected and stratified by ranking occurrence, severity, and detectability in aquestionnaire. Multiplication of these values offers the risk priority number (RPN). We implemented an ordinal rating scale (ORS) as acombination of earlier published scales from the literature. This scale was optimized for German radiation oncology. We compared RPN using this ORS versus use of arather subjective visual analogue rating scale (VRS). Mean RPN using ORS was 62.3 vs. 67.5 using VRS (p = 0.7). Use of ORS led to improved completeness of questionnaires (91 vs. 79%) and stronger agreement among the experts, especially concerning failure modes during radiation routine. The majority of interviewed experts found the analysis by using the ORS easier and expected asaving of time as well as higher intra- and interobserver reliability. The introduced rating scale together with aquestionnaire survey provides merit for conducting FMEA in radiation oncology as results are comparable to the use of VRS and the process is facilitated.

Implementation of durvalumab maintenance treatment after concurrent chemoradiotherapy in inoperable stage III non-small cell lung cancer (NSCLC)-a German radiation oncology survey.

BackgroundDurvalumab as maintenance treatment after platinum-based concurrent chemoradiotherapy (cCRT) has become the standard of care in inoperable stage III non-small cell lung cancer (NSCLC). In this nationwide survey, we solicited members of the German Radiation Oncology Society to review the current distribution and clinical settings of durvalumab treatment after cCRT, observed side effects and summarize follow-up management.MethodsWe surveyed radiation oncology institutions in Germany via an anonymous online questionnaire sent by e-mail to all members of the German Radiation Oncology Society which agreed their willingness to participate.ResultsWe received a total of 255 responses (response rate: 18%). Of which 203 (80%) were completed and returned and thus eligible for further evaluation. The respondents work in 87 different cities and 44% in a private medical practice, 29% in university and 22% in a general hospital. Durvalumab was implemented in clinical routine by 70% of respondents. Major reasons for failed implementation in clinical practice reported by the respondents were patient’s ineligibility (42%), lack of required PD-L1 status (25%), decision of medical oncologists (7%) or absence of updated German guidelines (7%). Thirty-six percent of all respondents report low (≤30%) PD-L1 testing before cCRT based on IHC assay. No respondent had applied durvalumab in less than 14 days after the completion of CRT. Severe side effects requiring hospital admission in more than 10% of all patients were reported by 12% of all respondents.ConclusionsDurvalumab maintenance is already implemented in the radiation oncology community and administered by the absolute majority of respondents. Low testing rates of PD-L1 at initial diagnosis were observed and should be considered a major barrier to universal adoption and integration in the clinical work-flow in countries with durvalumab approval restricted to PD-L1 positive patients. No respondent applies durvalumab in less than 14 days after cCRT.

State of clinical research of radiotherapy/chemoradiotherapy and immune checkpoint inhibitor therapy combinations in solid tumours—a German radiation oncology survey

Combinations of immune checkpoint inhibitors (ICIs) with radiotherapy and/or chemoradiotherapy are currently under investigation in many cancer types and clinical settings. In this survey, we solicited members of the German Radiation Oncology Society and young DEGRO (working group of DEGRO e.V.) to review the current status of research in this field and underline critical issues such as oncological benefit, treatment toxicity and obstacles in clinical research. The responses represent 14 different departments of radiation oncology at German university hospitals. Respondents of the same department were analysed for congruence. Sixty-one percent of all respondents perform radiotherapy/chemoradiotherapy and ICI therapy combination studies at their institutions and participate in multicentre studies. Combinations were investigated mainly in head and neck tumours (95%), lung cancer (57%), malignant melanoma (48%) and tumours of the upper gastrointestinal tract (9%). Combination of chemoradiotherapy with checkpoint inhibitors was only tested in head and neck cancers (52%), non–small-cell lung cancer (NSCLC) (8.70%) and malignant melanoma (4%). A combination of radiotherapy/chemoradiotherapy with ICIs is assumed to be effective or very effective by >85% of all respondents. The treatment of intracranial metastatic disease by this combination is assumed to be very effective by most respondents (61%). The present survey shows great acceptance of new combined modality treatment paradigm. ICIs with radiotherapy and/or chemoradiotherapy are under investigation at >75% of all participating centres. Head and neck tumours, NSCLC and malignant melanoma are the most frequently tested cancer types.

Health services research in German radiation oncology: new opportunities to advance cancer care.

Health services research (HSR) is of increasing relevance to scientists, health-care providers, and clinicians. Complex population-based secondary data are akey source of information for analyses of health-care effects in radiation oncology. In this short paper, we examine potential applications of secondary data focusing on statistics from the diagnosis-related groups (DRG). This data set incorporating all hospitalized cases in Germany is based on claims of reimbursements and is provided by the Research Data Centers (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states. Ashort outlook regarding other data sources is also presented. In radiation oncology, secondary data such as the DRG statistics have rarely been used to examine health-care effects, despite their great potential for reporting effects in abroad population-based setting. Furthermore, for most data sources, the application to use these data is accessible with minor effort. However, data concerning outpatient care are difficult to analyze on acomparable level. DRG statistics and related secondary data provide aremarkable source of information for analyses of health-care-related effects in radiation oncology.

Complementary medicine in radiation oncology

Recently, complementary and alternative medicine (CAM) has moved more into the focus, and cancer societies such as the German Cancer Society (Deutsche Krebsgesellschaft, DKG) have established working groups to develop aguideline for CAM. The present work aims to evaluate the acceptance of CAM in the whole radiation oncology community. We conducted an online survey on CAM and sent the modified questionnaire that was successfully distributed to all members of the Research Group on Gynecological Oncology (Arbeitsgemeinschaft Gynakologische Onkologie, AGO) of the DKG in 2014 to the members of the German Society of Radiation Oncology (Deutsche Gesellschaft für Radioonkologie und Strahlentherapie, DEGRO). The survey consisted of 17questions regarding personal information and current CAM guidelines within the workplace/clinic. Atotal of 143 members participated. Of these, 12% had some CAM qualification. For hematological cancer in 35% and in up to 76% for breast cancer, CAM treatment is offered in German radiation oncology facilities, mainly due to fatigue symptoms. CAM is part of routine treatment in 32.2%, 22.0% are planning to incorporate it. Most physicians advise patients to partake in sports activities and recommend dietary supplements and nutritional counseling. The cost of CAM treatment is fully covered in 9.8% of all participating facilities. Today, CAM is integrated into cancer care; however, skepticism regarding its effect still exists. Evidence-based results must be generated to convince physicians of the effectiveness of CAM methods. CAM qualifications must be included in physicians' training to improve their understanding and counseling regarding CAM options in cancer care.

86P Prophylactic cranial irradiation in SCLC: A survey of German radiation oncology institutions on recommendations for brain imaging

Background: Prophylactic cranial irradiation in SCLC is recommended in therapy responders to primary treatment. The landmark PCI trials largely took place in the pre-MRI era. Recently, the role of brain imaging in PCI has come under increased scrutiny. We conducted this survey to gauge the patterns of brain imaging in PCI amongst radiation oncologists in Germany. Methods: We surveyed radiation oncology institutions in Germany via an online questionnaire sent by e-mail to member institutions in the online directory of the German Society for Radiation Oncology (DEGRO e.V.). The questions covered aspects of brain imaging in limited- and extensive-stage SCLC. Results: We received a total of 39 responses. Of which 34 were completed and eligible for further evaluation. 97% and 92% of respondents recommended brain imaging prior to initial treatment in LS- and ES-SCLC, respectively with contrast-enhanced MRI being the preferred modality in 86% of cases. Ninety-one percent of respondents recommended brain imaging not older than 4 weeks prior to PCI delivery with 71% recommending commencing PCI <4 weeks after primary treatment. Of all responses, 38% followed their patients regularly with serial brain imaging following PCI with the absolute majority preferring image acquisition only in symptomatic patients. On detection of brain metastases (BMs), 59% recommended stereotactic radiosurgery (SRS) or repeat whole brain radiotherapy depending on the number of BMs. Conclusions: Patterns of brain imaging in Germany are in general consistent with the guidelines with contrast-enhanced MRI being the preferred modality for brain staging prior to primary treatment and especially after multimodality treatment and before PCI delivery. Legal entity responsible for the study: University Hospital, LMU Munich Funding: Has not received any funding Disclosure: All authors have declared no conflicts of interest.

84P Patterns of care for patients with small cell lung cancer: A survey of German radiation oncology institutions on recommendations for prophylactic cranial irradiation

84P Patterns of care for patients with small cell lung cancer: A survey of German radiation oncology institutions on recommendations for prophylactic cranial irradiation

Survival and Symptom Relief after Palliative Radiotherapy for Esophageal Cancer.

Purpose: The aim of this study was to assess the 6-months dysphagia-free survival, improvement in swallowing function, complication rate, and overall survival in patients with incurable esophageal cancer treated with palliative radiotherapy.Methods: We retrospectively reviewed data from 139 patients (median age 72 years) with advanced/recurrent incurable esophageal cancer, who were referred to 3 German radiation oncology centers for palliative radiotherapy between 1994 and 2014. Radiotherapy consisted of external beam radiotherapy (EBRT) with 30 - 40.5 Gy/2.5 - 3 Gy per fraction, brachytherapy alone (BT) with 15 - 25 Gy/5 - 7Gy per fraction/weekly and EBRT + BT (30 - 40.5 Gy plus 10 - 14 Gy with BT) in 65, 46, and 28 patients, respectively. Dysphagia-free survival (Dy-PFS) was defined as the time to worsening of dysphagia for at least one point, a new loco-regional failure or death of any cause.Results: Median follow-up time was 6 months (range 1-6 months). Subjective symptom relief was achieved in 72 % of patients with median response duration of 5 months. The 1-year survival rate was 30%. The 6-months Dy-PFS time for the whole group was 73 ± 4%. The 6-months Dy-PFS was 90 ± 4% after EBRT, 92 ± 5% after EBRT + BT and 37 ± 7% after BT, respectively (p<0.001). Five patients lived for more than 2 years, all of them were treated with EBRT ± BT. Ulceration, fistula and stricture developed in 3, 6 and 7 patients, respectively.Conclusions: Radiotherapy leads to symptom improvement in the majority of patients with advanced incurable esophageal cancer. The present results favor EBRT ± BT over BT alone. Due to the retrospective nature of this study, imbalances in baseline characteristics might have contributed to this finding, and further trials appear necessary.

Role of Surgical Versus Clinical Staging in Chemoradiated FIGO Stage IIB-IVA Cervical Cancer Patients—Acute Toxicity and Treatment Quality of the Uterus-11 Multicenter Phase III Intergroup Trial of the German Radiation Oncology Group and the Gynecologic Cancer Group

The Uterus-11 trial was designed to evaluate the role of surgical staging in patients with cervical cancer before primary chemoradiation therapy (CRT). The present report provides the toxicity data stratified by the treatment arm and technique. A total of 255 patients with carcinoma of the uterine cervix (International Federation of Gynecology and Obstetrics stage IIB-IVA) were randomized to either surgical staging followed by CRT (arm A) or clinical staging followed by CRT (arm B). Patients with para-aortic metastases underwent extended field radiation therapy (RT). Brachytherapy was mandatory. The present report presents the acute therapy-related toxicities stratified by treatment arm and radiation technique. A total of 240 patients were eligible (n=121 in arm A; n=119 in arm B). Of the 240 patients, 236 (98.3%) underwent external beam RT with a median total dose of 50.4 Gy. The mean treatment duration was 53 days. Of the patients, 60% underwent intensity modulated RT (IMRT). A total of 234 patients (97.5%) underwent chemotherapy, and 231 (96.3%) underwent brachytherapy, with a median single dose of 6 Gy covering the tumor to a median nominal total dose of 28 Gy. Treatment was well tolerated, with 0% grade ≥3 genitourinary and gastrointestinal toxicity, 6% grade 3 nausea, 3% grade 3 vomiting, and <2% grade 3 diarrhea. More patients after surgical staging experienced grade 2 anemia (54.3% in arm A vs 45.3% in arm B; P=.074) and grade 2 leukocytopenia (41.4% vs 31.6%; P=.56). Of the patients who received IMRT versus a 3-dimensional technique, 65.3% versus 33.7% presented with grade 2 anemia. Grade 3 gastrointestinal and grade 2 bladder toxicity were significantly reduced with the use of IMRT. The incidence and severity of acute therapy-related toxicity compared favorably with those from other randomized trials. Excellent adherence to treatment and treatment quality was achieved compared with patterns of care analyses. Surgical staging led to a doubled number of patients treated with extended field RT. The question of whether surgical staging is beneficial in the context of primary CRT requires further study.

Treatment of Early Stage Nodal Follicular Lymphoma Using Involved-Field Radiotherapy and Rituximab: Preliminary Results of the Mir Trial (phase II study of the German Low Grade Lymphoma Study Group (GLSG))

AbstractAbstract 1634 Background:The commonly recommended treatment for early stage follicular lymphoma grade 1 or grade 2 (stage I/II) is involved-field radiotherapy (IF RT). However, a prospective German trial showed improved progression free survival compared to historical data using large field radiation techniques as extended-field radiotherapy or total lymphatic irradiation (Stuschke et al, Cancer, 80, 1997). This trial led to the conclusion that large volume radiation techniques may prevent relapses of microscopic lymphatic disease and is confirmed by the a new study, which was presented at Lugano 2011 (Engelhard et al., Ann Oncol, 22 Suppl4, 2011). However, those extensive radiation protocols are associated with significant toxicities, especially grade 3 and grade 4 adverse events concerning the hematopoietic system. It has been shown that the CD20 antibody Rituximab also has an anti lymphoma activity in CD20 positive follicular lymphoma. It might prevent out field recurrences in case of involved field radiotherapy. The German Low Grade Lymphoma Study Group (GLSG) and the German Radiation Oncology Group (ARO) of the German Cancer Society conducted a prospective, multicenter phase II trial investigating the efficacy and toxicity of a combined involved-field radiotherapy in combination with Rituximab treatment (MIR = MabThera and Involved field Radiotherapy) with an accrual of 85 patients (ClinicalTrials.gov Identifier: NCT00509184). Patients and Methods:85 patients (47 male / 38 female) with early stage CD20 positive follicular lymphoma grade 1/2 were included in the trial at 16 German centers between February 2007 and October 2010. Median age at diagnosis was 55 years (21–75 years). Stage I disease was diagnosed in 48 patients and Stage II in 37 patients. Macroscopically left lymphoma after diagnostic surgery was observed in 55 patients, no macroscopic lymphoma in 26 patients and an equivocal status (e.g. due to postoperative tissue changes) in 4 patients. The treatment included a first block of Rituximab (4 weekly cycles; 375 mg/m2body surface), a 4 week treatment gap with a restaging CT / planning CT of the involved region in week 7 and followed by another block of Rituximab(4 weekly cycles) concurrently with an IF RT of 40 Gy for macroscopic tumor or 30 Gy in case of a complete remission (CR). The fractionation schedule was 5×2Gy per week. Primary endpoint of the study was progression free survival (PFS) at 2 years. Secondary endpoints were CR rate after Rituximab monotherapy (week 7) and after complete treatment (week 18). Additional endpoints were relapse rate, relapse pattern, overall survival, toxicity and quality of life. The protocol was approved by the ethics committee of the University of Heidelberg Medical School and the Paul-Ehrlich-Institute (PEI-registration number 432/06). The trial was in accordance to the Declaration of Helsinki. Recruitment was finished in October 2010. Clinical report form (CRF) collection is currently under way. Results:The treatment was well tolerated. There were 16 serious adverse events (SAE; toxicity grade 3 or higher): 3 infections, 1 hypersensitivity, 2 cardiac disorders, 1 vascular disorder, 1 respiratory disorder, 2 gastrointestinal disorders, 4 bone injuries. Two patients died due to secondary neoplasm. 3/16 were considered to be related to the treatment. Eight patients had to be excluded from the primary response evaluation due to failed inclusion criteria (e.g. stage, histology.) or early withdrawal of their consent. The mean follow-up of the remaining 78 patients has been 22.3 +/− 11.4 months, so far. Of 55 patients with remaining macroscopic lymphoma at inclusion, 26% showed a CR at week 7 after 4 cycles Rituximab (15% missing, CRF data still have to be collected). The CR rate improved to 60% at week 18 at the first follow-up examination at week 18 (15% of data still missing) and to 80% at month 6 (22% of data still missing). A total of 8 relapses have been detected (1 infield relapse) so far. The 2 years actuarial progression free survival and overall survival has been estimated to be 90% and 96%, respectively. Conclusion:The combination of Rituximab and IF RT in early stage nodal follicular lymphoma grade 1/2 is well tolerated and shows promising initial results. So far, 2 years PFS matches with that of large field radiotherapy without the accompanying toxicity and is superior to historic data of IF RT only. Disclosures:Herfarth:Roche: Honoraria, Research Funding. Borchmann:Roche: Honoraria, Research Funding. Budach:Roche: Honoraria. Viardot:Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Witzens-Harig:Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Hiddemann:Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Dreyling:Roche: Honoraria, Support of (other) clinical trials and Scientific Advisory Boards Other.

Patterns of Care and Course of Symptoms in Palliative Radiotherapy

To evaluate patterns of care as well as effectiveness and side effects of palliative treatment in four German radiation oncology departments. All referrals in four German radiation oncology departments (two university hospitals, one academic hospital, one private practice) were prospective documented for 1 month in 2008 (2 months at one of the university hospitals). In palliatively irradiated patients, treatment aims and indications as well as treated sites and fractionation schedules were recorded. In addition, symptoms and side effects were analyzed with standardized questionnaires before and at the end of radiotherapy. During the observation period, 603 patients underwent radiation therapy in the four centers and 153 (24%, study population) were treated with palliative intent. Within the study, patients were most frequently treated for bone (34%) or brain (27%) metastases. 62 patients reported severe or very severe pain, 12 patients reported severe or very severe dyspnea, 27 patients reported neurological deficits or signs of cranial pressure, and 43 patients reported a poor or very poor sense of well-being. The most frequent goals were symptom relief (53%) or prevention of symptoms (46%). Life prolongation was intended in 37% of cases. A wide range of fractionation schedules was applied with total doses ranging from 3-61.2 Gy. Of the patients, 73% received a slightly hypofractionated treatment schedule with doses of > 2.0 Gy to ≤ 3.0 Gy per fraction and 12% received moderate to highly hypofractionated therapy with doses of > 3.0 Gy to 8.0 Gy. Radiation therapy led to a significant improvement of well-being (35% of patients) and reduction of symptoms, especially with regard to pain (66%), dyspnea (61%), and neurological deficits (60%). Therapy was very well tolerated with only 4.5% grade I or II acute toxicities being observed. Unscheduled termination was observed in 19 patients (12%). Palliative radiation therapy is effective in reducing symptoms, increases subjective well-being, and has minimal side effects. More studies are necessary for subgroup analyses and for clarifying the different goals in palliative radiotherapy.