Radiation Therapy Patients Research Articles

Management of radiation therapy patients with cardiac defibrillator or pacemaker.

The increasing growth of population with cardiac implantable electronic devices (CIEDs) such as Pacemaker (PM) and Implantable Cardiac Defibrillators (ICD), requires particular attention in management of patients needing radiation treatment. This paper updates and summarizes some recommendations from different international guidelines. Ionizing radiation and/or electromagnetic interferences could cause device failure. Current approaches to treatment in patients who have these devices vary among radiation oncology centres. We refer to the German Society of Radiation Oncology and Cardiology guidelines (ed. 2015); to the Society of Cardiology Australia and New Zealand Statement (ed. 2015); to the guidelines in force in the Netherlands (ed. 2012) and to the Italian Association of Radiation Oncology recommendations (ed. 2013) as reported in the guidelines for the treatment of breast cancer in patients with CIED. Although there is not a clear cut-off point, risk of device failure increases with increasing doses. Cumulative dose and pacing dependency have been combined to categorize patients into low-, medium- and high-risk groups. Measures to secure patient safety are described for each category. The use of energy ≤6MV is preferable and it's strongly recommended not to exceed a total dose of 2Gy to the PM and 1Gy for ICD. Given the dangers of device malfunction, radiation oncology departments should adopt all the measures designed to minimize the risk to patients. For this reason, a close collaboration between cardiologist, radiotherapist and physicist is necessary.

Consolidative Radiation Therapy Following Autologous Transplantation in Relapsed or Refractory Hodgkin Lymphoma

Radiation therapy (RT) is an important treatment modality in relapsed or refractory Hodgkin lymphoma (HL), providing local control and potentially durable responses when used as salvage therapy. For decades, RT has also been administered before and after autologous stem cell transplantation (ASCT) for consolidation, but no consensus exists regarding the efficacy or optimal timing of peri-transplant RT. Data is especially lacking on post-transplant consolidative RT, which may be associated with reduced toxicity and improved disease control compared with pre-transplant RT. We provide here a single-institution retrospective analysis comparing survival outcomes and toxicities according to receipt of post-transplant consolidative RT.Sixty-four patients with relapsed or refractory HL received ASCTs at our institution between 2006 and 2013. Seventeen patients received post-transplant consolidative RT, defined as completing RT within 5 months of ASCT, whereas 47 received no RT. All patients received staging PET/CT scans prior to ASCT and had at least 1 year of follow-up after ASCT. Primary outcomes included progression-free survival (PFS), overall survival (OS), and local control (LC), defined as the absence of relapse at previous sites of PET-avid disease. The log rank test was used to compare survival measures. Radiation-associated toxicities, including pulmonary and hematologic complications, were reviewed.For the entire cohort, median age at ASCT was 41 years and median follow-up after ASCT was 40 months. In the post-transplant RT group, there were more cases of disease limited to one side of the diaphragm, as shown in Table 1. There were also more cases of refractory HL, defined as persistent disease following frontline therapy, and a trend towards younger age and absence of prior RT. Median dose of post-transplant RT was 3540 cGy (Range: 1500 - 4050 cGy) and median time from ASCT to RT was 4 months (Range: 2 - 5 months). 16/17 (94%) patients received RT to supra-diaphragmatic sites only.For the entire cohort, OS was 84% and PFS was 50% at 36 months following ASCT. There was no significant difference in OS₃₆ among patients who received post-transplant RT (87% v. 83% for no RT, p = 0.68). There was also no significant difference in PFS₃₆ among post-transplant RT patients (55% v. 47% for no RT, p = 0.33). There was significant improvement in LC₃₆ among patients who received post-transplant RT (78% v. 48%, p = 0.02). There were also non-significant trends toward improved PFS₃₆ among patients who received post-transplant RT and had relapsed (rather than refractory) disease (75% v. 48%, p = 0.13) or had no prior RT (53% v. 35%, p = 0.14).3/17 (18%) post-transplant RT patients died during the follow-up period, all secondary to disease progression. 9/47 (20%) patients with no post-transplant RT died during the follow-up period, of which 7 deaths were secondary to disease progression and 1 was a complication of ASCT. One patient developed grade III anemia and thrombocytopenia as an early complication of post-transplant RT, but no other acute or late RT-associated toxicities were observed.Patients receiving post-transplant consolidative RT have improved LC and limited RT-associated toxicity. While there was no significant improvement in PFS or OS in this group, patients who have not received radiation previously or who have relapsed disease may preferentially benefit from post-transplant RT. Our study was limited by small numbers. Selection bias may influence which patients are referred for post-transplant RT. For these reasons, analyses of larger patient populations and prospective study are warranted.Table 1Baseline Patient CharacteristicsCharacteristicsWith Post-Transplant RT (n = 17)Without Post-Transplant RT (n = 47)p-ValueMedian Age at ASCT (y)37430.06Male Gender - n (%)10 (59)23 (49)0.58Stage Category - n (%)I / II11 (65)22 (47)0.26III / IV6 (35)25 (53)Bulky Mediastinal Adenopathy - n (%)5 (29)7 (15)0.28Presence of B Symptoms - n (%)10 (59)24 (51)0.77Prior Radiation - n (%)3 (18)18 (38)0.14Relapsed v. Refractory Disease - n (%)Relapsed6 (35)31 (66)0.04Refractory11 (65)16 (34)Disease Burden at Relapse - n (%)One Side of Diaphragm16 (94)28 (60)0.01Both Sides of Diaphragm1 (6)19 (40)Disease Status at Transplant - n (%)Complete Response8 (47)28 (60)0.40Partial Response9 (53)19 (40) [Display omitted] DisclosuresSchuster:Genentech: Consultancy; Pharmacyclics: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Hoffman-LaRoche: Research Funding; Janssen: Research Funding; Gilead: Research Funding; Nordic Nanovector: Membership on an entity's Board of Directors or advisory committees; Novartis: Research Funding.

MPTH-25AN 18-GENE EXPRESSION SIGNATURE PREDICTS RECURRENCE-FREE SURVIVAL IN MENINGIOMA

Meningioma is the most common primary brain tumor and carries a substantial risk of local recurrence. While WHO grade correlates with recurrence to a degree, there is substantial within-grade variation of recurrence risk and current risk stratification does not accurately predict which patients are likely to benefit from adjuvant radiation therapy. We hypothesized that recurrent tumors have unique gene expression profiles (GEP) that could be used to better stratify patients for radiation therapy. We optimized a recurrence predictor using a training/validation approach and a support vector machine classification method with radial-basis smoothing kernel. Three publicly available Affymetrix gene expression datasets ({type:entrez-geo,attrs:{text:GSE9438,term_id:9438}}GSE9438, {type:entrez-geo,attrs:{text:GSE16581,term_id:16581}}GSE16581, {type:entrez-geo,attrs:{text:GSE43290,term_id:43290}}GSE43290) combining 127 newly diagnosed meningioma samples served as the training set. Unsupervised variable selection was used to identify an 18-gene GEP model (18-GEP) that separated recurrences with a negligible root mean square error of 0.17. The characteristics of the training dataset were as follows: WHO grade [I-92(73%), II-32(25%), III-2(2%)]; median follow-up = 5.53 years (range:0.05-25.42); recurrences = 18. This model was tested on 62 cases from our institution [validation dataset (VD)] with similar demographics, but enriched for cases with either long clinical follow-up or known recurrence. When applied to the VD, the 18-GEP separated recurrences with a misclassification error rate of 0.25 (log-rank p = 0.0003). 18-GEP was significantly predictive of tumor recurrence, independently [p = 0.0007, HR = 7.91, 95%CI = 2.35-35.78)] and was predictive after adjustment for WHO grade, mitotic index, and Simpson grade [p = 0.047, HR = 4.73, 95%CI = (1.02-26.55)]. The expression signature included genes encoding proteins involved in normal embryonic development, cell proliferation, tumor growth and invasion (FGF9, SEMA3C, EDNRA), angiogenesis (angiopoietin-2), cell cycle regulation (CDKN1A), membrane signaling (tetraspanin-7, caveolin-2), WNT-pathway inhibitors (DKK3), complement system (C1QA) and neurotransmitter regulation (SLC1A3, Secretogranin-II). In conclusion, our gene expression classifier accurately stratifies patients with meningioma by recurrence risk and has the potential to guide therapy.

Variation in Definitive Therapy for Localized Non-Small Cell Lung Cancer Among National Comprehensive Cancer Network Institutions

This study determined practice patterns in the staging and treatment of patients with stage I non-small cell lung cancer (NSCLC) among National Comprehensive Cancer Network (NCCN) member institutions. Secondary aims were to determine trends in the use of definitive therapy, predictors of treatment type, and acute adverse events associated with primary modalities of treatment. Data from the National Comprehensive Cancer Network Oncology Outcomes Database from 2007 to 2011 for US patients with stage I NSCLC were used. Main outcome measures included patterns of care, predictors of treatment, acute morbidity, and acute mortality. Seventy-nine percent of patients received surgery, 16% received definitive radiation therapy (RT), and 3% were not treated. Seventy-four percent of the RT patients received stereotactic body RT (SBRT), and the remainder received nonstereotactic RT (NSRT). Among participating NCCN member institutions, the number of surgeries-to-RT course ratios varied between 1.6 and 34.7 (P<.01), and the SBRT-to-NSRT ratio varied between 0 and 13 (P=.01). Significant variations were also observed in staging practices, with brain imaging 0.33 (0.25-0.43) times as likely and mediastinoscopy 31.26 (21.84-44.76) times more likely for surgical patients than for RT patients. Toxicity rates for surgical and for SBRT patients were similar, although the rates were double for NSRT patients. The variations in treatment observed among NCCN institutions reflects the lack of level I evidence directing the use of surgery or SBRT for stage I NSCLC. In this setting, research of patient and physician preferences may help to guide future decision making.

Characteristics of Inpatient Radiation Therapy Use

Characteristics of Inpatient Radiation Therapy Use

Factors Promoting Utilization of Acupuncture Among Radiation Therapy Patients

An IRB-approved retrospective chart review was performed analyzing 50 pts who utlilized acupuncture at Oregon Health and Science University between 05/2013 and 04/2014. A subset analysis included patients who underwent radiation therapy (RT) alone or in combination with other cancer treatment modalities. Variables investigated includes gender, age, cancer site, treatment modalities, chemotherapy agent, and type and number of symptoms prompting acupuncture referral. Breast Cancer patients Musculoskeletal complaints were predominant symptoms for breast cancer patients who received RT. Chemotherapy included taxanes (n=9; 75%) and alkylating agents (n=5; 42%). Discussion

Reconstruction of Out-of-Field Normal Tissue Dose for Intensity Modulated Radiation Therapy Patients for Large Scale Retrospective Epidemiological Studies of Late Effects

Reconstruction of Out-of-Field Normal Tissue Dose for Intensity Modulated Radiation Therapy Patients for Large Scale Retrospective Epidemiological Studies of Late Effects

Improving patient care and accuracy of given doses in radiation therapy using in vivo dosimetry verification ⁎

Abstract Objective This work aims to verify and improve the dose given for cancer patients in radiation therapy by using diodes to enhance patient in vivo dosimetry on a routine basis. Some characteristics of two available semi-conductor diode dosimetry systems were evaluated. Methods The diodes had been calibrated to read the dose at Dmax below the surface. Correction factors of clinical relevance were quantified to convert the diode readings into patient dose. The diode was irradiated at various gantry angles (increments of 45°), various Field Sizes and various Source to Surface Distances (SSDs). Results The maximal response variation in the angular response with respect to an arbitrary angle of 0° was 1.9%, and the minimum variation was 0.5%. The response of the diode with respect to various field sizes showed the minimum and the maximum variations in the measured dose from the diode; the calculated doses were -1.6% (for 5 cm × 5 cm field size) and 6.6% (for 40 cm × 40 cm field size). The diode exhibited a significant perturbation in the response, which decreased with increasing SSD. No discrepancies larger than 5% were detected between the expected dose and the measured dose. Conclusion The results indicate that the diodes exhibit excellent linearity, dose reproducibility and minimal anisotropy; that they can be used with confidence for patient dose verification. Furthermore, diodes render real time verification of the dose delivered to patients.

Abstract IA17: The Cdk4/E2F pathway drives centrosome amplification and chromosome instability in breast cancer cells

Abstract Chromosome instability (CIN) instigates various malignant phenotypes, including deregulated proliferation, apoptosis and invasion to initiate and sustain carcinogenesis. A major source of CIN in cancer is centrosome amplification (CA), defined as the acquisition of abnormal number of centrosomes (3 or more) that may result in defective mitosis, chromosome missegregation and aneuploidy. CA is present in pre-malignant breast lesions and high percentages of CA correlate with metastasis to the lymph nodes. CA may facilitate breast tumorigenesis, albeit this hypothesis has to be tested. Our laboratory found that CA and binucleation, intermediates to tetraploidy, are more likely to occur in Her2+ER-PR- (Her2+) breast cancers, while triple-negative (TN or Her2-ER-PR-) display other forms of CIN, such as micronuclei, defined as missegregated whole or fragmented chromosomes. The Her2 and TN subtypes differ from good-prognosis breast cancers such as luminal in that they accumulate high frequencies of CIN. Even though all breast cancer patients respond similarly to radiation therapy, Her2+ and TN patients are more likely to recur. Our laboratory searches for sources of CA and CIN in breast tumors and found that CA and CIN are suppressed by silencing of Cdk4 and the E2F activators. We have shown that silencing of CDK4 radiosensitizes TN and Her2+ breast cancer cells by activating intrinsic apoptotic pathways. We propose that inhibiting the cell and centrosome machinery would represent future treatment modalities for breast cancer. Citation Format: Harold I. Saavedra. The Cdk4/E2F pathway drives centrosome amplification and chromosome instability in breast cancer cells. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA17.

Predicción de recidiva bioquímica tras prostatectomía radical. Nueva herramienta para la selección de candidatos a radioterapia adyuvante

ObjectiveTo design a risk summation to select patients for adjuvant radiation therapy after prostatectomy. Materials and methodA retrospective study was conducted on 629 patients with localised prostate cancer (pN0–pNx) who were treated with prostatectomy and with a prostate-specific antigen (PSA) value <0.2ng/mL at 2–3 months. Biochemical recurrence was defined as a PSA >0.4ng/mL. A multivariate Cox regression analysis was performed. A score (0–2) was assigned according to the hazard ratio of the significant variables. The score summation defined the risk summation. ResultsA total of 19.7% of the patients were pT3, 24.2% had a Gleason score ≥8, and 26.3% had positive surgical margins. The median follow-up was 82 months. Some 26.6% of the patients experienced biochemical recurrence. The identified prognostic variables independent of biochemical recurrence were a Gleason score =7 (4+3) (HR, 2.01; P=.008), a Gleason score ≥8 (HR, 3.07; P <.001), a pT3b stage (HR, 1.93; p=.008) and a positive surgical margin (HR, 2.20; P<.001). We assigned 0 points to patients without risk prognosis variables; 1 point to patients with Gleason scores =7 (4+3), pT3b or positive surgical margins; and 2 points to patients with Gleason scores ≥8. The patients with a risk summation ≤2 had >50% survival free of biochemical recurrence at 5 and 8 years. In contrast, the patients with a risk summation ≥3 had <44% survival free of biochemical recurrence. ConclusionThe patients with a risk summation ≤2 did not benefit from adjuvant radiation therapy, while the patients with a risk summation ≥3 might benefit from adjuvant radiation therapy.

1415 An exploration of the health professionals' experiences and views of the needs of paediatric radiation therapy patients and their families

1415 An exploration of the health professionals' experiences and views of the needs of paediatric radiation therapy patients and their families

Acceptability of a Touch Screen Tablet Psychosocial Survey Administered to Radiation Therapy Patients in Japan.

Studies in western clinical settings suggest that touch screen computer surveys are an acceptable mode of collecting information about cancer patients' wellbeing We examined the acceptability of a touch screen tablet survey among cancer patients in Japan. Eligible patients (n = 262) attending a university hospital radiation therapy (RT) department were invited to complete a touch screen tablet survey about psychosocial communication and care. Survey consent and completion rates, the proportion and characteristics of patients who completed the touch screen survey unassisted, and patient-reported acceptability were assessed. Of 158 consenting patients (consent rate 60% [95% CI 54, 66%] of eligible patients), 152 completed the touch screen computer survey (completion rate 58% [95% CI 52, 64%] of eligible patients). The survey was completed without assistance by 74% (n = 113; 95% CI 67, 81%) of respondents. Older age was associated with higher odds of having assistance with survey completion (OR 1.09; 95% CI 1.04, 1.14%). Ninety-two percent of patients (95% CI 86, 96%) felt that the touch screen survey was easy to use and 95% (95% CI 90, 98%) agreed or strongly agreed that they were comfortable answering the questions. Overall, 65% (95% CI 57, 73%) of respondents would be willing to complete such a survey more than once while waiting for RT treatment. Although patient self-reported acceptability of the touch screen survey was high, self-administered touch screen tablet surveys may not be entirely appropriate for older cancer patients or possibly for patients with lower educational attainment.

Barriers to radiotherapy utilisation in New South Wales Australia: Health professionals' perceptions of impacting factors.

Utilisation of radiation therapy (RT) in Australia is below recommended evidence-based benchmarks. Barriers to the referral of patients for RT and the uptake of RT by patients may be affecting RT utilisation. The current study aimed to examine health professionals' (HPs) perceptions of potential barriers to RT referral and uptake. A custom survey was developed to assess perceptions regarding the degree to which a range of issues affect decisions regarding RT. Hard copy surveys were disseminated to HPs involved in the care of cancer patients across New South Wales (NSW): medical, radiation and surgical oncologists, physicians (including palliative care), and general practitioners with an interest in oncology. Electronic versions of the survey were disseminated via oncology multidisciplinary teams and professional networks at participating hospitals. Two hundred fifty-three HPs participated via hard copy (n = 208) or electronic (n = 45) surveys. Two-thirds of HPs perceived acute side effects of RT, their management and impact on daily commitments, as well as fear and anxiety about RT, to exert moderate to significant influence on RT decisions. Treatment-related travel, need for accommodation and relocation were also perceived by 64% of HPs to do the same. Over half of HPs rated concern regarding late effects of RT, disruption to family and work life, and the ability to organise family and work commitments around RT, as moderate to significant influences on RT uptake. Perceptions of HPs in NSW reveal potential important influencers of RT decisions by patients and clinicians. An understanding of these additional issues and their actual impact on RT-related decisions may inform future interventions to improve RT access and utilisation.

WE-A-BRD-01: MR Imaging for Treatment Planning: What Every Physicist Should Know

Ever since its introduction as a diagnostic imaging modality over 30 years ago, the radiation therapy community has acknowledged the utility of MR imaging as a tool for not only improved visualization of the target volume but also for demarcation of adjacent organs at risk. However, the adaptation of MR imaging in radiation oncology has, until recently been slow due in large part to the inability to image radiation therapy patients in their treatment position. With the introduction of so-called wide bore high field MR scanners, multi element flexible receive only RF coils, high performance imaging gradients and a range of volumetric imaging sequences it is now possible to obtain both high resolution and high signal-to-noise ratio images of in-treatment radiation therapy patients within clinically feasible imaging times. As a Result, there is renewed interest in the use of MR imaging for radiation oncology treatment planning that is being translated into physical siting and integration of these systems into radiation oncology departments. As MR imaging expands into the radiation oncology domain there is a significant and unmet need for radiation therapy physicists to become educated regarding the strengths, limitations and technical challenges associated with MR imaging. The purpose of this presentation is to address this need by providing an educational overview of the techniques and challenges associated with MR imaging of patients for radiation therapy treatment planning. As such this presentation will: 1) describe the fundamental differences between imaging of patients for diagnostic and therapeutic purposes (i.e. radiation therapy planning), 2) describe most commonly used imaging sequences and contrasts for identification of disease for radiation planning, 3) identify the most common sources of image distortion and techniques to reduce their effect on spatial fidelity of the MR data, 4) describe the effects of motion and methods to quantify/correct it, and 5) identify emergent techniques for performing MR only treatment simulation. Upon completion attendees will have a working understanding of the basic methodologies associated with MR imaging in radiation oncology, the unique technical challenges imposed by MR imaging in the treatment position and techniques to address these. Learning Objectives: 1. Understand the differences between MR imaging for diagnostic imaging and for radiation therapy planning. 2. Identify the most common sources of distortion and artifacts and simple methods to correct them. 3. Understand the challenges with MR imaging in the therapy treatment position and appropriate techniques to address them.

WE-A-BRD-00: MR Basics II

Ever since its introduction as a diagnostic imaging modality over 30 years ago, the radiation therapy community has acknowledged the utility of MR imaging as a tool for not only improved visualization of the target volume but also for demarcation of adjacent organs at risk. However, the adaptation of MR imaging in radiation oncology has, until recently been slow due in large part to the inability to image radiation therapy patients in their treatment position. With the introduction of so-called wide bore high field MR scanners, multi element flexible receive only RF coils, high performance imaging gradients and a range of volumetric imaging sequences it is now possible to obtain both high resolution and high signal-to-noise ratio images of in-treatment radiation therapy patients within clinically feasible imaging times. As a Result, there is renewed interest in the use of MR imaging for radiation oncology treatment planning that is being translated into physical siting and integration of these systems into radiation oncology departments. As MR imaging expands into the radiation oncology domain there is a significant and unmet need for radiation therapy physicists to become educated regarding the strengths, limitations and technical challenges associated with MR imaging. The purpose of this presentation is to address this need by providing an educational overview of the techniques and challenges associated with MR imaging of patients for radiation therapy treatment planning. As such this presentation will: 1) describe the fundamental differences between imaging of patients for diagnostic and therapeutic purposes (i.e. radiation therapy planning), 2) describe most commonly used imaging sequences and contrasts for identification of disease for radiation planning, 3) identify the most common sources of image distortion and techniques to reduce their effect on spatial fidelity of the MR data, 4) describe the effects of motion and methods to quantify/correct it, and 5) identify emergent techniques for performing MR only treatment simulation. Upon completion attendees will have a working understanding of the basic methodologies associated with MR imaging in radiation oncology, the unique technical challenges imposed by MR imaging in the treatment position and techniques to address these. Learning Objectives: 1. Understand the differences between MR imaging for diagnostic imaging and for radiation therapy planning. 2. Identify the most common sources of distortion and artifacts and simple methods to correct them. 3. Understand the challenges with MR imaging in the therapy treatment position and appropriate techniques to address them.

TU-F-CAMPUS-J-03: Evaluation of a New GE Device-Less Cine 4D-CT

Purpose: Standard cine 4D-CT (S-4DCT) is the cine CT scan of the thorax followed by image sorting with the respiratory signal recorded by the RPM. Although the feasibility of cine 4D-CT without RPM or device-less 4DCT (DL-4DCT) has been reported in a laboratory setting, the only commercial implementation of DL-4DCT was made recently by GE based on the measurements of the lung, body and air area and density. We report the initial results of this new DL-4DCT on its determination of gross tumor volume (GTV). Methods: 30 stereotactic body radiation therapy (SBRT) patients with NSCLC were included in the study. All patients received the S-4DCT for their treatment planning. Their cine CT data without the respiratory signal from RPM were submitted to the DL-4DCT. The DL-4DCT image quality was assessed in reference to S-4DCT. Using maximum intensity projection (MIP) images, the GTVs of the S-4DCT and DL-4DCT were compared on a subset of 9 patients whose tumors in the low density lung regions could be contoured using a region growing algorithm in MIM without contouring bias from the user. A lower threshold of −424 HU was used for all patients and other algorithm parameters were held constant for each patient. Results: The DL-4DCT was able to produce the 4DCT images on 29 out of the 30 SBRT cases. One case failed due to the enhanced calcification surrounding both the breast implants. The GTVs determined on the 9 patients with DL-4DCT were 4.2 ± 4.8% smaller than the GTVs with S-4DCT. However, this was statistically insignificant (p=0.15). The Dice similarity coefficients were 95.1 ± 1.8%. The image quality of DL-4DCT and S-4DCT was similar on the 29 cases. Conclusion: The first commercial DL-4DCT was promising in generating 4D-CT images without a respiratory monitoring device in this preliminary study of 30 patients.

SU‐E‐T‐469: Implementation of VAs Web‐Based Radiotherapy Incident Reporting and Analysis System (RIRAS)

Purpose:This Web‐based Radiotherapy Incident Reporting and Analysis System (RIRAS) is a tool to improve quality of care for radiation therapy patients. This system is an important facet of continuing effort by our community to maintain and improve safety of radiotherapy.Material andMethods:VA's National Radiation Oncology Program office has embarked on a program to electronically collect adverse events and good‐catch data of radiation treatment of over 25,000 veterans treated with radiotherapy annually. This VA‐Intranet based software design has made use of dataset taxonomies and data dictionaries defined in AAPM/ASTRO reports on error reporting. We used proven industrial and medical event reporting techniques to avoid several common problems faced in effective data collection such as incomplete data due to data entry fatigue by the reporters, missing data due to data difficult to obtain or not familiar to most reporters, missing reports due to fear of reprisal etc. This system encompasses the entire feedback loop of reporting an incident, analyzing it for salient details, and developing interventions to prevent it from happening again. The analysis reports with corrective, learning actions are shared with the reporter/facility and made public to the community (after deidentification) as part of the learning process.Results:Till date 50 incident/good catches have been reported in RIRAS and we have completed analysis on 100% of these reports. This is done due to the fact that each reported incidents is investigated and a complete analysis/patient‐safety‐work‐product report is generated by radiation oncology domain‐experts. Conclusions Because of the completeness of the data, the system has enabled us to analyze process steps and track trends of major errors which in the future will lead to implementing system wide process improvement steps and safe standard operating procedures for each radiotherapy treatment modality/technique and fulfills our goal of “Effecting Quality While Treating Safely”.RIRAS developed and copyrighted by TSG Innovations Inc.

Multidisciplinary Shared Decision Making in the Management of Ductal Carcinoma In Situ of the Breast.

Controversy continues regarding the use of adjuvant radiation therapy (RT) and hormonal therapy (HT) for patients undergoing breast-conserving therapy (BCT) for ductal carcinoma in situ (DCIS). A prospective database was queried to identify women 18 years of age or older treated for DCIS from 2002 to 2013. BCT was completed for 300 patients with a median age of 66 years. The median DCIS size was 0.7 cm (range 0.1-6.0 cm). The DCIS grades were high (44 %), intermediate (37 %), and low (19 %). The closest margin was wider than 3 mm in 80 % and wider than 5 mm in 63 % of the cases. Adjuvant RT was administered to 183 patients (61 %), and the RT status of 9 patients (3 %) was unknown. RT was associated with age, DCIS size, comedo necrosis, grade, and treatment in 2002-2007 versus 2008-2013. Adjuvant HT was administered to 86 estrogen receptor-positive patients (39 %), and the HT status of 4 patients (2 %) was unknown. The median follow-up period was 63 months (range 4-151 months). The 5-year overall local recurrence (LR) rate was 4 % (95 % confidence interval [CI] 2.1-7.4 %). The 5-year LR rate was 3.9 % (95 % CI 1.8-8.6 %) for the RT patients and 4.1 % (95 % CI 1.6-10.7 %) for the patients not receiving RT. Of 13 LRs, 10 (77 %) were DCIS, and 3 (23 %) were invasive including one node-positive recurrence. Multidisciplinary and joint decision making in the treatment of DCIS results in a substantial and increasing number of patients forgoing adjuvant RT, adjuvant HT, or both. Reasonable 5-year LR rates suggest that such decision making can appropriately allocate patients to adjuvant therapies.

The Accuracy of Clinical Diagnosis of Oral Lesions and Patient-Specific Risk Factors that Affect Diagnosis

To examine the rate of discrepancy between clinical impression and histologic diagnosis of oral lesions in patients undergoing biopsy examination and to determine whether there are patient-specific variables associated with a higher rate of discrepancy. The authors designed and implemented a retrospective cohort study that consisted of patients who underwent biopsy examination of oral lesions from 2005 through 2013 by oral and maxillofacial surgeons at the Massachusetts General Hospital. Accuracy was determined by comparing the clinical impression with the final histologic diagnosis. Clinical and histologic diagnoses were categorized as premalignant or malignant (group 1) or benign (group 2). The primary outcome variable was concordance (yes vs no) between clinical impression and histopathologic diagnosis. The effect of individual predictor variables (age, gender, duration, American Society of Anesthesiology status, cancer history, radiation therapy history, medications, alcohol abuse, and tobacco history) on outcome also was evaluated through univariate and multivariate regression analyses. The study sample was composed of 1,003 oral lesions (74 pathologically confirmed premalignant or malignant and 929 benign) from patients with a mean age of 44.8 years. Of the lesions evaluated, concordance between exact clinical and histologic diagnoses was found in 61% of cases. Overall, the clinical impression, reported as benign versus premalignant or malignant, was 48.6% sensitive and 98.1% specific. Clinicians accurately identified lesions as benign in 95.9% of cases. The most common of these were fibromas (positive predictive value [PPV], 99.2%), mucoceles (PPV, 98.1%), and squamous papillomas (PPV, 96.3%). Several independent risk factors were associated with discrepancy: radiation therapy history (P = .0102), male gender (P = .0381), and patient age (P = .0468). The results of this study suggest that the clinical impression, although highly accurate for common benign conditions, is not an acceptable alternative to definitive biopsy findings in other cases, particularly in cases of premalignancy or malignancy. In addition, patients with identified independent risk factors (age, gender, and radiation therapy) should receive timely biopsy examination.

Prospective Randomized Comparison of the Effectiveness of Radiation Therapy and Local Steroid Injection for the Treatment of Plantar Fasciitis

The purpose of this study was to conduct a randomized trial of radiation therapy for plantar fasciitis and to compare radiation therapy with local steroid injections. Between March 2013 and April 2014, 128 patients with plantar fasciitis were randomized to receive radiation therapy (total dose of 6.0 Gy applied in 6 fractions of 1.0 Gy three times a week) or local corticosteroid injections a 1 ml injection of 40 mg methylprednisolone and 0.5 ml 1% lidocaine under the guidance of palpation. The results were measured using a visual analog scale, a modified von Pannewitz scale, and a 5-level function score. The fundamental phase of the study was 3 months, with a follow-up period of up to 6 months. The median follow-up period for all patients was 12.5 months (range, 6.5-18.6 months). For the radiation therapy patients, the median follow-up period was 13 months (range, 6.5-18.5 months), whereas in the palpation-guided (PG) steroid injection arm, it was 12.1 months (range, 6.5-18.6 months). After 3 months, results in the radiation therapy arm were significantly superior to those in the PG steroid injection arm (visual analog scale, P<.001; modified von Pannewitz scale, P<.001; 5-level function score, P<.001). Requirements for a second treatment did not significantly differ between the 2 groups, but the time interval for the second treatment was significantly shorter in the PG steroid injection group (P=.045). This study confirms the superior analgesic effect of radiation therapy compared to mean PG steroid injection on plantar fasciitis for at least 6 months after treatment.