US Radiation Oncologists Research Articles

Hypofractionated Radiation Therapy: A Cross-sectional Survey Study of US Radiation Oncologists.

For many malignancies, hypofractionated radiotherapy (HFRT) is an accepted standard associated with decreased treatment time and costs. United States provider beliefs regarding HFRT likely impact its adoption but are poorly studied. We surveyed US-based radiation oncologists (ROs) to gauge HFRT utilization rates for prostate (PC), breast (BC), and rectal cancer (RC) and to characterize the beliefs governing these decisions. From July to October 2021, an anonymized, online survey was electronically distributed to ROs actively practicing in the United States. Demographic and practice characteristic information was collected. Questions assessing rates of offering HFRT for PC, BC, and RC and perceived limitations towards using HFRT were administered. A total of 203 eligible respondents (72% male, 72% White, 53% nonacademic practice, 69% with 11+ years in practice) were identified. Approximately 50% offered stereotactic body radiation therapy (SBRT) for early/favorable intermediate risk PC. Although >90% of ROs offered whole-breast HFRT for early-stage BC, only 33% offered accelerated partial-breast irradiation (APBI). Overall, 41% of ROs offered short-course neoadjuvant RT for RC. The primary reported barriers to HFRT utilization were lack of data, inexperience, and referring provider concerns. HFRT is safe, effective, and beneficial, yet underutilized-particularly prostate SBRT, APBI, and short-course RT for RC. Skills retraining and education of ROs and referring providers may increase utilization rates.

Experience of Telemedicine Visits in Radiation Oncology During the COVID-19 Pandemic: A US National Survey and Lessons Learned for Incorporating Telemedicine Post-COVID-19

PurposeWe sought to survey the attitudes and perceptions of US radiation oncologists toward the adoption of telemedicine during the COVID-19 pandemic and offer suggestions for its integration in the postpandemic era. Methods and MaterialsA 25-question, anonymous online survey was distributed nationwide to radiation oncologists. ResultsOne hundred and twenty-one respondents completed the survey, with 92% from academia. Overall, 79% worked at institutions that had implemented a work-from-home policy, with which 74% were satisfied. Despite nearly all visit types being conducted in-person before COVID-19, 25%, 41%, and 5% of the respondents used telemedicine for more than half of their new consultations, follow-up, and on-treatment visits, respectively, during the COVID-19 pandemic. Most (83%) reported being comfortable integrating telemedicine. Although telemedicine was appreciated as being more convenient for patients (97%) and reducing transmission of infectious agents (83%), the most commonly perceived disadvantages were difficulty in performing physical examinations (90%), patients’ inability to use technology adequately (74%), and technical malfunctions (72%). Compared with in-person visits, telemedicine was felt to be inferior in establishing a personal connection during consultation (90%) and assessing for toxicity while on-treatment (88%) and during follow-up (70%). For follow-up visits, genitourinary and thoracic were perceived as most appropriate for telemedicine while gynecologic and head and neck were considered the least appropriate. Overall, 70% were in favor of more telemedicine, even after pandemic is over. ConclusionsTelemedicine will likely remain part of the radiation oncology workflow in most clinics after the pandemic. It should be used in conjunction with in-person visits, and may be best used for conducting follow-up visits in certain disease sites such as genitourinary and thoracic malignancies.

Attitudes and access to resources and strategies to improve quality of radiotherapy among US radiation oncologists: A mixed methods study.

We aimed to assess contouring-related practices among US radiation oncologists and explore how access to and use of resources and quality improvement strategies vary based on individual- and organization-level factors. We conducted a mixed methods study with a sequential explanatory design. Surveys were emailed to a random 10% sample of practicing US radiation oncologists. Participating physicians were invited to a semi-structured interview. Kruskal-Wallis and Wilcoxon rank-sum tests and a multivariable regression model were used to evaluate associations. Interview data were coded using thematic content analysis. Survey overall response rate was 24%, and subsequent completion rate was 97%. Contouring-related questions arise in ≥50% of clinical cases among 73% of respondents. Resources accessed first include published atlases (75%) followed by consulting another radiation oncologist (60%). Generalists access consensus guidelines more often than disease-site specialists (P = 0.04), while eContour.org is more often used by generalists (OR 4.3, 95% CI 1.2-14.8) and younger physicians (OR 1.33 for each 5-year increase, 95% CI 1.08-1.67). Common physician-reported barriers to optimizing contour quality are time constraints (58%) and lack of access to disease-site specialists (21%). Forty percent (40%, n = 14) of physicians without access to disease-site specialists indicated it could facilitate the adoption of new treatments. Almost all (97%) respondents have formal peer review, but only 43% have contour-specific review, which is more common in academic centres (P = 0.02). Potential opportunities to improve radiation contour quality include improved access to disease-site specialists and contour-specific peer review. Physician time must be considered when designing new strategies.

Five-Year Development and Usage Outcomes of eContour, a Web-Based Interactive Contouring Atlas

<h3>Purpose/Objective(s)</h3> The delivery of safe and effective radiation therapy relies on accurate target delineation, particularly in the era of highly conformal treatment techniques. Contouring resources can improve accuracy but are fragmented and underused. We report the 5-year development and usage outcomes of a free, online, easily accessible web-based interactive contouring atlas. <h3>Materials/Methods</h3> <b>eContour</b> (https://econtour.org) was developed using modern web technologies, including HTML5, Python, and an interpreted computer programming language, to interactively display images and contours from real patient cases. The viewer has standard tools for image manipulation, contour display, image overlays, and radiation dose distribution. Information from evidence-based guidelines and clinical pearls are summarized and presented next to each case. Mixpanel software was used to collect web usage statistics, including user demographics, geography, and case views. <h3>Results</h3> In the first 5 years of operation (February 1, 2016 to February 1, 2021), a total of 22,889 users registered on eContour. Users represented a total of 146 countries, with the largest cohort from the United States (7,096, 31%). Other countries with > 700 registered users included Spain, India, Brazil, China, and Russia. The majority of registered users (58%) reported their profession as physicians, including 10,869 practicing radiation oncologists (47%) and 2,583 resident physicians (11%). There are 3,107 users who identified as physicians and were geographically within the US. The remaining users identified as radiation therapists (10%), dosimetrists (10%), medical physicists (8.7%), and medical students (6.6%). As of February 2021, a total of 65 cases have been developed covering 9 disease sites. The most commonly viewed disease site was head and neck (23% of all case views), followed by gynecological, gastrointestinal, and breast cancer. The most commonly viewed cases include pre-operative rectal cancer, head and neck organs-at-risk, and intact prostate cancer. Over 5 years, usage of <b>eContour</b> has increased both in terms of total users and case views. Total users have grown > 600% since 2017; 3,613 (2017), to 12,248 (2019), to 22,889 cumulative total users (2021). In the fourth quarter of 2020, <b>eContour</b> averaged 1,018 case views per weekday. Since the onset of the COVID pandemic, usage of <b>eContour</b> has accelerated. Annual case views increased 56% year-over-year from 2019 to 2020 (147,846 to 230,304 views) as compared to essentially stable from 2018 to 2019 (144,769 to 147,846). <h3>Conclusion</h3> With approximately 5,000 radiation oncologists in the US, we estimate 60% of US radiation oncologists are registered users. Growth in users and web site traffic over the first 5 years of <b>eContour</b> show its strong potential to increase the use of evidence-based contouring information at the point of care.

Unsolicited patient complaints among radiation, medical, and surgical oncologists.

Unsolicited patient complaints (UPCs) about physician practices are nonrandomly associated with malpractice claims and clinical quality. The authors evaluated the distributions and types of UPCs associated with oncologists by specialty and assessed oncologist characteristics associated with UPCs. This retrospective study reviewed UPCs associated with US radiation oncologists (ROs), medical oncologists (MOs), and surgical oncologists (SOs) from 35 health care systems from 2015 to 2018. Average total UPCs were compared by specialty in addition to sex, medical school graduation year, degree, medical school location, residency location, practice setting, and practice region. For continuous variables, linear regression was used to test for an association with total complaints. The study included 1576 physicians: 318 ROs, 1020 MOs, and 238 SOs. The average number of UPCs per physician was different and depended on the oncologic specialty: ROs had significantly fewer complaints (1.28; 95% confidence interval [CI], 1.02-1.54) than MOs (3.81; 95% CI, 3.52-4.10) and SOs (6.89; 95% CI, 5.99-7.79; P < .0001). In a multivariable analysis, oncologic specialty, recency of graduation, and academic practice were predictive of higher total UPCs (P < .05). UPCs described concerns with care and treatment (42.8%), communication (26.4%), accessibility (17.5%), concern for patient (10.3%), and billing (2.9%). ROs had significantly fewer complaints than MOs and SOs and may have a lower risk of malpractice claims as a group. In addition to oncologic specialty, a more recent year of medical school graduation and working at an academic center were independent risk factors for UPCs. Further research is needed to clarify the reasons underlying these associations and to identify interventions that decrease UPCs and associated risks. This study of 1576 oncologists found that radiation oncologists had significantly fewer complaints than medical oncologists, who in turn had significantly fewer complaints than surgical oncologists. Other characteristics associated with more patient complaints included recency of medical school graduation and practice in an academic setting. Oncologists' patient complaints provide information that may have practical applications for patient safety and risk management. Understanding and addressing the characteristics that increase the risk for complaints could improve patients' experiences and outcomes.

Neoadjuvant endocrine therapy use in early stage breast cancer during the covid-19 pandemic.

PurposePhysician treatment preferences for early stage, estrogen positive breast cancer (ER + BC) patients were evaluated during the initial surge of the COVID-19 pandemic in the US when neoadjuvant endocrine therapy (NET) was recommended to allow safe deferral of surgery.MethodsA validated electronic survey was administered May–June, 2020 to US medical oncologists (MO), radiation oncologists (RO), and surgeons (SO) involved in clinical trials organizations. Questions on NET use included practice patterns for locoregional management following NET.Results114 Physicians from 29 states completed the survey—42 (37%) MO, 14 (12%) RO, and 58 (51%) SO. Before COVID-19, most used NET ‘rarely’ (49/107, 46%) or ‘sometimes’ (36, 33%) for ER + BC. 46% would delay surgery 2 months without NET. The preferred NET regimen was tamoxifen for premenopausal and aromatase inhibitor for postmenopausal women. 53% planned short term NET until surgery could proceed. Most recommended omitting axillary lymph node dissection (ALND) for one micrometastatic node after 1, 2, or 3 months of NET (1 month, N = 56/93, 60%; 2 months, N = 54/92, 59%; 3 months, N = 48/90, 53%). With longer duration of NET, omission of ALND decreased, regardless of years in practice, percent of practice in BC, practice type, participation in multidisciplinary tumor board, or number of regional COVID-19 cases.ConclusionMore physicians preferred NET for ER + BC during the pandemic, compared with pre-pandemic times. As the duration of NET extended, more providers favored ALND in low volume metastatic axillary disease. The Covid-19 pandemic affected practice of ER + BC; it remains to be seen how this may impact outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s10549-021-06153-3.

Survey of Twitter and Social Media Use Among US Radiation Oncologists

Physicians have been utilizing Twitter at increasing rates since its founding in 2006. Little is known regarding US radiation oncologists’ (RO) use of Twitter. We conducted a survey to better understand RO utilization of Twitter. After IRB approval, we obtained a public list of RO on Twitter curated by one author (MSK). We emailed a 65-question online survey to these 133 individuals active within the prior month as of March 2019 using Survey Gizmo. We analyzed anonymized responses utilizing descriptive statistics. Of 133 individuals surveyed, 77 responded (58% response rate). 21% were female. Ages of respondents were: 43% 30-39, 36% 40-49, and 21% ≥ 50. 72% worked in an academic practice. Mean follower count was 1440 (SD 2421) and number of accounts followed was 712 (SD 892); no significant difference was found in the number of followers when analyzed by age group, gender, US region, or practice setting (academic vs non-academic). 31% reported using social media during cancer conferences or tumor boards. Workplace policy for social media was not statistically significant in RO academic (53%) vs non-academic setting (43%) (p = 0.4). Male RO reported using >50% of their overall social media time on professional/academic purposes, significantly more than women, (62% vs. 19%, p = 0.004). No significant difference was found between those in academic practices or non-academic practices who used >50% social media time for professional purposes (55% vs 50%, p = 0.5). Answering the question “What do you believe are the benefits to your Twitter engagement? Check all that apply” the most commonly endorsed responses were “educating myself regarding cancer research updates” 87% (67/77), “networking with colleagues in radiation oncology” 74% (57/77), and “educating myself regarding overall medical updates” 71% (55/77). 67.5% responded affirmatively to the question “Do you believe more radiation oncologists should join Twitter?” and 24.7% had “no opinion.” In response to the question “What are your fears regarding your Twitter use? Check all that apply,” responses included: “I am afraid of appearing as self-promoting” 49.4%, “I am afraid of appearing unprofessional” 41.6%, “I do not have any fears about using Twitter” 35.1%, “I am afraid of violating HIPAA” 14.3%, and “I am afraid of sharing erroneous cancer information with the public” 13.0%. Among RO active on twitter, follower counts do not vary by gender, age, or practice setting. Participants perceived both benefits and risks of Twitter engagement. The profession may benefit from further attention to engagement and representation of ROs in Twitter and other potentially influential social media contexts.Tabled 1Abstract 2977; TableStrongly Agree (%)Agree (%)Neutral (%)Disagree (%)Strongly Disagree (%)Social media can improve my clinical skills and knowledge in cancer care23521645Social media enhances my feeling of belonging to the radiation oncology community17472683Social media can be helpful for my career development31392514 Open table in a new tab

US Radiation Oncologists (Re)Defined: An American Society for Radiation Oncology Scope of Practice Study

PurposeTo assess US radiation oncologists’ views on practice scope and the ideal role of the radiation oncologist (RO), the American Society for Radiation Oncology (ASTRO) conducted a scope of practice survey.Methods and MaterialsIn spring 2019, ASTRO distributed an online survey to 3822 US RO members. The survey generated 984 complete responses (26% response rate) for analysis. Face validity testing confirmed respondents were representative of ASTRO’s RO membership.ResultsNearly all respondents agreed that “ROs should be leaders in oncologic care.” Respondents indicated the ideal approach to patient care was to provide “an independent opinion on radiation therapy and other treatment options” (82.5%) or “an independent opinion on radiation therapy but not outside of it” (16.1%), with only 1.4% favoring provision of “radiation therapy at the request of the referring physician” as the ideal approach. Actual practice fully matched the ideal approach in 18.2% of respondents. For the remaining majority, actual practice did not always match the ideal and comprised a mix of approaches that included providing radiation at the referring physician’s request 24.0% of the time on average. Reasons for the mismatch included fear of alienating referring physicians and concern for offering an unwelcome opinion. One-fifth of respondents expressed a desire to expand the scope of service though interspecialty politics and insufficient training were potential barriers. Respondents interested in expanding scope of practice were on average earlier in their career (average years in practice 13.3) than those who were not interested (average years in practice 17.2, P < .001). Radiopharmaceuticals administration, medical marijuana and anticancer medications prescribing, and RO inpatient service represented areas of interest for expansion but also knowledge gaps.ConclusionsThese results provide insight regarding US ROs’ scope of practice and attitudes on the ideal role of the RO. For most ROs, to provide an independent opinion on treatment options represented the ideal approach to care, but barriers such as concern of alienating referring physicians prevented many from fully adhering to their ideal in practice. Actual practice commonly comprised a mixed approach, including the least favored scenario of delivering radiation at the referring physician’s request one-quarter of the time, highlighting the influence of interspecialty politics on practice behavior. Advocacy for open communication and meaningful interdisciplinary collaboration presents an actionable solution toward a more balanced relationship with other specialties as ROs strive to better fulfill the vision of being leaders in oncologic care and being our best for our patients. The study also identified interest in expanding into nontraditional domains that offer opportunities to address unmet needs in the cancer patient’s journey and elevate radiation oncology within the increasingly value-based US health care system.

Federal Political Contribution Characteristics of Radiation Oncologists in the United States from 2003 to 2018

The health care industry has many stakeholders who seek relationships within government to ensure certain interests are considered in the legislative process. This study characterized the federal political contributions of US radiation oncologists (ROs). Public finance data from the Federal Election Commission (FEC) containing self-identified ROs' contributions to a federal candidate or committee were obtained from 2003 to 2018. Contribution recipients were classified as a political action committee (PAC) or a presidential, Senate, or House candidate. Political parties of recipients were based on FEC designations. For PACs, political parties of recipients were based on spending patterns to political parties in each 2-year election cycle or, when unavailable, overall spending patterns of greater than 50% to 1 political party, as detailed by the Center for Responsive Politics. Data were analyzed temporally, and Spearman's rho was used to assess trends. From 2003 to 2018, the FEC reported a total of 31,646,000 federal political contributions. Exactly 4617 federal political contributions were made from 1021 unique self-identified ROs, totaling $3,350,747. The number of ROs making contributions ranged from 56 in 2005 to 600 in 2016 (mean, 289 ± 191.4 ROs yearly), with a mean annual contribution of $209,422. Of all RO dollars, 61.5% went to Democrats, 37.5% to Republicans, and 1.0% to third-party candidates. Most RO dollars (81.0%) went to PACs rather than candidates, with the majority of those PAC dollars (50.2%) directed toward the American Society for Radiation Oncology Political Action Committee. There was a positive annual trend in number of donors by year (ρ = 0.83, P < .0001) as well as RO contributions to the House (ρ = 0.58, P < .02), Senate (ρ = 0.58, P < .02), Democrats (ρ = 0.81, P < .001), Republicans (ρ = 0.66, P < .006), third-parties (ρ = 0.87, P < .001), PACs (ρ = 0.85, P < .0001), and overall (ρ = 0.8, P < .001). There was not a significant trend in contributions to presidential candidates (ρ = 0.71, P = .06). ROs' federal political contributions have significantly increased over the last decade and a half. This growth overwhelmingly represents contributions to specialty-focused PACs and both Democratic and Republican congressional candidates.

Elective Nodal Irradiation for Limited-stage Small-cell Lung Cancer: Survey of US Radiation Oncologists on Practice Patterns

BackgroundTraditionally, elective nodal irradiation (ENI) has been used in clinical trials that have established thoracic radiotherapy as instrumental in improving survival for patients with limited-stage small-cell lung cancer (LS-SCLC). However, several reports have suggested that the omission of ENI might be appropriate. Current US practice patterns are unknown regarding ENI for patients with LS-SCLC. Materials and MethodsWe surveyed US radiation oncologists via an institutional review board-approved questionnaire. The questions covered demographics, treatment recommendations, and self-assessed knowledge of key clinical trials. χ2 and Cochran-Armitage tests were used to evaluate for statistically significant correlations between responses. ResultsWe received 309 responses. Of the respondents, 21% recommended ENI for N0 LS-SCLC, 29% for N1, and 30% for N2; 64% did not recommend ENI for any of these clinical scenarios. The respondents who recommended ENI were more likely to have been practicing for > 10 years (P < .001), more likely to be in private practice (P = .04), and less likely to be familiar with the ongoing Cancer and Leukemia Group B 30610 trial (P = .04). Almost all respondents (93%) prescribed the same radiation dose to the primary disease and involved lymph nodes. When delivering ENI, 36% prescribed the same dose to the involved and elective nodes, and 64% prescribed a lower dose to the elective nodes. ConclusionNearly two thirds of respondents did not recommend ENI, which represents a shift in practice. A recent large clinical trial that omitted ENI reported greater overall survival than previously reported and lower-than-expected radiation toxicities, lending further evidence that omitting ENI should be considered a standard treatment strategy.

Trends in Financial Relationships Between Industry and US Radiation Oncologists from 2014-2017: A Cohort Study

Trends in Financial Relationships Between Industry and US Radiation Oncologists from 2014-2017: A Cohort Study

Assessment of Differences in Clinical Activity and Medicare Payments Among Female and Male Radiation Oncologists

ImportanceAlthough physician sex is known to influence salary even after controlling for productivity, sex-based differences in clinical activity and reimbursement among radiation oncologists are poorly understood.ObjectivesTo evaluate differences by sex in productivity, breadth of practice, and payments and to characterize Medicare reimbursement by sex among similarly productive groups of radiation oncologists.Design, Setting, and ParticipantsA retrospective cohort study was conducted using the January 1 to December 31, 2016, Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use File (POSPUF) to identify charge and payment information for individual radiation oncologists. Clinicians were part of a population-based sample of US radiation oncologists who bill Medicare in both non–facility-based (NFB) and facility-based (FB) practice settings. Analysis was conducted from June 5 to 25, 2018.Main Outcomes and MeasuresOutcome measurements included physician productivity (measured by number of Medicare charges), physician payments (reported as total Medicare payments as well as mean payments per charge submitted and per beneficiary treated), and physician breadth of practice (measured by number of unique Medicare billing codes) in NFB and FB settings.ResultsA total of 4393 radiation oncologists (1133 women and 3260 men) were included in the POSPUF in 2016. Compared with their male counterparts, female physicians in the NFB setting submitted a mean of 1051 fewer charges (95% CI, –1458 to –644; P < .001), collected a mean of $143 610 less in revenue (95% CI, –$185 528 to –$101 692; P < .001), and used a mean of 1.32 fewer unique billing codes (95% CI, –2.23 to –0.41; P = .004). Compared with their male counterparts, female radiation oncologists in the FB setting submitted a mean of 423 fewer charges (95% CI, –506 to –341; P < .001), collected a mean of $26 735 less in revenue (95% CI, –$31 910 to –$21 560; P < .001), and submitted a mean of 1.28 fewer unique billing codes (95% CI, –1.77 to –0.78; P < .001). Women represented 46 of the 397 most highly productive radiation oncologists in the FB setting (11.6%) and collected a mean of $33 026 less (95% CI, –$52 379 to –$13 673; P = .001) than men who were similarly productive. In the NFB setting, women represented 54 of the 326 most highly productive radiation oncologists (16.6%) and collected $345 944 (95% CI, –$522 663 to –$169 225; P < .001) less than similarly highly productive men. Women collected a mean of $8.49 less per charge (95% CI, –$14.13 to –$2.86; P = .003) than men in the NFB setting.Conclusions and RelevanceThis study suggests that female radiation oncologists submit fewer Medicare charges, are reimbursed less per charge they submit, and receive lower Medicare payments overall compared with male radiation oncologists. Even among similarly productive radiation oncologists, women in this study still collected less revenue than men. Further research is required to understand the sex-based barriers to economic advancement within radiation oncology.

Abstract PD8-05: POSNOC - Positive sentinel node: Adjuvant therapy alone versus adjuvant therapy plus clearance or axillary radiotherapy

Abstract Background: Role of additional axillary treatment (AxT) (axillary lymph node dissection (ALND) or axillary radiotherapy (ART)) in women with ≤2 macrometastases and undergoing systemic therapy remains unclear. Z11 included both micro and macrometastases (around 40% micrometastases) and showed that ALND may be omitted in women with ≤2 positive nodes undergoing breast conserving surgery (BCS) and receiving whole breast RT. Paradoxically, NCIC MA20, demonstrated improved DFS following the addition of regional RT. 51.8% (949/1832) had 1 or 2 positive nodes. 98.9% (1812/1832) had T1/T2 tumours. A post-Z11 survey shows that most US radiation oncologists treat the undissected axilla in women with macrometastases with ART rather than omitting AxT. Therefore, a confirmatory study is needed to clarify the role of additional AxT in women with ≤2 macrometastases undergoing BCS and other subgroups that were not included in Z11 e.g. mastectomy, microscopic extranodal invasion and sentinel node biopsy (SNB) before neoadjuvant chemotherapy. Methods: Primary objective is to assess whether for women with ≤2 macrometastases at SNB, systemic therapy alone is non-inferior to systemic therapy plus AxT in terms of axillary recurrence at 5 years. Secondary objectives are arm morbidity assessed by LBCQ and QuickDASH questionnaires; QoL assessed by FACT-B+4 questionnaire; anxiety assessed by STAI; loco-regional recurrence; distant metastasis; time to axillary recurrence; axillary recurrence-free survival; DFS; OS; contralateral breast cancer; non-breast malignancy; and economic evaluation. Eligibility criteria include: ≥18 y, uni or multifocal invasive cancer, T1/T2, 1 or 2 macrometastases, with or without extranodal invasion. Target sample size is 1900 with a projected drop-out and non-compliance with treatment allocation rate of 10%. Primary analysis will be per protocol. The following pre-specified subgroup analyses shall be performed: number of macrometastases (1, 2), age (&amp;lt;50, ≥50), breast surgery (mastectomy, BCS), ER (positive, negative), tumour grade (1 or 2, 3), SN assessment technique (OSNA, non-OSNA), extranodal invasion (present, absent). POSNOC opened to recruitment in July 2014. To date 1100 women have been recruited at 82 sites in the UK and 18 sites in Australia and New Zealand. Clinicaltrials.gov NCT02401685. Citation Format: Goyal A, Mann B, Thompson AM. POSNOC - Positive sentinel node: Adjuvant therapy alone versus adjuvant therapy plus clearance or axillary radiotherapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-05.

Concurrent Radiation and Immunotherapy: Survey of Practice Patterns in the United States.

The objective of this study was to report on US radiation oncologists' (ROs) practice patterns and perceptions of concurrent radiation (RT) and immunotherapy (IT) (CRI). A 22-question survey was emailed to radiation oncologists in February 2018. CRI was defined as RT completed within 1 week before initial IT infusion through 4 weeks after final IT infusion. Of the 323 respondents from 45 states, 88% had experience treating a patient with CRI, including 51% private and 48% academic physicians. The most common reason for not offering CRI was concerns of increased toxicity (50%). Although 84% to 94% of respondents did not change RT dose, more ROs decreased dose when treating central structures (chest/abdomen/pelvis) versus noncentral structures (brain/head and neck/extremities): 13% to 15% versus 4% to 8%, P<0.001. The majority (58% to 80%) of respondents would not delay RT from last IT infusion. Moderate and significant actual toxicities were rare (medical intervention 6%, hospitalization/death <1%). 97.5% of ROs did not routinely prescribed prophylactic steroids for CRI. More ROs believed CRI with SBRT/SRS versus palliative RT had better local control (35% vs. 25%, P<0.05) and higher rates of abscopal responses (41% vs. 25%, P<0.01). Despite concerns for toxicity, ROs with CRI experience reported minimal toxicities. Most ROs do not alter RT dose, use prophylactic steroids, or delay starting RT from last IT infusion. Uncertainty remains about improved local control outcomes and abscopal responses from CRI, with a perception that concurrent SBRT offers better outcomes than palliative RT. These survey results may help guide ROs until more definitive data are available.

Evaluation of Sex Distribution of Industry Payments Among Radiation Oncologists

Industry relationships are an important measure of professional advancement; however, the association between physician sex and industry payments in radiation oncology has not been described. To update the trends in the sex distribution of industry payments in radiation oncology. This retrospective cross-sectional study was conducted between July 1, 2018, and August 31, 2018. It used the publicly available Centers for Medicare & Medicaid Services (CMS) Open Payments program and CMS Physician and Other Supplier Public Use File databases to obtain 2016 industry payment data for US radiation oncologists who reported receiving industry funding in that year (n = 3052). Total monetary value, number of payments, and median payment amounts were determined for each sex in the following categories: research, consulting, honoraria, industry grants, royalty or license, and services other than consulting. Industry payment amounts among 3052 radiation oncologists who reported receiving payments in 2016; association of median payment with the types of payment by sex. Of the total 4483 radiation oncologists who practiced in 2016, 1164 (25.9%) were female and 3319 (74.0%) were male. Industry payments were distributed among 3052 radiation oncologists (68.1%), of whom 715 (23.4%) were female and 2337 (76.6%) were male. The proportion of female radiation oncologists who received at least 1 industry payment was 61.4% (715 of 1164), whereas the proportion of their male counterparts was 70.4% (2337 of 3319). Across all payment types, female radiation oncologists received a smaller percentage of total industry funding than the percentage of female physicians represented in each category. The median payment value was smaller for female radiation oncologists in consulting (-$1000; 95% CI, -$1966.67 to $100.63; P = .005) and honoraria (-$500; 95% CI, -$1071.43 to $0; P = .007). This trend was also observed in research payments, but was not statistically significant (-$135.02; 95% CI, -$476.93 to $6.88; P = .08). Of the $1 347 509 royalty or license payments made to 72 physicians, none was for female radiation oncologists. Distribution of industry payments appears to show sex disparity in industry relationships among radiation oncologists; this observation warrants further investigation to determine the underlying reasons and provide avenues for increased parity.

Survey results of US radiation oncology providers' contextual engagement of watch-and-wait beliefs after a complete clinical response to chemoradiation in patients with local rectal cancer.

Watchful waiting in rectal cancer patients with a complete clinical response (cCR) to chemoradiation therapy (CRT) forgo upfront resection has been proposed. Growing evidence suggests that a watch-and-wait approach using resection for salvage of local recurrence may improve quality of life without jeopardizing outcomes. The current acceptance of watch-and-wait by US radiation oncologists (ROs) is unknown. US ROs completed our IRB-approved anonymous e-survey regarding non-surgical management of patients who achieved a cCR to neoadjuvant CRT. Self-ranked knowledge of the OnCoRe Project-UK prospective observational study of watch-and-wait-was tested for its association with ROs' attitudes using the Chi-squared or Fisher's test, as indicated. Supporters of observation are self-identified. Of the 220 respondents, 48% (n=106) of respondents support watchful waiting and 48% claimed familiarity with the OnCoRe Project. Respondents supporting observation were more likely to be familiar with the publication (P=0.029). Among watch-and-wait supporters, 59% (n=62) felt comfortable discussing this approach and 41% preferred the conversation be initiated by other specialists. There was no association between comfort level in discussing watch-and-wait and familiarity with the OnCoRe Project. ROs treating more than 10 locally advanced rectal cancer (LARC) patients annually felt more comfortable discussing watch-and-wait (P=0.015) compared to ROs seeing fewer patients. Almost half of surveyed US ROs support watch-and-wait, though many do not feel comfortable discussing this paradigm with patients. Knowledge of the OnCoRe Project is associated with support of watch-and-wait, yet not comfort level in leading the discussion. These results inform provider attitudes toward future clinical study participation.

Underutilization of the CROSS Regimen Among US Radiation Oncologists: A National Survey of Practice Patterns.

To examine patterns of clinical practice in locally advanced esophageal cancer among US radiation oncologists after publication of the CROSS trial. US radiation oncologists were surveyed on 13 questions pertaining to the management of esophageal cancer. Respondents' demographics and their clinical rationale were analyzed for statistical association with their treatment recommendations. Few respondents (15%) offered the CROSS regimen to patients considered suitable surgical candidates, while a near-equivalent number (16%) prescribed between 41.4 and 50.4 Gy contingent upon radiation planning parameters. Among respondents who prescribed 50.4 Gy, 50% and 17% reported concurrent administration of carboplatin/paclitaxel and cisplatin/5-FU, respectively. Higher radiation doses, over 50.4 Gy, were utilized by 15% and 38% of respondents for borderline surgical candidates and candidates unfit for surgery, respectively. The majority of respondents believed that higher complete pathological response and R0 resection would be achieved, as well as higher toxicity conferred using 50.4 Gy instead of 41.4 Gy. A clinical trial comparing 41.4 Gy to 50.4 Gy with concurrent carboplatin/paclitaxel was supported by 76% of respondents. Despite results from the CROSS trial, the majority of responding US radiation oncologists do not offer 41.4 Gy with concurrent chemotherapy for surgically-fit patients with locally advanced esophageal cancer, believing that a higher dose will translate to improved response.

Attitudes Toward Pre-Operative Short-Course Radiation Therapy for Rectal Cancer among US Radiation Oncologists

Several landmark studies revealed short-course preoperative radiotherapy (SC-RT, 25 Gy in 5 fractions) followed by chemotherapy to be non-inferior to conventionally fractionated long-course chemoradiation therapy (CF-CRT). The current attitude towards these treatment modalities among US practicing radiation oncologists (ROs) is unknown. We surveyed US ROs via an anonymous online institutional review board-approved survey. Questions pertained to management preferences, knowledge of landmark randomized trials and hypothetical approach within the frame of an alternative reimbursement system. We received 220 responses. Fifty-eight percent of respondents (n=128) support SC-RT. Approximately 81% of respondents were familiar with the results of the randomized Trans-Tasman Radiation Group Trial 0104 and 51% with results of the randomized Polish Colorectal Study Group. There was no association between the knowledge of these studies and support for SC-RT (p-value = 0.726). The majority of respondents (72%) prefer to manage their patients with CF-CRT. The reasons cited for this preference were to achieve higher pathological complete response rate, to decrease toxicity and to achieve a better rate of sphincter preservation. If patient insisted on receiving SC-RT, 92% would feel comfortable. In a hypothetical situation where reimbursement would not be based on the number of fractions, 72% of respondents would still continue to prefer CF-CRT. Most ROs who would preferentially use SC-RT if insurance reimbursed at the same rate as CF-CRT also indicated they supported SC-RT compared to those who did not support SC-RT (85.2% vs 14.8%, p-value < 0.001). Despite several randomized trials showing SC-RT to be comparable to CF-CRT, 42% of US radiation oncologists do not support SC-RT and 72% prefer to manage their localized rectal cancer patients with CF-CRT. This does not appear to be influenced by the US radiation oncology reimbursement system.Abstract TU_6_2947; Table 1Reasons stated by survey respondents (n=220) leading to preferred utilization of CF-CRT over SC-RT.Stated Reasons for choosing CF-CRT over SC-RTn (%)*Better overall survival14 (8.9%)Better local control30 (19.0%)Higher pCR rate64 (40.5%)Better sphincter preservation64 (40.5%)Fewer acute toxicities29 (18.4%)Fewer long-term toxicities62 (39.2%)*Percentages do not add up to 100% as multiple reasons could be selected by respondents. Open table in a new tab

Radiation Dose and Fractionation for Limited-stage Small-cell Lung Cancer: Survey of US Radiation Oncologists on Practice Patterns

BackgroundThoracic radiotherapy (TRT) with concurrent chemotherapy is standard for limited-stage small-cell lung cancer (LS-SCLC). However, the optimal dosing and fractionation remain unclear. The National Comprehensive Cancer Network guidelines have recommended either 45 Gy delivered twice daily (BID) or 60 to 70 Gy delivered once daily (QD). However, the current practice patterns among US radiation oncologists are unknown. Materials and MethodsWe surveyed US radiation oncologists using an institutional review board-approved questionnaire. The questions covered demographic data, self-rated knowledge of key trials, and treatment recommendations. ResultsWe received 309 responses from radiation oncologists. Of the 309 radiation oncologists, 60% preferred TRT QD and 76% acknowledged QD to be more common in their practice. The respondents in academic settings were more likely to endorse BID treatment by both preference (P = .001) and actual practice (P = .009). The concordance between preferring QD and administering QD in practice was 100%. In contrast, 40% of respondents who preferred BID actually administered QD more often. Also, 15% of physicians would be unwilling to switch from QD to BID and 3% would be unwilling to switch from BID to QD, even on patient request. Most respondents (88%) recommended a dose of 45 Gy for BID treatment. For QD treatment, the division was greater, with 54% recommending 60 Gy, 30% recommending 63 to 66 Gy, and 10% recommending 70 Gy. ConclusionSubstantial variation exists in how US radiation oncologists approach TRT dosing and fractionation for LS-SCLC. Three quarters of our respondents reported administering TRT QD most often. The most common doses were 60 Gy QD and 45 Gy BID. The results of the present survey have provided the most up-to-date information on US practice patterns for LS-SCLC.

Does a fine line exist between regional and metastatic pelvic lymph nodes in rectal cancer-striking discordance between national guidelines and treatment recommendations by US radiation oncologists.

Management of rectal cancer with involved lateral pelvic lymph nodes (LPLNs) at the time of diagnosis-the stage we refer institutionally to as Stage 3.5-is controversial. The American Joint Committee on Cancer's 7th edition classifies internal iliac lymph nodes (LNs) as regional (Stage III), but both external and common iliac LNs as metastatic (Stage IV). However, in many Asian countries all LPLNs are considered regional and patients are treated with curative intent, with literature supporting improved outcomes with LPLN dissection. Management patterns of these patients by US radiation oncologists (ROs) are unknown. American ROs completed an anonymous institutional review board-approved online questionnaire regarding rectal cancer management. Among the 220 completed responses, 45% treat more than 10 patients annually and 39% work in academia. We found 10.5% and 34.2% recommend biopsy of clinically involved internal and common iliac LNs, respectively. The vast majority of responders-98.6% and 94.5%-treat involved internal and common iliac LNs with curative intent, respectively. Respondents recommend treatment intensification to involved internal iliac LNs by dissection of the nodal basin (88.2%) and radiation therapy (RT) boost (59.1%), and treatment intensification to involved common iliac LNs by LN dissection (76.4%) and RT boost (63.6%). Our analysis reveals that the vast majority of US ROs approach patients with involved LPLNs, both regional (internal iliac) and metastatic (common iliac), with curative intent. They recommend treatment intensification with surgical resection and/or RT boost to involved nodes. Prospective clinical trials need to determine the appropriate management of patients with Stage 3.5 rectal cancer.