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Regan C, Transtrum MB, Jilakara B, Milbrandt TA, Larson AN. How Long Can You Delay? Curve Progression While Awaiting Vertebral Body Tethering Surgery. J Clin Med 2024; 13:2209. [PMID: 38673483 PMCID: PMC11050359 DOI: 10.3390/jcm13082209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Background: The implications of delaying surgical intervention for patients with adolescent idiopathic scoliosis (AIS) wishing to undergo vertebral body tethering (VBT) have not yet been explored. It is important to understand how these delays can impact surgical planning and patient outcomes. Methods: This was a retrospective review that analyzed all AIS patients treated between 2015 and 2021 at a single tertiary center. Time to surgery from initial surgical consultation and ultimate surgical plan were assessed. Patient characteristics, potential risk factors associated with increased curve progression, and reasons for delay were also analyzed. Results: 174 patients were evaluated and 95 were scheduled for VBT. Four patients later required a change to posterior spinal fusion (PSF) due to excessive curve progression. Patients requiring PSF were shown to have significantly longer delays than those who received VBT. Additionally, longer delays, younger age, greater curve progression, and lower skeletal maturity were correlated with significant curve progression (≥5 degrees). Conclusions: Surgical delays for AIS patients awaiting VBT may lead to significant curve progression and necessitate more invasive procedures. Patients with longer delays experienced an increased risk of needing PSF instead of VBT. Of those requiring PSF, the majority were due to insurance denials. Optimizing surgical timing and shared decision-making among patients, families, and healthcare providers are essential for achieving the best outcomes.
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Affiliation(s)
| | | | | | | | - A. Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (C.R.); (M.B.T.); (B.J.); (T.A.M.)
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Choi JI, Simone CB, Lozano A, Frank SJ. Advances and Challenges in Conducting Clinical Trials With Proton Beam Therapy. Semin Radiat Oncol 2023; 33:407-415. [PMID: 37684070 PMCID: PMC10503212 DOI: 10.1016/j.semradonc.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Advances in proton therapy have garnered much attention and speculation in recent years as the indications for proton therapy have grown beyond pediatric, prostate, spine, and ocular tumors. To achieve and maintain consistent access to this cancer treatment and to ensure the future viability and availability of proton centers in the United States, a call for evidence has been heard and answered by proton radiation oncologists. Answers provided in this review include the evolution of proton therapy research, rationale for proton clinical trial design, challenges in and barriers to the conduct of proton therapy research, and other unique considerations for the study of proton therapy.
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Affiliation(s)
- J Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.; New York Proton Center, New York, NY..
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.; New York Proton Center, New York, NY
| | - Alicia Lozano
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, VA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Tabbaa SM, Bugbee WD, Provencher M, Farr J, Crawford DC. Inconsistent Reporting of Preauthorization Medical Criteria for Osteochondral Allograft Transplantation Surgery. J Bone Joint Surg Am 2022; 104:1841-1853. [PMID: 35984006 DOI: 10.2106/jbjs.21.01191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although osteochondral allograft (OCA) transplantation has been a standard treatment for patients with osteochondral lesions, there is a disagreement in commercial payers' medical criteria regarding the definition of medical suitability and thus authorization for OCA transplantation. The primary goal of this study was to understand where consensus between a committee of experienced cartilage restoration surgeon scientists and payer policies existed and where there was significant disagreement. METHODS U.S. private payers were identified by reviewing health insurance market research literature. Medical criteria were then obtained from publicly available payer medical polices. A literature review was conducted to identify supporting evidence for consensus statements based on private payer medical criteria. The MOCA (Metrics of Osteochondral Allograft) Committee, 30 experienced surgeons and subject-matter experts in OCA transplantation, used a Likert scale of 1 (strongly disagree) to 5 (strongly agree) to rank each statement. The extent of agreement and disagreement among participants was measured for each statement. Consensus was defined as agreement or disagreement of >75%. RESULTS Fifty-seven statements regarding relevant medical criteria for OCA transplantation were included in the survey. All 30 MOCA Committee members completed the survey (100% response rate). Over half of the statements (52.6%) did not reach consensus. Of the remaining 27 statements that reached consensus, respondents agreed or strongly agreed with 16 statements, and disagreed or strongly disagreed with 11 statements. Inconsistent voting was observed for statements related to osteoarthritis, inflammation, and degenerative changes. CONCLUSIONS Commercial payers are not consistent in the medical criteria used to define patient eligibility for authorization of OCA transplantation. In contrast, an expert panel of cartilage surgeons reached a consensus that OCA transplantation was clearly suitable for a variety of specific indications. This study demonstrates the need to standardize medical criteria for cartilage restoration based on the most current literature, as well as in conjunction with experienced cartilage restoration experts. LEVEL OF EVIDENCE Therapeutic Level V . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Suzanne M Tabbaa
- University of California San Francisco, San Francisco, California
| | | | | | - Jack Farr
- Cartilage Restoration Center of Indiana, Greenwood, Indiana
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Laughlin BS, Anderson JD, Gagneur JD, Chungbin SJ, Bues M, Hobbis D, Fatyga M, Korte SM, Carroll SE, Vora S, Sio TT, Wong WW, Keole SR, Rong Y. Implementation of Photon Treatment Back-Up Workflow at a High-Volume Proton Center: Safety, Quality, and Patient Considerations. Pract Radiat Oncol 2022; 12:e453-e459. [PMID: 35272078 DOI: 10.1016/j.prro.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/11/2022] [Accepted: 01/19/2022] [Indexed: 11/30/2022]
Abstract
A successful proton beam therapy (PBT) center relies heavily on the proper function and maintenance of a proton beam therapy machine. However, when a PBT machine is non-operational, a proton facility is hindered with delays that can potentially lead to inferior treatment outcome due to treatment interruption. The implementation of a workflow for which proton plans are converted to photon plans so that patients can be treated using photon has been a successful strategy to reduce delays and mitigate its impact on patient care. This workflow was established through collaboration of physicians, physicists, dosimetrists, therapists, nurses, and schedulers. A tiered system established by disease site, number of fractions, and individualized circumstances is used to prioritize patients. This article provides an overview of workflow of conversion of PBT to photon when the PBT machine is down. Specific needs of patients undergoing proton beam therapy are addressed.
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Affiliation(s)
- Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Justin D Anderson
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Justin D Gagneur
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Suzanne J Chungbin
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Dean Hobbis
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Shawn M Korte
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Sarah E Carroll
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Sujay Vora
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054.
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Chhabra AM, Choi JI, Hasan S, Press RH, Kabarriti R, Lazarev S, Wolden S, Simone CB. Insurer's Black Box: Inexplicable Barriers to Proton Therapy Access for Young Adults. Int J Radiat Oncol Biol Phys 2021; 110:1538-1539. [PMID: 34273325 DOI: 10.1016/j.ijrobp.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/02/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Arpit M Chhabra
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - Shaakir Hasan
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - Robert H Press
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - Rafi Kabarriti
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Stanislav Lazarev
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Suzanne Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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Smith GL, Shih YCT, Frank SJ. Financial Toxicity in Head and Neck Cancer Patients Treated With Proton Therapy. Int J Part Ther 2021; 8:366-373. [PMID: 34285962 PMCID: PMC8270089 DOI: 10.14338/ijpt-20-00054.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/29/2020] [Indexed: 11/21/2022] Open
Abstract
Cancer-related financial toxicity impacts head and neck cancer patients and survivors. With increasing use of proton therapy as a curative treatment for head and neck cancer, the multifaceted financial and economic implications of proton therapy-dimensions of "financial toxicity"-need to be addressed. Herein, we identify knowledge gaps and potential solutions related to the problem of financial toxicity. To date, while cost-effectiveness analysis has been used to assess the value of proton therapy for head and neck cancer, it may not fully incorporate empiric comparisons of patients' and survivors' lost productivity and disability after treatment. A cost-of-illness framework for evaluation could address this gap, thereby more comprehensively identifying the value of proton therapy and distinctly incorporating a measurable aspect of financial toxicity in evaluation. Overall, financial toxicity burdens remain understudied in head and neck cancer patients from a patient-centered perspective. Systematic, validated, and accurate measurement of financial toxicity in patients receiving proton therapy is needed, especially relative to conventional photon-based strategies. This will enrich the evidence base for optimal selection and rationale for payer coverage of available treatment options for head and neck cancer patients. In the setting of cancer care delivery, a combination of conducting proactive screening for financial toxicity in patients selected for proton therapy, initiating early financial navigation in vulnerable patients, engaging stakeholders, improving oncology provider team cost communication, expanding policies to promote price transparency, and expanding insurance coverage for proton therapy are critical practices to mitigate financial toxicity in head and neck cancer patients.
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Affiliation(s)
- Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ya-Chen Tina Shih
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Chiang JS, Yu NY, Daniels TB, Liu W, Schild SE, Sio TT. Proton beam radiotherapy for patients with early-stage and advanced lung cancer: a narrative review with contemporary clinical recommendations. J Thorac Dis 2021; 13:1270-1285. [PMID: 33717598 PMCID: PMC7947490 DOI: 10.21037/jtd-20-2501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Although lung cancer rates are decreasing nationally, lung cancer remains the leading cause of cancer related death. Despite advancements in treatment and technology, overall survival (OS) for lung cancer remains poor. Proton beam therapy (PBT) is an advanced radiation therapy (RT) modality for treatment of lung cancer with the potential to achieve dose escalation to tumor while sparing critical structures due to higher target conformality. In early and late-stage non-small cell lung cancer (NSCLC), dosimetric studies demonstrated reduced doses to organs at risk (OARs) such as the lung, spinal cord, and heart, and clinical studies report limited toxicities with PBT, including hypofractionated regimens. In limited-stage SCLC, studies showed that regimens chemo RT including PBT were well tolerated, which may help optimize clinical outcomes. Improved toxicity profiles may be beneficial in post-operative radiotherapy, for which initial dosimetric and clinical data are encouraging. Sparing of OARs may also increase the proportion of patients able to complete reirradiation for recurrent disease. However, there are various challenges of using PBT including a higher financial burden on healthcare and limited data supporting its cost-effectiveness. Further studies are needed to identify subgroups that benefit from PBT based on prognostic factors, and to evaluate PBT combined with immunotherapy, in order to elucidate the benefit that PBT may offer future lung cancer patients.
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Affiliation(s)
- Jennifer S Chiang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Thomas B Daniels
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
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Acute Toxicities and Short-Term Patient Outcomes After Intensity-Modulated Proton Beam Radiation Therapy or Intensity-Modulated Photon Radiation Therapy for Esophageal Carcinoma: A Mayo Clinic Experience. Adv Radiat Oncol 2020; 5:871-879. [PMID: 33083649 PMCID: PMC7557123 DOI: 10.1016/j.adro.2020.04.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/02/2020] [Accepted: 04/07/2020] [Indexed: 11/20/2022] Open
Abstract
Purpose Intensity modulated proton beam radiation therapy (IMPT) has a clinically significant dosimetric advantage over intensity modulated photon radiation therapy (IMRT) for the treatment of patients with esophageal cancer, particularly for sparing the heart and lungs. We compared acute radiation therapy-related toxicities and short-term clinical outcomes of patients with esophageal cancer who received treatment with IMPT or IMRT. Methods and Materials We retrospectively reviewed the electronic health records of consecutive adult patients with esophageal cancer who underwent concurrent chemoradiotherapy with IMPT or IMRT in the definitive or neoadjuvant setting from January 1, 2014, through June 30, 2018, with additional follow-up data collected through January 31, 2019. Treatment-related toxicities were evaluated per the Common Terminology Criteria for Adverse Events, version 4. Survival outcomes were estimated with the Kaplan-Meier method. Results A total of 64 patients (32 per group) were included (median follow-up time: 10 months for IMPT patients vs 14 months for IMRT patients). The most common radiation therapy regimen was 45 Gy in 25 fractions, and 80% of patients received a simultaneous integrated boost to a median cumulative dose of 50 Gy. Similar numbers of IMPT patients (n = 15; 47%) and IMRT patients (n = 18; 56%) underwent surgery (P = .07), with no difference in pathologic complete response rates (IMPT: n = 5; 33% vs IMRT: n = 7; 39%; P = .14). At 1 year, the clinical outcomes also were similar for IMPT and IMRT patients, respectively. Local control was 92% versus 84% (P = .87), locoregional control 92% versus 80% (P = .76), distant metastasis-free survival 87% versus 65% (P = .08), progression-free survival 71% versus 45% (P = .15), and overall survival 74% versus 71% (P = .62). The rate of acute treatment-related grade 3 toxicity was similar between the groups (P = .71). Conclusions In our early experience, IMPT is a safe and effective treatment when administered as part of definitive or trimodality therapy. Longer follow-up is required to evaluate the effectiveness of IMPT.
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Lawell MP, Indelicato DJ, Paulino AC, Hartsell W, Laack NN, Ermoian RP, Perentesis JP, Vatner R, Perkins S, Mangona VS, Hill-Kayser CE, Wolden SL, Kwok Y, Chang JHC, Wilkinson JB, MacEwan I, Chang AL, Eaton BR, Ladra MM, Gallotto SL, Weyman EA, Bajaj BVM, Baliga S, Yeap BY, Berrington de Gonzalez A, Yock TI. An open invitation to join the Pediatric Proton/Photon Consortium Registry to standardize data collection in pediatric radiation oncology. Br J Radiol 2019; 93:20190673. [PMID: 31600082 DOI: 10.1259/bjr.20190673] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE The Pediatric Proton/Photon Consortium Registry (PPCR) is a comprehensive data registry composed of pediatric patients treated with radiation. It was established to expedite outcomes-based research. The attributes which allow the PPCR to be a successful collaboration are reviewed. METHODS AND MATERIALS Current eligibility criteria are radiotherapy patients < 22 years treated at one of the 15 US participating institutions. Detailed health and treatment data are collected about the disease presentation and treatment exposures, and annually thereafter, in REDCap (Research Electronic Data Capture). DICOM (Digital Imaging and Communications in Medicine) imaging and radiation plans are collected through MIM/MIMcloud. An optional patient-reported quality-of-life (PedsQL) study is administered at 10 sites. RESULTS Accrual started October 2012 with 2,775 participants enrolled as of 25 July 2019. Most patients, 62.0%, were treated for central nervous system (CNS) tumors, the most common of which are medulloblastoma (n = 349), ependymoma (n = 309), and glial/astrocytoma tumors (n = 279). The most common non-CNS diagnoses are rhabdomyosarcoma (n = 284), Ewing's sarcoma (n = 153), and neuroblastoma (n = 130). While the majority of participants are US residents, 18.7% come from 36 other countries. Over 685 patients participate in the PedsQL study. CONCLUSIONS The PPCR is a valuable research platform capable of answering countless research questions that will ultimately improve patient care. Centers outside of the USA are invited to participate directly or may engage with the PPCR to align data collection strategies to facilitate large-scale international research. ADVANCES IN KNOWLEDGE For investigators looking to carry out research in a large pediatric oncology cohort or interested in registry work, this paper provides an updated overview of the PPCR.
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Affiliation(s)
- Miranda P Lawell
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Daniel J Indelicato
- Department of Radiation Oncology, University of Florida, Gainesville, United States
| | - Arnold C Paulino
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, United States
| | - William Hartsell
- Department of Radiation Oncology, Northwestern Medicine Chicago Proton Center, Warrenville, United States
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, United States
| | - Ralph P Ermoian
- Department of Radiation Oncology, University of Washington, Seattle, United States
| | - John P Perentesis
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Ralph Vatner
- Department of Radiation Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, United States
| | - Stephanie Perkins
- Department of Radiation Oncology, Washington University, St. Louis, United States
| | - Victor S Mangona
- Department of Radiation Oncology, Texas Center for Proton Therapy, Irving, United States
| | | | - Suzanne L Wolden
- Department of Radiation Oncology, ProCure Proton Therapy Center, New Jersey, United States
| | - Young Kwok
- Department of Radiation Oncology, University of Maryland, College park, United States
| | - John Han-Chih Chang
- Department of Radiation Oncology, Oklahoma Proton Therapy Center, Oklahoma, United States
| | - J Ben Wilkinson
- Department of Radiation Oncology, Provision Healthcare, Knoxville, United States
| | - Iain MacEwan
- Department of Radiation Oncology, California Protons Cancer Therapy Center, San Diego, United States
| | - Andrew L Chang
- Department of Radiation Oncology, California Protons Cancer Therapy Center, San Diego, United States
| | - Bree R Eaton
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, United States
| | - Matthew M Ladra
- Department of Pediatric Radiation Oncology, John Hopkins Kimmel Cancer Center at Sibley Memorial Hospital, Washington, United States
| | - Sara L Gallotto
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Elizabeth A Weyman
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Benjamin V M Bajaj
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Sujith Baliga
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Beow Y Yeap
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
| | - Amy Berrington de Gonzalez
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer InstituteNational Institutes of Health, Bethesda, United States
| | - Torunn I Yock
- Department of Radiation Oncology, Harvard Medical School, Massachusetts General Hospital, Boston, United States
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