Stereotactic body radiotherapy for distant metastases to the head and neck

PURPOSE

To report clinical outcomes for patients with metastatic disease to the head and neck (HN) treated with stereotactic body radiation therapy (SBRT).

METHODS

A retrospective review of patients treated with SBRT to HN sites from 2012 to 2020 was conducted. Treatment indications included the following: oligometastases, oligoprogression, and control a dominant area of progression (DAP). Kaplan-Meier method was used to estimate local control (LC), regional control (RC), overall survival (OS), and progression-free survival (PFS). Univariable (UVA) and multivariable analyses (MVA) were performed. Grade 3-4 acute and late toxicities were reported by the Common Terminology Criteria for Adverse Events v5.0.

RESULTS

Fifty-six patients (58 lesions) were analysed with a median follow-up of 16 months. Primary sites included lung (25.0%), kidney (19.6%), breast (19.6%) and other (35.8%). SBRT indications were as follows: oligometastases (42.9%), oligoprogression (19.6%) and local control of a dominant area of progression (37.5%). Most patients received SBRT to a single neck node (n = 47, 81.0%). Median SBRT dose was 40 Gy (range 25-50 Gy) in five fractions, with a median biologically effective dose (BED10) of 72 Gy (range 37.5-100 Gy). One- and 2-year LC and RC rates were 97.6% and 72.7% as well as 100% and 86.7%, respectively. Median OS was 19.2 months (95% [CI] 14.8-69.4), and median PFS was 7.4 months (95% [CI] 5.2-11.9). The 1-year OS and PFS rates for oligometastases, oligoprogression and DAP were 95.8%, 63.6% and 38.1% (p = 0.0039) as well as 56.5%, 27.3% and 19.1% (p = 0.0004), respectively. On MVA, treatment indication and histology were predictive for OS, while indication and prior systemic therapy were predictive for PFS. Cumulative late grade 3 + toxicity rate was 11.3%, without grade 5 events.

CONCLUSION

The use of SBRT for metastatic disease to the HN provided excellent LC rates with low rates of regional failure and an acceptable toxicity profile, highlighting its utility in these patients. Patients with oligometastatic disease had better OS and PFS than others.

Uncovering the armpit of SBRT: An institutional experience with stereotactic radiation of axillary metastases

Purpose/objectives

The growing use of stereotactic body radiotherapy (SBRT) in metastatic cancer has led to its use in varying anatomic locations. The objective of this study was to review our institutional SBRT experience for axillary metastases (AM), focusing on outcomes and process.

Materials/methods

Patients treated with SBRT to AM from 2014 to 2022 were reviewed. Cumulative incidence functions were used to estimate the incidence of local failure (LF), with death as competing risk. Kaplan-Meier method was used to estimate progression-free (PFS) and overall survival (OS). Univariate regression analysis examined predictors of LF.

Results

We analyzed 37 patients with 39 AM who received SBRT. Patients were predominantly female (60 %) and elderly (median age: 72). Median follow-up was 14.6 months. Common primary cancers included breast (43 %), skin (19 %), and lung (14 %). Treatment indication included oligoprogression (46 %), oligometastases (35 %) and symptomatic progression (19 %). A minority had prior overlapping radiation (18 %) or surgery (11 %). Most had prior systemic therapy (70 %).Significant heterogeneity in planning technique was identified; a minority of patient received 4-D CT scans (46 %), MR-simulation (21 %), or contrast (10 %). Median dose was 40 Gy (interquartile range (IQR): 35-40) in 5 fractions, (BED10 = 72 Gy). Seventeen cases (44 %) utilized a low-dose elective volume to cover remaining axilla.At first assessment, 87 % had partial or complete response, with a single progression. Of symptomatic patients (n = 14), 57 % had complete resolution and 21 % had improvement. One and 2-year LF rate were 16 % and 20 %, respectively. Univariable analysis showed increasing BED reduced risk of LF. Median OS was 21.0 months (95 % [Confidence Interval (CI)] 17.3-not reached) and median PFS was 7.0 months (95 % [CI] 4.3-11.3). Two grade 3 events were identified, and no grade 4/5.

Conclusion

Using SBRT for AM demonstrated low rates of toxicity and LF, and respectable symptom improvement. Variation in treatment delivery has prompted development of an institutional protocol to standardize technique and increase efficiency. Limited followup may limit detection of local failure and late toxicity.

Stereotactic Body Radiotherapy for Extracranial Oligometastatic Disease from Head and Neck Primary Cancers: A Systematic Review and Meta-Analysis

INTRODUCTION

Stereotactic body radiotherapy (SBRT) is increasingly used to treat disease in the oligometastatic (OM) setting due to mounting evidence demonstrating its efficacy and safety. Given the low population representation in prospective studies, we performed a systematic review and meta-analysis of outcomes of HNC patients with extracranial OM disease treated with SBRT.

METHODS

A systematic review was conducted with Cochrane, Medline, and Embase databases queried from inception to August 2022 for studies with extracranial OM HNC treated with stereotactic radiotherapy. Polymetastatic patients (>five lesions), mixed-primary cohorts failing to report HNC separately, lack of treatment to all lesions, nonquantitative endpoints, and other definitive treatments (surgery, conventional radiotherapy, and radioablation) were excluded. The meta-analysis examined the pooled effects of 12- and 24-month local control (LC) per lesion, progression-free survival (PFS), and overall survival (OS). Weighted random-effects were assessed using the DerSimonian and Laird method, with heterogeneity evaluated using the I2 statistic and Cochran Qtest. Forest plots were generated for each endpoint.

RESULTS

Fifteen studies met the inclusion criteria (639 patients, 831 lesions), with twelve eligible for quantitative synthesis with common endpoints and sufficient reporting. Fourteen studies were retrospective, with a single prospective trial. Studies were small, with a median of 32 patients (range: 6-81) and 63 lesions (range: 6-126). The OM definition varied, with a maximum of two to five metastases, mixed synchronous and metachronous lesions, and a few studies including oligoprogressive lesions. The most common site of metastasis was the lung. Radiation was delivered in 1-10 fractions (20-70 Gy). The one-year LC (LC1), reported in 12 studies, was 86.9% (95% confidence interval [CI]: 79.3-91.9%). LC2 was 77.9% (95% CI: 66.4-86.3%), with heterogeneity across studies. PFS was reported in five studies, with a PFS1 of 43.0% (95% CI: 35.0-51.4%) and PFS2 of 23.9% (95% CI: 17.8-31.2%), with homogeneity across studies. OS was analyzed in nine studies, demonstrating an OS1 of 80.1% (95% CI: 74.2-85.0%) and OS2 of 60.7% (95% CI: 51.3-69.4%). Treatment was well tolerated with no reported grade 4 or 5 toxicities. Grade 3 toxicity rates were uniformly below 5% when reported.

CONCLUSIONS

SBRT offers excellent LC and promising OS, with acceptable toxicities in OM HNC. Durable PFS remains rare, highlighting the need for effective local or systemic therapies in this population. Further investigations on concurrent and adjuvant therapies are warranted.

Uncovering the Armpit of Axillary SBRT

PURPOSE/OBJECTIVE(S)

The growing use of stereotactic body radiotherapy (SBRT) in metastatic cancer has led to applications in new and unique anatomic locations, highlighting the importance of effective, safe, reproducible treatment delivery. The objective of this study was to review our institutional SBRT experience for axillary metastases (AM), focusing on outcomes, safety and process.

MATERIALS/METHODS

In this ethics approved single-institution retrospective review, patients treated with SBRT to AM from 2014-2022 had tumor, treatment planning, and dosimetric variables abstracted. Toxicity was assessed per Common Terminology for Adverse Events V5.0. Cumulative incidence functions were used to estimate the incidence of local failure (LF), with death as competing risk. Kaplan-Meier method was used to estimate progression-free (PFS) and overall survival (OS).

RESULTS

We analyzed 37 patients with 39 AM who received SBRT. Patients were predominantly female (60%), Eastern Cooperative Oncology Group performance status 0-1 (62%), and elderly (median age: 72), with a median follow-up of 14.6 months. Common primary sites included breast (n = 16, 43%), skin (n = 7, 19%), and lung (n = 5, 14%). Treatment indication included oligoprogression (n = 18, 46%), oligometastases (n = 14, 36%) and symptomatic progression (n = 7, 18%). A minority had prior overlapping radiation (n = 7, 18%) or regional surgery (n = 4, 11%), while most had prior systemic therapy (n = 26, 70%). Significant heterogeneity in simulation, planning and treatment was identified. Immobilization included 5-point thermoplastic mask (n = 12, 32%), Vacloc (n = 12, 32%) arms-up thorax bag (n = 11, 30%). 4-D CT scans were obtained in 46%, MR simulation in 21%, and intravenous contrast in 10%. Median dose was 40 Gy (interquartile range (IQR): 35-40) in 5 fractions, (BED10 = 72 Gy), over a median of 12 days (IQR: 9-14). Seventeen cases (44%) utilized a low-dose elective volume to cover remaining axilla; 14% used a high dose clinical target volume. Median planning target volume margin was 5mm (range: 3-10mm), and plans were generated with 5 different dose constraint protocols. At first radiographic assessment, 87% had partial or complete response, with a single progression. Of symptomatic patients (n = 14), 57% had complete symptom resolution and 21% had improvement. One and 2-year LF rate were 19% and 31%, respectively. Median OS was 21.0 months (95% [Confidence Interval (CI)] 17.3-not reached) and median PFS was 7.0 months (95% [CI] 4.3-11.3). Acute and late toxicities were uncommon, with two grade 3 events (1 plexopathy in a case with tumor involving brachial plexus, 1 skin ulceration) identified, and no grade 4/5.

CONCLUSION

In this series of AM SBRT, low rates of toxicity, and good rates of LF and symptom improvement were observed. As treatment was delivered with a variety of individual treatment differences, an institutional protocol is under development to standardize technique, optimize efficiency and improve evaluability.

All that Glitters is Not Gold: Examining Cost Effectiveness Analyses in Radiation Oncology

PURPOSE/OBJECTIVE(S)

Cost effectiveness analyses (CEA) provide data for health policy decisions in resource constrained environments. These are important in Radiation Oncology as infrastructure and delivery costs increase and indications expand. The purpose of this study was to systematically review methodologic quality and trends in CEAs involving radiotherapy (RT).

MATERIALS/METHODS

A systematic review was performed on cost effectiveness/utility studies involving RT, querying PubMed and Embase from inception to September 2020. Non-English, reviews, abstracts and cost-only studies were excluded. Independent reviewers screened and abstracted study demographics, economic parameters and methodological details.

RESULTS

After screening 1652 abstracts, 214 met criteria. The first publication was in 1995, and more than half (n = 113, 53%) were published after 2014. Author institutions were from North America (n = 128, 60%), Europe (n = 49, 23%) and Asia (n = 30, 14%) with most reporting in US$ (n = 143, 67%). A majority utilized a decision model (n = 164, 77%), healthcare payer perspective (n = 171, 80%) and a finite time horizon (n = 108, 50%). Publications spanned 96 unique journals, most commonly International Journal of Radiation and Oncological Biology and Physics (n = 35, 16%). Treatment intent was curative in 171 studies. Disease sites included breast (n = 34, 16%), genitourinary (n = 31, 14%), and gastrointestinal (n = 31, 14%). RT was mostly used as primary treatment (n = 144, 67%), followed by adjuvant (n = 70, 33%) and neoadjuvant (n = 10, 5%). Emerging topics included stereotactic RT (n = 45, 21%), immunotherapy (n = 6, 3%), oligometastasis (n = 4, 2%), and heavy particles (n = 23, 11%). RT was compared to other RT (n = 136, 64%), surgery (n = 43, 20%), drugs (n = 14, 7%) and observation (n = 31, 17%). Incomplete reporting was common. Missing elements included analysis perspective (n = 13, 6%), time horizon (n = 38, 18%), discounting of utilities (n = 71, 33%) or costs (n = 54, 25%), and willingness-to-pay threshold (n = 59, 28%). Furthermore, 27 studies did not perform sensitivity analyses, 36 did not evaluate incremental cost-effectiveness ratio and only 60 explicitly utilized recognized reporting guidelines. Conflict of interest statements were found in 63%, with sponsor statements in 59%; 25% were industry sponsors. Outcome parameters were obtained from primary (author institution/trial data) sources in 33%, including randomized trials (RCTs) (n = 20, 9%), retrospective data (n = 20, 9%) and population data (n = 9, 4%). The remainder utilized secondary sources including RCTs (n = 71, 33%), retrospective data (n = 35, 16%) or meta-analyses (n = 11, 5%). Outcomes included quality adjusted life years (n = 158, 74%), life-years (n = 30, 14%) or toxicity (n = 26,12%). 31% utilized author generated utilities; of literature derived only 49% were matched to disease and clinical context.

CONCLUSION

While CEAs are increasingly common in RT, reporting and methodologic rigor must improve. Greater use of published guidelines will improve data quality for decision makers.

Heatmaps to Assess Tumor Motion Probability with MRcine in Head and Neck Cancer

PURPOSE/OBJECTIVE(S)

Intrafraction motion affects tumor position during radiation for head and neck cancers (HNC) and can be assessed using magnetic resonance cine (MR-cine). Heatmaps - visual representation of patient specific temporal tumor location akin to internal target volume (ITV) - were analyzed to demonstrate the variation of population-based motion margins in primary oropharyngeal (OP) and laryngeal/hypopharyngeal (LH) sites with the goal to provide insights towards personalized margins.

MATERIALS/METHODS

MR-cine were performed for LH and OP HNC patients as part of simulation protocol. Images (900-1500 slices) were acquired across 3-5 minutes per patient. Gross target volumes were propagated on T1 contrast sagittal sequence using deformable image registration then adjusted manually. Tumor locations were integrated across all frames and displayed as heatmaps representing location probability. To determine individualized motion, a baseline contour representing average tumor rest position was expanded both isotropically and directionally in 1 mm increments in a novel analysis to define the contribution of each increment on target coverage. To assess directional dependence, displacements from rest position were evaluated in 4 planes from centroid: (A) 12 o'clock (OC) to 6OC (capturing volumetric shift in a portion of superior, posterior and inferior directions), B) 3OC-9OC, C) 6OC-12OC, D) 9OC-3OC. Histograms demonstrating the proportion of scan time the tumor was within expansions were generated, with expansion margins for 25%-95% coverage analyzed by patient. Wilcoxon-rank-sum test was performed to compare motion by site.

RESULTS

Motion was evaluated in 66 patients (LH n = 27, OP n = 39). In LH, a median (med) isometric expansion of 8.5mm to achieve 95% target was required, with large variations observed for minimum (min): 2.8mm and maximum (max):23.5mm. Smaller differences were observed for OP with med of 5.3mm, (min:1.9mm, max:14.6mm). At 75%, 50% and 25% coverage, expansions for LH (med: 4.8 min: 1.9 max: 17.3; med: 3.8 min: 1.2 max: 12.9; med: 3.3, min: 0.6, max: 9.3) were not significantly different than OP (med: 3.8, min: 1.7, max: 10.9; med: 3.1 min: 1.3, max: 9.4; med: 2.1, min: 0.7, max: 8.4), suggesting larger but infrequent shifts in LH. Directional tumor displacement varied widely (Table 1), and by site and points describing the need for personalized margins.

CONCLUSION

Current literature as well as the analysis in this study indicate a wide range of motion - both in magnitude and duty cycle - between and within HN sub-sites not captured on CT simulation. Moving forward, motion based heatmaps based on MR-cine may serve as visualization tool for ITV contouring or to generate personalized motion margins.

Outcomes for oligometastatic head and neck cancer treated with stereotactic body radiotherapy: Results from an international multi-institutional consortium

BACKGROUND

We report the results of an international multi-institutional cohort of oligometastatic (OMD) head and neck cancer (HNC) patients treated with SBRT.

METHODS

Patients with OMD HNC (≤5 metastases) treated with SBRT between 2008 and 2016 at six institutions were included. Treated metastasis control (TMC), progression-free survival (PFS), and overall survival (OS) were analyzed by multivariable analysis (MVA).

RESULTS

Forty-two patients with 84 HNC oligometastases were analyzed. The TMC rate at 1 and 2 years were 80% and 66%, with a median time to recurrence of 10.1 months. The median PFS and OS were 4.7 and 23.3 months. MVA identified a PTV point maximum (BED)10 > 100 Gy as a predictor of improved TMC (HR = 0.31, p = 0.034), and a cumulative PTV > 48 cc as having worse PFS (HR = 2.99, p < 0.001).

CONCLUSION

Favorable TMC and OS was observed in OMD HNCs treated with SBRT.

Surgeon, Pathologist and Pathology Technician Effects on Nodal Yield after a Neck Dissection

PURPOSE/OBJECTIVE(S)

A minimum nodal count of 18 lymph nodes has been associated with improved survival after neck dissection and has been suggested as a head and neck cancer quality metric. Despite its critical importance, factors affecting nodal yield are poorly studied. In particular, the relative contribution of surgeons, pathologists, and pathology technicians has not been evaluated. The purpose of this study was to understand both patient and provider related factors that affect nodal yield after neck dissection for patients with oral cavity squamous cell carcinoma (OCSCC).

MATERIALS/METHODS

This retrospective cohort study involved review of all adult patients with OCSCC undergoing primary neck dissection between 2000-2020 at an academic medical center. The outcome of interest was a continuous variable denoting the number of nodes removed per side during neck surgery. Surgeon and pathologist year of experience were calculated and represented in quartiles. A multilevel multivariable linear regression model was used to assess the association of surgeon/pathologist experience quartiles with nodal yield, controlling for patient age, comorbidity index, previous cancer, tumor grade, and clinical nodal status.

RESULTS

The 508 patients included in our cohort were treated by 5 surgeons and 6 pathologists and involved 44 pathology technicians. Of these patients, 310 (61.0%) were male with a mean age of 63. Oral tongue primary tumors were 46.7% of the cohort, while 64.4% of patients had cT1-T2 tumors, and 65.2% were cN0. The mean nodal yield was 24.2 nodes. The ANOVA analysis revealed significant difference in mean nodal yield by surgeon (p-value = 0.03), pathologist (p-value<0.01) and pathology technician (p-value = 0.037). After accounting for patient-level characteristics and patient clustering by surgeon, increasing surgeon experience was found to be significantly associated with a higher nodal yield (joint significance of surgeon years of experience quartiles < 0.01). Specifically, when compared to surgeons with the least experience (1st quartile), those whose years of experience fell into the 2nd, 3rd, and 4th quartile removed 4.69 (95% CI: 0.97 to 7.92), 4.47 (95% CI: 0.33 to 7.87), and 7.37 (95% CI: 0.73 to 11.27) more lymph nodes. Meanwhile, there was no association between pathologist experience and nodal yield (joint significance of pathologist years of experience quartiles = 0.27). Additionally, previous cancer diagnosis and cN0 disease were significantly associated with lower nodal yield (all p-values = 0.02).

CONCLUSION

This study demonstrates an independent association between increasing surgeon experience and higher nodal yields. Importantly, it also demonstrates that pathologists and pathology technicians contribute to the variation in nodal yield, and their contribution should not be overlooked in the implementation of a lymph node yield-based quality metric.

Real-World Analysis of Durvalumab after Chemoradiation in Stage III Non-Small-Cell Lung Cancer

The 2017 PACIFIC trial heralded the incorporation of routine adjuvant durvalumab following curative-intent chemoradiation for stage III non-small-cell lung cancer (NSCLC). However, carefully selected clinical trial populations can differ significantly from real-world populations, which can have implications on treatment toxicities and outcomes, making it difficult to accurately counsel patients. Consequently, we performed a real-world, retrospective analysis of outcomes and toxicities in 118 patients with stage III NSCLC treated with durvalumab after platinum-based chemoradiotherapy. The data were collected from patients who underwent treatment at a single, tertiary-level Canadian cancer centre from May 2018 to October 2020. The variables collected included patient demographics, treatment specifics, progression-free survival, overall survival, and immune-related adverse events (IRAE) from durvalumab. Descriptive statistics were used for toxicity analysis, and progression-free survival and overall survival estimates were calculated using the Kaplan-Meier method. The statistical analyses indicated a 64.4% (n = 76) toxicity rate, with a 21% (n = 25) toxicity rate of grade 3+ IRAEs. The most common documented IRAEs were pneumonitis (n = 44; 40%), followed by rash (n = 20; 18%) and thyroid dysfunction (n = 17; 15%). FEV1 and DLCO were not found to be associated predictors of pneumonitis toxicity. The median PFS and OS were estimated to be >1.7 years and >2.7 years, respectively.

Stereotactic or Conventional Radiation for Early-Stage Non-small Cell Lung Cancer: A Systematic Review and Meta-Analysis

Stereotactic ablative radiotherapy (SABR) has been increasingly used for the treatment of inoperable early-stage non-small cell lung cancer (NSCLC). It has been shown to provide promising local control (LC) and toxicity in prospective trials. However, randomized trials have shown conflicting results in terms of whether SABR confers an overall survival (OS) advantage compared to conventionally fractionated radiotherapy (CFRT). A systematic review of Medline and Embase (inception to December 2020) was performed on early-stage NSCLC patients randomized to SABR versus CFRT. Two independent reviewers screened titles, abstracts, and manuscripts. A random-effects model was used to estimate treatment effects. Toxicity outcomes were compared by the Cochran-Mantel-Haenszel test. Individual patient data were digitally approximated and pooled as secondary analysis. The literature search identified 1494 studies, and 16 studies were included for full-text review. Two randomized trials were identified, including a total of 203 patients, of which 115 (57%) received SABR, and 88 (43%) received CFRT. The weighted mean age was 74 years and 48% of patients were male. Most patients had T1 cancers (67%). Stereotactic ablative radiotherapy was not associated with a significant improvement in OS (hazard ratio: 0.84; 95% confidence interval (CI) 0.34-2.08, p=0.71). There was no significant difference in LC between SABR and CFRT (relative risk: 0.59; CI 0.28-1.23, p=0.16). Of the commonly reported adverse events, one grade 4 toxicity of dyspnea was reported for SABR, while all others i.e., grade 3 or higher toxicities were similar. Stereotactic ablative radiotherapy demonstrated less esophagitis, dyspnea, and skin reaction of any grade. Despite widespread adoption and extensive single-arm prospective and retrospective studies suggesting its benefit, this systematic review and meta-analysis of randomized trials fail to confirm improvements in LC, OS, and toxicity profile of SABR over CFRT in early NSCLC. This small study is likely underpowered to detect clinically significant differences.

Mistaken Metastasis: Radiation-Induced Rib Fracture Mimicking Malignancy on Computerized Tomography Case Report

A 62-year-old woman with a 40-pack-year smoking history and severe chronic obstructive pulmonary disease with early-stage right upper lobe non-small cell lung cancer (NSCLC) was treated with stereotactic ablative radiotherapy (SABR). Two years after treatment, a surveillance computerized tomography scan showed lesions of the posterior 4th and 5th ribs including expansion of the medulla that was unusual and of concern for possible malignant infiltration. A follow-up magnetic resonance imaging (MRI) scan revealed these lesions to be healing fractures post-radiotherapy. Although generally well tolerated, SABR is known to produce inflammatory and fibrotic changes both in-field and in organs at risk, and rib fractures are a well-established adverse event. MRI has high diagnostic accuracy and sensitivity for rib fractures and was able to rule out malignant spread. This case demonstrates the need for regular follow-up following SABR for early-stage NSCLC, as well as the challenge of interpreting indeterminate post-SABR radiography findings.

Medical Assistance in Dying in Oncology Patients: A Canadian Academic Hospital's Experience

BACKGROUND

Medical assistance in dying (MAID) was legislatively enacted in Canada in June 2016. Most studies of patients who received MAID grouped patients with cancer and non-cancer diagnoses. Our goal was to analyze the characteristics of oncology patients who received MAID in a Canadian tertiary care hospital.

METHODS

We conducted a retrospective review of all patients with cancer who received MAID between June 2016 and July 2020 at London Health Sciences Centre (LHSC). We describe patients' demographics, oncologic characteristics, symptoms, treatments, and palliative care involvement.

RESULTS

Ninety-two oncology patients received MAID. The median age was 72. The leading cancer diagnoses among these patients were lung, colorectal, and pancreatic. At the time of MAID request, 68% of patients had metastatic disease. Most patients (90%) had ECOG performance status of 3 or 4 before receiving MAID. Ninety-nine percent of patients had distressing symptoms at time of MAID request, most commonly pain. One-third of patients with metastatic or recurrent cancer received early palliative care. The median time interval between the first MAID assessment and receipt of MAID was 7 days.

INTERPRETATION

Most oncology patients who received MAID at LHSC had poor performance status and almost all had distressing symptoms. The median time interval between first MAID assessment and receipt of MAID was shorter than expected. Only one-third of patients with metastatic or recurrent cancer received early palliative care. Improving access to early palliative care is a priority in patients with advanced cancer.

STUDY REGISTRATION

We received research approval from Western University's Research Ethics Board (REB) with project ID number 115367, and from Lawson's Research Database Application (ReDA) with study ID number 9579.

Evaluating the Oncology Research Internship (ORIoN) during the COVID-19 Pandemic: A Comparison of Virtual and In-Person Iterations

Purpose/Objective(s)

The Oncology Research Internship (ORIoN), a novel resident-supervised initiative for medical students (MS), was first established in 2018 and found to be mutually beneficial to both residents and MS. The COVID-19 pandemic halted many scholarly programs, including ORIoN, which relied heavily on mentorship through in-person interactions. We report results of the first virtual program, adapted to the COVID-19 pandemic, and compare participant feedback to previous in-person iterations.

Materials/Methods

ORIoN application details were published online and emailed to first- and second-year MS. A panel of 3 physicians reviewed and scored applications independently. Successful MS applicants were paired with volunteer resident supervisors; each pair supervised by a staff oncologist. Compared to previous years, all meetings, correspondences and presentations between MS, residents, and supervising oncologists were conducted exclusively remotely. Only chart reviews were conducted on-site by MS. At the program's conclusion, each MS delivered a live virtual oral presentation of their completed case report, previously done in-person. Resident and MS participants completed questionnaires pre-/post program. Responses were collected on a 5-point Likert scale with open-ended free-text responses. Survey results from this virtual and the previous in-person programs were compared.

Results

Of 54 applications (previously 32 in 2018), 9 MS (three first-year, six second-year) were accepted and assigned to 9 volunteer residents (6 radiation oncology, 2 medical oncology, 1 pathology). To date, 9 manuscripts have been completed with 2 submitted for publication (1 published, 1 under review). Survey response rates were 100% (9/9) for residents and 89% (8/9) for MS. In the post-program surveys comparing the virtual and prior in-person programs, 87.5% (7/8) MS felt comfortable completing a clinical research project (22% strongly agree (SA), 62.5% agree (A), previously 25% and 75% respectively) and 100% (8/8) felt comfortable writing a case report (50% SA, 50% A, previously 75%, 25% respectively). All MS felt comfortable giving an oral research presentation (37.5% SA, 62.5% A) and teaching another MS to complete a case report (37.5% SA, 50% A). Similar to the in-person program, MS unanimously agreed that ORIoN was a beneficial experience (100%) and felt the program contributed to their career goals (100%, previously 88%). Post-program, all residents felt comfortable as a supervisor (67% SA, 22% A, previously 33%, 67% respectively), reviewing manuscripts (56% SA, 33% A, previously 33%, 50% respectively) and providing constructive feedback to trainees (67% SA, 33% A, previously 17%, 67% respectively).

Conclusion

Compared to the previous in-person program, the virtual ORIoN retained strongly favorable ratings from MS and residents alike. These findings support adapting similar scholarly and mentorship programs to a virtual setting when in-person interactions are not feasible.

Evaluating The Oncology Research Internship (Orion) During the Covid-19 Pandemic: A Comparison of Virtual and In-Person Iterations

Background

The Oncology Research Internship (ORIoN), a novel resident-supervised initiative for medical students (MS), was first established in 2018 and found to be beneficial to both residents and MS. The COVID-19 pandemic halted many scholarly programs which relied heavily on mentorship through in-person interactions. We report results of the first virtual program, adapted to the COVID-19 pandemic, and compare participant feedback to previous in-person iterations.

Methods

ORIoN applications were open to first- and second-year MS. A panel of 3 physicians reviewed and scored applications. Successful MS applicants were paired with resident supervisors; each pair supervised by a staff oncologist. Compared to previous years, all meetings, correspondences and presentations between MS, residents, and supervising oncologists were conducted exclusively remotely. At the program's conclusion, each MS delivered a live virtual oral presentation of their completed case report, previously done in-person. Resident and MS participants completed questionnaires pre-/post program. Responses were collected on a 5-point Likert scale. Survey results from this virtual and the previous in-person programs were compared.

Results

Of 54 applications (previously 32 in 2018), 9 MS (three first-year, six second-year) were accepted and assigned to 9 volunteer residents (6 radiation oncology, 2 medical oncology, 1 pathology). To date, 9 manuscripts have been completed with 2 submitted for publication (1 published, 1 under review). Survey response rates were 100% (9/9) for residents and 89% (8/9) for MS. In the post-program surveys comparing the virtual and prior in-person programs, 87.5% (7/8) MS felt comfortable completing a clinical research project (22% strongly agree (SA), 62.5% agree (A), previously 25% and 75% respectively) and 100% (8/8) felt comfortable writing a case report (50% SA, 50% A, previously 75%, 25% respectively). All MS felt comfortable giving an oral research presentation (37.5% SA, 62.5% A) and teaching another MS to complete a case report (37.5% SA, 50% A). Similar to the in-person program, MS unanimously agreed that ORIoN was a beneficial experience (100%) and felt the program contributed to their career goals (100%, previously 88%). Post-program, all residents felt comfortable as a supervisor (67% SA, 22% A, previously 33%, 67% respectively), reviewing manuscripts (56% SA, 33% A, previously 33%, 50% respectively) and providing constructive feedback to trainees (67% SA, 33% A, previously 17%, 67% respectively).

Discussion

Compared to the in-person program, the virtual ORIoN retained strongly favourable ratings from MS and residents alike. These findings support adapting similar programs to a virtual setting when in-person interactions are not feasible.

Recurrence-free survival following aggressive multimodal treatment of an isolated recurrence of adrenocortical carcinoma

A 43-year old woman demonstrated an intra-abdominal drop metastasis 6 years after initial presentation of stage-III adrenocortical carcinoma (ACC), previously treated with resection, adjuvant radiation and mitotane therapy. This recurrence was managed aggressively with complete excision, adjuvant radiation and mitotane. Imaging at 3.25-year follow-up showed no evidence of recurrence, a remarkable response given ACC’s poor prognosis and high recurrence rates. Management of oligometastatic ACC remains unclear and intra-abdominal drop metastases are particularly rare in ACC; both require further documentation. Aggressive management with adjuvant radiation and mitotane therapy may represent an effective and well-tolerated approach for improving local control for recurrent ACC, including drop metastases. Further research is required to codify potential benefits.

Research Productivity of Canadian Radiation Oncology Residents: A Time-Trend Analysis

(1) Background: Research productivity is a mandatory component of Canadian radiation oncology (RO) resident training. To our knowledge, Canadian RO resident research publication productivity has not previously been analysed. (2) Methods: We compiled a 12-year database of RO residents in Canadian training programs who completed residency between June 2005 and June 2016. Resident names and dates of training were abstracted from provincial databases and department websites and were used to abstract data from PubMed, including training program, publication year, journal, type of research, topic and authorship position. Residents were divided into four time periods and the linear trend test evaluated publication rates over time. Univariable and multivariable logistic regression analyses were performed to identify authorship predictors. (3) Results: 227 RO residents representing 363 publications were identified. The majority were first-author publications (56%) and original research (77%). Overall, 82% of first-author, and 80% of any-author articles were published in resident year 4 or higher. Mean number of publications for first-author and any-author positions increased significantly over time (p = 0.016 and p = 0.039, respectively). After adjusting for gender and time period, large institutions (> 3 residents per year) trended toward associations with more first-author publications (odds ratio (OR): 2.44; p = 0.066) and more any-author publications (OR: 2.49; p = 0.052). No significant differences were observed by gender. (4) Conclusions: Canadian RO resident publication productivity nearly doubled over a 12-year period. The majority of publications are released in the last 2 years of residency, and larger residency programs may be associated with more publications. These findings serve as a baseline as programs transition to Competency Based Medical Education (CBME).

Systematic review of patient reported quality of life following stereotactic ablative radiotherapy for primary and metastatic liver cancer

Background

Stereotactic ablative radiotherapy (SABR) is a safe and effective modality in patients with liver cancer who are ineligible for other local therapies. However SABR is not current standard of practice and requires further validation. Patient reported quality of life (QOL) is key to this validation, yet no systematic reviews to date have been performed to analyse QOL following liver SABR. QOL is a critical part of therapy evaluation, particularly in disease states with short life expectancy. The purpose of this study was to conduct a systematic review of QOL outcomes for liver SABR.

Materials and methods

MEDLINE and EMBASE databases from 1996 to October 2015 were queried to obtain English language studies analysing QOL following liver SABR. Included studies described patient-reported QOL as either a primary or secondary endpoint, and analysed QOL change over time. Studies were screened, and relevant data were abstracted and analysed.

Results

Of 2181 initially screened studies, 5 met all inclusion criteria. Extracted studies included a total of 392 eligible patients with hepatocellular carcinoma, liver metastases and intrahepatic cholangiocarcinoma. Four studies were prospective in design, and only one study was a conference abstract. Extracted studies were heterogeneous in dose prescription used (11–70 Gy in 3–30 fractions), in addition to reported QOL metrics (EORTC QLQ C-15 PAL,/C-30/LM-21, EuroQol 5D, FACT-Hep, FLIC) and final endpoints (range 6 weeks to 12 months). Despite this there were few statistically significant declines in QOL scores following SABR. Four studies demonstrated transient fatigue in the first 1–4 weeks, while 2 studies showed transient worsening of appetite at 1 month. In all but one instance (loss of appetite at 6 weeks), levels returned to insignificant difference baseline by the final endpoints. All studies showed no significant QOL decline in any domain at their respective endpoints. In studies with overlapping QOL tools, estimates of 3-month post SABR global QOL were similar.

Conclusion

Results of this systematic review demonstrate well-preserved post liver SABR QOL. These findings strengthen the argument for liver SABR, and should aim to support future comparative effectiveness trials with other local modalities including surgery, chemoembolization and radiofrequency ablation, with a focus on QOL outcomes as an important endpoint.

Electronic supplementary material

The online version of this article (doi:10.1186/s13014-017-0818-8) contains supplementary material, which is available to authorized users.

Distress in Caregivers Accompanying Patients to an Emergency Department: A Scoping Review

BACKGROUND

Despite substantial research interest in caregiver distress in the emergency department (ED), no recent review of the literature exists.

OBJECTIVE

Our aims were to map primary research on caregiver distress in the ED, synthesize key concepts underpinning the literature, identify gaps, and provide guidance for future work.

METHODS

We used a five-stage scoping review with tandem screening and data extraction.

RESULTS

Of 2121 records, 29 studies were included. The majority were small, conducted in North America or Europe, and published after 2000. Numerous methodologies and definitions of distress were represented. The majority involved children, with just five studies restricted to adults. Many involved higher-acuity scenarios, such as resuscitations or invasive procedures. The most common research topic was anxiety of parents of children undergoing procedures. Effects of witnessed resuscitation were also addressed. Parental presence may reduce anxiety during venipuncture, while only waiting room music reduced anxiety in parents of children not undergoing a procedure. No study explored interventions to reduce distress in caregivers of adults. While heterogeneity precluded evidence-based recommendations, clinically relevant observations emerged, including that anxiety can be worsened if a caregiver believes their patient has been forgotten; that parents are sensitive about being perceived as neglectful; and that sympathy and confidence ease distress, as does sensitivity toward end-of-life issues. Several studies suggested that negative staff behaviors affect caregiver anxiety.

CONCLUSIONS

Future studies should use validated measures of distress; include larger samples; and capture adult, geriatric, and rural populations. A focused systematic review might yield evidence-based guidance for clinicians.

Relationship between family caregiver burden and physical frailty in older adults without dementia: a systematic review

BACKGROUND

Physical frailty is a prevalent syndrome in older adults that increases vulnerability for a range of adverse outcomes including increased dependency and death. Caregivers of older adults experience significant physical, emotional, and financial burden, which is associated with poor physical and mental health. While it is known that care recipients' dementia is associated with burden, the literature regarding the impact of physical frailty on burden has yet to be synthesized. We conducted a systematic review to assess the state of the evidence regarding the relationship between these two prominent concepts in the geriatric literature.

METHOD

We used a structured search of databases to identify original English-language articles. Two researchers screened the titles and abstracts of all 1202 retrieved studies and then full-text versions of 265 retained studies. Screening was based on a priori inclusion criteria, which included discussion of physical frailty, caregiver burden, and a population of community-dwelling older adults without dementia. Nine included papers underwent data abstraction and critical appraisal using the Cochrane Risk of Bias Tool or the Newcastle-Ottawa Scale (for randomized controlled trials or cross-sectional studies, respectively). Heterogeneity of the included studies precluded meta-analysis.

RESULTS

Five publications had the same author and drew from the same population; these were treated as a single study. Three of our studies were of limited value since they did not include a validated measure of frailty. While caregivers of frail older adults experience burden, the scarce available evidence and lack of studies comparing this population with normative values does not allow conclusions to be drawn about the strength or nature of the relationship. Judging from excluded studies, the term "frailty" is often used without reference to a clear definition or is treated as synonymous with functional impairment or advanced age.

CONCLUSIONS

Our review suggests that caregivers of frail older adults experience burden and that the degree of burden may differ from that of other caregiver populations. The limited evidence does not allow conclusions to be drawn or to inform clinical practice. Further research is needed, given the salience of physical frailty and burden.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015019198.