MR-guided radiotherapy for prostate cancer: state of the art and future perspectives

Advances in radiotherapy technology have increased precision of treatment delivery and in some tumour types, improved cure rates and decreased side effects. A new generation of radiotherapy machines, hybrids of an MRI scanner and a linear accelerator, has the potential to further transform the practice of radiation therapy in some cancers. Facilitating superior image quality and the ability to change the dose distribution online on a daily basis (termed "daily adaptive replanning"), MRI-guided radiotherapy machines allow for new possibilities including increasing dose, for hard to treat cancers, and more selective sparing of healthy tissues, where toxicity reduction is the key priority.These machines have already been used to treat most types of cancer, although experience is still in its infancy. This review summarises the potential and current evidence for MRI-guided radiotherapy, with a predominant focus on prostate cancer. Current advantages and disadvantages are discussed including a realistic appraisal of the likely potential to improve patient outcomes. In addition, horizon scanning for near-term possibilities for research and development will hopefully delineate the potential role for this technology over the next decade.

A Century of Fractionated Radiotherapy: How Mathematical Oncology Can Break the Rules

Radiotherapy is involved in 50% of all cancer treatments and 40% of cancer cures. Most of these treatments are delivered in fractions of equal doses of radiation (Fractional Equivalent Dosing (FED)) in days to weeks. This treatment paradigm has remained unchanged in the past century and does not account for the development of radioresistance during treatment. Even if under-optimized, deviating from a century of successful therapy delivered in FED can be difficult. One way of exploring the infinite space of fraction size and scheduling to identify optimal fractionation schedules is through mathematical oncology simulations that allow for in silico evaluation. This review article explores the evidence that current fractionation promotes the development of radioresistance, summarizes mathematical solutions to account for radioresistance, both in the curative and non-curative setting, and reviews current clinical data investigating non-FED fractionated radiotherapy.

Magnetic resonance linear accelerator technology and adaptive radiation therapy: An overview for clinicians

Radiation therapy (RT) continues to play an important role in the treatment of cancer. Adaptive RT (ART) is a novel method through which RT treatments are evolving. With the ART approach, computed tomography or magnetic resonance (MR) images are obtained as part of the treatment delivery process. This enables the adaptation of the irradiated volume to account for changes in organ and/or tumor position, movement, size, or shape that may occur over the course of treatment. The advantages and challenges of ART maybe somewhat abstract to oncologists and clinicians outside of the specialty of radiation oncology. ART is positioned to affect many different types of cancer. There is a wide spectrum of hypothesized benefits, from small toxicity improvements to meaningful gains in overall survival. The use and application of this novel technology should be understood by the oncologic community at large, such that it can be appropriately contextualized within the landscape of cancer therapies. Likewise, the need to test these advances is pressing. MR-guided ART (MRgART) is an emerging, extended modality of ART that expands upon and further advances the capabilities of ART. MRgART presents unique opportunities to iteratively improve adaptive image guidance. However, although the MRgART adaptive process advances ART to previously unattained levels, it can be more expensive, time-consuming, and complex. In this review, the authors present an overview for clinicians describing the process of ART and specifically MRgART.

Contemporary radiotherapy: present and future

Oncology care is increasingly a multidisciplinary endeavour, and radiation therapy continues to have a key role across the disease spectrum in nearly every cancer. However, the field of radiation oncology is still one of the most poorly understood of the cancer disciplines. In this Review, we attempt to summarise and contextualise developments within the field of radiation oncology for the non-radiation oncologist. We discuss advancements in treatment technologies and imaging, followed by an overview of the interplay with advancements in systemic therapy and surgical techniques. Finally, we review new frontiers in radiation oncology, including advances within the metastatic disease continuum, reirradiation, and emerging types of radiation therapy.

Optimal Radiotherapy Dose in Anal Cancer: Trends in Prescription Dose and Association with Survival

PURPOSE

Definitive chemoradiotherapy represents a standard of care treatment for localized anal cancer. National Comprehensive Cancer Network guidelines recommend radiotherapy (RT) doses of ≥ 45 Gy and escalation to 50.4-59 Gy for advanced disease. Per RTOG 0529, 50.4 Gy was prescribed for early-stage disease (cT1-2N0), and 54 Gy for locally advanced cancers (cT3-T4 and/or node positive). We assessed patterns of care and overall survival (OS) with respect to the RT dose.

METHODS

The National Cancer Database identified patients with non-metastatic anal squamous cell carcinoma from 2004 to 2015 treated with chemoradiotherapy. Patients were stratified by RT dose: 40-< 45, 45-< 50, 50-54, and > 54-60 Gy. Crude and adjusted hazard ratios (HR) were computed using Cox regression modeling.

RESULTS

A total of 10,524 patients were identified with a median follow-up of 40.7 months. The most commonly prescribed RT dose was 54 Gy. On multivariate analysis, RT doses of 40-< 45 Gy were associated with worse OS vs. 50-54 Gy (HR 1.68 [1.40-2.03], P < 0.0001). There was no significant difference in OS for patients who received 45-< 50 or > 54-60 Gy compared with 50-54 Gy. For early-stage disease, there was no significant association between RT dose and OS. For locally advanced disease, 45-< 54 Gy was associated with worse survival vs. 54 Gy (HR 1.18 [1.04-1.34], P = 0.009), but no significant difference was detected comparing > 54-60 Gy vs. 54 Gy (HR 1.08 [0.97-1.22], P = 0.166).

CONCLUSIONS

For patients with localized anal cancer, RT doses of ≥ 45 Gy were associated with improved OS. For locally advanced disease, 54 Gy but not > 54 Gy was associated with improved OS.

Moving Forward in the Next Decade: Radiation Oncology Sciences for Patient-Centered Cancer Care

In a time of rapid advances in science and technology, the opportunities for radiation oncology are undergoing transformational change. The linkage between and understanding of the physical dose and induced biological perturbations are opening entirely new areas of application. The ability to define anatomic extent of disease and the elucidation of the biology of metastases has brought a key role for radiation oncology for treating metastatic disease. That radiation can stimulate and suppress subpopulations of the immune response makes radiation a key participant in cancer immunotherapy. Targeted radiopharmaceutical therapy delivers radiation systemically with radionuclides and carrier molecules selected for their physical, chemical, and biochemical properties. Radiation oncology usage of “big data” and machine learning and artificial intelligence adds the opportunity to markedly change the workflow for clinical practice while physically targeting and adapting radiation fields in real time. Future precision targeting requires multidimensional understanding of the imaging, underlying biology, and anatomical relationship among tissues for radiation as spatial and temporal “focused biology.” Other means of energy delivery are available as are agents that can be activated by radiation with increasing ability to target treatments. With broad applicability of radiation in cancer treatment, radiation therapy is a necessity for effective cancer care, opening a career path for global health serving the medically underserved in geographically isolated populations as a substantial societal contribution addressing health disparities. Understanding risk and mitigation of radiation injury make it an important discipline for and beyond cancer care including energy policy, space exploration, national security, and global partnerships.

No Longer a Match: Trends in Radiation Oncology National Resident Matching Program (NRMP) Data from 2010-2020 and Comparison Across Specialties

PURPOSE

To report trends in the number and types of applicants and matched trainees to radiation oncology in comparison to other specialties participating in the National Resident Matching Program (NRMP) between 2010 and 2020.

METHODS AND MATERIALS

Data from the NRMP and Electronic Residency Application System (ERAS) were obtained for 18 medical specialties between 2010 and 2020. We assessed the numbers and types of applicants and matched trainees relative to available positions in the NRMP and Supplemental Offer and Acceptance Program (SOAP).

RESULTS

In the 2020 NRMP, 122 US MD senior graduates preferentially ranked radiation oncology, a significant decrease from a median of 187 between 2010 to 2019 (interquartile range [IQR], 170-192; P < .001). Across all 18 specialties, radiation oncology experienced the greatest declines in the 2020 NRMP cycle relative to 2010 to 2019, in both the number of ERAS applicants from the United States and Canada (-31%) and the percentage of positions filled by US MD or DO senior graduates (-28%). Of 189 available positions, 81% (n = 154) filled in the NRMP prior to the SOAP, of which 65% (n = 122) were "matched" by US MD senior graduates who preferentially ranked radiation oncology as their top choice of specialty, representing a significant decrease from a median of 92% between 2010 to 2019 (IQR, 88%-94%; P = .002). The percentages of radiation oncology programs and positions unfilled in the NRMP prior to the SOAP were significantly increased in 2020 compared with 2010 to 2019 (programs: 29% vs 8% [IQR, 5%-8%; P < .001]; positions: 19% vs 4% [IQR, 2%-4%; P <.001]). Despite >99% (n = 127 of 128) of US MD or DO senior applicants preferring radiation oncology successfully matching to a radiation oncology position in the 2020 NRMP, 16 of 35 remaining unfilled positions were filled via the SOAP. Radiation oncology was the top user of the SOAP across all specialties participating in the 2020 NRMP, filling 15% of total positions versus a median of 0.9% (IQR, 0.3%-2.3%; P <.001).

CONCLUSIONS

The supply of radiation oncology residency positions now far exceeds demand by graduating US medical students. Efforts to nullify a market correction revealed by medical student behavior via continued reliance on the SOAP to fill historical levels of training positions may not be in the best of interest of trainees, individual programs, or the specialty as a whole.

Catching the Wave: Quantifying the Impact of COVID on Radiotherapy Delivery

The novel coronavirus of 2019 has had a broad impact of the delivery of healthcare, including cancer care. We chose to quantify the impact in the radiation oncology department of the largest academic center in the hardest hit city in Canada. With the approval of our ethics review board, data on each patient treated from March 13, 2020 to August 10, 2020 were compared to patients treated during the same period in 2019. We compared the case mix, delay from treatment decision to treatment start, and number of fractions per patient. We reviewed prospectively collected information regarding deviations from our usual practice. During the pandemic the caseload was reduced by 12%; this was more pronounced in prostate and CNS tumors. The average number of fractions per patient was reduced from 12.3 to 10.9. This reduction was most marked in prostate, breast, gastro-intestinal, and palliative cases. When physicians were questioned, they reported that 17% of treatment plans deviated from their usual practice because of the pandemic. The most common deviations were related to changes in department policies (77%) vs. patient-specific deviations (20%) or changes requested by the patient (3%). Rare deviations were due to patients contracting COVID-19 (2 patients). At its worse, the wait list contained 27% of patients who had a delay to radiotherapy of more than 28 days. However, the average wait time increased little (19.6 days vs. 18.2 days) as more pressing cases were prioritized. In an unprecedented health crisis, our radiation oncology department was able to reduce resource utilization, notably by decreasing the number of fractions per patient. It will be important to follow these patients' health outcomes for insight into these practices. More quantitative tools to simulate and plan future practice changes in response to resource constraints will be implemented.

A Systematic Review of Contouring Guidelines in Radiation Oncology: Analysis of Frequency, Methodology, and Delivery of Consensus Recommendations

PURPOSE

Clinical trials have described variation in radiation therapy plan quality, of which contour delineation is a key component, and linked this to inferior patient outcomes. In response, consensus guidelines have been developed to standardize contour delineation. This investigation assesses trends in contouring guidelines and examines the methodologies used to generate and deliver recommendations.

METHODS AND MATERIALS

We conducted a literature search for contouring guidelines published after 1995. Of 11,124 citations, 332 were identified for full-text review to determine inclusion. We abstracted articles for the intent of the consensus process, key elements of the methodology, and mode of information delivery. A Fisher exact test was used to identify elements that differed among the guidelines generated for clinical trials and routine care.

RESULTS

Overall, 142 guidelines were included, of which 16 (11%) were developed for a clinical trial. There was an increase in guideline publication over time (0 from 1995-1999 vs 65 from 2015- 2019; P = .03), particularly among recommendations for stereotactic radiation and brachytherapy. The most common disease sites were head and neck (24%), gastrointestinal (12%), and gynecologic (12%). Methods used to develop recommendations included literature review (50%) and image-based methods (45%). Panels included a median of 10 physicians (interquartile range, 7-16); 70% of panels represented multidisciplinary expertise. Guidelines developed for a clinical trial were more likely to include an image-based approach, with quantitative analysis of contours submitted by the panel members and to publish a full set of image-based recommendations (P < .005).

CONCLUSIONS

This review highlights an increase in consensus contouring recommendations over time. Guidelines focus on disease sites, such as head and neck, with evidence supporting a correlation between treatment planning and patient outcomes, although variation exists in the approach to the consensus process. Elements that may improve guideline acceptance (ie, image-based consensus contour analysis) and usability (ie, inclusion of a full image set) are more common in guidelines developed for clinical trials.

I Can't Breathe: The Continued Disproportionate Exclusion of Black Physicians in the United States Radiation Oncology Workforce

Purpose

Black physicians remain disproportionately underrepresented in certain medical specialties, yet comprehensive assessments in radiation oncology (RO) are lacking. Our purpose was to report current and historical representation trends for Black physicians in the US RO workforce.

Methods and Materials

Public registries were used to assess significant differences in 2016 representation for US vs RO Black academic full-time faculty, residents, and applicants. Historical changes from 1970 to 2016 were reported descriptively. Linear regression was used to assess significant changes for Black residents and faculty from 1995 to 2016.

Results

In 2016, Black people represented 3.2% vs 1.5% (P < .001), 5.6% vs 3.2% (P = .005), and 6.5% vs 5.4% (P = .352) of US vs RO faculty, residents, and applicants, respectively. Although RO residents nearly doubled from 374 (1974) to 720 (2016), Black residents peaked at 31 in 1984 (5.9%; 31 of 522) and fell to 23 (3.2%; 23 of 720) in 2016 across 91 accredited programs; Black US graduate medical education trainees nearly doubled over the same period: 3506 (1984) to 6905 (2016). From 1995 to 2016, Black US resident representation significantly increased by 0.03%/y, but decreased significantly in RO by –0.20%/y before 2006 and did not change significantly thereafter. Over the same period, Black US faculty representation significantly increased by 0.02%/y, whereas Black RO faculty significantly increased by 0.07%/y before 2006, then decreased significantly by –0.16%/y thereafter. The number of Black RO faculty peaked at 37 in 2006 (3.1%; 37 of 1203) and was 27 (1.5%; 27 of 1769) in 2016, despite the nearly 1.5-fold increase in the number of both RO faculty and Black US faculty overall (4169 in 2006 and 6047 in 2016) during that period.

Conclusions

Black physicians remain disproportionately underrepresented in RO despite an increasing available pipeline in the US physician workforce. Deliberate efforts to understand barriers to specialty training and inclusion, along with evidence-based targeted interventions to overcome them, are needed to ensure diversification of the RO physician workforce.

Molecular Imaging for Particle Therapy: Current Approach and Future Directions

During the last decades, radiation oncology has been subject to a number of technological innovations. Particle therapy has evolved in parallel to the modern high-precision photon radiotherapy techniques and offers a superior dose distribution with decreased integral dose to healthy tissues. With advancing precision of treatment, the necessity for accurate and confident target volume delineation is rising. When morphological imaging reaches its limitations, molecular imaging can provide valuable information.

Factual survey of the clinical use of deformable image registration software for radiotherapy in Japan

Deformable image registration (DIR) has recently become commercially available in the field of radiotherapy. However, there was no detailed information regarding the use of DIR software at each medical institution. Thus, in this study, we surveyed the status of the clinical use of DIR software for radiotherapy in Japan. The Japan Society of Medical Physics and the Japanese Society for Radiation Oncology mailing lists were used to announce this survey. The questionnaire was created by investigators working under the research grant of the Japanese Society for Radiation Oncology (2017-2018) and intended for the collection of information regarding the use of DIR in radiotherapy. The survey was completed by 161 institutions in Japan. The survey results showed that dose accumulation was the most frequent purpose for which DIR was used in clinical practice (73%). Various commissioning methods were performed, although they were not standardized. Qualitative evaluation with actual patient images was the most commonly used method (28%), although 30% of the total number of responses (42% of institutions) reported that they do not perform commissioning. We surveyed the current status of clinical use of DIR software for radiotherapy in Japan for the first time. Our results indicated that a certain number of institutions used DIR software for clinical practice, and various commissioning methods were performed, although they were not standardized. Taken together, these findings highlight the need for a technically unified approach for commissioning and quality assurance for the use of DIR software in Japan.

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

BACKGROUND

Health services research (HSR) is of increasing relevance to scientists, health-care providers, and clinicians. Complex population-based secondary data are a key source of information for analyses of health-care effects in radiation oncology.

METHODS

In this short paper, we examine potential applications of secondary data focusing on statistics from the diagnosis-related groups (DRG). This data set incorporating all hospitalized cases in Germany is based on claims of reimbursements and is provided by the Research Data Centers (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states. A short outlook regarding other data sources is also presented.

RESULTS

In radiation oncology, secondary data such as the DRG statistics have rarely been used to examine health-care effects, despite their great potential for reporting effects in a broad population-based setting. Furthermore, for most data sources, the application to use these data is accessible with minor effort. However, data concerning outpatient care are difficult to analyze on a comparable level.

CONCLUSION

DRG statistics and related secondary data provide a remarkable source of information for analyses of health-care-related effects in radiation oncology.

The Children's Oncology Group Radiation Oncology Discipline: 15 Years of Contributions to the Treatment of Childhood Cancer

PURPOSE

Our aim was to review the advances in radiation therapy for the management of pediatric cancers made by the Children's Oncology Group (COG) radiation oncology discipline since its inception in 2000.

METHODS AND MATERIALS

The various radiation oncology disease site leaders reviewed the contributions and advances in pediatric oncology made through the work of the COG. They have presented outcomes of relevant studies and summarized current treatment policies developed by consensus from experts in the field.

RESULTS

The indications and techniques for pediatric radiation therapy have evolved considerably over the years for virtually all pediatric tumor types, resulting in improved cure rates together with the potential for decreased treatment-related morbidity and mortality.

CONCLUSIONS

The COG radiation oncology discipline has made significant contributions toward the treatment of childhood cancer. Our discipline is committed to continuing research to refine and modernize the use of radiation therapy in current and future protocols with the goal of further improving the cure rates and quality of life of children with cancer.

The rise of reimbursement-based medicine: the case of bone metastasis radiation treatment

It has been hypothesised that the reimbursement system pertaining to radiotherapy is influencing prescription practices for patients with cancer with bone metastases. In this paper, we present and discuss the results of an empirical study that was undertaken on patient records, referred to radiotherapy for the treatment of bone metastases, in a medium-size city, in southern Brazil, during the period of March 2006 to March 2014. Our findings seem to confirm this hypothesis: after a change in the reimbursement method, radiation prescriptions were adapted accordingly, in order to maximise profits. Once such patients become highly vulnerable due to their diagnoses, they also become susceptible to a subtle form of exploitation; physicians let patients believe that more radiation will be better for their health, and they do so despite knowing otherwise, and as it seems, out of pecuniary interests.

Defining Value in Radiation Oncology: Approaches to Weighing Benefits vs Costs

The passage of the Affordable Care Act in 2010 initiated discussion regarding transitioning from a fee-for-service arrangement of care reimbursement to value-based care. Cost-effectiveness analysis (CEA) has been used in the past to quantify value as it relates to the provision of healthcare. New treatments or techniques being compared with other new or existing therapies or approaches to care were determined to be cost-effective if the incremental cost-effectiveness ratio was less than $50,000/life-year or quality-adjusted life-year. This result was accepted as a proxy for value in care delivery. The calculation of value, however, is the inverse of CEA, with units measured in outcome/cost. Given the wealth of medical information now available online, patients are becoming more sophisticated consumers of healthcare, investigating not only outcomes but also costs of care associated with different treatment approaches. Costs to be considered include direct medical costs; the indirect medical costs associated with treatment; and productivity costs resulting, for example, from time lost from work when patients must travel to a cancer center or clinic to receive treatment. Radiation oncologists must be mindful of these costs when designing treatment plans. Increased adoption of hypofractionated radiation treatment strategies (ie, higher radiation doses given over a shorter course of treatment) could increase patient value by reducing direct and indirect medical costs, as well as productivity costs.

Present state and issues in IORT Physics

Literature was reviewed to assess the physical aspects governing the present and emerging technologies used in intraoperative radiation therapy (IORT). Three major technologies were identified: treatment with electrons, treatment with external generators of kV X-rays and electronic brachytherapy. Although also used in IORT, literature on brachytherapy with radioactive sources is not systematically reviewed since an extensive own body of specialized literature and reviews exists in this field. A comparison with radioactive sources is made in the use of balloon catheters for partial breast irradiation where these are applied in almost an identical applicator technique as used with kV X-ray sources. The physical constraints of adaption of the dose distribution to the extended target in breast IORT are compared. Concerning further physical issues, the literature on radiation protection, commissioning, calibration, quality assurance (QA) and in-vivo dosimetry of the three technologies was reviewed. Several issues were found in the calibration and the use of dosimetry detectors and phantoms for low energy X-rays which require further investigation. The uncertainties in the different steps of dose determination were estimated, leading to an estimated total uncertainty of around 10-15% for IORT procedures. The dose inhomogeneity caused by the prescription of electrons at 90% and by the steep dose gradient of kV X-rays causes additional deviations from prescription dose which must be considered in the assessment of dose response in IORT.

Perspectives on Patient Access to Radiation Oncology Facilities and Services in Mainland China

The Chinese health care system and specifically, radiation oncology, has clearly improved during the past 30 years in equipment and its use, although the shortage of facilities and workforce remain to be improved. These constitute the targets for a nationwide effort to improve the access to service by patients with cancer, especially in the more remote and rural portions of the country. In this report, we would highlight the positive changes that have occurred during the time and outline what is still needed for the future of this important cancer specialty in China.

Current Trends in the Management of Ductal Carcinoma In Situ

Ductal carcinoma in situ (DCIS), once a rare entity, now comprises up to 30% of newly diagnosed breast cancers detected on mammography. It is now appreciated as a widely heterogeneous disease, with indolent lesions of minimal clinical significance on one end of the spectrum, and aggressive lesions with malignant invasive potential on the other. Therefore, the traditional guideline-concordant approach to treatment with surgery, radiation, and endocrine therapy may lead to overtreatment of certain patients, and insufficient treatment of others. Risk assessment using clinical and molecular prognostic tools is being investigated, addressing the possibility of delineating subpopulations that may be treated with more tailored therapy. This review will summarize the current trends in the diagnosis and management of DCIS and will highlight ongoing trials that are shaping future management of this entity.

Supply and Demand for Radiation Oncology in the United States: Updated Projections for 2015 to 2025

PURPOSE

Prior studies have forecasted demand for radiation therapy to grow 10 times faster than the supply between 2010 and 2020. We updated these projections for 2015 to 2025 to determine whether this imbalance persists and to assess the accuracy of prior projections.

METHODS AND MATERIALS

The demand for radiation therapy between 2015 and 2025 was estimated by combining current radiation utilization rates determined by the Surveillance, Epidemiology, and End Results data with population projections provided by the US Census Bureau. The supply of radiation oncologists was forecast by using workforce demographics and full-time equivalent (FTE) status provided by the American Society for Radiation Oncology (ASTRO), current resident class sizes, and expected survival per life tables from the US Centers for Disease Control.

RESULTS

Between 2015 and 2025, the annual total number of patients receiving radiation therapy during their initial treatment course is expected to increase by 19%, from 490,000 to 580,000. Assuming a graduating resident class size of 200, the number of FTE physicians is expected to increase by 27%, from 3903 to 4965. In comparison with prior projections, the new projected demand for radiation therapy in 2020 dropped by 24,000 cases (a 4% relative decline). This decrease is attributable to an overall reduction in the use of radiation to treat cancer, from 28% of all newly diagnosed cancers in the prior projections down to 26% for the new projections. By contrast, the new projected supply of radiation oncologists in 2020 increased by 275 FTEs in comparison with the prior projection for 2020 (a 7% relative increase), attributable to rising residency class sizes.

CONCLUSION

The supply of radiation oncologists is expected to grow more quickly than the demand for radiation therapy from 2015 to 2025. Further research is needed to determine whether this is an appropriate correction or will result in excess capacity.

Technology for Innovation in Radiation Oncology

Radiation therapy is an effective, personalized cancer treatment that has benefited from technological advances associated with the growing ability to identify and target tumors with accuracy and precision. Given that these advances have played a central role in the success of radiation therapy as a major component of comprehensive cancer care, the American Society for Radiation Oncology (ASTRO), the American Association of Physicists in Medicine (AAPM), and the National Cancer Institute (NCI) sponsored a workshop entitled "Technology for Innovation in Radiation Oncology," which took place at the National Institutes of Health (NIH) in Bethesda, Maryland, on June 13 and 14, 2013. The purpose of this workshop was to discuss emerging technology for the field and to recognize areas for greater research investment. Expert clinicians and scientists discussed innovative technology in radiation oncology, in particular as to how these technologies are being developed and translated to clinical practice in the face of current and future challenges and opportunities. Technologies encompassed topics in functional imaging, treatment devices, nanotechnology, and information technology. The technical, quality, and safety performance of these technologies were also considered. A major theme of the workshop was the growing importance of innovation in the domain of process automation and oncology informatics. The technologically advanced nature of radiation therapy treatments predisposes radiation oncology research teams to take on informatics research initiatives. In addition, the discussion on technology development was balanced with a parallel conversation regarding the need for evidence of efficacy and effectiveness. The linkage between the need for evidence and the efforts in informatics research was clearly identified as synergistic.

US radiation oncology practice patterns for posttreatment survivor care

PURPOSE

Increasing numbers of cancer survivors have driven a greater focus on care of cancer patients after treatment. Radiation oncologists have long considered follow-up of patients an integral part of practice. We sought to document current survivor-focused care patterns and identify barriers to meeting new regulatory commission guidelines for survivorship care plans (SCPs) and provide guidance for survivorship care.

METHODS AND MATERIALS

A 23-question electronic survey was e-mailed to all practicing US physician American Society of Radiation Oncology members. Responses were collected for 25 days in March 2014. Survey data were descriptively analyzed.

RESULTS

A total of 574 eligible providers responded, for a response percentage of 14.7%. Almost all providers follow their patients after treatment (97%). Length of follow-up was frequently extensive: 17% followed up to 2 years, 40% for 3-5 years, 12% for 6-10 years, and 31% indefinitely. Ancillary services, particularly social work and nutrition services, are commonly available onsite to patients in follow-up. Fewer than half of respondents (40%) indicated that they currently use SCPs for curative intent patients and those who do generally use internally developed templates. SCPs typically go to patients (91%), but infrequently to primary care providers (22%). The top 3 barriers to implementation of SCPs were cost (57%), duplicative survivorship care plans provided by other physicians (43%), and lack of consensus or professional guidelines (40%). Eighty-seven percent indicated that SCPs built into an electronic medical record system would be useful.

CONCLUSIONS

A significant part of radiation oncology practice includes the care of those in the surveillance of follow-up phase of care. SCPs may be beneficial in improving communication with the patient and other care but are not widely used within our field. This survey identified key barriers to use of SCPs and provides specialty guidance for important information to be included in a radiation oncology oriented SCP.

The need for radiotherapy in Europe in 2020: Not only data but also a cancer plan

BACKGROUND

Planning radiation oncology equipment and staffing is necessary in public healthcare systems in Europe.

METHODS

Three different data inputs were considered: evidence-based indications for radiotherapy, the incidence of cancer, and the stage at diagnosis of each cancer type, both the latter using population-based data from cancer registries. The availability of these data and the implications for the estimation of the proportion of new cancer patients who would need radiotherapy treatment at least once during the course of the disease is reviewed.

RESULTS

Depending on the frequency of cancers and the stage at diagnosis, it has been estimated that between 47% and 53% of incident cases among European countries would require external beam radiotherapy. When the actual data of utilization is compared with the evidence-based target, only one country in Europe has achieved full coverage.

CONCLUSION

It is argued that these should be considered the optimal proportions of cancer patients, but a more realistic policy target could be set at 80% or higher of the optimal proportion. This realistic target also takes into account the inherent uncertainties in the assessment of evidence, and other factors that influence clinical decision-making in cases of multi-morbidity or patient preferences. Other factors are associated with problems that should be dealt with in the framework of a cancer plan, such as accessibility, preference bias in physician evaluation of the indication or shortage of resources, and the impact of the reimbursement system. Finally, it is argued that a cancer plan is the framework for achieving policy targets in the appropriate coverage of the evidence-based indications for radiation oncology forecasts.

[Status report of Hungarian radiotherapy based on treatment data, available infrastucture, and human resources]

The purpose of the study is to report the status of Hungarian radiotherapy (RT) based on the assessment of treatment data in years 2012 to 2014, available infrastructure, and RT staffing. Between December 2014 and January 2015, a RT questionnaire including 3 parts (1. treatment data; 2. infrastructure; 3. staffing) was sent out to all Hungarian RT centers (n=12). All RT centers responded to all questions of the survey. 1. Treatment data: In 2014, 33,162 patients were treated with RT: 31,678 (95.5%) with teletherapy, and 1484 (4.5%) with brachytherapy (BT). Between 2012 and 2014, the number of patients treated with radiotherapy increased with 6.6%, but the number of BT patients decreased by 11%. Forty-two percent of all patients were treated in the two centers of the capital: 9235 patients (28%) at the National Institute of Oncology (NIO), and 4812 (14%) at the Municipial Oncoradiology Center (MOC). Out of the patients treated on megavoltage RT units (n=22,239), only 901 (4%) were treated with intensity-modulated RT (IMRT), and 2018 (9%) with image-guided RT (IGRT). In 2014, 52% of all BT treatments were performed in Budapest: NIO - 539 patients (36%); MOC - 239 patients (16%); and BT was not available in 3 RT centers. Prostate I-125 seed implants and interstitial breast BT was utilized in one, prostate HDR BT in two, and head&neck implants in three centers. 2. Infrastructure: Including ongoing development projects funded by the European Union, by the end of year 2015, 39 megavoltage teletherapy units, and 12 HDR BT units will be in use in 13 available Hungarian RT centers. 3. Staffing: Actually, 92 radiation oncologists (RO), 29 RT residents, 61 medical physicists, and 229 radiation therapy technologists are working in 12 RT centers. There are 23 vacant positions (including 11 RO positions) available at the Hungarian RT centers. According to the professional minimal requirements and WHO guidelines, the implementation of 11 new linear accelerators, and 1 BT units are needed in Hungary. Further resources for the development and upgrade of RT infrastructure and capacity should be allocated to RT centers in Budapest. Brachytherapy and modern teletherapy (e.g. IMRT and IGRT) are underutilized in Hungary compared to other European countries. Implementation of continuous education and practical training programs in leading Hungarian and international RT centers are suggested in an effort to a wider implementation of modern RT techniques in Hungarian RT centers.

[Historical overview and the current practice of intracavitary treatment of cervical and endometrial cancer in the Oncoradiology Center of Budapest]

The aims of our study were to describe the history and development of intracavitary brachytherapy in the treatment of gynecological tumors, to introduce our current practice for intracavitary brachytherapy treatments based on CT planning. Gynecological intracavitary brachytherapy has been applied in our department since the early 1930s. After a long development it has been completely renewed by 2014. In our center definitive and/or preoperative gynecological HDR-AL brachytherapy treatments were given to 25 patients (13 corpus uterine cancer patients and 12 cervical cancer patients) during the period of 01. 01. 2014-31. 01. 2015. In each case, target volumes were planned by CT images, DVH (dose volume histogram) analysis was performed in order to calculate the radiation tolerance dose of rectum and urinary bladder. Evaluation was performed by the EclipseTM 11.0.47. brachytherapy treatment planning system. During the definitive treatments of the 13 uterine cancer patients the D2cc value related to rectum tolerance was 66.3 GyEQD2 (46-91 Gy). The average D2cc value of urinary bladder tolerance was 76.5 GyEQD2 (30-112 Gy). CI was 0.72 (0.6-0.95). Average value of COIN was 0.57 (0.35-0.78). Compared to the prescribed dose D100 and D90 values were given in ratios. Compared to the volume which receives 100% of reference dose V150 and V200 values were also given in ratios. D100 and D90 were calculated to be 0.66 (0.47-0.97) and 0.91 (0.8-1.25). V150 and V200 volumes were 0.11 (0.04-0.18) and 0.06 (0.02-0.1). During the definitive treatments of 12 cervical cancer patients the D2cc value related to rectum tolerance calculated by DVH was 75.2 GyEQD2 (60-82 Gy). The average D2cc value of urinary bladder tolerance was 85 GyEQD2 based on DVH. CI was 0.66 (0.42-0.76). Average value of COIN was 0.52 (0.32-0.78). Mean value of DHI was 0.46 (0.27-0.54). D100 and D90 were calculated to be 0.72 (0.57-0.89) and 0.91 (0.84-1.11). V150 and V200 volumes were 0.057 (0.02-0.13) and 0.02 (0.002-0.06). During treatments no severe side effects were found. During gynecological intracavitary HDR therapies the calculated dose of the target volume can be given safely using the EclipseTM 11.0.47. brachytherapy planning system and CT-based planning. CT-based treatment planning provides optimal safety for organs at risk, acceptable doses for rectum and urinary bladder while the target volume receives the proper prescribed dose.

The PEDRO (Pocketable Electronic Devices in Radiation Oncology) project: how clinical practice is changing among young radiation oncologists

PURPOSE

To evaluate the impact of mobile devices and apps on the daily clinical activity of young radiation oncologists.

METHODS

A web-based questionnaire was sent to 382 young (≤ 40 years) members of the Italian Association of Radiation Oncology (AIRO). The 14 items investigated the diffusion of mobile devices (smartphones and/or tablets), their impact on daily clinical activity, and possible differences perceived by the participants over time.

RESULTS

A total of 158 questionnaires were available for statistical evaluation (response rate 41%). Up to 75% of respondents declared they used an electronic device during their clinical activity. Conversely, 82% considered the impact of smartphones/tables on daily practice low to moderate. Daily device use increased significantly from 2009 to 2012, with high daily use rates rising from 5% to 39.9%. Fulfillment of professional needs was declared by less than 42% of respondents and compliance with app indications by 32%. Almost all physicians desired in 2012 a comprehensive website concerning a variety of apps covering radiation oncologists' needs.

CONCLUSIONS

Mobile devices are widely used by young Italian radiation oncologists in their daily clinical practice, while the indications so obtained are not always followed. Nevertheless, it would be important to verify the consistency of information found within apps, in order to avoid potential errors that might be detrimental to patients.

Considerations for observational research using large data sets in radiation oncology

The radiation oncology community has witnessed growing interest in observational research conducted using large-scale data sources such as registries and claims-based data sets. With the growing emphasis on observational analyses in health care, the radiation oncology community must possess a sophisticated understanding of the methodological considerations of such studies in order to evaluate evidence appropriately to guide practice and policy. Because observational research has unique features that distinguish it from clinical trials and other forms of traditional radiation oncology research, the International Journal of Radiation Oncology, Biology, Physics assembled a panel of experts in health services research to provide a concise and well-referenced review, intended to be informative for the lay reader, as well as for scholars who wish to embark on such research without prior experience. This review begins by discussing the types of research questions relevant to radiation oncology that large-scale databases may help illuminate. It then describes major potential data sources for such endeavors, including information regarding access and insights regarding the strengths and limitations of each. Finally, it provides guidance regarding the analytical challenges that observational studies must confront, along with discussion of the techniques that have been developed to help minimize the impact of certain common analytical issues in observational analysis. Features characterizing a well-designed observational study include clearly defined research questions, careful selection of an appropriate data source, consultation with investigators with relevant methodological expertise, inclusion of sensitivity analyses, caution not to overinterpret small but significant differences, and recognition of limitations when trying to evaluate causality. This review concludes that carefully designed and executed studies using observational data that possess these qualities hold substantial promise for advancing our understanding of many unanswered questions of importance to the field of radiation oncology.

Is current technology improving outcomes with radiation therapy for gliomas?

Radiotherapy (RT) remains the principal component of glioma treatment, and three-dimensional conformal RT (3DCRT) is the current standard of RT delivery. Advances in imaging and in RT technology have enabled more precise treatment to defined targets combined with better means of avoiding critical normal structures, and this is complemented by intensive quality assurance, which includes on-treatment imaging. The refinements of 3DCRT include intensity modulated RT (IMRT), arcing IMRT, and high-precision conformal RT, formerly described as "stereotactic," which can be delivered using a linear accelerator or other specialized equipment. Although proton therapy uses heavy charged particles, the principal application can also be considered as refinement of 3DCRT. The technologies generally improve the dose differential between the tumor and normal tissue and enable more dose-intensive treatments. However, these have not translated into improved survival outcome in patients with low- and high-grade gliomas. More intensive altered fractionation regimens have also failed to show survival benefit. Nevertheless, novel technologies enable better sparing of normal tissue and selective avoidance of critical structures, and these need to be explored further to improve the quality of life of patients with gliomas. Principal clinical advance in RT has been the recognition that less intensive treatments are beneficial for patients with adverse prognosis high-grade gliomas. We conclude that the principal gain of modern RT technology is more likely to emerge as a reduction in treatment related toxicity rather than as an improvement in overall survival; the optimal avoidance strategies remain to be defined.

Progress of radiation oncology: known and unknown

OBJECTIVE

To elaborate known and unknown aspects of radiation oncology.

DATA SOURCES

Data cited in this review were obtained mainly from PubMed and Medline in English from 1999 to 2013, with keywords "individualized medicine", "personalized medicine", "radiation dose", "radiation target", "molecular targeted therapy", "molecular imaging" and "functional imaging".

STUDY SELECTION

Articles regarding radiation target delineation, radiation doses, new technology and equipment, combination of radiotherapy and molecular targeted therapy as well as other aspects were identified, retrieved and reviewed.

RESULTS

A larger radiation field and a higher radiation dose are not always better. New equipment and technology are also not always better than conventional equipment and technologies. Effectiveness of radiotherapy combined with molecular targeted therapy needs more data to verify.

CONCLUSION

Personalized radiotherapy is the direction for the future.

[Economic and logistical problems of radiation oncology]

An analysis of economic and logistical problems of radiation oncology is presented based on domestic and foreign literature. Despite the high efficacy of radiotherapy this branch of oncology is not financed enough in most countries. As a consequence, it is ubiquitously marked radiotherapy capacity deficit that does not allow to fully realize its therapeutic potential. Medical electron accelerators and related equipment have become increasingly complex and expensive and radiotherapy techniques more consuming. Even in developed countries growing waiting times for radiotherapy, not using the most modern and efficient radiotherapy technologies (image guiding, etc.) has become a daily reality. Based on these data, we assessed the prospects and possibilities of upgrading the technical base of radiation oncology in Russia including the development of hadron therapy.

Current status and recommendations for the future of research, teaching, and testing in the biological sciences of radiation oncology: report of the American Society for Radiation Oncology Cancer Biology/Radiation Biology Task Force, executive summary

In early 2011, a dialogue was initiated within the Board of Directors (BOD) of the American Society for Radiation Oncology (ASTRO) regarding the future of the basic sciences of the specialty, primarily focused on the current state and potential future direction of basic research within radiation oncology. After consideration of the complexity of the issues involved and the precise nature of the undertaking, in August 2011, the BOD empanelled a Cancer Biology/Radiation Biology Task Force (TF). The TF was charged with developing an accurate snapshot of the current state of basic (preclinical) research in radiation oncology from the perspective of relevance to the modern clinical practice of radiation oncology as well as the education of our trainees and attending physicians in the biological sciences. The TF was further charged with making suggestions as to critical areas of biological basic research investigation that might be most likely to maintain and build further the scientific foundation and vitality of radiation oncology as an independent and vibrant medical specialty. It was not within the scope of service of the TF to consider the quality of ongoing research efforts within the broader radiation oncology space, to presume to consider their future potential, or to discourage in any way the investigators committed to areas of interest other than those targeted. The TF charge specifically precluded consideration of research issues related to technology, physics, or clinical investigations. This document represents an Executive Summary of the Task Force report.

Place of proton radiotherapy in future radiotherapy practice

Proton beam therapy offers potential dosimetric advantages coupled with complexities not currently encompassed in the photon radiotherapy experience. The practice is evolving alongside other developments in oncology, which include higher precision of photon radiotherapy, greater understanding of the biological effect of radiation and its potential modification, and the recognition of new molecular targets with a plethora of agents aimed at affecting biological function. For proton therapy to have an impact on clinical practice requires full examination in rigorous clinical trials comparing proton with best photon therapy. Only the results of present and future studies, showing equivalent, superior, or even potentially worse clinical results will shape their application. The desired goal is to develop personalized treatment strategies of fractionation appropriate for protons potentially combined with targeted agents. We describe the steps in health technology assessment and the potential design of preclinical and clinical trials to define the role of proton therapy in the future.