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In the article "Thoughts of a psychoanalyst shortly after the beginning of the war in Ukraine," psychoanalyst Peter Gabriel reflects on the war in Ukraine and the nuclear threat. He emphasizes that illusions about the compatibility and prosociality of humans are naive and that willingness to negotiate and military strength are necessary to avoid a power vacuum. Gabriel argues that it is important to recognize the societal dimension of destructiveness within us humans and that a psychoanalysis that deals with this is in the tradition of Freud. He concludes with an appeal to support the desire for peace and strengthen realism. [Extracted from the article]

Purpose: Acute hospital encounters in patients undergoing curative-intent radiation therapy (RT) have not previously been well characterized. Understanding acute visit patterns among RT patients yields insights for risk assessments and cancer urgent care clinics that could decrease hospitalization rates and reduce health care costs. This study aims to identify patient, disease-site, and treatment characteristics associated with emergency department visits and inpatient admissions in cancer patients treated with definitive RT.Methods and Materials: A retrospective cohort study was conducted using data from a quaternary-care cancer center. The cohort was defined as all consecutive patients aged ≥ 18 years who began RT between July 1, 2011, and December 31, 2013; were without metastases; and were treated with curative intent. An acute encounter was defined as an emergency department visit or inpatient admission during RT or within 30 days after the conclusion of RT.Results: Among 1852 unique RT courses, 666 RT courses (36.0%) involved at least 1 acute encounter, and a total of 1418 acute encounters were identified. RT courses with at least 1 acute encounter corresponded to patients more likely to be on their second (odds ratio [OR], 1.96; P < .001) or third (OR, 3.82; P < .05) RT course and undergoing concurrent chemotherapy (OR, 6.38; P < .001). Among the RT courses with at least 1 acute encounter, the most common disease site was thoracic (22.8%), followed by head and/or neck (22.2%) and gastrointestinal (18.3%). Central nervous system tumors had the greatest proportion of RT courses with acute encounters (77.1%).Conclusions: In this retrospective analysis, more than one-third of curative-intent RT courses were associated with at least 1 acute hospital encounter during or shortly after irradiation. Given that acute encounters varied by patient, disease-site, and treatment characteristics, these findings can inform targeted preventive measures to reduce cancer-related acute hospital encounters and guide improved management protocols. [ABSTRACT FROM AUTHOR]

A clinical database is a repository of patient medical and sociodemographic information focused on one or more specific health condition or exposure. Although clinical databases may be used for research purposes, their primary goal is to collect and track patient data for quality improvement, quality assurance, and/or actual clinical management. This article aims to provide an introduction and practical advice on the development of small-scale clinical databases for chest physicians and practice groups. Through example projects, we discuss the pros and cons of available technical platforms, including Microsoft Excel and Access, relational database management systems such as Oracle and PostgreSQL, and Research Electronic Data Capture. We consider approaches to deciding the base unit of data collection, creating consensus around variable definitions, and structuring routine clinical care to complement database aims. We conclude with an overview of regulatory and security considerations for clinical databases. [ABSTRACT FROM AUTHOR]

Abstract: The use of inverse‐planned intensity‐modulated radiation therapy for whole breast radiation treatment has become more prevalent, but this may impose an increased cost on the health system. We hypothesized that when applied with the same treatment planning goals, tangential forward‐planned field‐in‐field 3D conformal radiotherapy and tangential inverse‐planned intensity‐modulated radiotherapy would be associated with comparable toxicities. Women who underwent tangential whole breast irradiation at our institution from 2011 to 2015 planned using either forward‐planned field‐in‐field 3D conformal radiotherapy or intensity‐modulated radiotherapy were retrospectively analyzed. Grade 2+ Radiation dermatitis was the primary endpoint. A total of 201 and 212 women had undergone field‐in‐field 3D conformal radiotherapy and intensity‐modulated radiotherapy, respectively. No differences were observed between the two modalities regarding acute radiation dermatitis, breast pain, or fatigue. In a multivariable logistic regression that incorporated the use of boost, hypofractionation, use of chemotherapy, patient positioning, use of a supraclavicular field, and breast planning target volume, intensity‐modulated radiotherapy was not correlated with different rates of Grade 2+ radiation dermatitis. This study supports the routine first‐line use of field‐in‐field 3D conformal radiotherapy for whole breast radiation instead of tangential intensity‐modulated radiotherapy from the standpoint of equivalence in acute toxicity. Further investigation is needed to assess whether there are subgroups of women who may still benefit from intensity‐modulated radiotherapy. [ABSTRACT FROM AUTHOR]

The article looks at recommended approaches in enhancing documentation of cancer stages in electronic health records (EHR). Topics discussed include clear documentation being promoted by the National Quality Forum, and approaches that can enhance cancer stage documentation like the natural language processing algorithm and use of cancer registrars.

The article discusses the benefits of capturing disease-specific structured data elements in electronic health records. Topics include the impact on efficiency and expressivity of clinical documentation, the importance of adhering to data standards when available, and the potential of electronic health records to improve health-care quality.

The implementation of the fundamental mission of medieval Dominicans, defined by their Constitutions - preaching for the salvation of souls - was necessarily connected with the book culture. For the Order of Preachers the book became a work tool, as well as a powerful weapon in the spiritual struggle. For this reason, medieval Dominican libraries were playing a truly important role and were significantly co-shaping the history of this institution. [ABSTRACT FROM AUTHOR]

Methods for the verification of the identity of offenders in cases involving video-surveillance images in criminal investigation events are currently under scrutiny by several forensic experts around the globe. The anthroposcopic, or morphological, approach based on facial features is the most frequently used by international forensic experts. However, a specific set of applicable features has not yet been agreed on by the experts. Furthermore, population frequencies of such features have not been recorded, and only few validation tests have been published. To combat and prevent crime in Europe, the European Commission funded an extensive research project dedicated to the optimization of methods for facial identification of persons on photographs. Within this research project, standardized photographs of 900 males between 20 and 31 years of age from Germany, Italy, and Lithuania were acquired. Based on these photographs, 43 facial features were described and evaluated in detail. These efforts led to the development of a new model of a morphologic atlas, called DMV atlas ('Düsseldorf Milan Vilnius,' from the participating cities). This study is the first attempt at verifying the feasibility of this atlas as a preliminary step to personal identification by exploring the intra- and interobserver error. The analysis yielded mismatch percentages from 19% to 39%, which reflect the subjectivity of the approach and suggest caution in verifying personal identity only from the classification of facial features. Nonetheless, the use of the atlas leads to a significant improvement of consistency in the evaluation. [ABSTRACT FROM AUTHOR]

Background: Despite the widespread implementation of telemedicine, there are limited data regarding its impact on key components of care for patients with incurable or high‐risk cancer. For these patients, high‐quality care requires detailed conversations regarding treatment priorities (advance care planning) and clinical care to minimize unnecessary acute care (unplanned hospitalizations). Whether telemedicine affects these outcomes relative to in‐person clinic visits was examined among patients with cancer at high risk for 6‐month mortality. Methods: This retrospective cohort study included adult patients with cancer with any tumor type treated at the University of Pennsylvania who were newly identified between April 1 and December 31, 2020, to be at high risk for 6‐month mortality via a validated machine learning algorithm. Separate modified Poisson regressions were used to assess the occurrence of advance care planning and unplanned hospitalizations for telemedicine as compared to in‐person visits. Additional analyses were done comparing telemedicine type (video or phone) as compared to in‐person clinic visits. Results: The occurrence of advance care planning was similar between telemedicine and in‐person visits (6.8% vs. 6.0%; adjusted risk ratio [aRR], 1.25; 95% CI, 0.92–1.69). In regard to telemedicine subtype, patients exposed to video encounters were modestly more likely to have documented advance care planning in comparison to those seen in person (7.5% vs. 6.0%; aRR, 1.48; 95% CI, 1.03–2.11). The 3‐month risk for unplanned hospitalization was comparable for telemedicine compared to in‐person clinic encounters (21% vs. 18%; aRR, 1.06; 95% CI, 0.81–1.38). Conclusions: In this study, care delivered by telemedicine, compared to in‐person clinic visits, produced comparable rates of advance care planning conversations without increasing hospitalizations, which suggests that vulnerable patients can be managed safely by telemedicine. In this study, care delivered by telemedicine, compared to in‐person clinic visits, produced comparable rates of advance care planning conversations without increasing hospitalizations, which suggests that vulnerable patients can be managed safely by telemedicine. [ABSTRACT FROM AUTHOR]

The author comments on the study "Electronic medical records: a practitioner's perspective on evaluation and implementation," by E. Diamond and colleagues, published within the issue. A brief reference to the American Recovery and Reinvestment Act of 2009 is offered. The author applauds the researchers for disclosing their three-year journey from vendor selection through system implementation to clinical quality improvement efforts for their 15-provider pulmonary practice. In conclusion, the author shares his support for health information technology.

Background: Increased breast density augments breast cancer risk and reduces mammography sensitivity. Supplemental breast MRI screening can significantly increase cancer detection among women with dense breasts. However, few women undergo this exam, and screening is consistently lower among racially minoritized populations. Implementation strategies informed by behavioral economics ("nudges") can promote evidence-based practices by improving clinician decision-making under conditions of uncertainty. Nudges directed toward clinicians and patients may facilitate the implementation of supplemental breast MRI. Methods: Approximately 1600 patients identified as having extremely dense breasts after non-actionable mammograms, along with about 1100 clinicians involved with their care at 32 primary care or OB/GYN clinics across a racially diverse academically based health system, will be enrolled. A 2 × 2 randomized pragmatic trial will test nudges to patients, clinicians, both, or neither to promote supplemental breast MRI screening. Before implementation, rapid cycle approaches informed by clinician and patient experiences and behavioral economics and health equity frameworks guided nudge design. Clinicians will be clustered into clinic groups based on existing administrative departments and care patterns, and these clinic groups will be randomized to have the nudge activated at different times per a stepped wedge design. Clinicians will receive nudges integrated into the routine mammographic report or sent through electronic health record (EHR) in-basket messaging once their clinic group (i.e., wedge) is randomized to receive the intervention. Independently, patients will be randomized to receive text message nudges or not. The primary outcome will be defined as ordering or scheduling supplemental breast MRI. Secondary outcomes include MRI completion, cancer detection rates, and false-positive rates. Patient sociodemographic information and clinic-level variables will be examined as moderators of nudge effectiveness. Qualitative interviews conducted at the trial's conclusion will examine barriers and facilitators to implementation. Discussion: This study will add to the growing literature on the effectiveness of behavioral economics-informed implementation strategies to promote evidence-based interventions. The design will facilitate testing the relative effects of nudges to patients and clinicians and the effects of moderators of nudge effectiveness, including key indicators of health disparities. The results may inform the introduction of low-cost, scalable implementation strategies to promote early breast cancer detection. Trial registration: ClinicalTrials.gov NCT05787249. Registered on March 28, 2023. [ABSTRACT FROM AUTHOR]

Background: Germline genetic testing is recommended by the National Comprehensive Cancer Network (NCCN) for individuals including, but not limited to, those with a personal history of ovarian cancer, young-onset (< 50 years) breast cancer, and a family history of ovarian cancer or male breast cancer. Genetic testing is underused overall, and rates are consistently lower among Black and Hispanic populations. Behavioral economics-informed implementation strategies, or nudges, directed towards patients and clinicians may increase the use of this evidence-based clinical practice. Methods: Patients meeting eligibility for germline genetic testing for breast and ovarian cancer will be identified using electronic phenotyping algorithms. A pragmatic cohort study will test three sequential strategies to promote genetic testing, two directed at patients and one directed at clinicians, deployed in the electronic health record (EHR) for patients in OB-GYN clinics across a diverse academic medical center. We will use rapid cycle approaches informed by relevant clinician and patient experiences, health equity, and behavioral economics to optimize and de-risk our strategies and methods before trial initiation. Step 1 will send patients messages through the health system patient portal. For non-responders, step 2 will reach out to patients via text message. For non-responders, Step 3 will contact patients' clinicians using a novel "pend and send" tool in the EHR. The primary implementation outcome is engagement with germline genetic testing for breast and ovarian cancer predisposition, defined as a scheduled genetic counseling appointment. Patient data collected through the EHR (e.g., race/ethnicity, geocoded address) will be examined as moderators of the impact of the strategies. Discussion: This study will be one of the first to sequentially examine the effects of patient- and clinician-directed strategies informed by behavioral economics on engagement with breast and ovarian cancer genetic testing. The pragmatic and sequential design will facilitate a large and diverse patient sample, allow for the assessment of incremental gains from different implementation strategies, and permit the assessment of moderators of strategy effectiveness. The findings may help determine the impact of low-cost, highly transportable implementation strategies that can be integrated into healthcare systems to improve the use of genomic medicine. Trial registration: ClinicalTrials.gov. NCT05721326. Registered February 10, 2023. https://www.clinicaltrials.gov/study/NCT05721326 [ABSTRACT FROM AUTHOR]

PURPOSE: Breast and ovarian tumors in germline BRCA1/2 carriers undergo allele-specific loss of heterozygosity, resulting in homologous recombination deficiency (HRD) and sensitivity to poly-ADP-ribose polymerase (PARP) inhibitors. This study investigated whether biallelic loss and HRD also occur in primary nonbreast/ovarian tumors that arise in germline BRCA1/2 carriers. METHODS: A clinically ascertained cohort of BRCA1/2 carriers with a primary nonbreast/ovarian cancer was identified, including canonical (prostate and pancreatic cancers) and noncanonical (all other) tumor types. Whole-exome sequencing or clinical sequencing results (n = 45) were analyzed. A pan-cancer analysis of nonbreast/ovarian primary tumors from germline BRCA1/2 carriers from The Cancer Genome Atlas (TCGA, n = 73) was used as a validation cohort. RESULTS: Ages of nonbreast/ovarian cancer diagnosis in germline BRCA1/2 carriers were similar to controls for the majority of cancer types. Nine of 45 (20%) primary nonbreast/ovarian tumors from germline BRCA1/2 carriers had biallelic loss of BRCA1/2 in the clinical cohort, and 23 of 73 (32%) in the TCGA cohort. In the combined cohort, 35% and 27% of primary canonical and noncanonical BRCA tumor types, respectively, had biallelic loss. High HRD scores (HRDex > 42) were detected in 81% of tumors with biallelic BRCA loss compared with 22% (P <.001) of tumors without biallelic BRCA loss. No differences in genomic profile, including mutational signatures, mutation spectrum, tumor mutational burden, or microsatellite instability, were found in primary nonbreast/ovarian tumors with or without biallelic BRCA1/2 loss. CONCLUSION: A proportion of noncanonical primary tumors have biallelic loss and evidence of HRD. Our data suggest that assessment of biallelic loss and HRD could supplement identification of germline BRCA1/2 mutations in selection of patients for platinum or PARP inhibitor therapy. Only 20% of noncanonical primary tumors from germline BRCA1/2 carriers have homologous recombination deficiency. [ABSTRACT FROM AUTHOR]

PURPOSE: Current guidelines recommend molecular genotyping for patients newly diagnosed with metastatic nonsquamous (mNSq) non–small-cell lung cancer (NSCLC). The association between availability of molecular genotyping before first line (1L) therapy and overall survival (OS) is not known. METHODS: We conducted a real-world cohort study using electronic health records in patients newly diagnosed with mNSq NSCLC. Cox proportional-hazards multivariable regression models were constructed to examine the association between OS and test result availability before 1L therapy, adjusting for covariates. Additional analyses were conducted to assess the consistency and strength of the relationship. Multivariable logistic regression models were used to examine the association between concurrent tissue and plasma testing (v tissue alone) and result availability. RESULTS: Three hundred twenty-six patients were included, 80% (261/326) with results available before 1L (available testing group), and 20% (65/326) without results available (unavailable testing group). With 14.2-month median follow-up, patients in the available testing group had significantly longer OS relative to the unavailable testing group (adjusted hazard ratio, 0.43; 95% CI, 0.30 to 0.62; P <.0001). The adjusted odds of availability of results before 1L therapy was higher with concurrent tissue and plasma testing (v tissue testing alone; adjusted odds ratio, 2.06; 95% CI, 1.09 to 3.90; P =.026). CONCLUSION: Among patients with mNSq NSCLC in a real-world cohort, availability of molecular genotyping results before 1L therapy was associated with significantly better OS. Concurrent tissue and plasma testing was associated with a higher odds of availability of results before 1L therapy. These findings warrant renewed attention to the completion of molecular genotyping before 1L therapy. Availability of NGS results before 1L therapy for patients with mNSCLC is associated with better overall survival. [ABSTRACT FROM AUTHOR]

PURPOSE: Machine learning (ML) algorithms that incorporate routinely collected patient-reported outcomes (PROs) alongside electronic health record (EHR) variables may improve prediction of short-term mortality and facilitate earlier supportive and palliative care for patients with cancer. METHODS: We trained and validated two-phase ML algorithms that incorporated standard PRO assessments alongside approximately 200 routinely collected EHR variables, among patients with medical oncology encounters at a tertiary academic oncology and a community oncology practice. RESULTS: Among 12,350 patients, 5,870 (47.5%) completed PRO assessments. Compared with EHR- and PRO-only algorithms, the EHR + PRO model improved predictive performance in both tertiary oncology (EHR + PRO v EHR v PRO: area under the curve [AUC] 0.86 [0.85-0.87] v 0.82 [0.81-0.83] v 0.74 [0.74-0.74]) and community oncology (area under the curve 0.89 [0.88-0.90] v 0.86 [0.85-0.88] v 0.77 [0.76-0.79]) practices. CONCLUSION: Routinely collected PROs contain added prognostic information not captured by an EHR-based ML mortality risk algorithm. Augmenting an EHR-based algorithm with PROs resulted in a more accurate and clinically relevant model, which can facilitate earlier and targeted supportive care for patients with cancer. How do patient-reported outcomes improve machine learning algorithms to predict mortality in cancer? In this predictive modeling study, @ravi_b_parikh @PennMedicine and colleagues find that ML algorithms based on PRO and EHR data significantly outperform other algorithms. [ABSTRACT FROM AUTHOR]

In this rare variant genetic association burden testing study of DNA repair genes, only BRCA2 was statistically significantly associated with localized prostate cancer and only in individuals of genetically determined European ancestry. Inherited mutations in the majority of DNA repair genes besides BRCA2 may not be associated with an increased risk of localized prostate cancer. Identification of germline mutations in DNA repair genes has significant implications for the personalized treatment of individuals with prostate cancer (PrCa). To determine DNA repair genes associated with localized PrCa in a diverse academic biobank and to determine genetic testing burden. A cross-sectional study of 2391 localized PrCa patients was carried out. Genetic ancestry and mutation rates (excluding somatic interference) in 17 DNA repair genes were determined in 1588 localized PrCa patients and 3273 cancer-free males. Burden testing within individuals of genetically determined European (EUR) and African (AFR) ancestry was performed between biobank PrCa cases and cancer-free biobank and gnomAD males. AFR individuals with localized PrCa had lower DNA repair gene mutation rates than EUR individuals (1.4% vs 4.0%, p = 0.02). Mutation rates in localized PrCa patients were similar to those in biobank and gnomAD controls (EUR: 4.0% vs 2.8%, p = 0.15, vs 3.1%, p = 0.04; AFR: 1.4% vs 1.8%, p = 0.8, vs 2.1%, p = 0.5). Gene-based rare variant association testing revealed that only BRCA2 mutations were significantly enriched compared with gnomAD controls of EUR ancestry (1.0% vs 0.28%, p = 0.03). Of the participants, 21% and 11% met high-risk and very-high-risk criteria; of them, 3.7% and 6.2% had any germline genetic mutation and 1.0% and 2.5% had a BRCA2 mutation, respectively. Limitations of this study include an analysis of a relatively small, single-institution cohort. DNA repair gene germline mutation rates are low in an academic biobank cohort of localized PrCa patients, particularly among individuals of AFR genetic ancestry. Mutation rates in genes with published evidence of association with PrCa exceed 2.5% only in high-risk, very-high-risk localized, and node-positive PrCa patients. These findings highlight the importance of risk stratification in localized PrCa patients to identify appropriate patients for germline genetic testing. In the majority of patients who develop localized prostate cancer, germline genetic testing is unlikely to reveal an inherited DNA repair mutation, regardless of race. High-risk features increase the possibility of a germline DNA repair mutation. [ABSTRACT FROM AUTHOR]

We tracked endocrine surgery patients with treatment delays due to COVID-19 to investigate the relationship between physician assigned priority scoring (PAPS), the Medically Necessary, Time Sensitive (MeNTS) scoring system and delay to surgery. Patients scheduled for endocrine surgery or clinically evaluated during COVID-19-related elective surgery hold at our institution (2/26/20–5/1/20) were prospectively enrolled. PAPS was assigned based on categories of high, moderate, or low risk, consistent with the American College of Surgeons' priority system. MeNTS scores were calculated. The primary outcome was delay to surgery. Descriptive statistics were performed, and receiver operator characteristic (ROC) curves and area under the curve (AUC) values were calculated for PAPS and MeNTS. Of 146 patients included, 68% (n = 100) were female; the median age was 60 years (IQR:43,67). Mean delay to surgery was significantly shorter (P = 0.01) in patients with high PAPS (35 d), compared with moderate (61 d) and low (79 d) PAPS groups. MeNTS scores were provided for 105 patients and were analyzed by diagnosis. Patients with benign thyroid disease (n = 17) had a significantly higher MeNTS score than patients with thyroid disease which was malignant/suspicious for malignancy (n = 44) patients (51.5 versus 47.6, P = 0.034). Higher PAPS correlated well with a delay to surgery of <30 d (AUC: 0.72). MeNTS score did not correlate well with delay to surgery <30 d (AUC: 0.52). PAPS better predicted delay to surgery than MeNTS scores. PAPS may incorporate more complex components of clinical decision-making which are not captured in the MeNTS score. [ABSTRACT FROM AUTHOR]

Background: To ensure safe delivery of oncologic care during the COVID-19 pandemic, telemedicine has been rapidly adopted. However, little data exist on the impact of telemedicine on quality and accessibility of oncologic care. This study assessed whether conducting an office visit for thoracic oncology patients via telemedicine affected time to treatment initiation and accessibility.Methods: This was a retrospective cohort study of patients with thoracic malignancies seen by a multidisciplinary team during the first surge of COVID-19 cases in Philadelphia (March 1 to June 30, 2020). Patients with an index visit for a new phase of care, defined as a new diagnosis, local recurrence, or newly discovered metastatic disease, were included.Results: 240 distinct patients with thoracic malignancies were seen: 132 patients (55.0%) were seen initially in-person vs 108 (45.0%) via telemedicine. The majority of visits were for a diagnosis of a new thoracic cancer (87.5%). Among newly diagnosed patients referred to the thoracic oncology team, the median time from referral to initial visit was significantly shorter amongst the patients seen via telemedicine vs. in-person (median 5.0 vs. 6.5 days, p < 0.001). Patients received surgery (32.5%), radiation (24.2%), or systemic therapy (30.4%). Time from initial visit to treatment initiation by modality did not differ by telemedicine vs in-person: surgery (22 vs 16 days, p = 0.47), radiation (27.5 vs 27.5 days, p = 0.86, systemic therapy (15 vs 13 days, p = 0.45).Conclusions: Rapid adoption of telemedicine allowed timely delivery of oncologic care during the initial surge of the COVID19 pandemic by a thoracic oncology multi-disciplinary clinic. [ABSTRACT FROM AUTHOR]

Background: Serious illness conversations (SICs) are an evidence-based approach to eliciting patients' values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics ("nudges") that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion-either alone or in combination with clinician nudges that additionally compare performance relative to peers-may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer.Methods: We will conduct a 2 × 2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system and their approximately 5500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects), palliative care referral among high-risk patients, and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape the effectiveness of nudges with an eye towards health equity.Discussion: This will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies.Trial Registration: ClinicalTrials.gov , NCT04867850 . Registered on April 30, 2021.Funding: National Cancer Institute P50CA244690. [ABSTRACT FROM AUTHOR]

Background: Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care.Methods: A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or "nudges") promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges.Discussion: This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers.Trial Registration: Clinicaltrials.gov, NCT04737031 . Registered 3 February 2021. [ABSTRACT FROM AUTHOR]

There are emerging data that patients <50 years are diagnosed with esophageal adenocarcinoma (EAC) more frequently, suggesting that the age threshold for screening should be revisited. This study aimed to determine the age distribution, outcomes, and clinical features of EAC over time. The pathology database at the Hospital of the University of Pennsylvania was reviewed from 1991 to 2018. The electronic health records and pathology were reviewed for age of diagnosis, pathology grade, race, and gender for a cohort of 630 patients with biopsy proven EAC. For the patients diagnosed from 2009 to 2018, the Penn Abramson Cancer Center Registry was reviewed for survival and TNM stage. Of the 630 patients, 10.3% (65 patients) were <50 years old [median 43 years, range 16–49]. There was no increase in the number of patients <50 years diagnosed with EAC (R  = 0.133, P  = 0.05). Characteristics of those <50 years versus >50 years showed no difference in tumor grade. Among the 179 eligible patients in the cancer registry, there was no significant difference in clinical or pathological stage for patients <50 years (P value = 0.18). There was no association between diagnosis age and survival (P  = 0.24). A substantial subset of patients with EAC is diagnosed at <50 years. There was no increasing trend of EAC in younger cohorts from 1991 to 2018. We could not identify more advanced stage tumors in the younger cohort. There was no significant association between diagnosis age and survival. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to compare the effectiveness of ensemble methods (e.g., random forests) and single‐model methods (e.g., logistic regression and decision trees) in predictive modeling of post‐RT treatment failure and adverse events (AEs) for breast cancer patients using automatically extracted EMR data. Methods: Data from 1967 consecutive breast radiotherapy (RT) courses at one institution between 2008 and 2015 were automatically extracted from EMRs and oncology information systems using extraction software. Over 230 variables were extracted spanning the following variable segments: patient demographics, medical/surgical history, tumor characteristics, RT treatment history, and AEs tracked using CTCAEv4.0. Treatment failure was extracted algorithmically by searching posttreatment encounters for evidence of local, nodal, or distant failure. Individual models were trained using decision trees, logistic regression, random forests, and boosted decision trees to predict treatment failures and AEs. Models were fit on 75% of the data and evaluated for probability calibration and area under the ROC curve (AUC) on the remaining test set. The impact of each variable segment was assessed by retraining without the segment and measuring change in AUC (ΔAUC). Results: All AUC values were statistically significant (P < 0.05). Ensemble methods outperformed single‐model methods across all outcomes. The best ensemble method outperformed decision trees and logistic regression by an average AUC of 0.053 and 0.034, respectively. Model probabilities were well calibrated as evidenced by calibration curves. Excluding the patient medical history variable segment led to the largest AUC reduction in all models (Average ΔAUC = −0.025), followed by RT treatment history (−0.021) and tumor information (−0.015). Conclusion: In this largest such study in breast cancer performed to date, automatically extracted EMR data provided a basis for reliable outcome predictions across multiple statistical methods. Ensemble methods provided substantial advantages over single‐model methods. Patient medical history contributed the most to prediction quality. [ABSTRACT FROM AUTHOR]

Purpose: To report acute and late genitourinary (GU) and gastrointestinal (GI) toxicities associated with post-prostatectomy proton therapy (PT). Methods: The first 100 consecutive patients from 2010 to 2016 were retrospectively assessed. Baseline characteristics, prospectively graded CTCAE v4.0 toxicities, and patient-reported outcomes were reported. Late outcomes were reported for 79 patients with 3 months minimum follow up. Toxicityfree survival Kaplan-Meier curves were estimated. Logistic regression assessed associations between toxicities and clinical and treatment characteristics (p<.05 significance). Results: Median age, months after surgery, and months of follow-up were respectively 64 years (range 42-77), 25 (5-216), and 25 (0-47). PT received was 70.2Gy (RBE) (89%), salvage (93%), prostate bed only (80%), pencil beam scanning (86%), with IMRT (31%), and with androgen deprivation (34%). Acute and late maximum toxicities, respectively were: GU grade 0 (14%; 18%), 1 (71%; 62%), 2 (15%; 20%), ≥3 (0), and GI: grade 0 (66%; 73%), 1 (34%; 27%), ≥2 (0). Toxicity-free survival at 24 months was GU grade 2 (83%) and GI grade 1 (74%). Mean (±std dev) baseline International Prostate Symptom Score (IPSS), International Index of Erectile Function, and Expanded Prostate Cancer Index Composite bowel function and bother were 6.6 ± 6.1, 10.5 ± 7.3, 90.9 ± 10.8, 93.3 ± 11.2, respectively, and largely unchanged at 2 years: 6.3 ± 3.6, 11.1 ± 6.3, 92.8 ± 5.8, and 90.9 ± 10.3. On multivariate analysis, baseline IPSS (p=.009) associated with GU grade 2 acute toxicity. Bladderless-CTV median dose, V30, and V40 associated with GU grade 2 acute toxicity and maximum dose with late (Ps <0.05). For GI, on multivariate analysis, baseline bowel function (p=.033) associated with acute grade 1 toxicity. Rectal minimum and median dose, V10, and V20, and anterior rectal wall median dose and V10 through V65 associated with acute grade 1 GI toxicity (Ps<.05). Conclusions: Post-prostatectomy PT for prostate cancer is feasible with a favorable GU and GI toxicity profile acutely and through early follow up. [ABSTRACT FROM AUTHOR]

It is an exciting time for big data efforts in radiation oncology. The use of big data to help aid both outcomes and decision‐making research is becoming a reality. However, there are true challenges that exist in the space of gathering and utilizing performance and outcomes data. Here, we summarize the current state of big data in radiation oncology with respect to outcomes and discuss some of the efforts and challenges in radiation oncology big data. [ABSTRACT FROM AUTHOR]

Purpose: TP53 mutation (MT) in epidermal growth factor receptor (EGFR) -MT non–small cell lung cancer (NSCLC) is associated with poor response to targeted therapy; however, its impact on survival is not clearly established. Patients and Methods: We performed an analysis of patients with stage IV EGFR MT NSCLC with available gene sequencing data. Associations between baseline characteristics; molecular profile, including TP53 MT; and survival outcomes were assessed. Results: We identified 131 consecutive patients with EGFR MT; 81 (62%) had a TP53 MT, and 55 (42%) had other coexisting oncogenic MTs. Emergent EGFR T790M MT was observed in 42 patients (32%). Overall survival (OS) was longer for younger patients (P =.003), never smokers (P =.002), those with Eastern Cooperative Oncology Group performance status 0 to 1 (P =.004), and emergent T790M MT (P =.018). TP53 MT (P =.021) and other coexisting oncogenic MTs (P = 0.011) were associated with inferior OS. In a multivariable regression analysis adjusted for age, smoking, Eastern Cooperative Oncology Group performance status, and the presence of TP53 MT (P =.063) and other coexisting MTs (P =.064) did not achieve statistical significance. Patients with EGFR T790M /TP53 double MT had worse OS compared with patients with T790M MT alone (46.4 months v 82.9 months). In our series, five patients transformed to small-cell lung cancer (5.6%). All had TP53 MT. In four patients, allelic fraction of TP53 MT increased at the time of transformation. Conclusion: The presence of TP53 and other coexisting MTs in EGFR MT NSCLC were associated with inferior OS, including patients with emergent T790M MT. An increase in TP53 mutation allelic fraction may potentially be a useful clinical predictor of small-cell transformation. [ABSTRACT FROM AUTHOR]

A substantial barrier to the single- and multi-institutional aggregation of data to supporting clinical trials, practice quality improvement efforts, and development of big data analytics resource systems is the lack of standardized nomenclatures for expressing dosimetric data. To address this issue, the American Association of Physicists in Medicine (AAPM) Task Group 263 was charged with providing nomenclature guidelines and values in radiation oncology for use in clinical trials, data-pooling initiatives, population-based studies, and routine clinical care by standardizing: (1) structure names across image processing and treatment planning system platforms; (2) nomenclature for dosimetric data (eg, dose-volume histogram [DVH]-based metrics); (3) templates for clinical trial groups and users of an initial subset of software platforms to facilitate adoption of the standards; (4) formalism for nomenclature schema, which can accommodate the addition of other structures defined in the future. A multisociety, multidisciplinary, multinational group of 57 members representing stake holders ranging from large academic centers to community clinics and vendors was assembled, including physicists, physicians, dosimetrists, and vendors. The stakeholder groups represented in the membership included the AAPM, American Society for Radiation Oncology (ASTRO), NRG Oncology, European Society for Radiation Oncology (ESTRO), Radiation Therapy Oncology Group (RTOG), Children's Oncology Group (COG), Integrating Healthcare Enterprise in Radiation Oncology (IHE-RO), and Digital Imaging and Communications in Medicine working group (DICOM WG); A nomenclature system for target and organ at risk volumes and DVH nomenclature was developed and piloted to demonstrate viability across a range of clinics and within the framework of clinical trials. The final report was approved by AAPM in October 2017. The approval process included review by 8 AAPM committees, with additional review by ASTRO, European Society for Radiation Oncology (ESTRO), and American Association of Medical Dosimetrists (AAMD). This Executive Summary of the report highlights the key recommendations for clinical practice, research, and trials. [ABSTRACT FROM AUTHOR]

Objectives Efficient use of nivolumab in non-small-cell lung cancer (NSCLC) has been limited by the lack of a definitive predictive biomarker. In patients with metastatic melanoma treated with ipilimumab, a pretreatment neutrophil-to-lymphocyte ratio (NLR) < 5 has been associated with improved survival. This retrospective cohort study aimed to determine whether the pretreatment NLR was associated with outcomes in NSCLC patients treated with nivolumab. Methods We reviewed the medical records of all patients with previously treated advanced NSCLC who received nivolumab between March 2015 and March 2016 outside of a clinical trial at the University of Pennsylvania. Patients were dichotomized according to pretreatment NLR < 5 vs. ≥5. Multivariable logistic regression and Cox proportional hazards models were used to assess the impact of pretreatment NLR on overall survival (OS), progression-free survival (PFS), and overall response rate (ORR). Results 175 patients were treated. Median age was 68 (range, 33–88); 54% were female. Twenty-five percent of patients had an Eastern Cooperative Oncology Group Performance Status (ECOG PS) ≥2; 46% had received ≥2 prior systemic therapies. In multivariate analyses, pretreatment neutrophil-to-lymphocyte ratio (NLR) ≥5 was independently associated with inferior OS (median 5.5 vs. 8.4 months; HR 2.07, 95% CI 1.3–3.3; p = 0.002) and inferior PFS (median 1.9 vs. 2.8 months; HR 1.43, 95% CI 1.02–2.0; p = 0.04). Conclusions In a cohort of patients with NSCLC treated with nivolumab in routine practice, pretreatment NLR ≥ 5 was associated with inferior outcomes. It is unclear whether this marker is predictive or prognostic. Prospective studies are warranted to determine the utility of NLR in the context of other biomarkers of programmed death-1 (PD-1) therapy. [ABSTRACT FROM AUTHOR]

Purpose/objectives: The clinical effects of radiation dose-intensification in locally advanced non-small cell lung (NSCLCa) and other cancers are challenging to predict and are ideally studied in randomized trials. The purpose of this study was to assess the use of dose-escalated radiation for locally advanced NSCLCa in the U.S., 2004-2013, a period in which there were no published level 1 studies on dose-escalation.Materials/methods: We performed analyses on two cancer registry databases with complementary strengths and weaknesses: the National Oncology Data Alliance (NODA) 2004-2013 and the National Cancer Database (NCDB) 2004-2012. We classified locally advanced patients according to the use of dose-escalation (>70 Gy). We used adjusted logistic regression to assess the association of year of treatment with dose-escalated radiation use in two periods representing time before and after the closure of a cooperative group trial (RTOG 0617) on dose-escalation: 2004-2010 and 2010-2013. To determine the year in which a significant change in dose could have been detected had dose been prospectively monitored within the NODA network, we compared the average annual radiation dose per year with the forecasted dose (average of the prior 3 years) adjusted for patient age and comorbidities.Results: Within both the NODA and NCDB, use of dose-escalation increased from 2004 to 2010 (p < 0.0001) and decreased from 2010 to 2013 (p = 0.0018), even after controlling for potential confounders. Had the NODA network been monitoring radiation dose in this cohort, significant changes in average annual dose would have been detected at the end of 2008 and 2012.Conclusions: Patterns of radiation dosing in locally advanced NSCLCa changed in the U.S. in the absence of level 1 evidence. Monitoring radiation dose is feasible using an existing national cancer registry data collection infrastructure. [ABSTRACT FROM AUTHOR]

Background High-reliability organizations (HROs) focus on continuous identification and improvement of safety issues. We sought to advance a large, multisite radiation oncology department toward high reliability through the implementation of a comprehensive safety culture (SC) program at the University of Pennsylvania Department of Radiation Oncology. Methods In 2011, with guidance from safety literature and experts in HROs, we designed an SC framework to reduce radiation errors. All state-reported medical events (SRMEs) from 2009 to 2016 were retrospectively reviewed and plotted on a control chart. Changes in SC grade were assessed using the Agency for Healthcare Research and Quality Hospital Survey. Outcomes measured included the number of radiation treatment fractions and days between SRMEs, as well as SC grade. Results Multifaceted safety initiatives were implemented at our main academic center and across all network sites. Post intervention results demonstrate increased staff fundamental safety knowledge, enhanced peer review with an electronic system, and special cause variation of SRMEs on control chart analysis. From 2009 to 2016, the number of days and fractions between SRMEs significantly increased, from a mean of 174 to 541 days (P <.0075) and 21,678 to 113,104 fractions (P < .0028) preintervention and postintervention, respectively. Agency for Healthcare Research and Quality results demonstrate a high patient SC grade over time. Conclusion Our journey toward becoming an HRO has led to the development of a robust SC through a comprehensive safety framework. Our multifaceted initiatives, focusing on culture and system changes, can be successfully implemented in a large academic radiation oncology department to yield measurable improvements in SC and outcomes. [ABSTRACT FROM AUTHOR]

Background and purpose Radiation is an important modality in treatment of thymic tumors. However, toxicity may reduce its overall benefit. We hypothesized that double-scattering proton beam therapy (DS-PT) can achieve excellent local control with limited toxicity in patients with thymic malignancies. Methods and materials Patients with thymoma or thymic carcinoma treated with DS-PT between 2011 and 2015 were prospectively analyzed for toxicity and patterns of failure on an IRB-approved study. Results Twenty-seven consecutive patients were evaluated. Patients were a median of 56 years and had thymoma (85%). They were treated with definitive (22%), salvage (15%) or adjuvant (63%) DS-PT to a median of 61.2/1.8 Gy [CGE]. No patient experienced grade ⩾3 toxicity. Acute grade 2 toxicities included dermatitis (37%), fatigue (11%), esophagitis (7%), and pneumonitis (4%). Late grade 2 toxicity was limited to a single patient with chronic dyspnea. At a median follow-up of 2 years, 100% local control was achieved. Three-year regional control, distant control, and overall survival rates were 96% (95% CI 76–99%), 74% (95% CI 41–90%), and 94% (95% CI 63–99%), respectively. Conclusions This is the first cohort and prospective series of proton therapy to treat thymic tumors, demonstrating low rates of early toxicity and excellent initial outcomes. [ABSTRACT FROM AUTHOR]

The age of the victim plays a crucial role for the legal implications concerning pornography. Judges therefore often call on forensic experts to verify the age of individuals depicted on photographs or videos. However, there is no scientifically established protocol available for forensic practice in such cases. The conventional methods such as the evaluation of secondary sexual characteristics provide unsatisfactory results particularly when the legally relevant ages for child pornography (i.e. 14 and 18 years) are concerned. To overcome these limits, a European research group has explored the applicability of facial proportions as an age indicator on images. In this pilot study, standardized facial images of 353 females and 20 males from four age groups (6, 10, 14 and 18 years) were randomly selected for the metric analysis from a large data set including German, Italian and Lithuanian subjects. In this sample, several indices extracted from the frontal and lateral photographs were closely correlated to their respective indices taken from the living individuals. Furthermore, age-related changes were identified for indices taken from the photographs. The discriminant analysis showed that for the pooled sample, 60.3% of the cases were correctly classified into the respective age group. The percentage of correctly classified cases increased in the respective country samples as follows: 69.9% for Germany, 69.4% for Lithuania and 80.5% for Italy. The present study suggests that the metric assessment of the face may be used for age estimation on images. Nonetheless, more work needs to be done in order to verify the reliability of these findings on a large sample. [ABSTRACT FROM AUTHOR]

Abstract: The issue of juvenile pornography has seen an increase in the past few years of the number of expert opinions requested to forensic pathologists, paediatricians and other various experts within the forensic and medical fields concerning the age of represented individuals. Regardless of the entity of the problem, no actual method exists which can allow us to give an objective and scientific answer, particularly in the postpubertal stage. Using parameters related to sexual maturation can be very dangerous. Nonetheless some experts still insist with similar types of “expertises”. This study aims at verifying the ability of different experts in assessing age of postpubertal individuals represented in pornographic material. Results underline the difficulties and major uncertainties of age evaluation by visual observation of photographic material particularly when the subjects have reached the sexual maturation stage – and therefore in verifying whether the individual is above or below 18 years of age (an important age limit for most European countries as far as this type of crime is concerned). Furthermore the study stresses the need both to search for an alternate approach and to apply extreme caution in judicial evaluation. [Copyright &y& Elsevier]

Introduction: Widespread adoption of Electronic Health Records (EHR) increased the number of reported disease association studies, or Phenome-Wide Association Studies (PheWAS). Traditional PheWAS studies ignore visit type (i.e., department/service conducting the visit). In this study, we investigate the role of visit type on disease association results in the first Visit-Wide Association Study or 'VisitWAS'. Results: We studied this visit type effect on association results using EHR data from the University of Pennsylvania. Penn EHR data comes from 1,048 different departments and clinics. We analyzed differences between cancer and obstetrics/gynecologist (Ob/Gyn) visits. Some findings were expected (i.e., increase of neoplasm diagnoses among cancer visits), but others were surprising, including an increase in infectious disease conditions among those visiting the Ob/Gyn. Conclusion: We conclude that assessing visit type is important for EHR studies because different medical centers have different visit type distributions. To increase reproducibility among EHR data mining algorithms, we recommend that researchers report visit type in studies. [ABSTRACT FROM AUTHOR]