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This cross-sectional study examines private equity backed acquisitions of medical and radiation oncology clinics in the US from 2003 to 2022 using financial databases and publicly available data.

As our power grids transition toward a decarbonized energy mix, ensuring reliability and provision of grid services remains paramount. The power system has always been heavily influenced by the weather—extreme temperatures determine the timing of peak demand, winter cold snaps can limit natural gas supply, gas turbine reliability and output are affected by ambient conditions, and hydro output varies seasonally and annually. However, as the grid increasingly relies on variable renewable energy (VRE), like wind and solar, the attention to reliability and weather conditions is increasingly important. The implications of changing reliability are large. The Electric Reliability Council of Texas (ERCOT) rolling blackouts from earlier this year impacted millions of people across the state and could be seen from space ( Figure 1 ).

In 2015, the US Food and Drug Administration passed a ban on the “generally recognized as safe” status of partially hydrogenated oils (PHOs), and in June 2018, PHOs were prohibited from being used. Our objective was to develop a predictive model to quantify trans-fat concentrations in bakery and snacks products using a portable mid-infrared (MIR) spectrometer. The approach was tested using 24 calibration standards (consisting of trielaidin in triolein and tripalmitin) and 87 bakery and snack products ranging from ND to 65% trans-fat. The fat was extracted by grinding products into powders and extracting the fat using petroleum ether. Gas Chromatography (AOCS Cd 14c-94) was used to determine the fatty acid profile and trans-fat content. Spectra were acquired by directly placing the fat (200 μL) onto the heated (65 ± 1°C) 5–reflection ZnSe crystal of a portable MIR spectrometer. Partial least squares regression (PLSR) models were developed using the calibration standards and extracted fats spectra targeting the signal of the C–H out-of-plane deformation band at 966 cm−1. Best model performances were obtained using the spectra of the extracted fat from bakery and snack products with the standard error of prediction of 0.5 g of trans-fats per 100 g of fat. We found that 25% of products labeled as zero trans-fat/serving did not comply with the maximum tolerance levels based on GC-FAME analysis. Portable FTIR devices operating in attenuated total reflection (ATR) mode can provide the food industry and government food inspectors with rapid, accurate, and high throughput measurements for routine screening to facilitate regulatory compliance.

The treatment of patients with cancer who test positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) poses unique challenges. In this commentary, the authors describe the ethical rationale and implementation details for the creation of a novel, multidisciplinary treatment prioritization committee, including physicians, frontline staff, an ethicist, and an infectious disease expert. Organizational obligations to health care workers also are discussed. The treatment prioritization committee sets a threshold of acceptable harm to patients from decreased cancer control that is justified to reduce risk to staff. The creation of an ethical, consistent, and transparent decision‐making process involving such frontline stakeholders is essential as departments across the country are faced with decisions regarding the treatment of SARS‐CoV‐2–positive patients with cancer., This commentary describes the ethical rationale and implementation details for a novel, multidisciplinary, treatment prioritization committee that makes treatment decisions regarding patients with cancer who are positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). This consistent, ethical, and transparent process could be adapted to any oncology department in which there is risk disparity between physician decision makers and the frontline staff who are implementing these decisions.

Background: Among patients diagnosed with stage IA non–small cell lung cancer (NSCLC), the incidence of occult brain metastasis is low, and several professional societies recommend against brain imaging for staging purposes. The goal of this study was to characterize the use of brain imaging among Medicare patients diagnosed with stage IA NSCLC. Methods: Using data from linked SEER-Medicare claims, we identified patients diagnosed with AJCC 8th edition stage IA NSCLC in 2004 through 2013. Patients were classified as having received brain imaging if they underwent head CT or brain MRI from 1 month before to 3 months after diagnosis. We identified factors associated with receipt of brain imaging using multivariable logistic regression. Results: Among 13,809 patients with stage IA NSCLC, 3,417 (25%) underwent brain imaging at time of diagnosis. The rate of brain imaging increased over time, from 23.5% in 2004 to 28.7% in 2013 (P=.0006). There was significant variation in the use of brain imaging across hospital service areas, with rates ranging from 0% to 64.0%. Factors associated with a greater likelihood of brain imaging included older age (odds ratios [ORs] of 1.16 for 70–74 years, 1.13 for 75–79 years, 1.31 for 80–84 years, and 1.46 for ≥85 years compared with 65–69 years; all PPPP1 vs score of 0; PConclusions: Roughly 1 in 4 patients with stage IA NSCLC received brain imaging at the time of diagnosis despite national recommendations against the practice. Although several patient factors are associated with receipt of brain imaging, there is significant geographic variation across the United States. Closer adherence to clinical guidelines is likely to result in more cost-effective care.

Patients with lung cancer and brain metastases represent a markedly heterogeneous population. Accurate prognosis is essential to optimally individualize care. In prior publications, we described the graded prognostic assessment (GPA), but a GPA for patients with small cell lung cancer (SCLC) has never been reported, and in non-small cell lung cancer (NSCLC), the effect of programmed death ligand 1 (PD-L1) was unknown. The 3-fold purpose of this work is to provide the initial report of an SCLC GPA, to evaluate the effect of PD-L1 on survival in patients with NSCLC, and to update the Lung GPA accordingly.A multivariable analysis of prognostic factors and treatments associated with survival was performed on 4183 patients with lung cancer (3002 adenocarcinoma, 611 nonadenocarcinoma, 570 SCLC) with newly diagnosed brain metastases between January 1, 2015, and December 31, 2020, using a multi-institutional retrospective database. Significant variables were used to update the Lung GPA.Overall median survival for lung adenocarcinoma, SCLC, and nonadenocarcinoma was 17, 10, and 8 months, respectively, but varied widely by GPA from 2 to 52 months. In SCLC, the significant prognostic factors were age, performance status, extracranial metastases, and number of brain metastases. In NSCLC, the distribution of molecular markers among patients with lung adenocarcinoma and known primary tumor molecular status revealed alterations/expression in PD-L1 50% to 100%, PD-L1 1% to 49%, epidermal growth factor receptor, and anaplastic lymphoma kinase in 32%, 31%, 30%, and 7%, respectively. Median survival of patients with lung adenocarcinoma and brain metastases with 0, 1% to 49%, and ≥50% PD-L1 expression was 17, 19, and 24 months, respectively (P.01), confirming PD-L1 is a prognostic factor. Previously identified prognostic factors for NSCLC (epidermal growth factor receptor and anaplastic lymphoma kinase status, performance status, age, number of brain metastases, and extracranial metastases) were reaffirmed. These factors were incorporated into the updated Lung GPA with robust separation between subgroups for all histologies.Survival for patients with lung cancer and brain metastases has improved but varies widely. The initial report of a GPA for SCLC is presented. For patients with NSCLC-adenocarcinoma and brain metastases, PD-L1 is a newly identified significant prognostic factor, and the previously identified factors were reaffirmed. The updated indices establish unique criteria for SCLC, NSCLC-nonadenocarcinoma, and NSCLC-adenocarcinoma (incorporating PD-L1). The updated Lung GPA, available for free at brainmetgpa.com, provides an accurate tool to estimate survival, individualize treatment, and stratify clinical trials.

The European Society for Therapeutic Radiology and Oncology Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) recently released new contouring guidelines for postmastectomy radiation therapy (PMRT) after implant-based reconstruction (IBR). As compared to prior ESTRO guidelines, the new guidelines primarily redefined the chest wall (CW) target to exclude the breast prosthesis. In this study, we assessed the impact of these changes on treatment planning and dosimetric outcomes using volumetric-modulated arc therapy (VMAT) and proton pencil-beam scanning (PBS) therapy.We performed a treatment planning study of 10 women with left-sided breast cancer who underwent PMRT after IBR. All target structures were delineated first using standard (ESTRO) breast contouring guidelines and then separately using the new (ESTRO-ACROP) guidelines. Standard organs-at-risk (OARs) and cardiac substructures were contoured. Four sets of plans were generated: (1) VMAT using standard ESTRO contours, (2) VMAT using new ESTRO-ACROP contours, (3) PBS using standard contours, and (4) PBS using new contours.VMAT plans using the new ESTRO-ACROP guidelines resulted in modest sparing of the left anterior descending coronary artery (LAD) (mean dose: 6.99 Gy standard ESTRO vs. 6.08 Gy new ESTRO-ACROP,PMRT after IBR using the new ESTRO-ACROP contouring guidelines with both VMAT and PBS therapy is associated with significant changes in exposure to several cardiopulmonary structures.

Cancer cells rewire their metabolism to promote cell proliferation, invasion, and metastasis. Alterations in the lactate pathway have been characterized in diverse cancers, correlate with outcomes, and lead to many downstream effects, including decreasing oxidative stress, promoting an immunosuppressive tumor microenvironment, lipid synthesis, and building chemo- or radio-resistance. Radiotherapy is a key modality of treatment for many cancers and approximately 50% of patients with cancer will receive radiation for cure or palliation; thus, overcoming radio-resistance is important for improving outcomes. Growing research suggests that important molecular controls of the lactate pathway may serve as novel therapeutic targets and in particular, radiosensitizers. In this mini-review, we will provide an overview of lactate metabolism in cancer, discuss three important contributors to lactate metabolism (lactate dehydrogenase, monocarboxylate transporters, and mitochondrial pyruvate carrier), and present data that inhibition of these three pathways can lead to radiosensitization. Future research is needed to further understand critical regulators of lactate metabolism and explore clinical safety and efficacy of inhibitors of lactate dehydrogenase, monocarboxylate transporters, and mitochondrial pyruvate carrier alone and in combination with radiation.

Renewable technologies are often characterized as being somewhat different to ‘conventional’ generating technologies in three ways, each with different implications for electricity markets. Firstly, some have highly variable and somewhat uncertain availability, meaning that electricity markets must be designed to elicit adequate flexibility. Secondly, many have very low short-run marginal costs (operating costs), meaning that the mechanisms for managing resource adequacy must be carefully considered. Thirdly, some are nonsynchronous, meaning that grid codes and regulatory requirements must be appropriately designed. Access to flexibility can be enhanced by a range of market design choices, such as short dispatch intervals, short delays from gate closure to dispatch, large balancing areas, high demand side participation, and exposing renewable technologies to market price signals commensurate with other technologies. The design of markets for frequency control ancillary services (FCAS) also provides opportunities to increase access to flexibility, by creating active real-time markets for a wide range of FCAS, allowing renewable technologies to provide FCAS, and determining FCAS reserve requirements dynamically in real time. Mechanisms for managing resource adequacy are a source of ongoing debate, with many of the key issues having been exacerbated by the entry of renewables. Rapid market change makes investment decisions difficult, regardless of the market model applied. Ultimately, given the existence of arguably successful examples of both energy-only and capacity market designs, the choice of market model may be less important than the quality of governance with which it is implemented and maintained. WIREs Energy Environ 2015, 4:279–289. doi: 10.1002/wene.137 For further resources related to this article, please visit the WIREs website. Conflict of interest: The authors have declared no conflicts of interest for this article.

Purpose/objective(s) Relapsed or refractory central nervous system lymphoma (CNSL) after high-dose methotrexate-based therapy is a challenging clinical entity with limited treatment options. Salvage systemic therapy and whole brain radiation therapy (WBRT) are commonly employed but are associated with significant toxicity and poor outcomes. Prior studies have shown that primary CNSLs frequently exhibit increased expression of PD-L1, and immune checkpoint inhibitor (ICI) therapy may be active in this setting. We assessed the safety and efficacy of concurrent ICI therapy and hypo-fractionated stereotactic radiation therapy (SRT) in patients with relapsed or refractory CNSL. Materials/methods We retrospectively analyzed the records of patients with relapsed or refractory CNSL treated with SRT + ICI at our institution from 2017 to 2020. ICI therapy included pembrolizumab 200 mg IV q3weeks or nivolumab 3 mg/mg IV q2weeks. Linac-based SRT was delivered in 5 daily fractions of 5 Gy. CTVs included all grossly enhancing disease on T1 weighted post-contrast MR scans, with 3 mm uniform PTV expansions. Patients were followed for symptomatic and radiographic response. Progression-free survival (PFS) and overall survival (OS) were calculated via Kaplan-Meier analysis. Results Seven consecutive patients with relapsed or recurrent CNSL were analyzed: 6 with primary CNSL, 1 with secondary CNSL. Patients presented at a median age of 72.2 years (range: 40.9 - 89.9) after a median of 2 prior courses of systemic therapy. Five patients had a solitary intracranial lesion and 2 had multiple lesions. None had active extracranial disease. Median pre-SRT Karnofsky Performance Status (KPS) was 60 (range 50 - 90). All 7 patients completed SRT and received concurrent and adjuvant ICI therapy. Median follow-up after completion of SRT was 9.1 months. Acute toxicities of SRT and ICI therapy were minimal, including fatigue (3 patients), diarrhea (2), and adrenal insufficiency requiring oral steroids (1). Five patients (71.4%) achieved symptomatic improvement after SRT including 2 patients (28.5%) with a clinical complete response (CR). Median post-SRT KPS was 70 (range: 60 - 100). Six patients had follow-up imaging, and all had an objective response including 3 (50%) with a radiographic CR. The median time to best radiographic response was 2.0 months (range 0.3 - 3.7 months), and all treated lesions remained controlled on all subsequent imaging. Three patients (42.9%) experienced out-of-field intracranial recurrence. Median PFS was 7.7 months (95% CI: 4.0 - 11.4 months) and median OS was 12.6 months (95% CI: 7.5 - 12.7 months) post-SRT. Conclusion Among patients with relapsed or refractory CNSL, SRT + ICI appears to be well tolerated and offers excellent symptomatic and radiographic local control. Further studies are needed to identify appropriate candidates for salvage SRT + ICI, and to evaluate the clinical efficacy and neurocognitive impact of this approach.

Purpose/Objective(s) Medical students underrepresented in medicine (UIM) are less likely to attend medical schools with associated radiation oncology (RO) programs. In response, the Radiation oncology Intensive Shadowing Experience (RISE) was created to proactively address inequities in exposure to RO for UIM. This analysis describes the experiences of participating mentors. We hypothesize that RISE will have an overall positive impact on participating physician mentors. Materials/Methods RISE was developed as a one-week virtual opportunity for UIM senior medical students, interested in RO, attending US or US-affiliated medical schools. Participating medical students were matched with 1-2 RO attendings, a senior resident, a physicist, and a dosimetrist. Mentors were provided with course objectives and a detailed schedule for the week. Mentors completed a post-program survey. Statistical analyses were performed using Fisher's exact test and Mann–Whitney U test. Free text responses provided additional descriptive data. Results Forty-three mentors participated in RISE across two academic medical centers from July-October 2020. Survey response rate was 93% (40/43); 14 attendings, 12 residents, 9 physicists and 5 dosimetrists. Mentors self-identified as White (55%), Asian (34%), Multiracial (5%), Black or African American (3%), and Hispanic/Latino (3%). The majority of attendings and residents found that the goals and objectives were clearly stated, interactions with students were meaningful, and they would recommend the experience to other colleagues (Table 1). Attendings reported a median of 6 hours [interquartile range (IQR) 5,8 hours] on RISE activities per week while residents reported 10 hours [IQR 9,13.5 hours] (P = 0.01). All attendings (100%) and 83% of residents agreed the time commitment was appropriate. Qualitative data revealed themes including positive mentor-mentee connections, improvement in student RO knowledge, positive perception of mentee enthusiasm and engagement, and a sense of personal fulfillment from participation. Conclusion RISE mentors reported a positive and fulfilling experience with the program, and manageable time commitments. Time commitment for resident mentors may need to be improved to ensure sustainability. Future work is merited to determine the long-term impact on both mentors and mentees.

PURPOSE/OBJECTIVE(S) Leptomeningeal disease (LMD) is a devastating diagnosis with limited treatment options and poor prognosis. With recent advances in treatment, women with breast cancer (BC) are living longer and the incidence of LMD in this population is increasing. There remains little data regarding the prognosis and optimal treatment of these patients. As such, we conducted a multi-institutional retrospective review of women with BC LMD and analyzed outcomes based on prognostic factors and treatments. MATERIALS/METHODS We analyzed the records of women diagnosed with BC LMD via MRIs of their brain and/or spine between 2000 and 2020 at two academic medical centers. Demographic and clinical characteristics were abstracted from electronic medical records and an in-depth radiographic review was performed by a neuro-radiologist for each case. Univariate and multivariate Cox proportional-hazards models were generated to identify factors associated with prolonged survival. Collection and analysis of the data was approved by institutional IRB. RESULTS We identified 227 women with BC LMD. Prior to developing LMD, most women initially presented with Stage I-III BC (62.1%) with ductal histology (67.0%) and biological subtypes including ER-positive/HER2-negative (56.8%), HER2-positive (17.6%), and triple-negative (22.0%). LMD was first diagnosed a median of 4.6 years (range: 0 to 34.1 years) after the initial diagnosis of BC, and the median age at LMD diagnosis was 54.6 years (range: 29.4 to 84.5 years). At time of LMD diagnosis, 146 (64.3%) women presented with a Karnofsky Performance Status (KPS) ≥ 70, 90 (39.6%) had a preceding parenchymal brain metastasis, and 23 (10.1%) had LMD as their only site of metastatic disease. Radiographically, classical LMD (61.7%) was observed more frequently than nodular-only LMD (13.2%). Brain-only LMD was present in 55.1% of patients, spine-only in 6.1% of patients, and both brain and spine in 38.8% of patients. Median survival from the time of LMD diagnosis was 4.5 months (95% CI: 3.4-7.8). Pre-treatment clinical factors associated with improved survival on univariate analysis included ER-positive/HER2-negative subtype (P = 0.010), KPS ≥ 70 (P < 0.001), LMD as the only site of metastasis (P = 0.004), stable or controlled extracranial metastases (P = 0.042), absence of leukopenia (P = 0.040) and the presence of nodular LMD (P < 0.001). After adjusting for these clinical factors, the receipt of radiation therapy (adjusted hazard ratio [AHR] 0.50, 95% CI: 0.37 - 0.68), systemic therapy (AHR 0.27, 95% CI: 0.19 - 0.38) and intrathecal chemotherapy (AHR 0.49, 95% CI: 0.33 - 0.75) were all associated with improved survival. CONCLUSION In one of the largest multi-institutional reviews to date, we found that several pre-treatment clinical factors were significantly associated with improved survival among women with breast cancer LMD. However, despite treatment overall survival remains poor, and there is a need for new, effective therapies. AUTHOR DISCLOSURE M.G. Milligan: None. A. Aitelli: None. W.A. Mehan: Consultant; Kura Oncology. D.D. Shi: None. D.N. Cagney: Research Grant; Viewray, NhTheraguix. K.S. Oh: None. N. Wang: None. P. Brastianos: Research Grant; Merck, Eli Lily, BMS. Honoraria; Merck, Genentech. Consultant; Angiochem, Dantari Pharmaceuticals, Elevatebio, Eli Lily, Genentech, Pfizer, SK Life Sciences, Tesaro. B. Moy: Research Grant; PUMA biotechnology. N.U. Lin: Research Grant; Genentech, Merck, Pfizer, Seattle Genetics. Consultant; PUMA Biotechnology, Seattle Genetics, Daiichi Sankyo, Astra Zeneca, Denali Therapeutics, California Institute for Regenerative Medicine, Prelude Therapeutics. H.A. Shih: Employee; Dartmouth Hitchcock. Research Grant; AbbVie, NIH. Honoraria; UpToDate. Consultant; Cleveland Clinic. Speaker's Bureau; prIME Oncology. advisory; The Radiosurgery Society. director of clinical operations; Massachusetts General Hospital. clinical operational leader; Massachusetts General Hospital.

The coronavirus disease 2019 pandemic has been intertwined with the movement for racial justice in the United States and has highlighted and risks aggravating educational and workforce disparities within radiation oncology. We discuss wide-ranging changes within radiation oncology training that are essential to developing and maintaining diversity, including utilization of competency-based educational models that allow for streamlining of training and examinations; responsiveness to the needs of residents and medical students of different gender, racial/ethnic, and socioeconomic groups; and technological integration to increase educational efficiency and decrease barriers.

Purpose Health care practices across the United States have been consolidating in response to various market forces. The degree of practice consolidation varies widely across specialties but has not been well studied within radiation oncology. This study used Medicare data to characterize the extent of practice consolidation among radiation oncologists and to investigate associated market factors. Methods and Materials We utilized Medicare Provider Enrollment, Chain, and Ownership System data to assess the practice size and billing patterns of U.S. radiation oncologists in 2013 and again in 2017. Individual practices were categorized by the number of radiation oncologists practicing together: solo practices had 1 radiation oncologist, small practices 2 to 10, and large practices 11 or more. Market consolidation within each hospital referral region (HRR) across the country was quantified using the Herfindahl-Hirschman Index. Hospital and market level data were obtained for each HRR, and factors associated with the growth of radiation oncology practices over time were calculated via multivariable linear regression. Results Across the United States, radiation oncology practices appear to be highly consolidated. The mean Herfindahl-Hirschman Index was 0.4711 in 2013—indicating high levels of consolidation at baseline—and increased further to 0.4865 by 2017. Between 2013 and 2017, the number of practices with radiation oncologists in the United States decreased 3.8%, from 1679 to 1615, whereas the number of practicing radiation oncologists increased 9.4%, from 4948 to 5415. Over the study period, the number of solo practices fell 11% (from 708 in 2013 to 627 in 2017), whereas the number of large practices (those with 11 or more radiation oncologists) increased 50% (from 60 to 90). Large practices likewise grew to employ a greater share of all radiation oncologists (23.9%-32.4%) and accounted for a larger proportion of total Medicare billing (21%-26%). Two market factors were predictive for increases in the mean radiation oncology practice size. HRRs with greater hospital market consolidation and those with lower levels of baseline radiation oncology consolidation were more likely to experience higher levels of growth over the study period. Conclusions Radiation oncologists are increasingly working in larger practices. By 2017, nearly one-third of all practicing radiation oncologists in the United States were employed by just the 90 largest practices. Radiation oncology, as a field, is highly concentrated, and represents one of the most consolidated specialties across the country. The implications of practice consolidation among radiation oncologists warrants further investigation.

1585 Background: Recent price transparency legislation mandated that hospitals across the country report their individually negotiated prices with insurers. Using this data, we sought to characterize the prices paid for standard intravenous (IV) chemotherapy infusions, and determine the hospital, regional, and market factors associated with higher prices. Methods: We utilized a database of U.S. hospital-reported price transparency data to characterize prices for the most commonly billed chemotherapy drug administration Common Procedural Terminology (CPT) codes— 96413 (initial IV chemotherapy infusion) and 96415 (additional hour of IV chemotherapy). We obtained standard charges and commercial prices negotiated with private payers from hospitals that directly administer chemotherapy. To assess variation in prices, we calculated the ratio of the 90th percentile price to the 10th percentile price among private payers in each hospital and among hospitals in each Hospital Referral Region (HRR). We performed multivariable linear regressions to assess hospital, regional, and market factors associated with higher prices. Results: A total of 1,458 hospitals reported at least one price for CPT code 96413 or 96415. Hospitals reported 1 chargemaster and a median of 18 (IQR: 8–35) commercial prices negotiated with different private payers. National median commercial prices for CPT codes 96413 and 96415 were $536.00 (IQR: $326.43-$784.63) and $175.06 (IQR: $98.28-$327.25), respectively. Within each hospital, the 90th percentile commercial price was 2.2 times higher, on average, than the 10th percentile price for CPT code 96413, and 2.8 times higher for 96415. Among different hospitals within each HRR, the median commercial price at the 90th percentile hospital was 1.5 times higher than at the 10th percentile for CPT code 96413, and 2.3 times higher for 96415. On multivariable analysis, higher prices for CPT code 96413 were observed at for-profit hospitals ($215.12 higher than government not-for-profit hospitals, 95% CI: $55.22-$429.61). Higher prices for CPT code 96415 were observed at hospitals with higher predicted practice costs ($35.79 for every 1% increase in the geographical practice cost index, 95% CI: $16.69-$54.87), and a lower disproportionate share percentage ($0.96 for every 1% decrease in DSH patient percentage, 95% CI: $0.08-$19.41). Conclusions: Commercial prices for commonly billed IV chemotherapy infusions demonstrate significant variability. Prices for identical infusions vary by a factor of 2 depending on which hospital or private payer a patient selects. While prices for CPT code 96415 are largely explained by the relative cost of care, prices for the more expensive 96413 appear to be driven by the profit-status of the hospital. Further study is required to characterize the implications of such high levels of price variability on access to care and overall healthcare costs.

e13627 Background: Physician practices across the U.S. are increasingly merging with hospitals and other practices. The extent of such “practice consolidation” varies by specialty and across geography but has not been well characterized within medical oncology. Methods: Utilizing Medicare data, we identified all medical oncologists (MO) who billed for Medicare services each year between 2015 and January 2022. We associated each physician to one or more unique practices via organizational Taxpayer Identification Numbers (TIN), and classified practices by the number of medical oncologists—including solo (1 MO), small (2-10 MOs), medium (11-24 MOs), and large (25+ MOs) practices. We defined the extent of regional healthcare markets according to Hospital Referral Regions (HRRs), and calculated levels of practice consolidation using the Herfindahl-Hirschman Index (HHI). The HHI is a commonly used measure of consolidation, calculated by summing the square of each practice’s market share. HHI values range from 0 to 1 with higher numbers indicating greater consolidation and less competition among practices. Finally, we generated a multivariable linear regression model to determine which regional market factors were associated with changes in levels of medical oncology practice consolidation over time. Results: Between 2015 and 2022, the number of practices with MOs in the U.S. declined 18.0% from 2,774 to 2,276, while the number of practicing MOs increased 14.5% from 11,727 to 13,433. The median medical oncology practice HHI increased from 0.3204 to 0.3480. Over time the proportion of solo practices fell (48.4% in 2015, 43.9% in 2022) while the proportion of medium and large practices increased (medium: 5.7% to 8.4%; large: 2.7% to 4.5%). By 2022, large practices had grown to employ a significantly larger proportion of all medical oncologists (33.6% to 43.7%, p < 0.001). Between 2015 and 2022, the proportion of practices solely comprised of MOs (as opposed to multispecialty practices) decreased from 40.0% to 28.2%. On multivariable analysis, HRRs with higher levels of hospital consolidation (p < 0.001), greater numbers of hospital beds per 1,000 persons (p = 0.02), and a lesser degree of baseline medical oncology practice consolidation in 2015 (p < 0.001) experienced more consolidation during the study period. Conclusions: Medical oncologists across the U.S. are increasingly working in larger practices. By 2022, more than 40% of all practicing MOs were employed at the largest 5% of practices. Consolidation of medical oncology practices occurred more readily in regions with higher levels of hospital consolidation and a greater supply of hospital beds, suggesting that integration into hospital systems may be a leading source of consolidation. Further study is required to determine the impact of practice consolidation on the cost, quality, and accessibility of cancer care.

The bulk power system is undergoing a digital revolution. With the recent and continuing growth of inverter-based generation, primarily wind and solar energy, the industry has begun exploring the implication of these new resources on power system reliability and resilience. This paper provides an overview and description of grid services that key resource types are able to provide, showing that new resources can provide many of the required grid reliability services.

Purpose Botswana has a high prevalence of HIV infection. Currently, there are few data regarding the sociodemographic factors, clinical characteristics, and outcomes of non-Hodgkin lymphoma (NHL)—an AIDS-defining cancer—in the country. Patients and Methods This study used a prospective cancer registry to identify patients with a new diagnosis of NHL reporting for specialty cancer care at three hospitals in Botswana between October 2010 and August 2016. Treatment patterns and clinical outcomes were analyzed. Results One hundred four patients with a new diagnosis of NHL were enrolled in this study, 72% of whom had HIV infection. Compared with patients not infected with HIV, patients infected with HIV were younger (median age, 53.9 v 39.1 years; P = .001) and more likely to present with an aggressive subtype of NHL (65.5% v 84.0%; P = .008). All patients infected with HIV received combined antiretroviral therapy throughout the course of the study, and similar chemotherapeutic regimens were recommended for all patients, regardless of subtype or HIV status (six to eight cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone; or cyclophosphamide, doxorubicin, vincristine, and prednisone plus rituximab). There was no difference in 1-year mortality among patients not infected with HIV and patients infected with HIV (unadjusted analysis, 52.9% v 37.1%; hazard ratio [HR], 0.73; P = .33; adjusted analysis, HR, 0.57; P = .14). However, when compared with a cohort of patients in the United States matched by subtype, stage, age, sex, and race, patients in Botswana fared worse (1-year mortality, 22.8% v 46.3%; HR, 1.89; P = .001). Conclusion Among patients with NHL reporting for specialty cancer care in Botswana, there is no association between HIV status and 1-year survival.

Purpose/Objective(s) Accurate radiation therapy targeting for stomach cancer is challenging given daily variations in the stomach's size and position. We evaluated daily MR-based imaging to quantify changes in stomach volume and characterized the impact of inter-fractional variation on dosimetry for gastric cancer radiation plans. Materials/Methods We assessed inter-fraction changes in the volume and position of the stomach via MR-based imaging for 10 patients who previously underwent abdominal stereotactic body radiation therapy. All patients were simulated and treated over 5 fractions and were instructed to fast for 3 hours before each session. The stomach and regional organs-at-risk (OARs) were contoured on each fraction's MR scan according to standard RTOG guidelines. Inter-fraction variation in the size and position of the stomach was quantified by calculating the percentage volume change and dice similarity coefficient (DSC) as compared to the simulation scan. To determine the potential impact of inter-fraction stomach motion on treatment planning, we generated mock plans to recapitulate neoadjuvant or definitive stomach cancer treatments. For the purpose of this study, the stomach contour was symmetrically expanded by 1.7 cm to generate a planning treatment volume (PTV) and a prescription dose of 45 Gy in 1.8 Gy fractions was applied. Intensity-modulated radiation therapy plans were then generated to meet the following dosimetric goals: PTV V95% of 95%, liver V30 less than 30%, and bilateral kidney V20 less than 20%. Finally, the impact of gastric variation on these dose metrics was assessed. Results Despite standard daily preparation and set up procedures, we observed significant variability in the size and location of the stomach between fractions. The mean absolute daily change in gastric volume compared to the planning MRI was 19.1% (total range: -42.0% to 58.4%). The average stomach DSC was 0.69 (range: 0.40 to 0.86). Given this degree of variability, mock gastric cancer treatment plans displayed suboptimal dose metrics. The average PTV V45 was 81.5% (range: 58.8% to 99.2%. 95% CI: 78.8% to 84.2%). Average liver V30 values were 12.7% (range: 3.5% to 20.1%. 95% CI: 11.7% to 13.9%) and bilateral kidney V20 values were 12.3% (range: 0.5% to 31.3%. 95% CI: 9.2% to 15.3%). Target metrics were highly correlated with the percent change in stomach volume—a 10% increase in stomach volume was associated with a 2.4% decrease in the V45 (P Conclusion We observed significant inter-fraction variability in the dimensions of the stomach using daily MRI-based imaging, leading to dosimetrically inferior mock gastric cancer treatment plans. Our study suggests that larger PTV margins may be necessary for conventional stomach plans, which would come at the expense of greater OAR exposure. Alternatively, MRI-based image guidance and daily adaptive treatments may improve the therapeutic window of radiation therapy for gastric tumors.

Purpose/Objective(s) To identify risk groups and patterns of recurrence after curative treatment of primary SGT treated with PORT +/- ST. Materials/Methods We retrospectively identified consecutive pts with stage I-IVA SGT, excluding adenoid cystic carcinoma (ca), treated with curative-intent surgery and postoperative IMRT with or without radiosensitizing chemotherapy from 12/2008-02/2020 at a tertiary care center. Pts were classified into clinical risk groups based on histologic diagnoses and pathologic features: (1) low-risk = morphologically low grade (LG) tumors (e.g. acinic cell, secretory, LG mucoepidermoid (MEC), epithelial-myoepithelial, basal cell adenocarcinoma), pN0, without lymphovascular invasion (LVI) or perineural invasion (PNI), including minimally invasive/non-invasive carcinoma ex-pleomorphic adenoma (CXPA); (2) intermediate-risk = intermediate grade morphology (e.g. grade 2 MEC) or LG morphology with PNI or LVI or pN+; (3) high-risk = high grade histology (e.g. salivary duct, high-grade MEC, poorly differentiated ca including invasive CXPA). Kaplan Meier estimates were used for recurrence-free survival (RFS) and univariable predictors. Results 72 pts were included. Median age at surgery was 59.6 years [interquartile range (IQR) 49.7,67.7 yrs]. Sites were: 86% parotid (n = 62), 8% submandibular (n = 6), 4% minor salivary (n = 3), and 1% unknown primary. SGT were classified into clinical risk groups: 26% low (n = 19), 25% intermediate (n = 18), and 49% high-risk (n = 35). Concurrent chemotherapy (CRT) was given to 3% of low-risk (n = 1), 13% of intermediate risk (n = 4), and 71% of high-risk pts (n = 25). Regimens included carboplatin + paclitaxel, cisplatin, and concurrent/adjuvant trastuzumab (in 10 pts with HER2-positive SGT). With a median follow-up of 40.5 months, 2-year OS was 95% (85-98%); there were 11 recurrences (9 distant metastasis (DM), 2 in-field local failure (LF) both in pts with gross residual after surgery), with 82% (9 of 11) having received CRT. All recurrences were in the high-risk group with 2-year RFS of 73% (54%-85%) and 2-year cumulative incidence of DM 21% and LF 6%. Factors associated with RFS included positive margins (P = 0.004) and low-neck positive lymph nodes (level III/IV/V vs. level I/II, P = 0.04). Thirteen pts (18%) had targeted genomic sequencing (4 with recurrence); common mutations included TP53 (n = 4), HRAS (n = 3), NFKBIZ (n = 3), and PIK3CA (n = 3). Mutations in NF1 (n = 3) and HNFA1 (n = 2) were observed only in pts that recurred. Conclusion DM are the primary mode of recurrence in pts with resected SGT treated with PORT +/- ST and occurred only in high-risk pts. After randomized trials like RTOG 1008 determine the added benefit of chemo to PORT, DM is likely to remain an unmet need. Further studies incorporating molecular characterization of high-grade SGT may identify potentially actionable targets to prevent distant recurrence.

This cohort study evaluates the number of petitions for temporary involuntary commitment of individuals who pose a risk to themselves or others after implementation of a pilot program to streamline the process in Boston, Massachusetts.

This paper discusses the importance and challenges of incentivizing flexibility during short-term operations of the bulk power system due to the increasing variability and uncertainty from growing penetrations of variable generation (VG). Operational flexibility can refer to many aspects of a resource’s capability to support the power system, such as the speed, range, and duration of power output, as well as the ability to autonomously respond to frequency or voltage changes. Inefficient utilization of existing flexibility, or unwillingness of resources to provide flexibility, can compromise system reliability by not meeting the changing net load, and it can also lead to higher costs when an inefficient use of flexibility resources occurs. There are many existing characteristics of market design that incentivize flexibility in some manner. How they incentivize the provision of flexibility as well as the level of flexibility is still debated. We explore some of these existing market designs, as well as new market mechanisms, such as pay-for-performance regulating reserve and flexible ramping products, that aim to explicitly incentivize the provision of more flexibility to the system, particularly as a result of increasing VG penetration levels.

This paper discusses challenges that relate to assessing and properly incentivizing the resources necessary to ensure a reliable electricity system with growing penetrations of variable generation (VG). The output of VG (primarily wind and solar generation) varies over time and cannot be predicted precisely. Therefore, the energy from VG is not always guaranteed to be available at times when it is most needed. This means that its contribution towards resource adequacy can be significantly less than the contribution from traditional resources. Variable renewable resources also have near-zero variable costs, and with production-based subsidies they may even have negative offer costs. Because variable costs drive the spot price of energy, this can lead to reduced prices, sales, and therefore revenue for all resources within the energy market. The characteristics of VG can also result in increased price volatility as well as the need for more flexibility in the resource fleet in order to maintain system reliability. We explore both traditional and evolving electricity market designs in the United States that aim to ensure resource adequacy and sufficient revenues to recover costs when those resources are needed for long-term reliability. We also investigate how reliability needs may be evolving and discuss how VG may affect future electricity market designs.

The Minnesota Supercomputing Institute has implemented Jupyterhub and the Jupyter notebook server as a general-purpose point-of-entry to interactive high performance computing services. This mode of operation runs counter to traditional job-oriented HPC operations, but offers significant advantages for ease-of-use, data exploration, prototyping, and workflow development. From the user perspective, these features bring the computing cluster nearer to parity with emerging cloud computing options. On the other hand, retreating from fully-scheduled, job-based resource allocation poses challenges for resource availability and utilization efficiency, and can involve tools and technologies outside the typical core competencies of a supercomputing center's operations staff. MSI has attempted to mitigate these challenges by adopting Jupyter as a common technology platform for interactive services, capable of providing command-line, graphical, and workflow-oriented access to HPC resources while still integrating with job scheduling systems and using existing compute resources. This paper will describe the mechanisms that MSI has put in place, advantages for research and instructional uses, and lessons learned., 6 pages, 2 figures, in PEARC '18: Proceedings of Practice and Experience in Advanced Research Computing, July 22--26, 2018, Pittsburgh, PA, USA