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Background: For randomized controlled trials (RCTs) to provide the highest levels of evidence for clinical practice, it is ethically imperative for patients assigned to the control arm to receive standard-of-care treatment. Oncologic medical trials investigating new systemic agents have demonstrated a high proportion of RCTs with inadequate control arms. It is unknown whether this finding is prevalent in oncologic trials investigating radiation therapy (RT) for cancer., Methods: ClinicalTrials.gov was queried for registered clinical trials investigating RT in patients with cancer from 2013 to 2023. Each control arm was analyzed, with the standard of care determined by National Comprehensive Cancer Center Network (NCCN) guidelines at the time of initial trial posting., Results: Five hundred eight interventional studies with results registered were included, of which 12 met inclusion criteria for final analysis. Two trials each investigated RT usage in central nervous system, prostate, head and neck, and breast disease sites, and 1 each for lung, hepatobiliary, rectal, and bone disease sites. Most trials were industry-funded (83%); 75% of studies took place in the United States. Hundred percent of trials had an adequate control arm per the corresponding NCCN guidelines., Conclusion: All recently completed oncologic RCTs investigating RT for cancer involved an adequate control arm. This finding contrasts with the high proportion of inadequate control arms in medical oncology trials. These findings suggest that adequate control arm treatments are feasible to achieve in trial design, emphasizing both the need for continued focus on improving the quality of ethical oncologic research trials and a possible subspecialty that may serve as an exemplar., Competing Interests: R.J. has stock options as compensation for her advisory board role in Equity Quotient, a company that evaluates culture in health care companies; she has received personal fees from the Greenwall Foundation, Doris Duke Charitable Foundation, the National Institutes of Health, the Blue Cross Blue Shield Association, Physicians Education Resource, and the American Medical Association; and grants or contracts from the National Institutes of Health, the Doris Duke Charitable Foundation, the American Cancer Society, and the Susan G. Komen Foundation. She has served as an expert witness for Kleinbard, LLC, and Hawks Quindel Law. Dr. McClelland receives research funding from the National Institutes of Health (National Cancer for Advancing Translational Sciences), the Gilead Sciences Research Scholars Program in Solid Tumors Award, the Radiation Oncology Institute, and the Susan G. Komen Career Catalyst Research Grant. The remaining authors declare no conflicts of interest., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Cancer accounts for 22% of all mortality and is the leading cause of death among Hispanic and/or Latinx patients in the United States. The disparities in access to radiation therapy (RT), mortality rates, and treatment outcomes among Hispanic-American breast cancer patients compared with other populations highlight the urgent need for targeted interventions. The Navigator-Assisted Hypofractionation (NAVAH) program, with its innovative patient navigation approach and culturally sensitive survey, aims to better identify the specific barriers faced by this population. This study is a report of the NAVAH program experience piloting a Spanish-language culturally sensitive survey in Hispanic-American volunteers., Methods: Hispanic-American volunteers with fluency in Spanish were recruited to participate in survey conduction, identified from local networks. Survey information was assessed by topic category, and survey responses were amalgamated into a representative score for each category. Survey categories include acceptability (comfort and prejudice among interactions with the system), accessibility (transportation, distance to care, and health care literacy), accommodation (access to the internet, navigating transportation), affordability (financial considerations, employment, and level of education), and availability (access to a medical center, coordinating care, and overall quality of care)., Results: A total of 6 volunteers meeting inclusion criteria completed the survey; 4 in person and 2 by telephone. The median survey completion time was 12 minutes 38 seconds. Respondents noted satisfaction and trust in their interactions with medical providers; however, responses in the acceptability category highlighted a high perception of disparities in the medical system, including a high prevalence of racial and ethnic prejudice and a high prevalence of treatment differences between high-income and low-income patients in clinical settings., Conclusions: In the first Spanish-language survey of its kind, our findings indicate that this survey design is feasible in the Hispanic-American population. Implementation of this survey in breast cancer patients will provide more definitive and comprehensive answers regarding other categories in the survey, including financial challenges during treatment, access to accommodations, and perception of treatment during cancer care. The investigation involving patients actively receiving breast cancer RT is currently underway., Competing Interests: A.S.-F. was supported by the American Society for Radiation Oncology (ASTRO) Medical Student Fellowship Award. Dr S.M. receives research funding from the National Institutes of Health (National Cancer for Advancing Translational Sciences), University Hospitals Minority Faculty Career Development Award, the Robert Winn Diversity in Clinical Trials Career Development Award (sponsored by the Bristol Myers Squibb Foundation), the Case Comprehensive Cancer Center Accelerator Pilot Project Award, the Gilead Sciences Research Scholars Program in Solid Tumors Award, the Radiation Oncology Institute, and the Susan G Komen Career Catalyst Research Grant. The other authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The primary treatment of metastatic spine disease is radiation therapy (RT), traditionally conventional external beam RT (EBRT) or stereotactic body RT (SBRT). Until recently, there had been no Level 1 evidence supporting SBRT over EBRT, which has led to difficulties obtaining insurance approval. Publication of the first randomized controlled trial (RCT) comparing SBRT to EBRT for spine metastases [Canadian Cancer Trials Group (CCTG)] helped change this. The results showed superiority of SBRT in pain response; however, the results were not cited by The National Comprehensive Cancer Network (NCCN) until March 24, 2023. We present results from an ongoing RCT to assess the impact of this NCCN inclusion on insurance denials for trial-eligible patients., Materials and Methods: The ongoing SPORTSMEN RCT randomizes metastatic spine cancer patients to SBRT versus EBRT. Trial-eligible patients during the first six months were examined to assess if SBRT was denied by insurance before March 24, 2023, versus afterwards. Fisher's exact test was used to assess for statistical significance., Results: Prior to CCTG NCCN inclusion, 25% of 12 trial-eligible patients experienced SBRT insurance denial. Following NCCN inclusion, of 8 patients, one (12.5%) has undergone insurance denial of SBRT. These differences were not statistically significant., Conclusions: The inclusion of Level 1 evidence in the NCCN guidelines has resulted in a numerical halving of spine SBRT insurance denials on a RCT, with the small sample size likely the largest culprit of not meeting statistical significance. These findings illustrate the importance of generating high-quality evidence, followed by timely inclusion into the NCCN guidelines., Competing Interests: Conflicts of interest: Dr. Gardner receives research funding from the National Institutes of Health (R01 CA237005-05S1). Dr. Spratt receives research funding from the National Institutes of Health and the Prostate Cancer Foundation and receives personal fees from Astellas, AstraZeneca, Bayer, BlueEarth, Boston Scientific, Elekta, GT Medical Technologies Inc., Myovant, Pfizer, Janssen, Novartis, and Varian. Dr. McClelland receives research funding from the National Institutes of Health (National Cancer for Advancing Translational Sciences), University Hospitals Minority Faculty Career Development Award, the Robert Winn Diversity in Clinical Trials Career Development Award (sponsored by the Bristol Myers Squibb Foundation), the Gilead Sciences Research Scholars Program in Solid Tumors Award, the Radiation Oncology Institute, and the Susan G Komen Career Catalyst Research Grant. No other author has any conflicts of interest., (© 2024 Greater Poland Cancer Centre.)

Competing Interests: Conflict of interest: Dr. McClelland receives research funding from the National Institutes of Health (National Cancer for Advancing Translational Sciences), University Hospitals Minority Faculty Career Development Award, the Robert Winn Diversity in Clinical Trials Career Development Award (sponsored by the Bristol Myers Squibb Foundation), the Gilead Sciences Research Scholars Program in Solid Tumors Award, the Radiation Oncology Institute, and the Susan G. Komen Career Catalyst Research Grant.

Knowledge related to how oncology treatment trial design influences enrollment of racial and ethnic minorities is limited. Rigorous identification of clinical trial design parameters that associate favorably with minority accrual provides educational opportunities for individuals interested in designing more representative treatment trials. We identified oncology trials with a minimum of 10 patients at an NCI-Designated Comprehensive Cancer Center from 2010 to 2021. We defined a study endpoint of racial and ethnic minority accrual greater than zero. Multivariable logistic regression was used to determine whether co-variables predicted our study endpoint. P-values of less than 0.05 were considered significant. A total of 352 cancer trials met eligibility criteria. These studies enrolled a total of 7981 patients with a total of 926 racial and ethnic minorities leading to a median enrollment of 10%. Trials open in community sites (yes versus no) were more likely to have a minority patient (OR, 2.21; 95% CI, 1.02-4.96) as well as pilot/phase I studies compared to phase II/III (OR, 3.19; 95% CI, 1.34-8.26). Trials incorporating immunotherapy (yes versus no) were less likely to have a minority patient (OR, 0.47; 95% CI, 0.23-0.94). Trials open in community sites as well as early phase treatment studies were more likely to accrue minority patients. However, studies including immunotherapy were less likely to accrue racial and ethnic minorities. Knowledge gained from our analysis may help individuals design oncology treatment trials that are representative of more diverse populations., (© 2024. The Author(s) under exclusive licence to American Association for Cancer Education.)

Objectives: For patients with metastatic cancer, a key aspect of interdisciplinary care has involved the overall prognosis provided by Medical Oncology. This study represents prospective evaluation of Medical Oncology prognosis accuracy for patients considered for enrollment onto an ongoing randomized controlled trial., Methods: The Spine Patient Optimal Radiosurgery Treatment for Symptomatic Metastatic Neoplasms (SPORTSMEN) phase 2 randomized clinical trial examines optimal radiation therapy treatment of symptomatic spinal metastases with a primary end point of pain freedom at 3 months post-treatment. A key eligibility criterion for trial enrollment is overall prognosis exceeding 3 months, typically provided by Medical Oncology. During the first year of trial enrollment, Medical Oncology prognosis for patients considered for SPORTSMEN inclusion was prospectively assessed for accuracy., Results: Twenty-seven patients with documented Medical Oncology prognosis were considered for SPORTSMEN enrollment. The prognosis administered by Medical Oncology exceeded 3 months in 26 patients, and <3 months in 1 patient. The overall accuracy of Medical Oncology prognosis was correct for 15 of 27 patients (56%), significantly worse for inpatients than outpatients ( P =0.0381)., Conclusions: In patients with metastatic spine disease, the estimated prognosis provided by Medical Oncology is often optimistic, as nearly half of patients assigned a prognosis of >3 months failed to reach this threshold before experiencing death or hospice. These findings indicate that a more heuristic approach to assessing patient prognosis may be necessary to avoid unwarranted prognostic optimism, particularly for inpatients. Such an approach could potentially provide a more compassionate and cost-effective management of these patients' remaining lifespan thereby optimizing quality of life., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: S.M. receives research funding from the National Institutes of Health (National Cancer for Advancing Translational Sciences), University Hospitals Minority Faculty Career Development Award, the Robert Winn Diversity in Clinical Trials Career Development Award (sponsored by the Bristol Myers Squibb Foundation), the Gilead Sciences Research Scholars Program in Solid Tumors Award, the Radiation Oncology Institute, and the Susan G Komen Career Catalyst Research Grant. The other authors declare no conflicts of interest.

Purpose: The Audiovisual-Assisted Therapeutic Ambience in Radiotherapy (AVATAR) trial was a prospective multicenter study (NCT03991156) examining the combination of video immersion with radiation therapy and was successfully conducted through the collaboration of pediatric radiation oncology teams at 10 institutions independent of any pre-existing consortium. We sought to analyze and report the methodology of trial conception and development, process map, and cost., Methods and Materials: The study enrolled patients aged 3 to 10 years preparing to undergo radiation therapy, integrated the combination of AVATAR-based video immersion with radiation therapy at each institution, and offered AVATAR use as an alternative to anesthesia, with rates of anesthesia use and outcomes of serial standardized anxiety and quality-of-life assessments assessed among the 81 children enrolled. A process map was created based on the trial timeline with the following components: study development time (time from conception of the trial to the accrual of the first patient, including design phase, agreement and approval phase, and site preparation phase), and accrual duration time (time from the first to last accrual). Costs and institutional success rates were calculated., Results: Time from inception of study to last accrual was 3.6 years (1313 days). The study development time was 417 days (31.7%), and accrual duration time was 896 days (68.3%), with the final 50% of accrual occurring in <6 months. Equipment cost was approximately $550 per institution and was covered by funding from the lead study institution. All 10 centers were successful with AVATAR implementation, defined as ≥50% of patients able to avoid anesthesia with the use of AVATAR, including centers with both photon and proton therapy., Conclusions: This report elaborates on the methodology and timeline of trial conception and development using data from a previously published supportive care study combining video immersion with radiation therapy among 10 cooperating pediatric oncology institutions. It highlights the potential for multicenter collaborations on prospective trials integrating supportive care therapies with radiation therapy., (© 2024 The Author(s).)

Objectives: For inpatients with metastatic intracranial disease burden exceeding established guidelines for stereotactic radiosurgery (SRS), the standard of care involves whole brain radiation therapy (WBRT), typically administered as a 2-week course of treatment with biologically effective dose (BED) of 60 Gy. However, shorter course WBRT provides theoretical advantages in quality of life and decreasing systemic therapy delay. This retrospective study evaluates our early experience with BED-comparable short-course WBRT (23 Gy in 5 fractions; BED=58.3 Gy) for metastatic intracranial disease., Methods: Over a recent 2-month timeframe, 3 inpatients with intracranial disease burden exceeding SRS guidelines were administered BED-comparable short-course WBRT. Due to the high intracranial disease burden, 23 Gy was chosen over 20 Gy for 5-fraction WBRT due to the desire to optimally mimic the durability of the classic 30 Gy in 10 fraction treatment regimen., Results: The mean age at treatment was 65.7 years, the mean Karnofsky Performance Status (KPS) was 60, and the mean number of intracranial metastases was 20.3. The mean duration between inpatient Radiation Oncology consultation and the start of WBRT (following CT radiation therapy simulation) was 6.7 days. All patients completed WBRT no later than 2 weeks from the initial inpatient consultation., Conclusions: For inpatients with intracranial metastatic disease burden exceeding established SRS guidelines, BED-comparable short-course WBRT administered to 23 Gy in 5 fractions (4.6 Gy/fraction) is safe and efficacious. Given previous literature indicating that nearly half of the patients prescribed traditional 2-week WBRT die without completing treatment, BED-comparable WBRT represents an attractive and promising WBRT alternative in this patient population., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The optimal adjuvant therapy (antiestrogen therapy [ET] + radiation therapy or ET alone, or in some reports radiation therapy alone) in older women with early-stage breast cancer has been highly debated. However, granular details on the role of insurance in the out-of-pocket cost for patients receiving ET with or without radiation therapy are lacking. This project disaggregates out-of-pocket costs by insurance plans to increase treatment cost transparency., Methods and Materials: Several radiation therapy schedules are accepted standards as per the National Comprehensive Cancer Network guidelines. For our financial estimate model, we used the 5-fraction and 15-fraction radiation therapy and ET prescribed over a 5-year duration. The total aggregate out-of-pocket costs were determined from the sum of treatment costs, deductibles, and copays/coinsurance based on Medicaid, Original Medicare, Medigap Plan G, and Medicare Part D Rx plans. The model assumes a Medicare- and/or Medicaid-eligible patient ≥70 years of age with node-negative, early-stage estrogen-receptor-positive breast cancer. Patient out-of-pocket costs were estimated from publicly available insurance data from plan-specific benefit coverage materials using a 5-year time horizon., Results: Original Medicare beneficiaries face a total out-of-pocket treatment charge of $2738.52 for ET alone, $2221.26 for 5-fraction radiation therapy alone, $2573.92 for 15-fraction radiation therapy alone, $3361.26 for combined ET+ 5-fraction radiation therapy, and $3713.92 for combined ET + 15-fraction radiation therapy. Medigap Plan G beneficiaries have an out-of-pocket charge of $1130.00 with radiation therapy alone and face an out-of-pocket of $2270.00 for ET alone and combined ET+ radiation therapy. For Medicaid beneficiaries, all treatments approved by Medicaid are covered without limit, resulting in no out-of-pocket expense for either adjuvant treatment option., Conclusions: This model (based on actual cost estimates per insurance plan rather than claims data), by estimating expenses within Medicare and Medicaid plans, provides a level of transparency to patient cost. With knowledge of the costs borne by patients themselves, treatment decisions informed by patients' individual priorities and preferences may be further enhanced., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Spinal metastases are common in metastatic cancer, affecting around 40% of patients. The primary treatment involves radiation therapy, transitioning from conventional external beam radiation therapy (EBRT) to stereotactic body radiation therapy (SBRT) for its superior, durable response. While spine SBRT has gained popularity in the United States, Level I evidence supporting it over EBRT is limited to a Canadian trial using a 2-fraction SBRT regimen. We present our findings from one of the earliest US experiences of 2-fraction spine SBRT for spinal metastases., Methods: A retrospective analysis of patients with metastatic spine cancer receiving 2-fraction spine SBRT at a single center was conducted. Patients received treatment based on Level 1 evidence (24 Gy in 2 fractions). Follow-up records were assessed for local control outcomes and toxicity., Results: Twenty patients since August 2022 have been treated with 2-fraction spine SBRT. Most patients were treated at 1 (45%) or 2 (40%) spinal levels, with the thoracic (55%) and lumbar (50%) spine being the most common locations. Common primary sites included the lung (30%), breast (20%), esophagus (15%), and prostate (10%). The rate of local control was 100%, while the rate of vertebral compression fracture was 15%. No esophageal or bowel toxicity occurred, and no fractures required intervention., Conclusions: These findings suggest that 2-fraction spine SBRT is safe and effective, consistent with existing Level I evidence. Our local control rate exceeding 95% aligns with the literature, indicating the feasibility and achievability of implementing this approach in the United States over a short period of time., Competing Interests: Dr S.McC. serves as a consultant for Gilmartin Capital (a company that evaluates surgically targeted radiation therapies), receives travel funding from GT Medical Technologies Inc. and receives research funding from the University Hospitals Minority Faculty Career Development Award, the ASTRO Emerging Investigator Award, the Robert Winn Diversity in Clinical Trials Career Development Award (sponsored by the Bristol Myers Squibb Foundation), the Case Comprehensive Cancer Center Accelerator Pilot Project Award, the Gilead Sciences Research Scholars Program in Solid Tumors Award, and the Susan G Komen Career Catalyst Research Grant. The remaining author declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

With the expansion of proton radiation therapy centers across the United States and a gradually expanding body of academic evidence supporting its use, more patients are receiving-and asking about-proton therapy than ever before. Here, we outline, for nonradiation oncologists, the theoretical benefits of proton therapy, the clinical evidence to date, the controversies affecting utilization, and the numerous randomized trials currently in progress. We also discuss the challenges of researching and delivering proton therapy, including the cost of constructing and maintaining centers, barriers with insurance approval, clinical situations in which proton therapy may be approached with caution, and the issue of equitable access for all patients. The purpose of this review is to assist practicing oncologists in understanding the evolving role of proton therapy and to help nonradiation oncologists guide patients regarding this technology.

Background: Invitations for grand rounds are typically used to evaluate faculty promotion in Radiation Oncology. To shed light on potential barriers to career progression, we conducted a study examining the racial and gender demographics of invited speakers and the inclusion of diversity, equity, and inclusion (DEI)-related talks among African-American radiation oncology speakers., Materials and Methods: Radiation oncology programs in the US were contacted to obtain a list of speakers invited to their institution along with their topics presented between January 2021 and December 2022. Speakers were categorized demographically by race and gender; speaker demographics were determined by facial recognition and internet investigation. Non-faculty were eliminated from analysis. Talk topics were categorized as either DEI or non-DEI from the speaker's talk title. The Fisher's exact test was used for statistical analysis, with significance set at p < 0.05., Results: A total of 252 invited speakers and their associated talk topics were obtained from 51 radiation oncology programs. Of these speakers, 98 were female (38.9%) and 16 were African-American race (6.3%). The invited talk topic was DEI-related in 7% of total cases. Among speakers not of African-American race, this was 4.2% (10/236); among African-American speakers, it was 50% (8/16). This difference reached statistical significance (p < 0.0001)., Conclusions: A significant proportion of invited African-American radiation oncology grand rounds/visiting professor talks are focused on the topic of diversity, equity, and inclusion (DEI), compared with less than 5% of non-African-American invited speakers. Targeted efforts to expand African-American representation in non-DEI topics are needed to ensure and expand diversity in Radiation Oncology., Competing Interests: Conflict of interest: Authors declare no conflict of interest., (© 2024 Greater Poland Cancer Centre.)

As the number of cancer survivors increases, so does the demand for preserving male fertility after radiation. It is important for healthcare providers to understand the pathophysiology of radiation-induced testicular injury, the techniques of fertility preservation both before and during radiation, and their role in counseling patients on the risks to their fertility and the means of mitigating these risks. Impaired spermatogenesis is a known testicular toxicity of radiation in both the acute and the late settings, as rapidly dividing spermatogonial germ cells are exquisitely sensitive to irradiation. The threshold for spermatogonial injury and subsequent impairment in spermatogenesis is ~ 0.1 Gy and the severity of gonadal injury is highly dose-dependent. Total doses < 4 Gy may allow for recovery of spermatogenesis and fertility potential, but with larger doses, recovery may be protracted or impossible. All patients undergoing gonadotoxic radiation therapy should be counseled on the possibility of future infertility, offered the opportunity for semen cryopreservation, and offered referral to a fertility specialist. In addition to this, every effort should be made to shield the testes (if not expected to contain tumor) during therapy., Competing Interests: Competing interests: N/A. Conflict of interest: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. The authors declare no potential conflicts of interest, including financial interests, activities, relationships and affiliations., (© 2023 Greater Poland Cancer Centre.)

Objectives: There has been a recent emphasis in the peer-reviewed oncology literature on examining disparities by gender. Such emphasis provides an excellent opportunity to simultaneously examine race/ethnicity disparities in the same cohort. The degree to which gender disparities research has been performed concomitantly with racial disparities research at prominent oncologic societies has yet to be investigated., Methods: ABSTRACTs presented at the American Society of Clinical Oncology (ASCO) annual meeting were reviewed. Abstracts selected for the oral abstract or clinical science symposium sessions at the 2020, 2021, and 2022 annual meetings were evaluated to determine the amount of gender disparities research presented. Such research was further assessed to determine whether racial/ethnicity disparities were examined simultaneously., Results: From 2020 to 2022, 1219 abstracts were presented at the ASCO annual meetings, oral abstract or clinical science symposium sessions. Of these, 7 involved gender disparities examination, of which only 2 (29%) concomitantly examined race/ethnicity. No study since 2020 concomitantly examined gender and racial disparities., Conclusions: More than 70% of gender disparities work presented at ASCO has been disaggregated from concomitant racial disparities examination, with complete disaggregation since 2021. Gender disparities work remains a miniscule aspect of the overall research landscape. Future work in examining gender disparities may be best aggregated with racial/ethnicity disparities to optimize timely solutions in both areas; such work could potentially be incentivized from the inclusion criteria of future funding mechanisms., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Insurance denials for clinical trials serve as a pertinent barrier for patients to remain trial-eligible, thus hindering the development of therapies and the overall advancement of health care. We present results from an ongoing oncology randomized clinical trial regarding insurance denials and peer-to-peer authorization (P2PA) success rate in allowing patients to remain trial-eligible., Methods: The ongoing Spine Patient Optimal Radiosurgery Treatment for Symptomatic Metastatic Neoplasms Phase II trial randomizes spine cancer patients to treatment with spine radiosurgery/stereotactic body radiation therapy (SBRT) versus conventional external beam radiation therapy (EBRT). Trial-eligible patients during the first 3 months of enrollment are examined to determine whether the option of SBRT was denied by their insurance. Advocacy for overcoming SBRT denial in P2PA centered on SBRT being recommended as a preferred treatment modality in the National Comprehensive Cancer Network guidelines, and the recent level I evidence demonstrating the advantages of SBRT over EBRT for symptomatic spine cancer., Results: Of 15 trial-eligible patients, 3 (20%) experienced insurance denials for SBRT. P2PA resulted in the reversal of denials in all 3 patients, allowing each to remain trial-eligible for randomization between SBRT and cEBRT., Conclusions: Despite a clinical oncologic treatment modality for which recent Level 1 evidence is available, the insurance denial rate was 20%. A vigilant P2PA strategy focusing on highlighting National Comprehensive Cancer Network guidelines and the supporting Level 1 evidence resulted in a very high rate of reversing initial denial., Competing Interests: S.M. serves as a consultant for Gilmartin Capital (a company that evaluates surgically targeted radiation therapies), receives travel funding from GT Medical Technologies Inc., and receives research funding from the University Hospitals Minority Faculty Career Development Award, the ASTRO Emerging Investigator Award, the Robert Winn Diversity in Clinical Trials Career Development Award, the National Cancer Institute Paul Calabresi K12 Clinical Oncology Research Career Development Program, the Case Comprehensive Cancer Center Accelerator Pilot Project Award, the Gilead Sciences Research Scholars Program in Solid Tumors Award, and the Susan G Komen Career Catalyst Research Grant. D.E.S. receives research funding from the National Institutes of Health and the Prostate Cancer Foundation and personal fees from Astellas, AstraZeneca, Bayer, BlueEarth, Boston Scientific, Elekta, GT Medical Technologies Inc., Myovant, Pfizer, Janssen, Novartis, and Varian. The remaining authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose/objectives: Radiation therapy (RT) is a central component of cancer treatment with survival and long-term quality-of-life benefits across a spectrum of oncologic diagnoses. However, RT has been associated with varying levels of fatigue, pain, weight loss, and changes in mental health both during and post-treatment. Prehabilitation aims to optimize health prior to anti-neoplastic therapy in order to reduce side effects, increase adherence to treatment, expedite post-treatment recovery, and improve long-term outcomes. Though prehabilitation has been studied in those undergoing cancer-related surgery, literature on prehabilitation in individuals undergoing RT has not been comprehensively explored. Thus, this scoping review aims to summarize the existing literature focused on prehabilitation interventions for patients receiving RT., Materials/methods: The PRISMA-ScR checklist for conducting scoping reviews was adopted to identify and evaluate studies investigating the efficacy of prehabilitation before and during RT for cancer over the past 21 years (10/2002-10/2022). A search of prehabilitation and RT was performed to identify studies investigating prehabilitation interventions in adult cancer patients undergoing RT., Results: A total of 30 articles met inclusion criteria, yielding 3657 total participants. Eighteen (60%) studies were randomized controlled trials (RCTs) with sample sizes ranging from 21 to 221. The most commonly studied populations were patients with head and neck cancer, followed by rectal, breast, and lung cancer. A majority (80%) of studies evaluated one prehabilitation intervention (i.e., unimodal). Targeted physical exercises were the most common intervention, followed by general physical exercises and technology/apps. Adherence/feasibility was the most common primary outcome, representing 30% of studies. All studies reported data on sex, and 5 (17%) reported data on race and/or ethnicity., Conclusions: Prehabilitation interventions have been successfully implemented in patients with cancer undergoing surgical treatment. Based on limited current literature, prehabilitation appears to have a promising effect in reducing morbidity in adult cancer patients requiring RT. Though our review identified many RCTs, they were frequently small sample trials with primary outcomes focused on feasibility, rather than functional status or quality of life. Thus, there is a need for adequately powered, randomized controlled intervention trials to investigate the efficacy of prehabilitation and maximize the treatment outcomes for patients undergoing RT., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: For early stage breast cancer (BC), the choice of radiation therapy duration (1 vs 3 weeks) is highly debated. Cost and financial toxicity are major concerns that patients with BC face. Nonetheless, there remain limited discussions providing granular details of the role of insurance in the aggregate cost of 1 week versus 3 weeks of radiation therapy for patients. This project aims to disaggregate costs by plan to increase transparency of out-of-pocket (OOP) cost estimates in radiation therapy., Methods and Materials: Treatment procedures were determined through the National Comprehensive Cancer Network guidelines. OOP treatment costs, deductibles, and copays/coinsurance were calculated by using Medicaid, Original Medicare, Medigap Plan G, and Medicare Part D prescription plans. The medicare.gov, medicaid.oh.gov, aarpmedicareplans.com, and the physician fee schedule from cms.gov were used to determine costs by treatment. Price estimates reflect actual costs per insurance plan rather than costs estimated from claims data. All procedures were considered to be performed in an Ohio hospital setting. One-week radiation therapy was defined as 5 fractions without boost, and 3-week radiation therapy was defined as 15 fractions without boost., Results: Medicare beneficiaries with Original Medicare coverage face an OOP treatment charge of $649.24 for 1 week of radiation therapy and $1006.20 for 3 weeks of radiation therapy. Assuming the deductible is met postlumpectomy, Medigap Plan G beneficiaries are faced with no additional charges for both lengths of radiation therapy. Similarly for Medicaid beneficiaries (assuming treatment is approved by Medicaid), all expenses are covered without limit, resulting in no OOP expense., Conclusions: Considerations of 1 and 3 weeks of radiation therapy for postlumpectomy early-stage BC are often dependent on cancer characteristics and patient preferences. This model (based on actual cost estimates per insurance plan rather than claims data) compares OOP costs across Medicaid and Medicare plans, which more holistically informs providers and patients in radiation therapy duration decision making., Competing Interests: Disclosures Reshma Jagsi has stock options as compensation for her advisory board role in Equity Quotient, a company that evaluates culture in health care companies; she has received personal fees from the National Institutes of Health as a special government employee (in her role as a member of the Advisory Committee for Research on Women's Health), the Greenwall Foundation, and the Doris Duke Charitable Foundation. She has received grants for unrelated work from the National Institutes of Health, the Doris Duke Foundation, the Greenwall Foundation, the American Cancer Society, the Komen Foundation, and Blue Cross Blue Shield of Michigan for the Michigan Radiation Oncology Quality Consortium. She had a contract to conduct an investigator-initiated study with Genentech. She has served as an expert witness for Sherinian and Hasso, Dressman Benzinger LaVelle, and Kleinbard LLC. Shearwood McClelland III serves as a consultant for Gilmartin Capital (a company that evaluates surgically targeted radiation therapies), receives travel funding from GT Medical Technologies Inc, and research funding from the University Hospitals Minority Faculty Career Development Award, the American Society of Radiation Oncology Emerging Investigator Award, the Robert Winn Diversity in Clinical Trials Career Development Award, and the National Cancer Institute Paul Calabresi K12 Clinical Oncology Research Career Development Program., (Copyright © 2023 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Background: Patient navigation has been demonstrated to improve access to standard-of-care oncologic therapy. However, many patients - particularly those of African-American race - often do not have access to navigation upon receiving a diagnosis of cancer. As the most common cancer among African-American women is breast cancer, we sought to assess the rate of patient navigation among African-American breast cancer patients at our institution, which resides in a regional ZIP code comprised of 46% African-American residents., Materials and Methods: African-American breast cancer patients who had been discussed at our weekly breast cancer multidisciplinary tumor board over a recent three-month period were assessed by a patient navigator representing the Navigator-Assisted Hypofractionation (NAVAH) program to determine their access to navigation in their cancer care. Responses were assessed from a breast cancer support group and culled to determine a baseline proportion of navigation utilization., Results: A total of 18 women of African-American race having been diagnosed with breast cancer were identified and assessed. Of these a total of 4 noted that they had received navigation, yielding a navigation utilization percentage of 22.2% among African-American breast cancer patients at our institution., Conclusion: The rate of navigation utilization among African-American breast cancer patients is poor. Despite our center residing in a region comprised of increased African-Americans, such predominance has not translated into optimizing navigation access for African-American breast cancer patients. This 22% rate of navigation utilization serves as a starting benchmark for initiatives such as the NAVAH program to provide tangible improvement in this patient population., (© 2023 Greater Poland Cancer Centre.)

Purpose: The Audio-Visual Assisted Therapeutic Ambience in Radiotherapy (AVATAR) system was the first published radiation therapy (RT)-compatible system to reduce the need for pediatric anesthesia through video-based distraction. We evaluated the feasibility of AVATAR implementation and effects on anesthesia use, quality of life, and anxiety in a multicenter pediatric trial., Methods and Materials: Pediatric patients 3 to 10 years of age preparing to undergo RT at 10 institutions were prospectively enrolled. Children able to undergo at least 1 fraction of RT using AVATAR without anesthesia were considered successful (S). Patients requiring anesthesia for their entire treatment course were nonsuccessful (NS). The PedsQL3.0 Cancer Module (PedsQL) survey assessed quality of life and was administered to the patient and guardian at RT simulation, midway through RT, and at final treatment. The modified Yale Preoperative Anxiety Scale (mYPAS) assessed anxiety and was performed at the same 3 time points. Success was evaluated using the χ 2 test. PedsQL and mYPAS scores were assessed using mixed effects models with time points evaluated as fixed effects and a random intercept on the subject., Results: Eighty-one children were included; median age was 7 years. AVATAR was successful at all 10 institutions and with photon and proton RT. There were 63 (78%) S patients; anesthesia was avoided for a median of 20 fractions per patient. Success differed by age (P = .04) and private versus public insurance (P < .001). Both patient (P = .008) and parent (P = .006) PedsQL scores significantly improved over the course of RT for patients aged 5 to 7. Anxiety in the treatment room decreased for both S and NS patients over RT course (P < .001), by age (P < .001), and by S versus NS patients (P < .001)., Conclusions: In this 10-center prospective trial, anesthesia avoidance with AVATAR was 78% in children aged 3 to 10 years, higher than among age-matched historical controls (49%; P < .001). AVATAR implementation is feasible across multiple institutions and should be further studied and made available to patients who may benefit from video-based distraction., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Approximately 40% of patients with metastatic cancer will have spinal metastatic disease. Historically treated with external beam radiation therapy (EBRT) with limited durability in pain control, the increased lifespan of this patient population has necessitated more durable treatment results via spine radiosurgery/stereotactic body radiation therapy (SBRT). The goal of this study is to assess three-month pain freedom rates via the Spine Patient Optimal Radiosurgery Treatment for Symptomatic Metastatic Neoplasms (SPORTSMEN) randomized trial., Materials and Methods: This study is a prospective randomized three-arm phase II trial which will recruit patients with symptomatic spine metastases. All patients will be randomized to standard-of care SBRT (24 Gy in 2 fractions), single-fraction SBRT (19 Gy in 1 fraction), or EBRT (8 Gy in 1 fraction), with the primary endpoint of three-month pain freedom (using the Brief Pain Inventory). We expect that SPORTSMEN will help definitively answer the efficacy of spine SBRT versus EBRT for achieving pain freedom, while defining the safety and efficacy of 19 Gy single-fraction spine SBRT. Local control will be defined according to Spine Response Assessment in Neuro-Oncology (SPINO) criteria., Discussion: This is the first phase II trial to objectively assess optimal spine SBRT dosing in the treatment of symptomatic spine metastatic disease, while assessing spine SBRT versus EBRT. Findings should allow for better determination of the efficacy of two-fraction spine SBRT versus EBRT in the United States, as well as for the novel single-fraction 19 Gy spine SBRT regimen in patients with symptomatic spine metastases., Trial Registration: Clinicaltrials.gov identifier: NCT05617716 (registration date: November 14, 2022)., Competing Interests: Conflicts of interest Dr. McClelland serves as a consultant for Gilmartin Capital (a company that evaluates surgically targeted radiation therapies), receives travel funding from GT Medical Technologies Inc., and receives research funding from the University Hospitals Minority Faculty Career Development Award, the ASTRO Emerging Investigator Award, the Robert Winn Diversity in Clinical Trials Career Development Award, and the National Cancer Institute Paul Calabresi K12 Clinical Oncology Research Career Development Program. Dr. Spratt receives research funding from the National Institutes of Health and the Prostate Cancer Foundation and personal fees from Astellas, AstraZeneca, Bayer, BlueEarth, Boston Scientific, Elekta, GT Medical Technologies Inc., Myovant, Pfizer, Janssen, Novartis, and Varian., (© 2023 Greater Poland Cancer Centre.)

Purpose: Compared with conventional external-beam radiation therapy (cEBRT) for patients with breast cancer (BC) and prostate cancer (PC), shorter radiation regimens may be associated with lower treatment noncompletion rates. We assess disparities in receipt of shorter radiation regimens and treatment noncompletion for BC and PC., Patients and Methods: The 2004-2017 National Cancer Database was queried for adjuvant cEBRT or hypofractionated EBRT (hEBRT) for nonmetastatic BC; and definitive cEBRT, moderate hypofractionation (mEBRT), or stereotactic body radiotherapy (SBRT) for localized PC. Multivariable logistic regression identified factors associated with treatment noncompletion and receipt of shorter regimens., Findings: We identified 170,386 men with PC (median age [interquartile range], 70 [64-75] years; Black, 17.5%; White, 82.5%) and 306,846 women with BC (61 [52-69] years; Black, 12.3%; White, 87.7%). Among patients who received cEBRT for PC, Black men had higher treatment noncompletion rates compared with White (14.1% v 13.0%; odds ratio [95% CI] 1.07 [1.03 to 1.12]; P < .001). In contrast, treatment noncompletion was not disparate with SBRT (Black 1.6% v White 1.3%; 1.20 [0.72 to 2.00], P = .49) or mEBRT (Black 9.0% v White 7.1%; 1.05 [0.72 to 1.54], P = .79). From 2004 to 2017, SBRT (0.07% to 11.8%; 1.32 [1.31 to 1.33]) and mEBRT (0.35% to 9.1%; 1.27 [1.25 to 1.28]) increased (both P < .001); however, Black men were consistently less likely to receive SBRT (7.4% v White, 8.3%; 0.84 [0.79 to 0.89], P < .001). Among women with BC, there were no racial differences in treatment noncompletion; however, hEBRT was associated with lower treatment noncompletion rates (1.0% v cEBRT 2.3%; 0.39 [0.35 to 0.44], P < .001). Although hEBRT for BC increased (0.8% to 35.6%) between 2004 and 2017, Black women were less likely to receive hEBRT (10.4% v 15.3%; 0.78 [0.75 to 0.81], P < .001)., Interpretation: Black patients were consistently less likely to receive hypofractionated radiation for PC or BC, despite evidence suggesting that shorter regimens may lower rates of treatment noncompletion with similar oncologic outcomes.

Purpose: The American Society for Radiation Oncology (ASTRO) Annual Meeting is one of the primary venues for radiation oncologists to present new research, network, and share innovations. In this brief report, we describe the racial representation of invited physician speakers at the Annual Meeting relative to the specialty., Methods and Materials: The program list of all invited educational sessions and panel speakers in the ASTRO annual meetings from 2021 was accessed via the ASTRO website. Race was determined by a combination of facial recognition and Internet investigation. Speakers and panels were divided by race and specialty. Underrepresented in medicine (URiM) was defined as Black race and/or Hispanic ethnicity., Results: We identified 182 cumulative speaking panels at the 2021 ASTRO annual meeting and 960 individuals who filled these panels. The majority of speakers were of White race (57%), followed by Asian race (34.2%). URiM speakers made up approximately 8.6% of speakers and were mostly congregated in diversity, equity, and inclusion in health care (DEI) panels. A total of 15.6% of panels were White-only, and 14.8% of panels had at least 1 URiM member. URiM race speakers were mostly congregated in DEI panels, comprising 44.9% of DEI speaker positions and 4.1% of non-DEI speaker positions; this difference reached statistical significance ( P < .0001)., Conclusions: The proportion of underrepresented minorities receiving panel invitations at ASTRO remains minimal and is virtually nonexistent outside of DEI-related panels. Targeted efforts to increase URiM representation will be needed to make tangible progress on this issue, just as they have yielded progress on increasing gender diversity in panel invitations., (© 2023 The Author(s).)

Racial disparities in medicine have greatly harmed patients, particularly those of Black race. This review focuses on the persistent paucity of Black physicians in medicine, elucidating the common barriers impeding the Black academic physician workforce. Multiple studies over several decades have established that Black academic faculty members remain persistently underrepresented at all faculty ranks regardless of medical subspecialty at less than 4% overall, far below the 13% Black representation in the United States census. The three major barriers facing Black academic physician faculty are: 1. Disparities in NIH grant funding, 2. Absence of mentorship, and 3. Increased activities not resulting in promotion (commonly known as the "minority tax"). Potential tangible solutions discussed include targeted research funding directed towards junior minority faculty, increasing non-concordant race mentors early in the pipeline, and incorporating diversity-related activities and committees into promotion and compensation processes. Most likely, only a multifaceted approach will provide tangible success against the longstanding and persistently active racial disparities facing Black physicians., (Copyright © 2022 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Brain metastases are a devastating sequela of common primary cancers (e.g., lung, breast, and skin) and have limited effective therapeutic options. Previously, systemic chemotherapy failed to demonstrate significant benefit in patients with brain metastases, but in recent decades, targeted therapies and more recently immune checkpoint inhibitors (ICIs) have yielded promising results in preclinical and clinical studies. Furthermore, there is significant interest in harnessing the immunomodulatory effects of radiotherapy (RT) to synergize with ICIs. Herein, we discuss studies evaluating the impact of RT dose and fractionation on the immune response, early studies supporting the synergistic interaction between RT and ICIs, and ongoing clinical trials assessing the benefit of combination therapy in patients with brain metastases.

Background: Recent work has demonstrated multiple measures of citation-based scholarly activity. Measures including Hirsch index (h-index), h-index limited to first author manuscripts (hf), h-index limited to first or second author only manuscripts (hs), and g-index have been associated with radiation oncology resident choice of academic versus private practice career. To date, there has been no evaluation of the progression of citation-based scholarly activity during residency., Methods: A list of United States radiation oncology residents from the graduating class of 2022 [postgraduate year two (PGY-2) academic year of 2018-2019] was obtained through internet investigation. Citation-based scholarly activity was collected and calculated from searches of the Scopus bibliometric citation database for h-index, hf, hs, and g-index for each resident as previously described. Calculations were derived in June 2018 for the postgraduate year one (PGY-1) year, and in June 2019 for the PGY-2 year. Fisher's exact test was used for statistical analysis., Results: Analysis of 195 residents from the 2022 class revealed that the citation-based scholarly activity significantly increased from PGY-1 to PGY-2 for h-index (2.6 to 3.2; P=0.047) and g-index (4.0 to 5.1; P=0.045), but not for hf (1.0 to 1.3; P=0.170) or hs (1.5 to 1.9; P=0.065). Underrepresented minority race/ethnicity (African-American/Hispanic) did not impact the significance of the h-index and g-index findings., Conclusions: From the PGY-1 to PGY-2 academic year, residents significantly increased in citation-based academic productivity, with an increase in the proportion of residents with a cited first-or-second author manuscript. Further study is necessary to determine how this trend persists in future years.

Background: African-Americans have the highest overall cancer death rate and shortest survival time of any racial or ethnic group in the United States. The most common cancer studied in African-American radiation therapy (RT) access disparities research is breast cancer. The goal of this study is to evaluate the impact of patient navigation on RT access for African-American breast cancer patients., Material and Methods: This study is a prospective survey-based evaluation of the impact of patient navigation on access to hypofractionated RT and financial toxicity in African-American breast cancer patients. The impact of patient navigation on RT access will be collated and analyzed from survey results pre-RT versus post-RT as well as for patients with versus without receipt of patient navigation. The validated COST-Functional Assessment of Chronic Illness Therapy score will be used to compare hypofractionation versus standard fractionated RT financial toxicity for patients with early-stage breast cancer who have received lumpectomy., Conclusion: This is the first study to investigate the impact of patient navigation on reducing RT access disparities facing African-American breast cancer patients. The natural progression of this work will be to expand this model to include additional breast cancer populations most vulnerable to suffering RT access disparities (Native American, Hispanic American, Appalachian) within the United States., Competing Interests: Conflict of interest None declared., (© 2022 Greater Poland Cancer Centre.)

Competing Interests: Conflicts of interest No author has any conflicts of interest.

Purpose: The landscape of the profession of academic radiation oncology is constantly changing. We sought to determine the demographic makeup of the current academic radiation oncology workforce., Materials and Methods: Internet web site searches of the 51 National Cancer Institute-designated Comprehensive Cancer Centers (CCCs) were conducted in September 2019. The Scopus database was subsequently searched in December 2019 to ascertain the h-index for each radiation oncologist. Geographic location was economically stratified (New York, California, Massachusetts, Illinois, and Washington DC) as previously reported. Race and binary sex were attributed by authors using publicly available information. Univariate analysis involved the chi-square test; a multivariable model considered several factors including rank and sex., Results: Of 993 radiation oncologists at CCCs, 53.6% are junior faculty, 24.8% associate professors, and 21.7% full professors. The average radiation oncologist at a CCC has been a physician for 19.7 (standard deviation = 11.3) years; 4.7% (47/993) are under-represented minorities. 24.6% of men and 15.5% of women were full professors, a statistically significant difference ( P = .001). Of the 51 department chairs, 11.8% are women and 5.6% are under-represented minorities. There are fewer female than male program directors in the most economically stratified locations ( P = .02). The mean h-index for all faculty is 17.6 (standard deviation = 16.9), and significantly differs between junior faculty (8.21), associate professors (18.46), and full professors (40.05; P < .0001). It also differs between men (19.35) and women (14.11). On multivariable analysis, sex, academic rank, and a secondary advanced degree were independently significant correlates of h-index., Conclusion: Among academic radiation oncologists at CCCs, under 5% are under-represented minorities, men are significantly over-represented among senior faculty, and women have significantly lower h-indices than men., Competing Interests: Mu ShanEmployment: LillyStock and Other Ownership Interests: Lilly Emma B. HollidayResearch Funding: Merck Serono Reshma JagsiEmployment: University of MichiganStock and Other Ownership Interests: Equity QuotientResearch Funding: Genentech (Inst)Expert Testimony: Baptist Health/Dressman Benziger Lavalle Law, Kleinbard, LLC, Sherinian and HassoTravel, Accommodations, Expenses: AmgenOther Relationship: JAMA OncologyOpen Payments Link: https://openpaymentsdata.cms.gov/physician/373670/summaryNo other potential conflicts of interest were reported.

Purpose: Major advances in radiation therapy (RT) for prostate cancer increase the importance of equity in the use of RT. We sought to assess the evolution of RT utilization disparities in prostate cancer to inform clinicians and health care organizations of persistent areas of need that can be addressed in their practices and policies., Methods and Materials: A comprehensive PubMed literature search was undertaken in June 2020 and subsequently in March 2021. Studies were excluded that were not based in the United States, did not examine health disparities or inequities, did not examine RT or related resource utilization, or did not examine prostate cancer., Discussion: Of 257 studies found, 32 met inclusion criteria. Health disparities were most prominently reported by race, socioeconomic status, geographic location, insurance status, practice characteristics, and age. Older men were less likely to receive definitive RT or prostatectomy. Black men were less likely to receive curative therapy or dose-escalated RT. Black, Hispanic, and Asian men were less likely to receive proton therapy. Lower income was associated with decreased prostate-specific antigen testing and treatment with proton therapy or stereotactic body RT. Medicaid patients were less likely to receive definitive treatments. Rural residents were less likely to receive RT. Minority-serving hospitals were less likely to offer definitive treatments for prostate cancer., Conclusions: Sociodemographic disparities and inequities in RT for prostate cancer persist. Robust efforts are imperative to eliminate disparities to improve outcomes for all patients with prostate cancer., (© 2022 The Author(s).)

Background: The mortality of the SARS-CoV-2 virus (COVID-19) has been associated with a pulmonary inflammatory response resulting in hypoxemia and rapid clinical decline. PREVENT is an ongoing prospective multicenter Phase II randomized controlled trial where patients hospitalized with COVID-19 pneumonia are randomized to low dose radiation therapy (RT) versus control (clinicaltrials.gov, NCT04466683). We describe the inpatient onboarding process of the center contributing the largest number of patients to this trial., Materials and Methods: COVID-19 hospital admissions were attained by the clinical research manager and radiation oncologist daily. Text message contact was made with infectious disease, critical care, and nursing staff with reciprocal discussion of the trial protocol and approval for virtual consulting of the patient. Witnessed informed consent was obtained first by telephone and later in person. Simulation and treatment (performed without a computer plan) was performed on a linear accelerator with one personal protective equipment-protected therapist moving in and out of the treatment room, and a second therapist manning the console. Following on-site dose calculation by physics, the radiation oncologist approved the fields prior to treatment delivery., Results: Between August 28, 2020 and October 6, 2020, the first 10 enrolled patients on this multicenter trial were randomized and treated at our institution; no team member (research staff, radiation oncology) contracted COVID-19 while employing this protocol., Conclusion: This represents the first published protocol to address efficient and safe recruitment of COVID-19 patients for a radiation oncology trial, serving as a model for conducting recruitment of COVID-19 patients for clinical trials., Competing Interests: Conflicts of interest No author has any conflicts of interest., (© 2021 Greater Poland Cancer Centre.)

Background and Purpose: Tumor treating fields (TTFields) are a non-invasive, efficacious treatment modality currently approved for supratentorial glioblastomas. Despite their ability to improve overall survival in supratentorial tumors, the current placement of arrays is limited to the supratentorial head, precluding its use in infratentorial tumors. Infratentorial malignancies are in need of new therapy modalities given their poor prognoses in both children and adults. The aim of this research is to determine whether rearrangement of TTFields may allow for management of infratentorial tumors., Materials and Methods: Delivery of TTFields using Novocure's prototype Optune™ device human male head model was simulated based on brain MRIs from patients with brainstem gliomas to develop a novel array layout designed to extend adequate infratentorial coverage., Results: Array placement on the vertex, bilateral posterolateral occiput, and superior-posterior neck achieved intensities above 1.1 V/cm (average 1.7 V/cm; maximum 2.3 V/cm) in the vertical field direction and above 1 V/cm (average 2 V/cm; maximum 2.8 V/cm) in the horizontal field direction of the infratentorium. The calculated field intensity within the simulated tumors were in the therapeutic range and demonstrated the effective delivery of TTFields to the infratentorial brain., Conclusions: Our findings suggest that rearrangement of the TTFields standard array with placement of electrodes on the vertex, bilateral posterolateral occiput, and superior-posterior neck allows for adequate electric field distribution in the infratentorium that is within the therapeutic range., Competing Interests: Conflicts of interest Dr. Ze’ev Bomzon, and Mr. Ariel Naveh receive salaried support from Novocure and own stocks in the same. No other author has any conflicts of interest. The initial draft of this manuscript was writen by Dr. Ramirez-Fort and Dr. McClelland and was free of ghostwriting by any Novocure employees., (© 2021 Greater Poland Cancer Centre.)

Background: Pleomorphic xanthoastrocytomas (PXAs) account for <1% of primary brain tumors, occurring predominantly in children and young adults. Surgical resection serves as the primary treatment for PXAs, while radiotherapy (RT) and chemotherapy protocols remain poorly defined., Aim: This study aims to determine current care patterns utilized for pediatric patients (≤ 18 years) diagnosed with PXAs and their effect on overall survival., Methods: The United States National Cancer Database (NCDB) was queried between 2004 and 2015 for pediatric patients (≤18 years) diagnosed with PXAs., Results: From the 224 qualifying patients, most patients proceeded with surgery only (78.1%), while 11.6% of patients received both adjuvant RT and chemotherapy. In the 2010-2015 cohort, patients with subtotal resection were associated with poorer prognosis than those with gross-total resection (hazard ratio = 17.44, 95% confidence interval = 2.10-144.90, p < .001). RT and chemotherapy recipients were similarly associated with poorer survival than those treated with surgery only, with p-values of <.001 and respective hazard ratios of 3.82 (95% confidence interval = 1.85-7.90) and 6.68 (95% confidence interval = 3.21-13.89). The key factors impacting the probability of RT delivery involved WHO grade (p < .001) and chemotherapy administration (p < .001). However, WHO grade alone did not significantly impact survival (p-value = .088)., Conclusion: Maximally safe resection is the current treatment goal for patients with PXAs. RT and chemotherapy are poorly utilized but had a greater role in managing more aggressive cases of PXAs. Additional research focusing on the impact of adjuvant therapies on tumor progression is needed to better guide treatment decisions., (© 2021 The Authors. Cancer Reports published by Wiley Periodicals LLC.)

Background: The impact of hospital volume on cancer patient survival has been demonstrated in the surgical literature, but sparsely for patients receiving radiation therapy (RT). This analysis addresses the impact of hospital volume on patients receiving RT for the most common central nervous system tumor: brain metastases., Materials and Methods: Analysis was conducted using the National Cancer Database (NCDB) from 2010-2015 for patients with metastatic brain disease from lung cancer, breast cancer, and colorectal cancer requiring RT. Hospital volume was stratified as high-volume (≥ 12 brain RT/year), moderate (5-11 RT/year), and low (< 5 RT/year). The effect of hospital volume on overall survival was assessed using a multivariable Cox regression model., Results: A total of 18,841 patients [9479 (50.3%) men, 9362 (49.7%) women; median age 64 years] met the inclusion criteria. 16.7% were treated at high-volume hospitals, 36.5% at moderate-volume, and the remaining 46.8% at low-volume centers. Multivariable analysis revealed that mortality was significantly improved in high-volume centers (HR: 0.95, p = 0.039) compared with low-volume centers after accounting for multiple demographics including age, sex, race, insurance status, income, facility type, Charlson-Deyo score and receipt of palliative care., Conclusion: Hospitals performing 12 or more brain RT procedures per year have significantly improved survival in brain metastases patients receiving radiation as compared to lower volume hospitals. This finding, independent of additional demographics, indicates that the increased experience associated with increased volume may improve survival in this patient population., Competing Interests: Conflict of interest Dr. McClelland receives research support from the Indianapolis Public Transportation Corporation. No author has any conflict of interest., (© 2021 Greater Poland Cancer Centre.)

Introduction: The improved survival of patients even with metastatic cancer has led to an increase in the incidence of spine metastases, suggesting the need for a more aggressive palliative treatment than conventional external beam radiation therapy (cEBRT). Consequently, spinal stereotactic body radiation therapy (SBRT) has increased in popularity over the past decade. However, there has been no comparison of patterns of usage of cEBRT versus SBRT in the treatment of spinal metastases in the US., Methods: The National Cancer Data Base (NCDB) from 2004-2013 was used for analysis. cEBRT was defined as 30 Gy in 10 fractions, 20 Gy in 5 fractions, or 8 Gy in 1 fraction. SBRT was defined as 25-32 Gy infive5 fractions, 24-32 Gy in 4 fractions, 20-32 Gy in three fractions, 14-32 Gy in 2 fractions, or 14-24 Gy in 1 fraction. Single and multivariable associations between patient demographic and cancer characteristics and type of radiation were performed., Results: From 2004-2013, 23,181 patients with spinal metastases in the United States received cEBRT, while 1,030 received SBRT as part of their first course of treatment. Most patients (88%) received 10 fractions of radiation. Multivariable analysis suggested that non-Medicare or private insurance (adjusted OR 0.4-0.7), African-American race (adjusted OR = 0.8, 95%CI = 0.7-1.0), age 65+ (adjusted OR = 0.8), living in a region with lower population (adjusted OR 0.7), earlier year of diagnosis (OR = 0.9), and receiving treatment in a non-academic/research facility (adjusted OR 0.6) were associated with cEBRT. After controlling for other variables, regional education level was no longer significantly associated with cEBRT., Conclusions: Most patients with spine metastases were treated with cEBRT, usually with 10 fractions. Receipt of SBRT was significantly associated with race, insurance, geography, population, type of treatment facility, and year of diagnosis, even after controlling for other factors. These findings raise questions about disparities in access to and delivery of care that deserve further investigation.

Background: The increasing proportion of women in medicine has not been adequately reflected in the gender distribution of radiation oncology residents. The presence of at least one pre-residency peer-reviewed publication (PRP) has been associated with radiation oncology resident choice of academic over private practice career, with no significant gender difference in the likelihood of having a PRP (McClelland et al., 2017). We sought to pursue a gender-based analysis of PRP productivity in a current junior resident class., Methods: A list of radiation oncology residents from the graduating class of 2022 (PGY-2 academic year of 2018-2019) was obtained through internet investigation. Research productivity was calculated using PRP number, defined as the number of a resident's publications listed in PubMed (pubmed.gov) through the calendar year of residency application (2016 for this class)., Results: Of 195 residents examined from the 2022 class, 61 (31%) were women, representing a nine percent increase from the resident class of 2016. Four-fifths of women had 1+ PRP, 31% had dual degrees, and 18% had a PhD. These percentages were comparable to their male counterparts, 73% with 1+ PRP, 28% with dual degrees, and 15% with a PhD. There were no statistically significant differences by gender in any of these benchmarks., Conclusions: While slower than the overall trend of increased female representation in medicine, the proportion of women in radiation oncology residency has increased by 0.9-1.5% annually over a recent six-year span. There remain no significant differences in PRP productivity, dual degree status, or PhD status by gender.

Background: Whole breast radiation therapy (RT) has become standard of care in early stage breast cancer treatment following lumpectomy. Predictors of RT completion have been sparsely studied, with no previous nationwide examination of the impact of fractionation regimen on completion rate., Patients and Methods: The National Cancer Database identified patients with early stage breast cancer having undergone lumpectomy and RT from 2004 through 2015. Fraction size of 1.8-2.0 Gray (Gy) was defined as standard fractionation (SFRT); 2.66-2.70 Gy/fraction as hypofractionation (HFRT). RT completion was defined as receipt of at least 46 Gy for SFRT and 40 Gy for HFRT. A multivariable logistic regression model characterized RT completion predictors., Results: A total of 100,734 patients were identified where fraction size could be reliably characterized as above; more than 87% completed RT. Of these, 66.8% received SFRT, yet HFRT use significantly increased over time (5.2% increase/year; P < .0001). RT completion rates were significantly greater following HFRT (99.3%) versus SFRT (79.7%); patients receiving SFRT had higher odds of not completing RT (odds ratio, 41.5; 95% confidence interval, 36.6-47.1; P < .0001). Multivariable analysis revealed that African-American and Caucasian patients treated with SFRT versus HFRT had 22 and 43 times the odds of not completing RT, respectively (P < .0001)., Conclusions: SFRT remained the majority of RT fractionation in the studied time period, although HFRT use has increased over time. Patients residing > 10 miles from a treatment facility or of African-American race had lower odds of completing RT, as were patients treated with SFRT versus HFRT. These findings suggest compliance advantages of HFRT for patients with early stage breast cancer having undergone lumpectomy., (Copyright © 2020 Elsevier Inc. All rights reserved.)