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Background This study was conducted in order to develop a model for predicting response to neoadjuvant chemotherapy (NAC) in patients with locally advanced breast cancer (LABC) using pretreatment quantitative ultrasound (QUS) radiomics. Methods This was a multicenter study involving four sites across North America, and appropriate approval was obtained from the individual ethics committees. Eighty‐two patients with LABC were included for final analysis. Primary tumors were scanned using a clinical ultrasound system before NAC was started. The tumors were contoured, and radiofrequency data were acquired and processed from whole tumor regions of interest. QUS spectral parameters were derived from the normalized power spectrum, and texture analysis was performed based on six QUS features using a gray level co‐occurrence matrix. Patients were divided into responder or nonresponder classes based on their clinical‐pathological response. Classification analysis was performed using machine learning algorithms, which were trained to optimize classification accuracy. Cross‐validation was performed using a leave‐one‐out cross‐validation method. Results Based on the clinical outcomes of NAC treatment, there were 48 responders and 34 nonresponders. A K‐nearest neighbors (K‐NN) approach resulted in the best classifier performance, with a sensitivity of 91%, a specificity of 83%, and an accuracy of 87%. Conclusion QUS‐based radiomics can predict response to NAC based on pretreatment features with acceptable accuracy., This multi‐institutional study investigated the role of radiomics from quantitative ultrasound (QUS) in predicting the final response to neoadjuvant chemotherapy (NAC) for 82 patients with locally advanced breast cancer (LABC). We had shown the QUS‐radiomics model can predict the response to treatment with an accuracy of 87% from spectroscopic features obtained before the start of NAC.

Background In patients with hepatocellular carcinoma (HCC), macrovascular invasion (MVI) is associated with a poor prognosis. The purpose of this study is to describe long-term outcomes of patients with HCC and MVI treated with stereotactic body radiation therapy (SBRT). Methods Patients with HCC and MVI who were treated with SBRT from January 2003 to December 2016 were analyzed. Patients who had extrahepatic disease or previous liver transplant were excluded. Demographical, clinical, and treatment variables were analyzed. Results 128 eligible patients with HCC and MVI were treated with SBRT. Median age was 60.5 years (39 to 90 years). Baseline Child-Pugh (CP) score was A5 in 67%, A6 in 20%. Median SBRT dose was 33.3 Gy (range: 27 to 54 Gy) in 5 fractions. Local control at 1 year was 87.4% (95% CI 78.6 to 96.1%). Median overall survival (OS) was 18.3 months (95% CI 11.2 to 21.4 months); ECOG performance status > 1 (HR:1.85, p = 0.0138) and earlier treatment era (HR: 2.20, p = 0.0015) were associated with worsening OS. In 43 patients who received sorafenib following SBRT, median OS was 37.9 months (95% CI 19.5 to 54.4 months). Four patients developed GI bleeding possibly related to SBRT at 2 to 8 months, and 27% (31/112 evaluable patients) had worsening of CP class at three months after SBRT. Conclusions SBRT was associated with encouraging outcomes for patients with HCC and MVI, especially in those patients who received sorafenib after SBRT. Randomized phase III trials of SBRT with systemic and/or regional therapy are warranted and ongoing.

Adjuvant whole-breast radiotherapy (RT) is a significant part of the standard of care treatment after breast cancer (BC) conserving surgery. Modern techniques including intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) have constituted to better target coverage and critical organs sparing. However, BC survivors are at risk of developing radiation-induced cardiac toxicity. Hence, deep-inspiration breath-hold (DIBH) techniques have been implemented at many centers to further reduce cardiac exposure but require compliance. 4D-CT robust optimization can account for heart intrafractional motion per breathing phase. The optimization has been explored in cardiac sparing of breast IMRT compared to DIBH in a small sample size but has not been evaluated in substructures sparing, nor in VMAT. To provide patients who are not compliant to breath-hold with an optimal treatment approach, various heart sparing techniques need to be evaluated for statistical significance and clinical feasibility.This retrospective study aimed to provide an extensive dosimetric heart sparing comparison of free-breathing, 4D-CT-based treatment planning, including robust optimization with DIBH-based treatment planning. Combinations of forward and inverse IMRT and VMAT are also considered.Fifteen early stage left-sided BC standard treatment plans were selected. Breast, lung, left anterior descending artery (LAD), left ventricle (LV), and the whole heart were contoured on each 4D-CT phase and DIBH CT dataset. Each treatment plan was optimized using forward/inverse IMRT and VMAT on the following CT datasets: DIBH, average 4D-CT, and the complete 4D-CT dataset needed for robust optimization. Dose-volume histograms were used to compare VAll RT techniques assessed including 4D robust optimization were clinically feasible. Statistically significant differences in mean heart, LAD and LV dose, max LAD dose, and VThis study demonstrated the clinical feasibility of 4D robust optimization in limiting the cardiac and substructures dose during free-breathing RT with both IMRT/VMAT for patients who are not compliant with breath-hold RT. However, this study also presents that 4D robust optimization can reduce LAD dose but not fully outperform DIBH or conventional 4D-CT-based planning with IMRT/VMAT in heart sparing in treating early staged left-sided BC patients.

Purpose: To investigate the utility of hybrid 18FDG-PET/MRI and serial blood work to detect early inflammatory response and cardiac functionality changes at one-month post-radiation therapy (RT) in patients with left-sided breast cancer.Methods: Fifteen left-sided breast cancer patients enrolled in the RICT-BREAST study underwent hybrid PET/MRI cardiac imaging at baseline and one-month after standard RT. Eleven patients received deep-inspiration breath-hold RT, while others received free-breathing RT. A list-mode 18FDG/PET scan with glucose suppression was acquired. Myocardial inflammation was quantified by the change of mean 18FDG standard uptake and analyzed based on the coronary vascular territory (left anterior descending (LAD), left circumflex or right coronary artery).MR assessments, including LV functional and extracellular volume matrices (ECV), were extracted from T1 (pre and during-constant infusion of gadolinium) and cine images, respectively, acquired simultaneously during PET acquisition. Cardiac injury and inflammation biomarker measurements of hs-TnT, hs-CRP and erythrocyte sedimentation rate were compared at the 1-month follow-up in this study.Results: At one-month follow-up, a significant increase (10%) of 18FDG/PET myocardial uptake (meanSUVbw) in LAD segments (p=0.04) and ECV in slices at the apex (6%) and base (5%) were detected (p≤0.02). Further, a significant reduction of LV stroke volume (-7%) was seen (p Conclusions: 18FDG/PET myocardial uptake and functional MR, including SV and ECV were sensitive to changes at one-month after breast cancer RT with findings suggesting an acute cardiac inflammatory response which is an important cardiotoxicity surrogate to RT. The clinical pilot study (NCT03748030, November 16, 2018) was approved by the Western University Human Research Ethics Board (HSREB ID 112991), funded by Lawson Strategic Research Fund (R19-292).

Purpose We develop a multi-centric response predictive model using QUS spectral parametric imaging and novel texture-derivate methods for determining tumour responses to neoadjuvant chemotherapy (NAC) prior to therapy initiation. Materials and methods QUS Spectroscopy provided parametric images of mid-band-fit (MBF), spectral-slope (SS), spectral-intercept (SI), average-scatterer-diameter (ASD), and average-acoustic-concentration (AAC) in 78 patients with locally advanced breast cancer (LABC) undergoing NAC. Ultrasound radiofrequency data were collected from Sunnybrook Health Sciences Center (SHSC), University of Texas MD Anderson Cancer Center (MD-ACC), and St. Michaels Hospital (SMH) using two different systems. Texture analysis was used to quantify heterogeneities of QUS parametric images. Further, a second-pass texture analysis was applied to obtain texture-derivate features. QUS, texture- and texture-derivate parameters were determined from both tumour core and a 5-mm tumour margin and were used in comparison to histopathological analysis for developing a response predictive model to classify responders versus non-responders. Model performance was assessed using leave-one-out cross-validation. Three standard classification algorithms including a linear discriminant analysis (LDA), k-nearest-neighbors (KNN), and support vector machines-radial basis function (SVM-RBF) were evaluated. Results A combination of tumour core and margin classification resulted in a peak response prediction performance of 88% sensitivity, 78% specificity, 84% accuracy, 0.86 AUC, 84% PPV, and 83% NPV, achieved using the SVM-RBF classification algorithm. Other parameters and classifiers performed less well running from 66% to 80% accuracy. Conclusions A QUS-based framework and novel texture-derivative method enabled accurate prediction of responses to NAC. Multi-centric response predictive model provides indications of the robustness of the approach to variations due to different ultrasound systems and acquisition parameters.

Background Stereotactic Body Radiation Therapy (SBRT) is a non-invasive ablative treatment for hepatocellular carcinoma (HCC). This report aimed to address the limited availability of long-term outcomes after SBRT for HCC from North America. Methods Localized HCC patients without vascular invasion, who were ineligible for other liver-directed therapies and treated with SBRT at the University of Toronto or University of Michigan, were pooled to determine overall survival (OS), cumulative recurrence rates, and ≥ grade-3 toxicity. Multivariable analysis determined factors affecting OS and local recurrence rates. Results In 297 patients with 436 HCCs (42% > 3 cm), one-, three- and five-year OS was 77·3%, 39·0% and 24·1%, respectively. On Cox proportional hazards regression analysis, liver transplant after SBRT, Child–Pugh A liver function, alpha-fetoprotein ≤ 10 ng/ml, and Eastern Co-operative Oncology Group performance status 0 significantly improved OS (hazard ratio [HR] = 0·06, 95% confidence interval [CI- 0·02–0·25; p Conclusions SBRT confers high local control and long-term survival in a substantial proportion of HCC patients unsuitable for, or refractory to standard loco-regional treatments. Liver transplant should be considered if appropriate downsizing occurs after SBRT.

Cigarette smoking is carcinogenic and has been linked to inferior treatment outcomes and complication rates in cancer patients. Here, we report the results of an 18-month pilot smoking cessation program that provided free nicotine replacement therapy (nrt). In January 2017, the smoking cessation program at our institution began offering free nrt for actively cigarette-smoking patients with cancer. The cost of 4 weeks of nrt was covered by the program, and follow-up was provided by smoking cessation champions. From January 2017 to June 2018, 8095 patients with cancer were screened for cigarette use, of whom 1135 self-identified as current or recent smokers. Of those 1135 patients, 117 enrolled in the program and accepted a prescription for nrt. The rates of patient referral and patients attending a referral appointment were significantly higher in 2018&ndash, 2018 than they had been in 2015&ndash, 2016 (100% vs. 80.3%, p 10 vs. &le, 10 initial cigarettes) was significantly predictive of smoking reduction (odds ratio: 5.04, 95% confidence interval: 1.46 to 17.45, p = 0.011). This pilot study of free nrt demonstrated rates of referral and acceptance of nrt that were improved compared with historical rates, and most referred patients either decreased their use of cigarettes or quit entirely.

As the coronavirus disease 2019 (COVID-19) pandemic continues to disrupt nearly all facets of daily life, residency programs must ensure the safety and wellness of their residents while maintaining a commitment to their training and advancement. In addition to standard clinical training, radiation oncology residency programs integrate highly specialized elements specific to the delivery of radiation therapy. Few publications have addressed the significant effects of the pandemic on medical training and even fewer have addressed concerns specific to radiation oncology. We report our experience developing a resident-led adaptation of our training program in response to the COVID-19 pandemic with the aim of assisting other programs to meet this challenge.

PURPOSE In 2015, men undergoing radical prostatectomy in Ontario, Canada were recommended to undergo multidisciplinary care by seeing a radiation oncologist or discussion at multidisciplinary rounds before surgery. The a priori target rate was ≥76%. We used population-based data to explore factors associated with not receiving multidisciplinary care prior to radical prostatectomy. MATERIALS AND METHODS Men who underwent radical prostatectomy for localized prostate cancer in Ontario between 2007 and 2017 were identified using administrative data. Physician billings identified patients who received multidisciplinary care. Multivariable logistic regression was used to predict receipt of multidisciplinary care. RESULTS A total of 31,485 men underwent radical prostatectomy between 2007 and 2017. Of these patients 28.7% saw a radiation oncologist, 1.2% underwent multidisciplinary discussion and 1.9% had both before surgery. Multidisciplinary care receipt increased from 17.8% in 2007 to 47.8% in 2017 (p

Purpose Exercise may be an alternative strategy to helping early-stage breast cancer (ESBC) patients manage their cancer-related fatigue and anxiety during radiation therapy. This observational study aims to investigate the impact of self-reported exercise on fatigue and anxiety levels pre (T0), mid (T1), and post (T2) radiation therapy in patients with ESBC. Methods Following informed consent, subjects completed three standardized questionnaires measuring physical activity, fatigue/quality of life, and anxiety at T0, T1, and T2. Results A total of 58 female patients (57 ± 9 years) completed this study. Mean activity level at T0 was 2548 (3292) metabolic equivalent units (METs), T1 was 3072 (3974) METs, and T2 was 2963 (2442) METs. There was no significant change between the three time points with measures of physical activity. Many patients moved from the moderately active group at T0 to the active group at T1. The mean T0 score using the quality of life questionnaire was 38.97 (11.30), T1 was 36.93 (11.69), and T2 was 35.36 (11.18). There was no significant change between the three time points with measures of quality of life (P = .211). There was statistical significance at P = .025 at T1 for lower quality of life compared to T0 across all exercise types. There was also statistical significance at P = .026 at T1 for the active group with higher quality of life compared to the inactive one. All three physical activity categories showed a decline in quality of life scores over time. Anxiety decreased between the three time point measurements. Mean T0 score for anxiety was 47.33 (5.95), T1 was 43.16 (6.49), and T2 was 38.48 (8.46). The interaction of exercise level and time is not significant for anxiety (P = .91). There was statistical significance (P = .015) for anxiety at T2 compared to T1 across exercise types. Discussion This study demonstrated that ESBC patients showed signs of fatigue and anxiety while undergoing radiation therapy regardless of self-reported exercise measured by a physical activity questionnaire. Several trends were observed that showed improved outcomes for patients consistent with previously published studies. The present study highlights a nonsignificant change in fatigue. As fatigue is one of the main side effects from radiation, it may be difficult to demonstrate significance. There are some studies in the field that demonstrate significance between fatigue and exercise with larger sample sizes. The results also highlight a decrease in anxiety from the baseline to the end of treatment. It is postulated that patients become less anxious as treatment progresses due to familiarity of a routine. The present study is limited by several factors including sample size and the study not being a randomized controlled one. Conclusions Exercise may reduce anxiety during radiation treatment for ESBC patients. Further investigation is required to assess the impact of fatigue.

Background and purpose This study aimed to determine the effects of reducing the dose of contrast agent (CA) in a DCE-MRI scan on inter- and intra-observer variability in the context of MRI-guided target volume delineation for stereotactic body radiation therapy of early stage breast cancer patients. This is in hopes of reducing risks to patients due to findings of residual CA in brain and bone. Materials and methods Twenty-three patients receiving neoadjuvant radiation therapy were enrolled. Five observers delineated the gross target volume (GTV) using DCE-MRI for guidance. 14/23 patients received the full clinical dose of CA and 9/23 received half. Clinical target volumes (CTV) were created through a 0.5 cm uniform expansion. Several metrics were used to quantify the inter and intra-observer reliability including differences in delineation volume and the reliability coefficient. Results There were no significant differences in the volume, though half contrast patients had a lower median for both the GTV and CTV (difference of 0.26 cm3 and 1.27 cm3, respectively). All indicated a high degree of agreement between and within observers for both dose groups. However, the full dose group had a greater inter-observer variability, most likely due to the full CA causing more pronounced enhancement in the periphery. Conclusions Reducing the dose of contrast agent did not significantly alter inter- or intra-observer variability. These results have prompted our centre to reduce the dose of gadolinium in all patients enrolled in the SIGNAL trial.

Purpose/objective(s) Men with localized prostate cancer have many options for initial definitive treatment. In 2015, Cancer Care Ontario Quality Based Procedures (QBP) recommended that men undergoing radical prostatectomy (RP) in Ontario be seen by a radiation oncologist (RO) or discussed at a multidisciplinary case conference (MCC) prior to surgery. An a-priori target rate of 76% was set by QBP, but to our knowledge, has not been reported upon to date. Our objective was to use population-based data to explore factors associated with not receiving RO consult/MCC prior to RP. Materials/methods Men with localized prostate cancer diagnosed and treated in Ontario, Canada with RP between 2007 and 2017 were identified using administrative data from the Institute for Clinical Evaluative Sciences. Physician billing data was utilized to identify patients who received RO consult/MCC prior to RP. Trends were evaluated using the Cochran-Armitage test. Multivariable logistic regression was used to identify patient and provider factors predictive of RO/MCC prior to RP. Results 31,467 men with localized prostate cancer underwent RP between 2007 and 2017. Prior to RP, 29.3% of men were seen by RO, 1.0% underwent MCC, and 1.6% had both. RO consult/MCC prior to RP increased from 18.0% in 2007 to 47.8% in 2017 (P Conclusion Despite increasing rates of utilization, a large proportion of men are not seen by RO or MCC prior to RP in Ontario, Canada. While the largest factors predicting RO consult/MCC discussion appear to be geographic and which urologist performs the RP, these factors are closely intertwined. In addition, these factors may be related to RO availability and radiation system capacity, which would need to be addressed to meet patient demand should QBP consultation rates be mandated to reduce disparities in pre-RP consultation practices.

Early-stage breast cancer patients comprise a large proportion of patients treated with radiotherapy in Canada. Proponents have suggested that five-fraction hypofractionated radiotherapy for these patients would result in significant cost savings. An assessment of this argument is thus warranted. The FAST-Forward and UK FAST clinical trials each demonstrated that their respective hypofractionated regimens provided equivalent outcomes compared with standard regimens. Thus, a cost-minimization analysis was performed to quantify the potential savings associated with these regimens, which were designated as FAST-Forward 1 (26 Gy/5 fractions/1 week) and FAST-Forward 2 (27 Gy/5 fractions/1 week), and UK FAST 1 (28.5 Gy/5 fractions/5 weeks) and UK FAST 2 (30 Gy/5 fractions/5 weeks). A standard regimen of 42.5 Gy/16 fractions/5 weeks was also included. A comprehensive model of radiotherapy costs for a Canadian cancer centre was created. Time, labour costs, and capital costs were calculated for each regimen and applied using established measures. The total costs per patient for the FAST-Forward trials were $851.77 for FAST-Forward 1 and $874.77 for FAST-Forward 2, providing a total savings of $487.99 and $464.99, respectively. Similarly, the total costs per patient for the FAST trials were $979.75 for UK FAST 1 and $1017.70 for UK FAST 2, providing savings of $360.01 and $322.06, respectively. Following the FAST-Forward 1 regimen results in the greatest reduction of infrastructure and human resources costs at 36.42% compared with the standard. Sensitivity analysis shows a maximum per-patient costs savings ranging from $474.60 to $508.53 for the FAST-Forward 1 trial, which translates to an annual savings of $174,700/year locally and $2.06 million/year province-wide, based on a moderate-to-large size department workload. Compared with a standard radiotherapy regimen, all FAST-Forward and UK FAST hypofractionated regimens provide cost savings for the treatment of early-stage breast cancer. The cost savings associated with each of these equivalent regimens can be directly calculated, activities in this model can easily be adjusted to account for cost variations, allowing other centres to calculate cost impacts specific to their own centres.

Background and purpose: Declining prostate brachytherapy utilization has been reported in several studies, despite strong evidence for efficacy and safety compared to alternatives. We sought to evaluate contemporary trends in brachytherapy, external beam radiotherapy (EBRT) and prostatectomy utilization in a publicly funded healthcare system. Materials and methods: Men with localized prostate cancer diagnosed and treated between 2006 and 2017 in Ontario, Canada were identified using administrative data. Men received EBRT, brachytherapy (monotherapy or boost) or prostatectomy as initial definitive management. Multivariable logistic regression evaluated patient-, tumour-, and provider-factors on treatment utilization. Results: 61,288 men were included. On multivariable regression, the odds of receiving brachytherapy boost increased 24% per year (odds ratio [OR]:1.24, 95% CI 1.22–1.26, p < 0.01), brachytherapy monotherapy increased 3% per year (OR:1.03, 95% CI:1.02–1.04, p < 0.01), and prostatectomy declined by 6% per year (OR:0.94, 95% CI 0.93–0.95, p < 0.01). Treatment year was not significant on multivariable modelling of EBRT. In a separate multivariable model limited to those who received radiotherapy, if the first radiation oncologist seen performed brachytherapy, the OR of receiving brachytherapy monotherapy over EBRT was 5.66 (95% CI: 5.11–6.26, p < 0.01) and 2.88 (95% CI: 2.60–3.19, p < 0.01) for brachytherapy boost over EBRT alone. Substantial geographic, provider and patient variation in treatment receipt was observed. Conclusion: We found increasing brachytherapy utilization, largely driven by increasing utilization of brachytherapy boost. To our knowledge, this is the first report of increasing brachytherapy use in the era of dose escalated EBRT.

// Ali Hosni 1 , Kathy Han 1 , Lisa W. Le 2 , Jolie Ringash 1 , James Brierley 1 , Rebecca Wong 1 , Robert Dinniwell 1 , Anthony Brade 1 , Laura A. Dawson 1 , Bernard J. Cummings 1 , Monika K. Krzyzanowska 3 , Eric X. Chen 3 , David Hedley 3 , Jennifer Knox 3 , Alexandra M. Easson 4 , Patricia Lindsay 1 , Tim Craig 1 and John Kim 1 1 Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada 2 Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada 3 Department of Medical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada 4 Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada Correspondence to: John Kim, email: john.kim@rmp.uhn.ca Keywords: anal cancer; chemoradiotherapy; IMRT; pattern of failure; outcomes Received: November 11, 2017 Accepted: February 27, 2018 Published: April 17, 2018 ABSTRACT Purpose: Patterns of failure and long term outcomes were prospectively evaluated following tumor factors-stratified radiation dose for anal/perianal cancer. Methods: Between 2008–2013, patients with anal/perianal squamous cell carcinoma were accrued to an institutional REB-approved prospective study. All patients were treated with image-guided intensity-modulated radiation therapy (IG-IMRT). Radiation dose selection (27–36 Gy for elective target, and 45–63 Gy for gross target) was based on tumor clinico-pathologic features. Chemotherapy regimen was 5-fluorouracil/mitomycin-C (weeks 1&5). Local [LF], regional failure [RF], distant metastasis [DM], overall- [OS], disease-free [DFS], colostomy-free survival [CFS] and late toxicity were analyzed. Results: Overall, 101 patients were evaluated; median follow-up: 56.5 months; 49.5% male; 34.7% T3/4-category, and 35.6% N+. Median radiation dose was 63 Gy. The most common acute grade ≥3 toxicities were skin (41.6%) and hematological (30.7%). Five-year OS, DFS, CFS, LF, RF, DM rates were 83.4%, 75.7%, 74.7, 13.9%, 4.6% and 5% respectively. Five-year LF for patients with T1-2 and T3-4 disease were 0% and 39.2% respectively. All LF ( n = 14, after 63 Gy, in tumors ≥5 cm) were in the high dose volume except one marginal to the high dose volume. All RF ( n = 4) were within elective dose volume except one within the high dose volume. On multivariable analysis, T3/4-category predicted for poor DFS, CFS and OS. The overall late grade ≥3 toxicity was 36.2% (mainly anal [20%]). Conclusions: Individualized radiation dose selection using IG-IMRT resulted in good long term outcomes. However, central failures remain a problem for locally advanced tumors even with high dose radiation (63 Gy/7weeks).

Key Points Question Do male and female physicians in Ontario, Canada, receive equal payments for equal work? Findings In this cross-sectional study including 31 481 physicians (nearly all physicians in Ontario), women earned 32.8% less than men annually and 22.5% less daily. After controlling for observable factors associated with earnings, such as practice characteristics, geography (degree of rurality), and specialty, the daily pay gap remained significant, at 13.5%. Meaning This cross-sectional study describes a complex set of factors associated with payment disparities affecting female physicians, considering both daily and annual payment gaps and the variations by specialty, rurality, and practice settings., This cross-sectional study examines differences in pay by gender among physicians in Ontario, Canada., Importance Men and women should earn equal pay for equal work. An examination of the magnitude of pay disparities could inform strategies for remediation. Objective To examine gender-based differences in pay within a large, comprehensive physician population practicing within a variety of payment systems. Design, Setting, and Participants This cross-sectional study used data from the Ontario Health Insurance Plan (OHIP) in the 2017 to 2018 fiscal year to estimate differences in gross payments between men and women physicians in Ontario, Canada. Pay gaps were calculated annually and daily. Regression analyses were used to control for observable practice characteristics that could account for individual differences in daily pay. In Canada’s largest province, Ontario, medical services are predominantly provided by self-employed physicians who bill the province’s single payer, OHIP. All physicians who submitted claims to OHIP were included. Data were analyzed from January 2020 to July 2021. Exposures Physician gender, obtained from the OHIP Corporate Provider Database. Gender is recorded as male or female. Main Outcomes and Measures Gross clinical payments were tabulated for individual physicians on a daily and annual basis in conjunction with each physician’s practice characteristics, setting, and specialty. Results A total of 31 481 physicians were included in the study sample (12 604 [40.0%] women; 18 877 [60.0%] men; mean [SD] time since graduation, 23.3 [13.6] years), representing 99% of active physicians in Ontario. The unadjusted differences in clinical payments between male and female physicians were 32.8% (95% CI, 30.8%-34.6%) annually and 22.5% (95% CI, 21.2%-23.8%) daily. After accounting for practice characteristics, region, and specialty, the overall daily payment gap was 13.5% (95% CI, 12.3%-14.8%). The pay gap persisted with differing magnitudes when examined by specialty (ranging from 6.6% to 37.6%), practice setting (8.3% to 17.2%), payment model (13.4% to 22.8% for family medicine; 8.0% to 11.6% for other specialties), and rurality (8.0% to 16.5%). Conclusions and Relevance This cross-sectional study examined differences in magnitude of annual and daily payment gaps and between unadjusted and adjusted gaps. Comparing the gaps for different specialties, geography, and payment systems illustrated the complexity of the issue by showing that the pay gap varied for physicians in different practice settings. As such, multiple directed interventions will be necessary to ensure that all physicians are paid equally for equal work, regardless of gender.

The need to minimize in-person interactions during the COVID-19 pandemic has led to fewer clinical learning opportunities for trainees. With ongoing utilization of virtual platforms for resident education, efforts to maximize their value are essential. Herein we describe a resident-led quality improvement initiative to optimize remote contouring and virtual contour review. From April to June 2020, radiation oncology (RO) residents at our institution were assigned modified duties. We implemented a program to source and assign cases to residents for remote contouring and to promote and optimize virtual contour review. Resident-perceived educational value was prospectively collected and analyzed. All nine RO residents at our institution (PGY1–5) participated, and 97 cases were contoured during the evaluation period. Introduction of the Remote Contouring and Virtual Review (RECOVR) program coincided with a significant increase in mean cases contoured per week, from 5.5 to 17.3 (p = 0.015), and an increased proportion of cases receiving virtual review, from 14.8% to 58.6% (p < 0.001). Residents reported that the value of immediate feedback during virtual review was similar to that of in-person review (4.6 ± 0.1 vs. 4.5 ± 0.2, p = 0.803) and significantly higher than feedback received post hoc (e.g., email; 3.6 ± 0.2, p < 0.001). The implementation of a remote process for contour review led to significant increases in contouring, and virtual contour review was rated as highly as in-person interactions. Our findings provide a data-driven rationale and framework for integrating remote contouring and virtual review into competency-based medical education.

Improved treatments resulting in a rising number of survivors of breast cancer (bca) calls for optimization of current specialist-based follow-up care. In the present study, we evaluated well survivors of bca with respect to their supportive care needs and attitudes toward follow-up with various care providers, in varying settings, or mediated by technology (for example, videoconference or e-mail). A cross-sectional paper survey of well survivors of early-stage pT1&ndash, 2N0 bca undergoing posttreatment follow-up was completed. Descriptive and univariable logistic regression analyses were performed to examine associations between survivor characteristics, supportive care needs, and perceived satisfaction with follow-up options. Qualitative responses were analyzed using conventional content analysis. The 190 well survivors of bca who participated (79% response rate) had an average age of 63 &plusmn, 10 years. Median time since first follow-up was 21 months. Most had high perceived satisfaction with in-person specialist care (96%, 177 of 185). The second most accepted model was shared care involving specialist and primary care provider follow-up (54%, 102 of 190). Other models received less than 50% perceived satisfaction. Factors associated with higher perceived satisfaction with non-specialist care or virtual follow-up by a specialist included less formal education (p < 0.01) and more met supportive care needs (p < 0.05). Concerns with virtual follow-up included the perceived impersonal nature of virtual care, potential for inadequate care, and confidentiality. Well survivors of bca want specialists involved in their follow-up care. Compared with virtual follow-up, in-person follow-up is perceived as more reassuring. Certain survivor characteristics (for example, met supportive care needs) might signal survivor readiness for virtual or non-specialist follow-up. Future work should examine multi-stakeholder perspectives about barriers to and facilitators of shared multimodal follow-up care.

e17052 Background: Men with localized prostate cancer have many options for initial definitive treatment. In 2015, Cancer Care Ontario Quality Based Procedures (QBP) recommended that men undergoing radical prostatectomy (RP) in Ontario be seen by a radiation oncologist (RO) or discussed at a multidisciplinary case conference (MCC) prior to surgery. An a-priori target rate of 76% was set by QBP, but to our knowledge, has not been reported upon to date. Our objective was to use population-based data to explore factors associated with not receiving RO consult/MCC prior to RP. Methods: Men with localized prostate cancer diagnosed and treated in Ontario, Canada with RP between 2007 and 2017 were identified using administrative data from the Institute for Clinical Evaluative Sciences. Physician billing data was utilized to identify patients who received RO consult/MCC prior to RP. Trends were evaluated using the Cochran-Armitage test. Multivariable logistic regression was used to identify patient and provider factors predictive of RO/MCC prior to RP. Results: 31,467 men with localized prostate cancer underwent RP between 2007 and 2017. Prior to RP, 29.3% of men were seen by RO, 1.0% underwent MCC, and 1.6% had both. RO consult/MCC prior to RP increased from 18.0% in 2007 to 47.8% in 2017 ( p

A prospective study was conducted to assess the acute and late toxicity of hypofractionated whole breast irradiation with a weekly concomitant boost for women with early breast cancer (EBC). Women with EBC who underwent breast-conserving surgery were eligible. A dose of 40Gy in 15 fractions over 3 weeks was delivered to the whole breast with a concomitant weekly boost to the post-operative cavity of 3Gy in three fractions. Toxicity was graded using the Radiation Therapy Oncology Group (RTOG) acute toxicity and RTOG/EORTC late toxicity scales. A total of 67 women were enrolled with a median age of 49 years (range 31–69). Median follow-up was 25 months (range 11–34). Acute skin reactions included grade (G) 1 (n = 47, 70%), G2 (n = 10, 13%), and G3 (n = 1, 1.5%). Late skin toxicity was observed in 13 patients (19%), all of whom experienced G1 toxicity only. On multivariable analysis, diabetes mellitus was predictive of acute skin toxicity (p = 0.003), while age less than 50 years (p = 0.029) and diabetes mellitus (p = 0.013) were predictive of late skin toxicity. Whole breast irradiation with concomitant weekly boost appears feasible and safe. Further investigation is required to fully evaluate this schedule as an alternative to conventional whole breast irradiation with a sequential boost.

Purpose Locoregional recurrence is common after surgery for gastric cancer. Adjuvant therapy improves outcomes but with toxicity. This phase 1/2 study investigated infusional 5-fluorouracil (5-FU) in combination with biweekly cisplatin delivered concurrently with image guided high-precision radiation therapy. Methods and Materials Eligible patients had completely resected stage IB to IV (Union for International Cancer Control TNM 6th edition) nonmetastatic gastric adenocarcinoma. Treatment constituted 12 weeks of infusional 5-FU (200 mg/m2/day) with cisplatin added in a standard 3 + 3 dose escalation protocol (0, 20, 30, and 40 mg/m2) during weeks 1, 3, 5, and 7, and an additional week 9 dose in the final cohort. Radiation therapy (45 Gy in 25 fractions) was delivered during weeks 3 to 7. Maximum tolerated dose (MTD) was determined in phase 1 and confirmed in phase 2. Results Among the 55 patients (median age, 54 years; range 28-77 years; 55% male), the median follow-up time was 3.0 years (range, 0.3-5.3 years). Five patients in phase 1 experienced dose-limiting toxicity, and MTD was determined as 4 cycles of 40 mg/m2 cisplatin. Twenty-seven patients were treated at MTD. Acute grade 3 to 4 toxicity rate was 37.0% at MTD and 29.1% across all dose levels. No treatment-related deaths occurred. Fourteen patients experienced recurrent disease. The 2-year overall survival (OS) and relapse-free survival were 85% and 74%, respectively. Median OS has not been reached. Quality of life (QOL) was impaired during treatment, but most scores recovered by 4 weeks. Conclusion Cisplatin can be safely delivered with 5-FU–based chemoradiation therapy. Acute toxicity was acceptable, and patient-reported QOL showed the regimen was tolerable. Outcomes are encouraging and justify further study of this regimen.

Purpose To determine the maximally tolerated dose of sorafenib delivered before, during, and after stereotactic body radiation therapy (SBRT) in hepatocellular carinoma (HCC). Methods and Materials Eligible patients had locally advanced Child-Pugh class A HCC, showed Eastern Cooperative Oncology Group performance status 0-1, and were ineligible for standard local-regional therapies. Sorafenib was dose escalated in 2 strata: ( 1 ) low effective irradiated liver volume (veff) 2 ) high veff 30%to 60%. Sorafenib (400 mg daily = dose level 1) was administered for 12 weeks, with 6 fractions SBRT delivered weeks 2 and 3, and escalation to full dose (400 mg twice daily) after 12 weeks as tolerated. Standard 3 + 3 cohorts with dose escalation of sorafenib were planned. Results Sixteen patients (4 low veff, median dose 51 Gy; 12 high veff, median dose 33 Gy) were treated at 2 sorafenib dose levels. Of those patients 75% were had Barcelona Clinic Liver Cancer stage C, and 63% had main branch portal vein invasion. In the low veff stratum, no dose-limiting toxicities (DLTs) were observed in 4 patients treated with SBRT and sorafenib 400 mg. Inb the high veff stratum: 2 of 3 evaluable patients treated with sorafenib 400 mg experienced DLT (grade 3 large bowel bleed and grade 4 bowel obstruction 51 and 27 days, respectively, after SBRT). One of 6 evaluable patients at dose level −1 (200 mg once daily) experienced a grade 3 tumor rupture at week 5. Median overall survival and in-field local progression have not been reached. Worsening of Child-Pugh liver function class was seen in 6 of 12 patients in the high veff stratum. Conclusions Significant toxicity was observed in the high veff stratum, and concurrent SBRT with sorafenib is not recommended outside a clinical trial.

e17608 Background: A worldwide decline in prostate brachytherapy (BT) utilization has been reported in multiple health care settings/jurisdictions, despite strong evidence for efficacy and safety compared to other alternatives. We sought to evaluate contemporary trends in BT, EBRT and prostatectomy utilization in a publicly funded healthcare system. Methods: Men with localized prostate cancer diagnosed and treated between 2007 and 2017 in Ontario, Canada were identified using administrative data from the Institute for Clinical Evaluative Sciences. Men were coded to have received EBRT, BT (monotherapy or boost) or prostatectomy as initial definitive management. Trends were evaluated using the Cochran-Armitage test. Multivariate logistic regression was used to evaluate patient-, tumour-, and provider-factors on treatment utilization over time. Results: 57,655 men were included in our study. Prostate BT use increased from 7.5% of all treatments in 2007 to 15.4% in 2017 ( p< 0.01), primarily due to increased use of BT boost (1.7% in 2007 to 10.4% in 2017, p < 0.01). Relative to EBRT, BT use increased from 17.9% in 2007 to 28.1% in 2017 ( p< 0.01). On multivariate analysis (MVA), BT boost use increased by 28% per year (OR 1.28, 95% CI 1.26–1.31, p< 0.01) and BT monotherapy use increased by 12% per year (OR 1.12, 95% CI 1.10–1.14, p< 0.01), offset by decreasing prostatectomy use (12% per year, OR 0.88, 95% CI 0.87–0.89, p< 0.01). Comparing BT to EBRT, the strongest predictors of receiving BT were geographic residence (OR 27.6, 95% CI: 20.3–37.6, p< 0.01 between highest/lowest Local Health Integration Networks) and whether the first consulting radiation oncologist performed BT (OR 3.46, 95% CI: 3.15–3.80, p< 0.01). Other significant factors predicting BT use vs. EBRT included lower age, lower PSA, lower Charlson comorbidity score and increasing neighborhood income quintile. Low-intermediate, high-intermediate and high-risk groups were predictive of receiving BT boost, whereas BT monotherapy was predominantly used in low-risk disease. Conclusions: Contrary to trends observed in other jurisdictions, utilization of prostate BT is increasing over time in Ontario. However, substantial variation in BT utilization was found, strongly driven by both geographic region and radiation oncologist BT practice patterns. To our knowledge, this is the first study to report increasing BT utilization in the era of dose-escalated EBRT, with Ontario potentially serving as a model to promote BT utilization elsewhere.

The aromatase inhibitor (AI) letrozole is a first-line drug in the adjuvant treatment of breast cancer in postmenopausal women. Adherence to AI therapy, including letrozole, remains problematic due to the development of debilitating AI-induced arthralgia. Letrozole is metabolized in the liver by CYP2A6. It remains unknown if plasma letrozole levels or CYP2A6 genetic variation is associated with the development of arthralgia. We enrolled 126 female breast cancer patients initiated on letrozole therapy and prospectively collected blood samples at baseline and two follow-up time points to determine letrozole plasma concentrations and CYP2A6 genotype. At each visit, participants completed two validated questionnaires to assess the severity of arthralgia symptoms. More than half (55%) of patients experienced a significant increase in their arthralgia symptoms after initiation of treatment. The clinical variables of body mass index (P = 0.0003) and age (P = 0.0430) were negatively and positively associated with plasma letrozole concentrations, respectively. CYP2A6 genotype was significantly associated with letrozole levels (P

Background Cancer patients frequently search the Internet for treatment options, and hospital websites are seen as reliable sources of knowledge. Guidelines support the use of proton radiotherapy in specific disease sites or on clinical trials. This study aims to evaluate direct-to-consumer advertising content and claims made by proton therapy centre (PTC) websites worldwide. Methods Operational PTC websites in English were identified through the Particle Therapy Co-Operative Group website. Data abstraction of website content was performed independently by two investigators. Eight international guidelines were consulted to determine guideline-based indications for proton radiotherapy. Univariate and multivariate logistic regression models were used to determine the characteristics of PTC websites that indicated proton radiotherapy offered greater disease control or cure rates. Results Forty-eight PTCs with 46 English websites were identified. 60·9% of PTC websites claimed proton therapy provided improved disease control or cure. U.S. websites listed more indications than international websites (15·5 ± 5·4 vs. 10·4 ± 5·8, p = 0·004). The most common disease sites advertised were prostate (87·0%), head and neck (87·0%) and pediatrics (82·6%), all of which were indicated in least one international guideline. Several disease sites advertised were not present in any consensus guidelines, including pancreatobiliary (52·2%), breast (50·0%), and esophageal (43·5%) cancers. Multivariate analysis found increasing number of disease sites and claiming their centre was a local or regional leader in proton radiotherapy was associated with indicating proton radiotherapy offers greater disease control or cure. Conclusions Information from PTC websites often differs from recommendations found in international consensus guidelines. As online marketing information may have significant influence on patient decision-making, alignment of such information with accepted guidelines and consensus opinion should be adopted by PTC providers. Electronic supplementary material The online version of this article (10.1186/s13014-018-0988-z) contains supplementary material, which is available to authorized users.

Purpose High-precision radiotherapy relies on accurate anatomic localisation. Urethrography is often used to localise the prostatic apex. However, urethrography is an invasive localisation procedure and may introduce a systemic error. The penile bulb (PB) is contoured to minimise the risk of erectile dysfunction. The purpose of this study is to assess the value of using the PB, as an alternative to urethrography, to localise the prostate. Methods and Materials The PB was localised on 10 patients treated with simplified intensity-modulated arc radiotherapy at computed tomography simulation during treatment weeks 1 and 7. All patients underwent placement of fiducial markers. Urethrography was used only at simulation. Distances from the superior PB contour to the inferior prostate contour, the apex fiducial marker, and to the inferior prostate contour were obtained as well. The PB was contoured by two observers independently. Agreement coefficients and analysis of variance were used to assess reliability between rates and consistency of measurements over time. Results The PB-apex distance was greater than or equal to the urethrogram-apex distance in 24/30 (80%) measurements, and the median difference was 3 mm and was consistent between raters. The greatest variation in PB-IM distance between weeks was 6 mm, the median was 3 mm, and the agreements of measurements between weeks for raters 1 and 2 were 0.79 and 0.69, respectively. These differences were not statistically different and were consistent with the computed tomography slice thickness. Conclusions The PB can be used to identify the prostate apex and can be reliably contoured between observers. Measurements are consistent between patients and through the duration of treatment. The PB distance measurements support studies indicating that urethrography causes a shift of the prostate superiorly. The distance from the PB to prostate apex remains stable during treatment for individual patients but varies between patients.

Background and objectives: About half of the head and neck cancer patients treated with radiotherapy suffer from late radiation effects months to years after the treatment. The most common diagnosis and monitoring methods for such oral toxicities are based on surface examination of the oral tissue, which is subjective. Therefore, subsurface imaging and image quantification tools can be highly useful for monitoring these late effects as these approaches are more robust and objective. In this study, we demonstrate the ability of optical coherence tomography (OCT) technology and its newly developed quantitative imaging platform to reveal subsurface microstructural and microvascular changes in late oral radiation toxicity patients, not detectable by available clinical tools. Materials and methods: Fifteen patients exhibiting late oral radiation toxicity, and five healthy age-matched volunteers were imaged with OCT in a clinical pilot study. Image assessment methods, developed in-house, were used to extract four quantitative metrics of potential clinical importance from the acquired microstructural and microvascular oral OCT images. Results: The statistically significant differences in the patients compared to healthy volunteers were: lower epithelium to lamina propria thickness (indicating epithelial atrophy and/or fibrosis of lamina propria), smaller vessel diameter (indicating vessel lumen narrowing), and higher blood velocity. The observed in-vivo morphological changes correlated well with reported histology findings. No significant changes were observed in vessel tortuosity between the cohorts. Conclusion: The quantitative metrics extracted from the OCT images demonstrated significant microstructural and microvascular differences between the two cohorts. Potentially, OCT and its newly developed image analysis platform can be used as a noninvasive in-vivo subsurface tool for “shedding light” on late oral radiation toxicity, for example in palliative treatment efficacy monitoring.

Summary The prognosis for locally advanced esophageal cancer is poor despite the use of trimodality therapy. In this phase II study, we report the feasibility, tolerability and efficacy of adjuvant sunitinib. Included were patients with stage IIa, IIB or III cancer of the thoracic esophagus or gastroesophageal junction. Neoadjuvant therapy involved Irinotecan (65 mg/m2) + Cisplatin (30 mg/m2) on weeks 1 and 2, 4 and 5, 7 and 8 with concurrent radiation (50Gy/25 fractions) on weeks 4–8. Sunitinib was commenced 4–13 weeks after surgery and continued for one year. Sixty-one patients were included in the final analysis, 36 patients commenced adjuvant sunitinib. Fourteen patients discontinued sunitinib due to disease recurrence (39%) within the 12-month period, 12 (33%) discontinued due to toxicity, and 3 (8%) requested cessation of therapy. In the overall population, median survival was 26 months with a 2 and 3-year survival rate of 52% and 35%, respectively. The median survival for the 36 patients treated with sunitinib was 35 months and 2-year survival probability of 68%. In a historical control, a prior phase II study with the same trimodality therapy (n = 43), median survival was 36 months, with a 2-year survival of 67%. Initiation of adjuvant sunitinib is feasible, but poorly tolerated, with no signal of additional benefit over trimodality therapy for locally advanced esophageal cancer.

Background and purposeThis study aims to develop an expedited radiotherapy (RT) process and evaluate its time savings in women requiring whole breast RT.Material and methodsAn inter-professional RT team streamlined the computed tomography (CT) simulation and treatment pathway for a ‘QuickStart’ process. Target delineation was performed by an advanced practice radiation therapist and approved by the radiation oncologist (RO) for planning. Automated breast planning software was used for treatment planning and standard quality checks were performed. To assess time savings, the initial 25 QuickStart patients were matched with women who underwent whole breast simulation on the same day (±3 days), treated using the conventional process.ResultsA total of 73 post-lumpectomy women were treated through the QuickStart process; the median consent-to-RT was 2 days (range: 0–13) and the mean CT simulation-to-RT treatment was 2 hours and 42 minutes (SD 0:30). In the subgroup analysis, QuickStart patients saved an average of 11 days from CT simulation-to-RT and had shorter median wait-times for both surgery/chemotherapy-to-RT (60 versus 38 days;p=0·002) and consultation-to-RT (7 versus 20 days;pConclusionsThrough inter-professional team efforts and the application of automated planning software, we have achieved a process that significantly decreases patient wait-times while maintaining the quality of whole breast RT.

We have presented a collection of prospectively collected data pertaining to the nature of e-mail messages received in modern clinical oncology practice. Despite all the limitations of the study, some useful information emerged. Use of ooo appears to reduce the number of e-mail messages a physician receives. If you use ooo so that people sending you messages of importance recognize that they won’t be receiving a reply, then there is value in using it. Further, physicians could have some peace of mind that senders are aware not to expect a response as quickly as they might otherwise anticipate. Perhaps a notification saying “your e-mail message will be deleted; if it is important that I see it, please resend upon my return” might ultimately be the optimal way to manage an inbox during an absence from work?

Purpose To demonstrate the large-scale clinical implementation and performance of an automated treatment planning methodology for tangential breast intensity modulated radiation therapy (IMRT). Methods and Materials Automated planning was used to prospectively plan tangential breast IMRT treatment for 1661 patients between June 2009 and November 2012. The automated planning method emulates the manual steps performed by the user during treatment planning, including anatomical segmentation, beam placement, optimization, dose calculation, and plan documentation. The user specifies clinical requirements of the plan to be generated through a user interface embedded in the planning system. The automated method uses heuristic algorithms to define and simplify the technical aspects of the treatment planning process. Results Automated planning was used in 1661 of 1708 patients receiving tangential breast IMRT during the time interval studied. Therefore, automated planning was applicable in greater than 97% of cases. The time for treatment planning using the automated process is routinely 5 to 6 minutes on standard commercially available planning hardware. We have shown a consistent reduction in plan rejections from plan reviews through the standard quality control process or weekly quality review multidisciplinary breast rounds as we have automated the planning process for tangential breast IMRT. Clinical plan acceptance increased from 97.3% using our previous semiautomated inverse method to 98.9% using the fully automated method. Conclusions Automation has become the routine standard method for treatment planning of tangential breast IMRT at our institution and is clinically feasible on a large scale. The method has wide clinical applicability and can add tremendous efficiency, standardization, and quality to the current treatment planning process. The use of automated methods can allow centers to more rapidly adopt IMRT and enhance access to the documented improvements in care for breast cancer patients, using technologies that are widely available and already in clinical use.

350 Background: To report outcomes of pooled data from patients with early stage hepatocellular carcinoma (HCC) treated with stereotactic body radiation therapy (SBRT) at two North American Institutions. Methods: An IRB approved collaborative review of patients with HCC treated with radical intent SBRT was conducted. Inclusion criteria included patients with Stage I-IIIA HCC (UICC/AJCC 7th Ed.) treated with SBRT (≥ 4.5 Gy/ fraction) from June 2003 until Dec 2016. Patients who were treated with SBRT were ineligible for resection, percutaneous ablative or hepatic intravascular therapies. Patients with vascular invasion and those treated with palliative intent (e.g. HCC rupture) were excluded. Overall survival, local control and toxicity of treatment were reviewed retrospectively. Results: Of 310 eligible patients, 23% were Child-Pugh (CP) class B/C (21%/2%), and 40% had failed prior liver directed therapies. The median HCC diameter was 2.4 cm (range 0.5-18.1 cm), and the median prescribed dose was 39 Gray (Gy) in 5 fractions (range: 14 - 60 Gy in 2-6 fractions). Median BED was 78.75 Gy (Range: 23.8-180.0 Gy). 8.4% of patients underwent liver transplant after SBRT. Local control at 1, 3 and 5 years was 91.5%, 82.6% and 82.6%. On multivariable analysis (MVA), the use of breath-hold motion management, but not T stage, size or dose, was significantly associated with local control (p = 0.0098). The 1, 3, and 5 year overall survival (OS) was 77.3%, 37.9% and 23.5%. Factors associated with improved OS on MVA included baseline CP A score (HR = 0.58, p < 0.0045), AFP < 10 µg/L (HR = 0.66, p = 0.0094), and transplant post SBRT (HR = 0.05, p < 0.0001). The median survival of CP A vs. B/C patients was 30.3 and 17.6 months respectively. CTCAE (v4.0) grade 3 or higher luminal gastrointestinal organ toxicity occurred in 2.5% of patients, while a decline in CP score ≥ 2 points was seen in 16.7% of patients at 3 months post SBRT. Grade 3 and above elevated liver enzymes were seen in 12.6% and 8.1% of patients at baseline and at 3 months post SBRT. Conclusions: Similar to Asian series, this North American pooled analysis found high sustained local control and excellent survival in patients with early stage HCC treated with SBRT.

428 Background: In patients with hepatocellular carcinoma (HCC), macrovascular invasion (MVI) is associated with a poor prognosis. This study describes long-term outcomes of patients with HCC and MVI treated with stereotactic body radiation therapy (SBRT). Methods: Patients with HCC and MVI who were treated with SBRT from January 2003 to December 2016 were eligible for analysis. Patients who had extrahepatic disease or who had prior liver transplant were excluded. Demographical, clinical, and treatment variables were collected, under IRB approval. The degree of vascular invasion was quantified into two categories: main portal vein branch/IVC and distal portal/hepatic vein. Results: 128 eligible pts with HCC and MVI were treated with SBRT ( > 4.5 Gy/fraction). The median age was 61 yrs (range: 39 to 90 yrs). Underlying liver disease was hepatitis B in 23%, hepatitis C in 45%, other in 20%; no known liver disease in 12%. Baseline Child-Pugh (CP) score was A5 in 67%, A6 in 20%, B7 or higher in 13%. 35% received previous liver-directed therapies. Median HCC volume was 153.7 mL (range: 3.9 to 1,813.5 mL). Median AFP was 205 ug/L (range: 1 to 171,154 ug/L). Median SBRT dose was 33.3 Gy (range: 27 to 54 Gy) in 6 fractions. Local control at 1 year was 87.4% (95% CI 78.6 to 96.1%). SBRT dose or HCC volume were not significant on univariate analysis. Median overall survival was 18.3 months (95% CI 11.2 to 21.4 months). ECOG PS > 1 (HR:1.73, p = 0.03), CP score (HR: 1.67, p = 0.04), and treatment between 2004 and 2010 (HR: 2.28, p = 0.0009) were significant on multivariable analysis, while SBRT dose, HCC volume, and degree of vascular invasion were not. In 35 patients who received sorafenib following SBRT, median survival was 38.5 months (95% CI 17.23 to 43.16 months). 4/128 pts. developed GI bleeding and 35/112 patients with liver function evaluable at baseline and 3 months had a deterioration in CP class. Conclusions: SBRT was associated with excellent outcomes for patients with HCC and MVI. Randomized phase III trials of SBRT are warranted and ongoing.

Summary Head-and-neck small cell carcinoma (HN-SmCC) is a rare entity and there is limited data to support management decisions. The role of prophylactic cranial irradiation (PCI) remains controversial. A retrospective review of 21 consecutive HN-SmCCs was performed. No case received PCI. The 2-year overall survival, local, regional and distant control rates were 65%, 94%, 88%, and 76% respectively. Despite no patient receiving PCI, brain metastases were uncommon ( n = 2) and routine use of PCI is not justified in this population.

Purpose To evaluate the feasibility and response of liver radiotherapy (RT) in improving symptoms and quality of life in patients with hepatocellular carcinoma (HCC) or liver metastases (LM). Patients and Methods Eligible patients had HCC or LM, unsuitable for or refractory to standard therapies, with an index symptom of pain, abdominal discomfort, nausea, or fatigue. The Brief Pain Inventory (BPI), Functional Assessment of Cancer Therapy–Hepatobiliary (FACT-Hep), and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) were completed by patients at baseline and each follow-up. The primary outcome was the percentage of patients with a clinically significant change at 1 month in the BPI subscale of symptom on average in the past 24 hours. Secondary outcomes were improvement in other BPI subscales and at other time points, FACT-Hep and EORTC QLQ-C30 at each follow-up, and toxicity at 1 week. Results Forty-one patients (30 men and 11 women) with HCC (n = 21) or LM (n = 20) were accrued. At 1 month, 48% had an improvement in symptom on average in the past 24 hours. Fifty-two percent of patients had improvement in symptom at its worst, 37% at its least, and 33% now. Improvements in the FACT-G and hepatobiliary subscale were seen in 23% and 29% of patients, respectively, at 1 month. There were also improvements in EORTC QLQ-C30 functional (range, 11% to 21%) and symptom (range, 11% to 50%) domains. One patient developed grade 3 nausea at 1 week. Conclusion Improvements in symptoms were observed at 1 month in a substantial proportion of patients. A phase III study of palliative liver RT is planned.

PurposeThe clinical specialist radiation therapist (CSRT) is a radiation therapist with advanced site-specific clinical skills and knowledge that can be utilised to enhance the education of radiation therapy (RT) students within an academic setting. The aim of this study is to assess the students’ perception of the teaching provided by a CSRT within a case-based learning workshop tailored for breast cancer.MethodsA workshop that followed the patient's RT treatment pathway (consultation, CT simulation, treatment planning and delivery) was led by a breast-site CSRT to 16 third-year students. Following completion of the workshop, a 4-point Likert-scale survey was distributed to explore the students’ didactic and clinical experiences and their general perceptions of the CSRT's contribution to their breast-site module education.ResultsThe median didactic experience reported by the students were ‘a lot’ in patient care and ‘some’ in treatment unit and treatment planning. In contrast, the students reported less clinical experience; the median response for patient care and treatment unit experience was ‘a little’ and ‘none’ for treatment planning. All 13 students who responded to the survey agreed that the CSRT enhanced their understanding of the material. The students felt engaged in the CSRT-lecture and perceived it as value added. The majority of the students (92%) indicated the CSRT to be a useful learning resource in their training and education. Additional comments provided by the students noted the utility of the CSRT-led lecture in consolidating their knowledge of the breast cancer treatment planning and delivery and suggest further expansion of this learning format to other disease sites.ConclusionsThird-year RT students commencing their clinical practicum will have had a greater proportion of their learning from didactic teaching as opposed to clinical experience. In transitioning to their final year, the focus of the curriculum shifts to the application of theory into the clinical environment. The students perceived the CSRT to be a useful resource to enhance their understanding of the breast-site module and their feedback supports the instructional quality and effectiveness of the CSRT in this clinical teaching role.

Background and purpose To determine maximum tolerated dose (MTD) and toxicities of sorafenib combined with stereotactic radiotherapy (SBRT) or whole liver radiotherapy (WLRT) in patients with liver metastases. Material and methods Eligible patients had unresectable liver metastases. Sorafenib dose was escalated in 2 strata: I – SBRT: effective liver volume irradiated ( V eff ) V eff >80% (21.6Gy in 6 fractions). Four weeks of sorafenib, with radiotherapy during weeks 2–3, was delivered at 3 escalating dose levels (200–400mg twice daily). Dose limiting toxicity was defined as any grade 3+ liver toxicity, or grade 4+ treatment-related toxicity. Results Thirty-three patients were treated: 18 in stratum I (median dose 42Gy), 15 in stratum II. The MTD was not reached. Grade 3+ toxicity was seen in 33% of patients, at a median of 10days. Two deaths from non-classic liver toxicity occurred post WLRT in stratum II. The median overall survival was 22.3 and 5.7months for strata I and II respectively. Conclusions Sorafenib and 21.6Gy in 6 fraction WLRT resulted in unacceptably high rates of liver toxicity. Although sorafenib combined with SBRT was tolerable, the observed efficacy does not merit further clinical evaluation.