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Background: Preoperative or postoperative radiotherapy reduces the risk of local recurrence in patients with operable rectal cancer. However, improvements in surgery and histopathological assessment mean that the role of radiotherapy needs to be reassessed. We compared short-course preoperative radiotherapy versus initial surgery with selective postoperative chemoradiotherapy.Methods: We undertook a randomised trial in 80 centres in four countries. 1350 patients with operable adenocarcinoma of the rectum were randomly assigned, by a minimisation procedure, to short-course preoperative radiotherapy (25 Gy in five fractions; n=674) or to initial surgery with selective postoperative chemoradiotherapy (45 Gy in 25 fractions with concurrent 5-fluorouracil) restricted to patients with involvement of the circumferential resection margin (n=676). The primary outcome measure was local recurrence. Analysis was by intention to treat. This study is registered, number ISRCTN 28785842.Findings: At the time of analysis, which included all participants, 330 patients had died (157 preoperative radiotherapy group vs 173 selective postoperative chemoradiotherapy), and median follow-up of surviving patients was 4 years. 99 patients had developed local recurrence (27 preoperative radiotherapy vs 72 selective postoperative chemoradiotherapy). We noted a reduction of 61% in the relative risk of local recurrence for patients receiving preoperative radiotherapy (hazard ratio [HR] 0.39, 95% CI 0.27-0.58, p<0.0001), and an absolute difference at 3 years of 6.2% (95% CI 5.3-7.1) (4.4% preoperative radiotherapy vs 10.6% selective postoperative chemoradiotherapy). We recorded a relative improvement in disease-free survival of 24% for patients receiving preoperative radiotherapy (HR 0.76, 95% CI 0.62-0.94, p=0.013), and an absolute difference at 3 years of 6.0% (95% CI 5.3-6.8) (77.5%vs 71.5%). Overall survival did not differ between the groups (HR 0.91, 95% CI 0.73-1.13, p=0.40).Interpretation: Taken with results from other randomised trials, our findings provide convincing and consistent evidence that short-course preoperative radiotherapy is an effective treatment for patients with operable rectal cancer. [ABSTRACT FROM AUTHOR]

Introduction: In April 2019, French authorities mandated dihydropyrimidine dehydrogenase (DPD) screening, specifically testing uracilemia, to mitigate the risk of toxicity associated with fluoropyrimidine-based chemotherapy. However, this subject is still of debate as there is no consensus on a standardized DPD deficiency screening test. We conducted a real-life retrospective study with the aim of assessing the impact of DPD screening on the occurrence of severe toxicity and exploring the potential benefits of complete genotyping using next-generation sequencing., Methods: All adult patients consecutively treated with 5-fluorouracil (5-FU) or its oral prodrug at six cancer centers between March 2018 and February 2019 were considered for inclusion. Dihydropyrimidine dehydrogenase deficiency screening included gene encoding DPD (DPYD) genotyping using complete genome sequencing and DPD phenotyping (uracilemia or dihydrouracilemia/uracilemia ratio) or both tests. Associations between each DPD screening method and (i) severe (grade ≥3) early toxicity and (ii) fluoropyrimidine dose reduction in the second chemotherapy cycle were evaluated using multivariable logistic regression analysis. Furthermore, we assessed the concordance between DPD genotype and phenotype using Cohen's kappa., Results: A total of 551 patients were included. Most patients were tested for DPD deficiency (86%) including DPYD genotyping only (6%), DPD phenotyping only (8%), or both (72%). Complete DPD deficiency was not detected in the study population. Severe early toxicity events were observed in 73 patients (13%), with two patients (0.30%) presenting grade 5 toxicity. Despite the numerically higher toxicity rate in untested patients, the occurrence of severe toxicity was not significantly associated with the DPD screening method (p = 0.69). Concordance between the DPD genotype and phenotype was weak (Cohen's kappa of 0.14)., Conclusion: Due to insufficient numbers, our study was not able to demonstrate any added value of DPYD genotyping using complete genome sequencing to prevent 5-FU toxicity. The optimal strategy for DPD screening before fluoropyrimidine-based chemotherapy requires further clinical evaluation., (© 2024 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Purpose: Radiation treatment planning (RTP) is a unique skill that requires interdisciplinary collaboration among radiation oncologists (ROs), dosimetrists, and medical physicists (MP) to train and assess residents. With the adoption of competency-based medical education (CBME) in Canada, it is essential residency program curricula focuses on developing competencies in RTP to facilitate entrustment. Our study investigates how radiation oncology team members' perspectives on RTP education align with requirements of the CBME approach, and its implications for improving residency training., Methods and Materials: This qualitative research study took place in the Department of Oncology at a midsize academic institution. Through convenience sampling, focus groups were conducted with radiation oncologists (n = 11), dosimetrists (n = 7), medical physicists (n = 7), and residents (n = 7). Thematic design was adopted to analyze the transcripts through open coding resulting in 3 overarching themes., Results: The results identified existing strengths and weaknesses of the residency program and future opportunities to redesign the curriculum and assessment process within a CBME model. Three overarching themes emerged from the analysis: (1) the strengths of RTP in the CBME environment; (2) challenges of RTP in CBME; and (3) opportunities for change. Stakeholders were optimistic CBME will help enrich resident learning with the increased frequency and quality of competency-based assessments. Participants suggested building a library of cases and developing computer-based learning resources to provide a safe environment to develop skills in contouring, dosimetry, and plan evaluation, in accordance with CBME training., Conclusions: This study identified future opportunities to redesign the RTP curriculum and assessment process within a CBME model. The need for innovative teaching and learning strategies, including case libraries, computer-based learning, and quality assessments, were highlighted in designing an innovative RTP planning curriculum., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Physicians entering independent practice often express apprehension in managing the non-clinical aspects of practice. This study examined the perceived preparedness of radiation oncology (RO) residents for independent practice, identified education gaps, and discussed how these deficiencies could be addressed., Materials and Methods: Focus groups with senior RO residents, fellows, new-to-practice radiation oncologists (ROs), and residency program directors were conducted. Data were coded using the Canadian Medical Education Directives for Specialists (CanMEDS) competencies using thematic analysis., Results: Commonly reported gaps in the transition to practice (TtP) for ROs were lack of experience with: practice management, understanding the structure and function of the health care system and how it varies by jurisdiction, financial planning, effective communication and collaboration with other health care team members, creation of accurate and timely documentation, and radiotherapy problem-solving related to treatment planning and evaluation. Suggestions to address these challenges included use of mentorship, educational resources, courses, simulation-based medical education, improved graded responsibility, resident longitudinal clinics, and formal curricula in radiation therapy planning and evaluation., Conclusion: There are gaps in TtP education for RO trainees with opportunities for enrichment through the forthcoming implementation of a competency-based medical education framework in 2019. The gap in perceived competency in physician-related radiotherapy tasks may be caused by the complex interaction of clinical workflow processes, people and technology that has led to ineffective integration of trainees. The data are informative to medical education leaders for the development of comprehensive TtP curricula., (Crown Copyright © 2019. Published by Elsevier B.V. All rights reserved.)

Background and Purpose: The scope and effect of radiation oncology (RO) outreach activities within centralized radiotherapy (RT) systems is poorly defined. The purpose of this study was to describe the outreach activities of Ontario's regional cancer centres, and to explore the relationship between radiation oncology (RO) outreach clinics and rates of radiotherapy (RT) utilization at hospitals without RT on site (HWOS-RT)., Materials and Methods: Ontario RO centres' outreach activities were identified by semi-structured interview. A multivariate analysis determined the association between on-site RT facilities, or presence of RO clinic at HWOS-RT, and RT utilization within one year of diagnosis (RT 1Y ), for all patients diagnosed with cancer in Ontario in 2011-2012., Results: RO outreach varied widely by region. Of the largest 58 diagnosing hospitals, 14 had RT on-site, 19 had no RT but RO outreach clinic(s) and 25 had no RT or RO clinic. RT was used more frequently for patients diagnosed at hospitals with on-site RT compared to those at HWOS-RT (RT 1Y  = 35% vs. 29%, RR = 1.32 [95% CI 1.27-1.38]). For HWOS-RT, RT was used more frequently if there was an RO clinic (RT 1Y  = 31% vs. 29%, RR = 1.06 [95% CI 1.02-1.10])., Conclusions: RO outreach clinics were associated with a small but significant increase in RT utilization. There is opportunity to improve access to RT by optimizing the effectiveness of RO outreach., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background and Purpose: Radiation therapy (RT) for breast cancer has evolved considerably over the past two decades. A concise list of optimal care indexes is lacking. The purpose of this project was to generate a suite of quality of care indicators for breast cancer RT., Materials and Methods: A modified Delphi approach was used including a comprehensive literature and guideline review (1995-2015), an initial review of potential quality indicators (QIs) by a steering committee, a survey of Canadian Radiation Oncologists, and a face-to-face consensus development meeting with breast cancer experts to develop a list of breast RT quality indicators., Results: The literature review identified 163 potential QIs, which was reduced to 73 by the steering committee. After all rounds of the Delphi process the final suite included 33 QIs. Of these, 28 (85%) received at least 80% acceptance from the Radiation Oncologists who participated in the final online survey., Conclusions: A suite of measureable RT quality indicators to be considered during management of invasive breast cancer was developed. These indicators could be used to assess the quality and consistency of breast cancer RT practices., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: A multi-institutional phase II trial was performed to assess a hypofractionated accelerated radiotherapy regimen for early stage non-small cell lung cancer (NSCLC) in an era when stereotactic body radiotherapy was not widely available., Methods: Eighty patients with biopsy-proven, peripherally located, T1-3 N0 M0 NSCLC were enrolled. Eligible patients received 60 Gy in 15 fractions using a three-dimensional conformal technique without inhomogeneity correction. The gross tumour volume (GTV) was the primary tumor only, and the planning target volume (PTV) margin was 1.0 to 1.5cm. The primary endpoint was the 2-year primary tumor control rate. Toxicities were measured using the Common Terminology Criteria for Adverse Events version 3.0., Results: The median follow-up of patients was 49 months (range = 21-63 months). The median age of patients was 75.9 years. The actuarial rate of primary tumor control was 87.4% (95% confidence interval [CI] = 76.2% to 93.5%) at 2 years. Overall survival was 68.7% (95% CI = 57.2% to 77.6%) at 2 years. The actuarial rates of developing regional and distant relapse at 2 years were 8.8% (95% CI = 4.1% to 18.7%) and 21.6% (95% CI = 13.5% to 33.5%), respectively. Tumor size greater than 3cm was associated with an increased risk of developing distant relapse (hazard ratio = 3.11; 95% CI = 1.30 to 7.42; two-sided log-rank test P = .007). The most common grade 3+ toxicities were fatigue (6.3%), cough (7.5%), dyspnea (13.8%), and pneumonitis (10.0%), Conclusions: Conformal radiotherapy to a dose of 60 Gy in 15 fractions resulted in favorable primary tumor control and overall survival rates in patients with T1-3 N0 M0 NSCLC. Severe toxicities were uncommon with this relatively simple treatment technique., (© The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Purpose: The specialty of radiation oncology has experienced significant workforce planning challenges in many countries. Our purpose was to develop and validate a workforce-planning model that would forecast the balance between supply of, and demand for, radiation oncologists in Canada over a minimum 10-year time frame, to identify the model parameters that most influenced this balance, and to suggest how this model may be applicable to other countries., Methods: A forward calculation model was created and populated with data obtained from national sources. Validation was confirmed using a historical prospective approach., Results: Under baseline assumptions, the model predicts a short-term surplus of RO trainees followed by a projected deficit in 2020. Sensitivity analyses showed that access to radiotherapy (proportion of incident cases referred), individual RO workload, average age of retirement and resident training intake most influenced balance of supply and demand. Within plausible ranges of these parameters, substantial shortages or excess of graduates is possible, underscoring the need for ongoing monitoring., Conclusions: Workforce planning in radiation oncology is possible using a projection calculation model based on current system characteristics and modifiable parameters that influence projections. The workload projections should inform policy decision making regarding growth of the specialty and training program resident intake required to meet oncology health services needs. The methods used are applicable to workforce planning for radiation oncology in other countries and for other comparable medical specialties., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To assess radiation oncology residents' needs and satisfaction in their first postgraduate year (PGY-1) in the province of Ontario., Methods and Materials: Of 62 radiation oncology residents, 58 who had completed their PGY-1 and were either enrolled or had graduated in 2006 were invited to participate in a 31-item survey. The questionnaire explored PGY-1 residents' needs and satisfaction in four domains: clinical workload, faculty/learning environment, stress level, and discrimination/harassment. The Fisher's exact and Wilcoxon nonparametric tests were used to determine relationships between covariate items and summary scores., Results: Of 58 eligible residents, 44 (75%) responded. Eighty-four percent of residents felt that their ward and call duties were appropriate. More than 50% of respondents indicated that they often felt isolated from their radiation oncology program. Only 77% agreed that they received adequate feedback, and 40% received sufficient counseling regarding career planning. More than 93% of respondents thought that faculty members had contributed significantly to their learning experience. Approximately 50% of residents experienced excessive stress and inadequate time for leisure or for reading the medical literature. Less than 10% of residents indicated that they had been harassed or experienced discrimination. Eighty-three percent agreed or strongly agreed that their PGY-1 experience had been outstanding., Conclusions: Most Ontario residents were satisfied with their PGY-1 training program. More counseling by radiation oncology faculty members should be offered to help residents with career planning. The residents might also benefit from more exposure to "radiation oncology" and an introduction to stress management strategies.

We describe four patients with epithelial ovarian carcinoma and cerebral metastases. Cerebral metastases are still an infrequent occurrence in this malignancy but, as treatment for ovarian cancer produces more long-term survivors, such uncommon patterns of spread may become more frequent. Part of a future successful cure for this disorder may require the recognition of the central nervous system as a potential sanctuary site for metastatic disease.