American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part III: low-dose-rate and pulsed-dose-rate brachytherapy

PurposeTo develop a guideline for quality practice of low-dose-rate (LDR) and pulsed-dose-rate (PDR) brachytherapy for locally advanced cervical cancer.MethodsMembers of the American Brachytherapy Society (ABS) with expertise in cervical cancer brachytherapy formulated updated guidelines for LDR and PDR brachytherapy for locally advanced (International Federation of Gynecology and Obstetrics [FIGO] Stages IB2–IVA) cervical cancer based on literature review and clinical experience.ResultsThe ABS strongly recommends the use of brachytherapy as a component of the definitive treatment of locally advanced cervical carcinoma. Precise applicator placement is necessary to maximize the probability of achieving local control without major side effects. The ABS recommends a cumulative delivered dose of approximately 80–90 Gy for definitive treatment. Dosimetry must be performed after each insertion before treatment delivery. The dose delivered to point A should be reported for all intracavitary brachytherapy applications regardless of treatment planning technique. The ABS also recommends adoption of the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology guidelines for contouring, image-based treatment planning and dose reporting. Interstitial brachytherapy may be considered for a small proportion of patients whose disease cannot be adequately encompassed by intracavitary application and should be performed by practitioners with special expertise in these procedures. Quality management measures must be performed, and follow-up information should also be obtained.ConclusionsUpdated ABS guidelines are provided for LDR and PDR brachytherapy for locally advanced cervical cancer. Practitioners and cooperative groups are encouraged to use these guidelines to formulate their clinical practices and to adopt dose-reporting policies that are critical for outcome analysis.     

American Brachytherapy Society consensus guidelines for high-dose-rate prostate brachytherapy

PurposeA well-established body of literature supports the use of high-dose-rate (HDR) brachytherapy as definitive treatment for localized prostate cancer. Most of the articles describe HDR as a boost with adjuvant external beam radiation, but there is a growing experience with HDR monotherapy.Methods and MaterialsThe American Brachytherapy Society has convened a group of expert practitioners and physicists to develop guidelines for the use of HDR in the management of prostate cancer. This involved an extensive literature review and input from an expert panel.ResultsDespite a wide variation in doses and fractionation reported, HDR brachytherapy provides biochemical control rates of 85–100%, 81–100%, and 43–93% for low-, intermediate-, and high-risk prostate cancers, respectively. Severe toxicity is rare, with most authors reporting less than 5% Grade 3 or higher toxicity. Careful attention to patient evaluation for appropriate patient selection, meticulous technique, treatment planning, and delivery are essential for successful treatment.ConclusionThe clinical outcomes for HDR are excellent, with high rates of biochemical control, even for high-risk disease, with low morbidity. HDR monotherapy, both for primary treatment and salvage, are promising treatment modalities.     

American Brachytherapy Society consensus guidelines for interstitial brachytherapy for vaginal cancer

PurposeTo present recommendations for the use of interstitial brachytherapy in patients with vaginal cancer or recurrent endometrial cancer in the vagina.MethodsA panel of members of the American Brachytherapy Society reviewed the literature, supplemented that with their clinical experience, and formulated recommendations for interstitial brachytherapy for primary or recurrent cancers in the vagina.ResultsPatients with bulky disease (approximately >0.5 cm thick) should be considered for treatment with interstitial brachytherapy. The American Brachytherapy Society reports specific recommendations for techniques, target volume definition, and dose–fractionation schemes. Three-dimensional treatment planning is recommended with CT scan and/or MRI. The treatment plan should be optimized to conform to the clinical target volume and should reduce the dose to critical organs, including the rectum, bladder, urethra, and sigmoid colon. Suggested doses in combination with external beam radiation therapy and summated equivalent doses in 2 Gy fractions are tabulated.ConclusionRecommendations are made for interstitial brachytherapy for vaginal cancer and recurrent disease in the vagina. Practitioners and cooperative groups are encouraged to use these recommendations to formulate treatment and dose-reporting policies. Such a process will result in meaningful outcome comparisons, promote technical advances, and lead to appropriate utilization of these techniques.     

American Brachytherapy Society consensus guidelines for transrectal ultrasound-guided permanent prostate brachytherapy

PurposeTo provide updated American Brachytherapy Society (ABS) guidelines for transrectal ultrasound-guided transperineal interstitial permanent prostate brachytherapy (PPB).Methods and MaterialsThe ABS formed a committee of brachytherapists and researchers experienced in the clinical practice of PPB to formulate updated guidelines for this technique. Sources of input for these guidelines included prior published guidelines, clinical trials, published literature, and experience of the committee. The recommendations of the committee were reviewed and approved by the Board of Directors of the ABS.ResultsPatients with high probability of organ-confined disease or limited extraprostatic extension are considered appropriate candidates for PPB monotherapy. Low-risk patients may be treated with PPB alone without the need for supplemental external beam radiotherapy. High-risk patients should receive supplemental external beam radiotherapy if PPB is used. Intermediate-risk patients should be considered on an individual case basis. Intermediate-risk patients with favorable features may appropriately be treated with PPB monotherapy but results from confirmatory clinical trials are pending. Computed tomography–based postimplant dosimetry performed within 60 days of the implant is considered essential for maintenance of a satisfactory quality assurance program. Postimplant computed tomography–magnetic resonance image fusion is viewed as useful, but not mandatory.ConclusionsUpdated guidelines for patient selection, workup, treatment, postimplant dosimetry, and followup are provided. These recommendations are intended to be advisory in nature with the ultimate responsibility for the care of the patients resting with the treating physicians.     

The American Brachytherapy Society consensus statement for electronic brachytherapy

PurposeBrachytherapy is utilized in the treatment of many different malignancies; although traditionally performed with low-dose-rate or high-dose-rate techniques, more recently, electronic brachytherapy (EB) has emerged as a potential alternative. At this time, there are no evidence-based guidelines to assist clinicians in patient selection for EB and concerns exits regarding differences in dosimetry as compared to traditional brachytherapy techniques. As such, the American Brachytherapy Society appointed a group of physicians and physicists to create a consensus statement regarding the use of EB.Methods and MaterialsPhysicians and physicists with expertise in brachytherapy created a site-directed consensus statement for appropriate patient selection and utilization of EB based on a literature search and clinical experience.ResultsEB has been utilized to deliver accelerated partial breast irradiation with, thus far acceptable local control and toxicity rates including a randomized trial that used EB to deliver intraoperative radiotherapy; however, prospective data with large patient numbers and long-term follow up are needed. Increasing numbers of patients have been treated with EB for nonmelanomatous skin cancers; although, preliminary data are promising, there is a lack of data comparing EB to traditional radiotherapy techniques as well as a lack of long-term follow up. For treatment of the vaginal cuff with EB, small retrospective studies have been reported without long-term follow up.ConclusionsIn light of a randomized trial in breast showing higher rates of recurrence and the lack of prospective data with mature follow up with other sites, as well as concerns regarding dosimetry, it is not recommended that EB be utilized for accelerated partial breast irradiation, nonmelanomatous skin cancers, or vaginal cuff brachytherapy outside prospective clinical trials at this time.     

The American Brachytherapy Society consensus statement for accelerated partial-breast irradiation

PurposeAdjuvant radiation after breast-conserving surgery remains the standard-of-care treatment for patients with ductal carcinoma in situ and early-stage invasive breast cancer. Multiple alternatives to standard whole-breast irradiation exist including accelerated partial-breast irradiation (APBI). Therefore, the purpose of this APBI guideline is to provide updated data for clinicians as well as recommendations regarding appropriate patient selection and techniques to deliver APBI.MethodsMembers of the American Brachytherapy Society with expertise in breast cancer and breast brachytherapy in particular created an updated guideline for appropriate patient selection based on an extensive literature search and clinical experience. In addition, data were evaluated with respect to APBI techniques and recommendations presented.ResultsAppropriate candidates for APBI include patients aged 45 years or older, all invasive histologies and ductal carcinoma in situ, tumors 3 cm or less, node negative, estrogen receptor positive/negative, no lymphovascular space invasion, and negative margins. With respect to techniques, the strongest evidence is for interstitial brachytherapy and intensity-modulated radiation therapy APBI with moderate evidence to support applicator brachytherapy or three-dimensional conformal radiotherapy APBI. Intraoperative radiation therapy and electronic brachytherapy should not be offered regardless of technique outside of clinical trial.ConclusionsThe updated guidelines presented offer clinicians with a summary of data supporting APBI and guidelines for the appropriate and safe utilization of the technique.     

The American Brachytherapy Society consensus statement for accelerated partial breast irradiation

PurposeTo develop clinical guidelines for the quality practice of accelerated partial breast irradiation (APBI) as part of breast-conserving therapy for women with early-stage breast cancer.Methods and MaterialsMembers of the American Brachytherapy Society with expertise in breast cancer and breast brachytherapy in particular devised updated guidelines for appropriate patient evaluation and selection based on an extensive literature search and clinical experience.ResultsIncreasing numbers of randomized and single and multi-institution series have been published documenting the efficacy of various APBI modalities. With more than 10-year followup, multiple series have documented excellent clinical outcomes with interstitial APBI. Patient selection for APBI should be based on a review of clinical and pathologic factors by the clinician with particular attention paid to age (≥50 years old), tumor size (≤3 cm), histology (all invasive subtypes and ductal carcinoma in situ), surgical margins (negative), lymphovascular space invasion (not present), and nodal status (negative). Consistent dosimetric guidelines should be used to improve target coverage and limit potential for toxicity following treatment.ConclusionsThese guidelines have been created to provide clinicians with appropriate patient selection criteria to allow clinicians to use APBI in a manner that will optimize clinical outcomes and patient satisfaction. These guidelines will continue to be evaluated and revised as future publications further stratify optimal patient selection.     

American Brachytherapy Society (ABS) consensus statement for sarcoma brachytherapy

PurposeTo present recommendations for the use of brachytherapy (BT) in patients with soft tissue sarcoma (STS).MethodsA group of practitioners with expertise and experience in sarcoma BT formulated recommendations for BT in STS based on clinical experience and literature review.ResultsThe indications for adjuvant BT are discussed. There is no consensus on the use of BT alone or in combination with external beam radiation therapy (EBRT), but factors that influence the selection of this modality include tumor grade and size, prior surgeries, and tumor recurrence. Low-dose-rate, high-dose-rate, and pulsed-dose-rate radiation are all acceptable BT modalities to use for STS. Recommendations are made for patient selection, techniques, dose rates, and dosages. Outcome data and toxicity data are reviewed.ConclusionsBT is a useful component of the treatment of STS. The advantages of BT are the targeted dose distribution, low integral dose, and short treatment times. Ultimately the clinician should select the modality or combination of modalities that are most familiar to the treatment team and suitable to the patient.     

American Brachytherapy Society (ABS) consensus statement for soft-tissue sarcoma brachytherapy

PurposeGrowing data supports the role of radiation therapy in the treatment of soft tissue sarcoma (STS). Brachytherapy has been used for decades in the management of STS and can be utilized as monotherapy or as a boost to external beam radiation. We present updated guidelines from the American Brachytherapy Society regarding the utilization of brachytherapy in the management of STS.Methods and MaterialsMembers of the American Brachytherapy Society with expertise in STS and STS brachytherapy created an updated clinical practice guideline including step-by-step details for performing STS brachytherapy based on a literature review and clinical experience.ResultsBrachytherapy monotherapy should be considered for lower-recurrence risk patients or after a local recurrence following previous external beam radiation; a brachytherapy boost can be considered in higher-risk patents meeting implant criteria. Multiple dose/fractionation regimens are available, with determination based on tumor location and treatment intent. Techniques to limit wound complications are based on the type of wound closure; wound complication can be mitigated with a delay in the start of brachytherapy with immediate wound closure or by utilizing a staged reconstruction technique, which allows an earlier treatment start with a delayed wound closure.ConclusionsThese updated guidelines provide clinicians with data on indications for STS brachytherapy as well as guidelines on how to perform and deliver high quality STS brachytherapy safely with minimal toxicity.     

The American Brachytherapy Society consensus statement for permanent implant brachytherapy using Yttrium-90 microsphere radioembolization for liver tumors

PURPOSETo develop a multidisciplinary consensus for high quality multidisciplinary implementation of brachytherapy using Yttrium-90 (⁹⁰Y) microspheres transarterial radioembolization (⁹⁰Y TARE) for primary and metastatic cancers in the liver.METHODS AND MATERIALSMembers of the American Brachytherapy Society (ABS) and colleagues with multidisciplinary expertise in liver tumor therapy formulated guidelines for ⁹⁰Y TARE for unresectable primary liver malignancies and unresectable metastatic cancer to the liver. The consensus is provided on the most recent literature and clinical experience.RESULTSThe ABS strongly recommends the use of ⁹⁰Y microsphere brachytherapy for the definitive/palliative treatment of unresectable liver cancer when recommended by the multidisciplinary team. A quality management program must be implemented at the start of ⁹⁰Y TARE program development and follow-up data should be tracked for efficacy and toxicity. Patient-specific dosimetry optimized for treatment intent is recommended when conducting ⁹⁰Y TARE. Implementation in patients on systemic therapy should account for factors that may enhance treatment related toxicity without delaying treatment inappropriately. Further management and salvage therapy options including retreatment with ⁹⁰Y TARE should be carefully considered.CONCLUSIONSABS consensus for implementing a safe ⁹⁰Y TARE program for liver cancer in the multidisciplinary setting is presented. It builds on previous guidelines to include recommendations for appropriate implementation based on current literature and practices in experienced centers. Practitioners and cooperative groups are encouraged to use this document as a guide to formulate their clinical practices and to adopt the most recent dose reporting policies that are critical for a unified outcome analysis of future effectiveness studies.     

An evaluation of gender diversity in the American Brachytherapy Society

PurposeRecent evaluation of female representation in major radiation oncology organizations was published by Knoll et al. (IJROBP, 2018) but did not include information about the American Brachytherapy Society (ABS). The objective of this study is to assess trends in gender diversity in the ABS.Materials and MethodsPublicly available information from the ABS and American Society for Radiation Oncology (ASTRO) websites were used to determine the proportion of women in various leadership positions and receiving awards and honors. The data were organized by comparing female representation up until 2004 and then from 2005 until current as was done in the article of Knoll et al. to facilitate comparisons with ASTRO.ResultsOf the 579 US physician members of the ABS, 155 (27%) are women. There has been an increase in the proportion of female ABS presidents and female Hensche Award recipients between 1978–2004 and 2005–2018. There was a significant difference in the female makeup of the editorial board of the main journals for the ABS (18%) and ASTRO (43%) (p = 0.02). Two other prominent differences between the ABS and ASTRO, however not statistically significant, were the female representation of 2018 fellows (10% vs. 26%, respectively) and recipients of each organization's highest honor between 2005 and 2017 (25% vs. 6%, respectively).ConclusionsOver the past decade, there has been an increase in women representation in the ABS presidency and Henschke awardees. Representation still remains low, relative to ASTRO, in other areas suggesting room for further improvement. Exploring these trends is imperative in developing potential solutions to improve gender diversity in the field of brachytherapy.     

Evaluation of burnout in physician members of the American Brachytherapy Society

PURPOSETo evaluate the prevalence of burnout among brachytherapy specialists and to identify factors associated with burnout.METHODS AND MATERIALSAn anonymous, online, cross-sectional survey was administered to non-trainee physician members of the American Brachytherapy Society. Burnout was evaluated using the validated Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Demographic and practice-specific questions were collected from respondents. Univariate and multivariable analysis of outcomes were performed using probabilistic index models.RESULTSOverall, 51 of 400 physicians responded (13% response rate). Fifty-seven percent of respondents demonstrated at least one symptom of professional burnout. However, only 6% of respondents met strict criteria for high burnout. Analysis of the individual MBI-HSS subdomains demonstrated higher subscale scores for emotional exhaustion and depersonalization, but also higher scores for personal accomplishment. On multivariable analysis after adjusting for increased feelings of burnout due to the COVID-19 pandemic or total hours of work per week, younger age was associated with both increased subscale scores for emotional exhaustion (p = 0.026) and lower personal accomplishment (p = 0.010). Lastly, nearly half of all respondents (47%) reported increased feelings of burnout due to the COVID-19 pandemic. Respondents from academic facilities were significantly more likely to report increased burnout due to COVID-19 compared to those from non-academic facilities (odds ratio, 7.04; 95% CI 1.60–31.0; p = 0.010).CONCLUSIONSNearly 60% of brachytherapists demonstrated symptoms of professional burnout, which is higher than other radiation oncology groups (academic chairs, program directors, residents). Managing stressors related to workload, COVID and support for junior physicians are potential areas for improving feelings of burnout.