New directive for documentation review in radiation oncology.

A new directive from the Health Care Financing Administration regarding reimbursement for daily patient care underscores the importance of accurate documentation in radiation oncology. Ms. Blue describes a quality control system in use at her institution which involves a comparison of what is documented in the medical record with what has been charged.     

Interest of diffusion-weighted echo-planar MR imaging and apparent diffusion coefficient mapping in gynecological malignancies: a review

Magnetic resonance imaging (MRI) remains the standard modality for the local staging of gynecological malignancies but it has several limitations, particularly for lymph node staging or evaluating peritoneal carcinomatosis. Consequently, there has been a growing interest in functional imaging modalities. Based on molecular diffusion, diffusion-weighted imaging (DWI) is a unique, noninvasive modality that provides excellent tissue contrast and was shown to improve the radiological diagnosis of malignant tumors. Using quantitative apparent diffusion coefficient (ADC) measurement of DWI provides a new tool for better distinguishing malignant tissues from benign tumors. The aim of the present review is to report on the results of DWI for the assessment of patients with gynecological malignancies. An analysis of the literature suggests that DWI studies would improve the diagnosis of cervical and endometrial tumors. It may also improve the assessment of tumor extension in patients with peritoneal carcinomatosis from gynecological malignancies. However, since the signal intensity of some cancers can range from high intensity to low intensity, a degree of uncertainty was demonstrated due to the proximity of the normal uterine myometrium and ovaries. Interestingly, there is also evidence that ADC might improve the follow-up and monitoring of patients who receive anticancer therapies, including chemotherapy or radiation therapy.     

Setup errors in patients treated with intensity-modulated whole pelvic radiation therapy for gynecological malignancies.

Intensity-modulated whole pelvic radiation therapy (IM-WPRT) has decreased the incidence of gastrointestinal complications by reducing the volume of normal tissue irradiated in gynecologic patients. However, IM-WPRT plans result in steep dose gradients around the target volume, and thus accurate patient setup is essential. To quantify the accuracy of our patient positioning, we examined the weekly portal films of 46 women treated with IM-WPRT at our institution. All patients were positioned using a customized immobilization device that was indexed to the treatment table. Setup errors were evaluated by comparing portal images to simulation images using an algorithm that registers user-defined open curve segments drawn on both sets of film. The setup errors, which were separated into systematic and random components, ranged from 1.9 to 3.7 mm for the translations and 1.3 degrees to 4.4 degrees for the 2 in-plane translations. The systematic errors were all less than the respective random errors, with the largest error in the anterior/posterior direction. In addition, there was no correlation between the magnitude of these errors and patient-specific factors (age, weight, height). In the future, we will investigate the effect of these setup errors on the delivered dose distribution.     

A review of digital image networking technologies for radiation oncology treatment planning

Dosimetrists, physicists, and physicians rely heavily upon digital imaging modalities in their daily work. In the current healthcare marketplace, many radiotherapy facilities operate satellite centers or may be undergoing mergers with other service providers in their community. As a consequence, the development of network-based radiotherapy image communication may yield a significant impact on the clinical operation of such centers. Digital image networking will become an everyday tool in radiotherapy treatment planning in the near future. As responsible users of this technology, an accurate perception of what the network does is essential and enhances our ability to utilize it. This article presents a review of the network architecture and transmission standards necessary for understanding and developing a radiotherapy image network.     

A review of digital image networking technologies for radiation oncology treatment planning

Dosimetrists, physicists, and physicians rely heavily upon digital imaging modalities in their daily work. In the current healthcare marketplace, many radiotherapy facilities operate satellite centers or may be undergoing mergers with other service providers in their community. As a consequence, the development of network-based radiotherapy image communication may yield a significant impact on the clinical operation of such centers. Digital image networking will become an everyday tool in radiotherapy treatment planning in the near future. As responsible users of this technology, an accurate perception of what the network does is essential and enhances our ability to utilize it. This article presents a review of the network architecture and transmission standards necessary for understanding and developing a radiotherapy image network.     

Metastasis to the breast from extramammary malignancies: a report of four cases and a review of literature

Breast metastases from extramammary tumours are rare with few cases reported. Four cases of metastasis to the breast are presented and the diagnostic problems of this condition are reviewed. Correlation between the histology of primary tumour and the cytology of breast metastatic tumour can avoid the surgical breast biopsy and unnecessary mastectomy. Metastasis to the breast has poor prognosis.     

Proton radiation therapy for pediatric malignancies: Status report

Proton radiation therapy allows high degrees of conformity of radiation dose around irregular target volumes of variable sizes. Long-term follow-up in adults, and preliminary data for pediatric patients suggest that local control and survival can be improved in histologies requiring high radiation dose, without increased incidence of late toxicities. In the pediatric patient, avoidance of even moderate amounts of irradiation to normal tissues is of paramount importance. Conformal 3-D planned proton irradiation can contribute to this goal. For late effects, one can expect that reduced dose and volume irradiated will reduce radiation effects. However, full expression of late effects may occur in children five to ten years after treatment, or even later. Proton irradiation is therefore also indicated and used at Loma Linda University Medical Center for pediatric solid neoplasms in which conventional dose levels yield satisfactory local control and survival.

     

Part-time consultants in radiation oncology

The aim of this study was to evaluate the attitudes and experiences of staff towards radiation oncologists who work part-time. A questionnaire was sent to all radiation oncologists, radiation oncology registrars and radiation therapists, and a nursing and clerical representative working in all radiation oncology departments throughout Australia and New Zealand. Of 1242 questionnaires, 446 (35.9%) were returned. Of these, 323 out of 435 respondents (74.2%) supported the concept of a radiation oncologist working part-time. The main barriers to part-time work were inadequate provision of cover, the inability to be contacted when not rostered on, and perceived reduced quality of patient care. The majority of respondents supported part-time employment in radiation oncology. However, the conclusions made from this survey are limited by the poor response rate. For a successful part-time career in radiation oncology, the following points need to be ensured: (i) an equitable pro-rata workload that encompasses both clinical and non-clinical duties; (ii) a clear and well-publicized timetable that is strictly adhered to with special emphasis on completing work prior to non-rostered days; (iii) clear mechanisms in place to deal with patient or other queries on non-rostered days; (iv) a mechanism for being contacted for urgent problems; and (v) good communication between the part-time radiation oncologist, other staff and patients.     

Patient satisfaction in radiation oncology

As part of a quality improvement exercise at the Perth Radiation Oncology Centre, a survey was undertaken to ascertain the current level of patient satisfaction with the information they were receiving from their treating radiation oncologist. In addition, the effect of radiation on patients' anxiety levels was investigated. Two questionnaires were given to patients having radical radiotherapy for malignancy. The first questionnaire consisted of the Information Satisfaction Questionnaire and the State Trait Anxiety Index. It was given to patients before the commencement of their course of radiotherapy. The second questionnaire consisted of the State Trait Anxiety Index and was given at the completion of their radiotherapy. A total of 120 patients completed both the questionnaires. The majority of patients were satisfied/very satisfied with the explanation of their illness and radiation toxicities. Fewer patients were satisfied with the explanation of lifestyle (e.g. diet, exercise, smoking) and practical issues such as parking and treatment costs. The patients showed a statistically significant reduction in both their State and Trait Anxiety scores following radiotherapy. Following this study, we have developed new information booklets addressing lifestyle and practical issues, which were not being adequately addressed as shown in this study. Our next study will assess the effect of these new information booklets.     

Complementary medicine in radiation oncology

Introduction

Recently, complementary and alternative medicine (CAM) has moved more into the focus, and cancer societies such as the German Cancer Society (Deutsche Krebsgesellschaft, DKG) have established working groups to develop a guideline for CAM. The present work aims to evaluate the acceptance of CAM in the whole radiation oncology community.

Methods

We conducted an online survey on CAM and sent the modified questionnaire that was successfully distributed to all members of the Research Group on Gynecological Oncology (Arbeitsgemeinschaft Gynakologische Onkologie, AGO) of the DKG in 2014 to the members of the German Society of Radiation Oncology (Deutsche Gesellschaft für Radioonkologie und Strahlentherapie, DEGRO). The survey consisted of 17 questions regarding personal information and current CAM guidelines within the workplace/clinic.

Results

A total of 143 members participated. Of these, 12% had some CAM qualification. For hematological cancer in 35% and in up to 76% for breast cancer, CAM treatment is offered in German radiation oncology facilities, mainly due to fatigue symptoms. CAM is part of routine treatment in 32.2%, 22.0% are planning to incorporate it. Most physicians advise patients to partake in sports activities and recommend dietary supplements and nutritional counseling. The cost of CAM treatment is fully covered in 9.8% of all participating facilities.

Conclusion

Today, CAM is integrated into cancer care; however, skepticism regarding its effect still exists. Evidence-based results must be generated to convince physicians of the effectiveness of CAM methods. CAM qualifications must be included in physicians’ training to improve their understanding and counseling regarding CAM options in cancer care.

     

Repopulation in radiation oncology: perspectives of clinical research

Cellular repopulation is one of the most important biological determinants of the clinical outcome of fractionated radiation therapy. A number of randomized controlled trials of altered dose‐fractionation have been conducted in patients with squamous cell carcinoma of the head and neck (HNSCC) and the main biological lessons from these are summarised. Data for other tumour histologies are relatively sparse. Further progress in radiotherapy for HNSCC is unlikely to result from altered fractionation alone, but a number of novel strategies for overcoming or exploiting repopulation are being researched. In the next 5 years, the top prioirties for clinical and translational research in this field should be the development of clinically applicable predictive assays, functional imaging as an aid to optimize the dose distribution, optimization of combined modality therapies and novel biological strategies specifically targeting tumour cell proliferation.     

New therapeutic strategies for Hodgkin lymphoma in cooperation of radiation oncology and medical oncology

BACKGROUND: Between 1984 and 2002 more than 9500 pts. were enrolled in the multicentric randomized trials of the German Hodgkin Study Group (GHSG) and are evaluable for response, survival, recurrences, and toxicities. Actually the GHSG evaluates the efficacy of risk-adapted therapy composed of polychemotherapy (CT) and radiotherapy (RT). An extensive RT quality assurance program has been practiced during the study generations and will be continued. PATIENTS AND METHODS: The 4th study generation (1998-2002) includes the following trials: In the HD10 trial (early stages) 4x ABVD are tested against 2x ABVD followed by 20 Gy Involved Field (IF)-RT vs. 30 Gy IF-RT (4 arms). In order to optimize CT-regimen and IF-RT dose for pts. with intermediate stage, the HD11 trial compares 4x ABVD with 4x BEACOPP baseline followed by 20 Gy IF-RT vs. 30 Gy IF-RT in a 4 arm design. Concerning advanced stages (HD12), the BEACOPP regimen is to be optimized and the necessity of additive RT is tested. The standard arm (8x BEACOPP escalated) is compared with the toxicity reduced arm (4x BEACOPP escalated + 4x BEACOPP baseline) followed by 30 Gy RT on initial bulky disease and/or residual tumor vs. no RT (4 arms). RESULTS: Interim results (without arm comparisons) with a median follow-up of 18 months for HD10 and HD11 and 20 months for HD12 are as follows: Freedom from Treatment Failure (FFTF) at 18 months is in the HD10 trial (390 pts.) 96.4%, in the HD11 trial (480 pts.) 91.5% and in the HD12 trial (550 pts.) 90.2%.The overall survival (OS) at 18 months is in HD10 98.2%, in HD11 98.5%, in HD12 93.5%. In HD10, HD11 and HD12 respectively, 1.8%, 1.9% and 2.5% of pts. died and 1.0%, 2.5% and 2.2% suffered early progression. CONCLUSION/FURTHER STRATEGY: In order to reduce the relapse rate and toxicity and to improve the quality of life, the new HD13 trial for early stages (Fig. 1a) compares 2x ABVD, 2x ABV, 2x AVD und 2x AV, each followed by 30 Gy IF-RT. For the intermediate stages, the FFTF rate should be improved by intensifying the standard regimen. Therefore the new trial HD14 (Fig. 1b) compares 4x ABVD with 2x BEACOPP escalated + 2x ABVD, each followed by 30 Gy IF-RT. In the new trial for advanced stages HD15 (Fig. 1c),the FFTF/OS rates are to be maintained and the quality of life to be improved. 8x BEACOPP escalated, 6x BEACOPP escalated and 8x BEACOPP baseline with shortened 14-day cycle are compared. The use of PET to decide on additive RT will also be investigated.     

Repopulation in radiation oncology: perspectives of clinical research

Cellular repopulation is one of the most important biological determinants of the clinical outcome of fractionated radiation therapy. A number of randomized controlled trials of altered dose-fractionation have been conducted in patients with squamous cell carcinoma of the head and neck (HNSCC) and the main biological lessons from these are summarised. Data for other tumour histologies are relatively sparse. Further progress in radiotherapy for HNSCC is unlikely to result from altered fractionation alone, but a number of novel strategies for overcoming or exploiting repopulation are being researched. In the next 5 years, the top priorities for clinical and translational research in this field should be the development of clinically applicable predictive assays, functional imaging as an aid to optimize the dose distribution, optimization of combined modality therapies and novel biological strategies specifically targeting tumour cell proliferation.     

Subspecialty training and certification for radiation oncology

To address the recurring issues regarding subspecialty training and certification in radiation oncology, and using pediatric radiation oncology as an example, the authors considered the problem of inadequate case material for resident teaching. Potential solutions to the identified problems are addressed, and the roles of oversight committees and regulatory bodies are clarified. The problem of the nonuniform distribution of pediatric case material across residency programs cannot be solved by removing pediatric radiation oncology from the core radiation oncology educational curriculum or by offering fellowship training to those who may select it. As a result, the authors believe that subspecialty training and certification in radiation oncology is not a near-term possibility.