Recent initiatives for radiation oncology resident education in radiation and cancer biology

Nearly all residents from accredited radiation oncology residency programs in the United States are required to take the American College of Radiology (ACR) In-Training examination each year. The test is comprised of three sections: Clinical Radiation Oncology, Radiological Physics, and Radiation (and Cancer) Biology. Here we provide an update on changes to the biology portion of the ACR exam. We also discuss the availability and use of the ACR and biology practice exams as assessment and teaching tools for both the instructors of radiation and cancer biology and the residents they teach.     

Toward a consensus on radiobiology teaching to radiation oncology residents

There are approximately 82 radiation oncology residency programs in the United States, which provide training opportunities for about 400 residents. All accredited radiation oncology residency programs must have at least one basic scientist on the faculty, and it is these individuals who often assume, wholly or in part, the responsibility of teaching radiation and cancer biology to radiation oncology residents in preparation for the American College of Radiology (ACR) In-Training Examination in Radiation Oncology and the American Board of Radiology (ABR) written examinations. In response to a perceived lack of uniformity in radiation and cancer biology curricula currently being taught to residents and a perceived lack of guidance for instructors in formulating course content for this population, a special session was presented at the Forty-eighth Annual Radiation Research Society meeting on April 23, 2001. The session, entitled "Toward a Consensus on Radiobiology Teaching to Radiation Oncology Residents", was focused on issues related to teaching radiobiology to radiation oncology residents and targeted for individuals who actively teach radiation and cancer biology as well as coordinators of residency training programs. The speakers addressed current challenges and future problems facing instructors and programs. Among these were lack of feedback on resident performance on ABR and ACR written examinations and on course content, uncertainty about what topics residents must know to pass the ABR examination, and, in the near future, a reduction (due to retirement) of instructors qualified to teach radiobiology. This article provides a synopsis of the information that was presented during that session, offers a glimpse into how the ABR and ACR examinations are prepared and details of the content of past and future examinations, and summarizes the activities of the Joint Working Group on Radiobiology Teaching which was formed to educate instructors, to establish a consensus for course curricula, and to improve the overall quality of resident teaching.     

Serial cross-sectional estimation of vaccine-and infection-induced SARS-CoV-2 seroprevalence in British Columbia,Canada

Background:The evolving proportion of the population considered immunologically naive versus primed for more efficient immune memory response to SARS-CoV-2 has implications for risk assessment. We sought to chronicle vaccine- and infection-induced seroprevalence across the first 7 waves of the COVID-19 pandemic in British Columbia, Canada.Methods:During 8 cross-sectional serosurveys conducted between March 2020 and August 2022, we obtained anonymized residual sera from children and adults who attended an outpatient laboratory network in the Lower Mainland (Greater Vancouver and Fraser Valley). We used at least 3 immunoassays per serosurvey to detect SARS-CoV-2 spike and nucleocapsid antibodies. We assessed any seroprevalence (vaccineor infection-induced, or both), defined by positivity on any 2 assays, and infection-induced seroprevalence, also defined by dual-assay positivity but requiring both antinucleocapsid and antispike detection. We used estimates of infection-induced seroprevalence to explore underascertainment of infections by surveillance case reports.Results:By January 2021, we estimated that any seroprevalence remained less than 5%, increasing with vaccine rollout to 56% by May–June 2021, 83% by September–October 2021 and 95% by March 2022. Infection-induced seroprevalence remained less than 15% through September–October 2021, increasing across Omicron waves to 42% by March 2022 and 61% by July–August 2022. By August 2022, 70%–80% of children younger than 20 years and 60%–70% of adults aged 20–59 years had been infected, but fewer than half of adults aged 60 years and older had been infected. Compared with estimates of infection-induced seroprevalence, surveillance case reports underestimated infections 12-fold between September 2021 and March 2022 and 92-fold between March 2022 and August 2022.Interpretation:By August 2022, most children and adults younger than 60 years had evidence of both SARS-CoV-2 vaccination and infection. As previous evidence suggests that a history of both exposures may induce stronger, more durable hybrid immunity than either exposure alone, older adults — who have the lowest infection rates but highest risk of severe outcomes — continue to warrant prioritized vaccination.

The British Columbia Centre for Disease Control (BCCDC) has a long-established serosurvey protocol to monitor population susceptibility to emerging or re-emerging respiratory viruses. The approach was first deployed during the influenza A (H1N1) pandemic in 2009 to monitor changes in seroprevalence across successive pandemic waves and the mass vaccination campaign.^1–7 The methodology is predicated upon serial cross-sectional convenience sampling of anonymized residual sera from children and adults of all ages in the most populated Lower Mainland region of BC.^8,9Adapting this protocol, the BCCDC launched its first SARS-CoV-2 serosurvey in March 2020, just before the World Health Organization’s declaration of the COVID-19 pandemic. ¹⁰ Baseline assessment was followed by additional serosurveys that spanned the time from mRNA vaccine availability in mid-December 2020, through 7 pandemic waves associated with multiple variants of concern to August 2022 (Figure 1).^11–13 Using these serosurveys, we sought to track the evolving proportion of the population that remained immunologically naive and, thus, fully susceptible to COVID-19, versus the evolving proportion that was immunologically primed (through vaccination or infection) and, thus, poised for more efficient memory response in mitigating the risk of SARS-CoV-2. Recognizing the spectrum of illness, including asymptomatic or mild infections, and variable diagnostic access, case identification and reporting, we also used estimates of infection-induced seroprevalence to explore the potential underascertainment of infections by surveillance case reports.Open in a separate windowFigure 1:Provincial surveillance case reports to the British Columbia Centre for Disease Control (BCCDC) by epidemiological week from January 2020 to September 2022, with timing of serosurveys and select public health measures, in BC, Canada. We group case tallies by epidemiological week (7-d period) as per standard surveillance methods for comparing data by period from year to year. Epidemic waves are enumerated sequentially and are displayed with the predominant variant of concern (VOC). Publicly funded access to nucleic acid amplification tests (NAATs) or rapid antigen tests (RATs) is displayed below the X-axis. For details on public health measures, vaccines, schedules and coverage estimates, see Appendix 1, Supplementary Material 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.221335/tab-related-content. *Nonessential travel discouraged, health care service delivery adjusted, public gatherings > 50 people prohibited. Provincial state of emergency declared. †Interactions limited to households or “core bubble” (immediate family or those in same dwelling) or to a maximum of 2 other people if living alone. ‡Dine-in food services and indoor fitness activities banned, only essential travel permitted. §Gradual return to gatherings, recreational travel, in-person work, which was interrupted by the fourth wave. ¶Indoor and personal gatherings limited, 50% capacity limit at venues of > 1000 people, sports tournaments paused. Social restrictions lifted during epidemiological week 7, 2022. **Mask mandates lifted during epidemiological week 10, 2022. ††The first 2 spike-based mRNA vaccine formulations were authorized during epidemiological weeks 50 and 52, 2020, respectively, with mRNA vaccines comprising most doses (> 90%) administered in BC and Canada across the pandemic. In epidemiological week 8, 2021, a chimpanzee adenoviral-vectored (ChAdOx1) vaccine was also authorized. ‡‡Vaccines (mRNA) initially deployed to high-risk individuals, including residents and staff of long-term care and assisted-living facilities, essential visitors within those settings and health care workers. §§Community-based vaccine roll-out, prioritized by age, beginning with the oldest adults in mid-March 2021. Access to booster doses followed similar prioritization sequence, inclusive of clinically extremely vulnerable individuals of any age. ¶¶Single-dose vaccine card required for entry into social and recreational settings starting in epidemiological week 37, 2021; 2-dose cards were required beginning in epidemiological week 43, 2021. Vaccine cards were ultimately repealed in epidemiological week 14, 2022.     

Radiotherapy for cervical cancer: Chilean consensus of the Society of Radiation Oncology

BackgroundCervical cancer is a public health problem in Latin America. Radiotherapy plays a fundamental role both as definitive or adjuvant treatment. There are important intra and inter-country differences regarding access and availability of radiotherapy facilities in this region. The aim of a study was to standardize the basic clinical and technical criteria for the radiation treatment of patients with CC in Chile and provide a guide for Latin American Radiation Oncologists.Materials and methodsForty-one expert radiation oncologists from the Chilean Radiation Oncology Society made a consensus using the Delphi methodology.ResultsThere was a high degree of agreement for each of the recommendations. Those with the lowest percentage were related to the definition of the conformal 3D technique as the standard for definitive external radiotherapy (81%) and the criteria for extended nodal irradiation (85%).ConclusionsThese recommendations present an updated guide for radiotherapy treatment of patients with cervical cancer for Latin America. Those should be implemented according to local resources of each institution.     

Evaluation of medical physics training in radiology residency in 67 countries

PurposeThe main aim of medical physics training in radiology residency is to have appropriate and safer imaging of patients and safety of personnel. The need to have adequate coverage of medical physics and radiation safety in curricula of radiology residency is well perceived, but it is not known how far it is implemented in practice.MethodsWe have analysed the data from 67 countries on medical physics teaching and assessment of residents in radiology programs, considering differences between countries in function of their human development index (HDI).ResultsThe results indicate that teaching of medical physics by radiologists rather than by medical physicists is very common and there is relationship with the developmental status of a country. The majority of countries with very high HDI used a written test (69%) for medical physics topics, often in combination with other subjects (63%). Further, there is lack of direct involvement of medical physicists during the examination phase of residents. Geographically, it can be seen that Latin American countries in particular lack involvement of medical physicists during both the teaching and examination phase.ConclusionThe lack of adequate involvement of medical physicists in training and in the formal examination of radiology residents in both developed and developing countries is a matter of concern with likely implications on patient and staff safety.     

Hypo- vs. normofractionated radiation therapy in breast cancer: A patterns of care analysis in German speaking countries

Aim and backgroundTo assess the use of hypofractionated (HG-RT) versus normofractionated radiation therapy (NF-RT) in Breast Cancer in German speaking countries.Materials and methodsBetween July 2017 and August 2017, an email-based survey was sent to all 1408 physicians that are members of the German Society of Radiation Oncology (DEGRO). The survey was completed by 180 physicians including 10 private practice owners and 52 heads of departments. The majority (82.1%) of the participants had >15 years of experience in radiation therapy (RT).ResultsThe majority (83.9%) of the heads of the departments agreed on using the normofractionated regimen of RT as standard treatment for breast cancer. Several physicians were skeptical about HF-RT with 6.5% of the heads refusing to use HF-RT. 40.3% of the departments had not seen the new German guidelines suggesting HF-RT as the standard treatment for all patients as positive or merely adopted a neutral position toward the guidelines (33.9%). The main points of criticism were increased side effects, an impaired toxicity profile and insufficient data. Most departments (46.8%) that perform HF-RT do so in an individual based manner.ConclusionsHF-RT remains controversial in German speaking countries. Our data shows that NF-RT remains the predominant method of treatment. HF-RT is only used in a defined group of patients as most German physicians agree that particular patients, especially those at higher risk of RT late effects, may benefit from a less intense, extended fractionation schedule.     

Issues on diversity, training, and mentorship of young scientists: an interview

Academic institutions across the country have long recognized the value of racial integration and have consistently opposed legal challenges to affirmative action policies. Despite these efforts, the percentage of underrepresented minorities in academic positions has not increased in proportion to their representation in society. Recruitment of underrepresented minorities into scientific and academic careers is important, because these individuals provide valuable contributions to research and teaching, and they serve as positive role models to others aspiring to such professions. In this interview, Renato Aguilera, Chair of the ASCB Minorities Affairs Committee, answers questions from MBoC Features Editor Doug Kellogg about diversity in the scientific workforce.     

Current Trainee and Workforce Patterns for Thyroid and Parathyroid Surgery in the United States

ObjectiveThyroid and parathyroid surgery is performed by both general surgeons and otolaryngologists. We describe the proportion of surgeries performed by specialty, providing data to support decisions about when and to whom to direct research, education, and quality improvement interventions.MethodsWe tabulated case numbers for privately insured patients undergoing thyroid and parathyroid surgery in Marketscan: 2010–2016 and trainee case logs for residents and fellows in general surgery and otolaryngology. Summary statistics and tests for trends and differences were calculated.ResultsMarketscan data captured 114 500 thyroid surgeries. The proportion performed by each specialty was not significantly different. Otolaryngologists performed 58 098 and general surgeons performed 56 402. Otolaryngologists more commonly performed hemithyroidectomy (n = 25 148, 43.29% of all thyroid surgeries performed by otolaryngologists) compared to general surgeons (n = 20 353, 36.09% of all thyroid surgeries performed by general surgeons). Marketscan data captured 21 062 parathyroid surgeries: 6582 (31.25%) were performed by otolaryngologists, and 14 480 (68.75%) were performed by general surgeons. The case numbers of otolaryngology and general surgery trainees completing residency and fellowship varied 6- to 9-fold across different sites. The wide variation may reflect both the level of exposure a particular training program offers and trainee level of interest.ConclusionThyroid surgical care is equally provided by general surgeons and otolaryngologists. Both specialties contribute significantly to parathyroid surgical care. Both specialties should provide input into and be targets of research, quality, and education interventions.     

Contribution of changes in demography and in the risk factors to the predicted pattern of cancer mortality among Spanish women by 2022

BackgroundChanges in the burden of cancer mortality are expected to be observed among Spanish women. We predict those changes, in Spain, for breast cancer (BC), colorectal cancer (CRC), lung cancer (LC) and pancreatic cancer (PC) from 2013 to 2022.MethodsBayesian age–period–cohort modeling was used to perform projections of the cancer burden in 2013–2022, extrapolating the trend of cancer mortality data from 1998 to 2012. We assessed the time trends of the crude rates (CRs) during 1998–2012, and compared the number of cancer deaths between the periods 2008–2012 and 2018–2022 to assess the contribution of demographic changes and changes in the risk factors for cancer.ResultsDuring 1998–2012, CRs of cancer decreased for BC (0.3% per year) and increased for LC (4.7%), PC (2%) and CRC (0.7%). During 2013–2022, CRs might level off for CRC, whereas the time trends for the remaining cancers might continue at a similar pace. During 2018–2022, BC could be surpassed by CRC as the most frequent cause of cancer mortality among Spanish women, whereas LC could be the most common cause of cancer mortality among women aged 50–69 years (N/year = 1960 for BC versus N/year = 1981 for LC). Comparing 2018–2022 and 1998–2012, changes in the risk factors for cancer could contribute 37.93% and 18.36% to the burden of LC and PC, respectively, and demographic shifts – mainly due to ageing (19.27%) – will drive the burden of CRC.ConclusionsDuring 2018–2022, demographic changes (ageing) and changes in risk factors could have a different impact on the lifetime risk of cancer among Spanish women.     

Type 2 Endoleaks: The Diagnostic Performance of Non-Specialized Readers on Arterial and Venous Phase Multi-Slice CT Angiography

PurposeTo define the diagnostic precision of non-specialized readers in the detection of type 2 endoleaks (T2EL) in arterial versus venous phase acquisitions, and to evaluate an approach for radiation dose reduction.MethodsThe pre-discharge and final follow-up multi-slice CT angiographies of 167 patients were retrospectively analyzed. Image data were separated into an arterial and a venous phase reading set. Two radiology residents assessed the reading sets for the presence of a T2EL, feeding vessels, and aneurysm sac size. Findings were compared with a standard of reference established by two experts in interventional radiology. The effective dose was calculated.ResultsOverall, experts detected 131 T2ELs, and 331 feeding vessels in 334 examinations. Persistent T2ELs causing aneurysm sac growth > 5 mm were detected in 20 patients. Radiation in arterial and venous phases contributed to a mean of 58.6% and 39.0% of the total effective dose. Findings of reader 1 and 2 showed comparable sensitivities in arterial sets of 80.9 versus 85.5 (p = 0.09), and in venous sets of 73.3 versus 79.4 (p = 0.15), respectively. Reader 1 and 2 achieved a significant higher detection rate of feeding vessels with arterial compared to venous set (p = 0.04, p < 0.01). Both readers correctly identified T2ELs with growing aneurysm sac in all cases, independent of the acquisition phase.ConclusionArterial acquisitions enable non-specialized readers an accurate detection of T2ELs, and a significant better identification of feeding vessels. Based on our results, it seems reasonable to eliminate venous phase acquisitions.     

Advances and future of Radiation Oncology

Aim

Review of recent advances and vision for future developments in clinical practice of Radiation Oncology.

Background

There have been substantial research and technological developments in Radiation Oncology over the past 40 years.

Materials and methods

The relevant literature was reviewed and the authors offer their perspective on future opportunities for advancement in Radiation Oncology.

Conclusions

Significant innovative technological developments have been introduced in the practice of Radiation Oncology, with more precise target delineation and tracking and three dimensional treatment planning, optimal delivery of radiation therapy to the target and lower doses to surrounding Organs at Risk. This dose optimization and adaptive therapy have enhanced the role of Radiation Therapy to more effectively treat patients with cancer. Further creativity and refinements will continue to advance the field into new applications of ionizing radiations in cancer therapy.     

Radiation therapy for bone-only metastases in breast cancer patients: A GOCO survey of current clinical practice

IntroductionThe role of radiation therapy (RT) for patients with bone-only metastatic (BOM) breast cancer has not been investigated sufficiently. The aim of this survey was to evaluate current clinical practice in treating breast cancer patients with BOM in Radiation Therapy Departments in Catalonia and Occitania within the scope of the GOCO group.Materials and methodsAn electronic questionnaire was completed by experienced radiation oncologists from fourteen RT centers. The items surveyed the professional experience, therapeutic approach, technique, dose stereotactic body RT (SBRT) availability.ResultsAll Radiation Oncology Departments (ROD) in Catalonia (12) and Occitania (2) responded to the survey. Eleven (78.5%) of the RODs advise RT for BOM as initial treatment in the oligometastatic setting. RT to asymptomatic bone oligometastases is more often restricted for “risky lesions”. The most inconsistent approaches were the treatment for asymptomatic lesions, when to treat bone metastases with respect to systemic treatment (ST) and the indication for RT after a complete response to ST.ConclusionWhile BOM breast cancer patients have a relatively good prognosis, there is a lack of consistency in their approach with RT. This can be explained by the absence of evidence-based guidelines and an incomplete availability of SBRT.     

Who Will Manage American Patients With Diabetes? Residents’ Career Preferences and Perceptions of Diabetes Care

ObjectiveTo identify the factors that encourage or discourage internal medicine and pediatric residents regarding specializing in endocrinology with a focus on diabetes.MethodsWe conducted an electronic survey of internal medicine and pediatric residents using a $10 participation incentive. A total of 653 residents responded to the survey (estimated response rate of 9.2%)—626 from residency programs that were contacted for our survey and 27 from referrals.ResultsAmong internal medicine and pediatric residents surveyed, 39 respondents (6.0%) planned to specialize in endocrinology, and 27 of these (4.1% of total respondents) planned to focus on diabetes. “Intellectual satisfaction, ” “emotional satisfaction, ” and “work-life balance” were identified by respondents as the most important factors in their choice of a specialty, with ratings of 5.5, 5.4, and 5.3 on a 6-point Likert scale. Among these factors identified as most important to a medical career, endocrinology with a focus on diabetes scored poorly with regard to intellectual and emotional satisfaction but received high ranking with regard to lifestyle. With regard to other factors, endocrinology was rated negatively on “compensation, ” “number of procedures, ” and “patient adherence to prescribed treatment.” Exposure to diabetes during training had no major influence on the decision to enter endocrinology.ConclusionEndocrinology with a focus on diabetes care is not an attractive specialty for most internal medicine and pediatric residents. Therefore, new strategies to attract residents to the field of diabetes care are needed. (Endocr Pract. 2011;17:235-239)     

康柏西普联合全视网膜光凝治疗糖尿病黄斑水肿的疗效分析

目的:研究康柏西普联合全视网膜光凝(panretinal photocoagulation,PRP)治疗糖尿病黄斑水肿(diabetic macular edema, DME)的疗效及安全性。方法:回顾性分析2016年4月到2018年4月本院接诊的DME患者238例,按照治疗方式的不同将其分成观察组及对照组。对照组采用PRP治疗,观察组则采用抗血管内皮生长因子(vascular endothelial growth factor, VEGF)药物康柏西普联合PRP实施治疗。比较两组患者治疗后的临床效果、手术前后视力和黄斑中心凹厚度的变化及预后情况。结果:治疗后,观察组的治疗效率为94.96%,较对照组(84.87%)显著升高(P0.05)。观察组术后视力明显高于手术前(P0.05),且显著高于对照组(P0.05);观察组术后黄斑中心凹厚度明显小于术前(P0.05),且显著小于对照组。观察组并发症发生率(3.36%)明显低于对照组(10.92%,P0.05)。结论:康柏西普联合PRP治疗DME患者的效果显著优于单用PRP治疗,且安全性更高。     

The status of medical physics in radiotherapy in China

PurposeTo present an overview of the status of medical physics in radiotherapy in China, including facilities and devices, occupation, education, research, etc.Materials and methodsThe information about medical physics in clinics was obtained from the 9-th nationwide survey conducted by the China Society for Radiation Oncology in 2019. The data of medical physics in education and research was collected from the publications of the official and professional organizations.ResultsBy 2019, there were 1463 hospitals or institutes registered to practice radiotherapy and the number of accelerators per million population was 1.5. There were 4172 medical physicists working in clinics of radiation oncology. The ratio between the numbers of radiation oncologists and medical physicists is 3.51. Approximately, 95% of medical physicists have an undergraduate or graduate degrees in nuclear physics and biomedical engineering. 86% of medical physicists have certificates issued by the Chinese Society of Medical Physics. There has been a fast growth of publications by authors from mainland of China in the top international medical physics and radiotherapy journals since 2018.ConclusionsDemand for medical physicists in radiotherapy increased quickly in the past decade. The distribution of radiotherapy facilities in China became more balanced. High quality continuing education and training programs for medical physicists are deficient in most areas. The role of medical physicists in the clinic has not been clearly defined and their contributions have not been fully recognized by the community.     

Equity in clinical trials for HIV-associated cryptococcal meningitis: A systematic review of global representation and inclusion of patients and researchers

BackgroundIt is essential that clinical trial participants are representative of the population under investigation. Using HIV-associated cryptococcal meningitis (CM) as a case study, we conducted a systematic review of clinical trials to determine how inclusive and representative they were both in terms of the affected population and the involvement of local investigators.MethodsWe searched Medline, EMBASE, Cochrane, Africa-Wide, CINAHL Plus, and Web of Science. Data were extracted for 5 domains: study location and design, screening, participants, researchers, and funders. Data were summarised and compared over 3 time periods: pre-antiretroviral therapy (ART) (pre-2000), early ART (2000 to 2009), and established ART (post-2010) using chi-squared and chi-squared for trend. Comparisons were made with global disease burden estimates and a composite reference derived from observational studies.ResultsThirty-nine trials published between 1990 and 2019 were included. Earlier studies were predominantly conducted in high-income countries (HICs) and recent studies in low- and middle-income countries (LMICs). Most recent studies occurred in high CM incidence countries, but some highly affected countries have not hosted trials. The sex and ART status of participants matched those of the general CM population. Patients with reduced consciousness and those suffering a CM relapse were underrepresented. Authorship had poor representation of women (29% of all authors), particularly as first and final authors. Compared to trials conducted in HICs, trials conducted in LMICs were more likely to include female authors (32% versus 20% p = 0.014) but less likely to have authors resident in (75% versus 100%, p < 0.001) or nationals (61% versus 93%, p < 0.001) of the trial location.ConclusionsThere has been a marked shift in CM trials over the course of the HIV epidemic. Trials are primarily performed in locations and populations that reflect the burden of disease, but severe and relapse cases are underrepresented. Most CM trials now take place in LMICs, but the research is primarily funded and led by individuals and institutions from HICs.