Search

In summary, the ASTRO Committee on Human Resources believes that there is ample evidence for the existence of an oversupply of radiation oncologists in the United States at the present time. It believes that this oversupply has already affected the specialty in a variety of ways that are difficult to measure, for example, increased competition, conflicts between radiation oncology groups, conflicts between the private sector and academics, and increased costs, and that it is beginning to have a significant effect on the job market. This oversupply came about because of the rapid expansion in medical school enrollment in the 1970s. This led to an increased number of graduates available for enrollment into specialty residencies, one of which was radiation oncology. The actual number of radiation oncology residency positions offered has not changed significantly since 1972. However, only about half of the residency positions were filled in the early years. Since 1986, virtually all radiation oncology training positions in the United States have been filled, and this has led to a significantly greater number of radiation oncologists entering the field than have left the field through death or retirement. Preliminary data suggest that a shift to a managed care system would result in decreased demand for radiation oncology services, and that would increase the manpower problem for our specialty.

Purpose: Health care delivery in the United States is in the midst of a structural revolution called managed care. Demands for cost control within the managed care environment force radiation oncologists to defend the need and obligation to follow their patients. Methods and Materials: We have analyzed this follow-up requirement from six potential justifications: patient care, medical-legal, quality assurance, outcome measurement, cost, and improvement of care. Results: Practical recommendations for discussing the need for follow-up with the medical directors and primary care physicians of managed care entities are given. Follow-up without valid documentation of benefit is hard to justify in this era of managed care. Conclusions: Collaborative follow-up between the referring physician, the treating radiation oncologist, and the other oncologic specialists will allow for outcome measurement and improvement in practice without driving up cost or exposing the patient to undue risk.

Radiation treatment is generally safe. The reported adverse event rate requiring follow-up care is low: (e.g., z1.2/ 10,000 treated patients; NY State Department of Health estimates [J. Krishnamoorthy, personal communication, August 6, 2010]). Recently however, there is increased interest in patient safety within radiation oncology, prompted, at least in part, by articles in the New York Times (1–4). These articles complement other articles in the lay press (5, 6) and several reports within the radiation oncology literature (7). Taken in concert, these reports implicate the increasing complexity of radiation oncology as a potential source of increased risks for patients (8). Even though radiation therapy is generally safe and efficacious, the potentially devastating effects of misadministrations remind us that we need to be continually vigilant. Subsequent to the NY Times articles, patient safety concerns have been the topic of recent congressional hearings, and meetings sponsored by the Food and Drug Administration (May 2010) and ASTRO/AAPM (June 2010). ASTRO has committed itself to a six-point ‘‘Target Safely’’ action plan (9). The device manufacturers have committed themselves to their own response to the challenge (10). These activities will change the way we practice. There will likely be new standards for clinical practice and training, certification, and recertification of personnel. Quality assurance procedures may be redefined with mandatory time-outs and checklists, and human–computer interfaces will be reengineered to facilitate correct use (11). These initiatives should be applauded and may improve patient safety. Improvements in patient safety will also require us to broaden the scope of our concern. Radiation oncology is a component of an increasingly complicated health care system: We routinely evaluate, treat, and follow patients with

observational cohort study since October 2010. Information on diagnosis, stage, risk factors for cancer, and treatment plan are collected at the initial visit. During subsequent phone calls and follow-up visits, treatment response and survival are assessed. We report on patients enrolled through February 2012. Results: One hundred forty-four participants were enrolled; median age at cancer diagnosis was 45.4 years and 64% were female. Of the 136 patients with known HIV status, 85 (63%) were HIV-infected and 67 (49%) were on antiretroviral therapy. For 90 (66%), the diagnosis of HIV preceded the diagnosis of cancer, and median time from HIV diagnosis to cancer diagnosis was 3.7 years. Forty patients (30%) had a smoking history but only 14 (10%) were active smokers. The most common cancer types for women were breast (24% of all women), cervix (20%), and Kaposi’s sarcoma (KS, 14%), and for men were KS (33% of all men), head and neck (19%), and non-Hodgkin lymphoma (15%). Nearly all patients (96%) presented due to symptoms, the most common being palpable lump/mass, pain, or bleeding. Of patients who had staging studies (n Z 124), 68% had advanced stage cancers (III/IV). Pathologic confirmation of cancer diagnosis was obtained in 81% of patients. The treatment plan involved surgery in 77 patients, chemotherapy in 81, and radiation therapy (RT) in 39. Of the 38 patients who started RT (one died prior to starting), the most common conditions were cervical cancer, breast cancer, and KS. Median dose prescribed was 60 Gy (range, 8-78 Gy). Thirty-four patients completed RT with the average course duration of 53.7 days (range, 1-113 days). RT was delivered at Gaborone Private Hospital on a linear accelerator with photon, electron, or combined modality therapy. With median follow-up of 14.2 months, the median survival was 22.5 months for early stage disease and 16.5 months for advanced disease. Conclusions: In this limited sample of patients, the majority of cancers were HIV-associated and diagnosed at advanced stage after presentation with symptoms, even for preventable/detectable cancers such as cervix and breast. A greater understanding of cancer in Botswana will inform decisions of resource allocation and infrastructure development, including cancer prevention/screening and RT availability. Author Disclosure: G. Suneja: None. S. Dryden-Peterson: None. M. Boyer: None. Z. Musimar: None. M. Nsingo-Bvochora: None. D. RamogolaMasire: None. H. Medhin: None. J. Bekelman: None. S. Lockman: None. T. Rebbeck: None.

Parasternal lymphoscintigraphy is an easily performed technique for visualizing and accurately determining thethree dimensional location of internal mammary lymph nodes. Sixty-eight women with primary or locally recurrent breast cancer underwent parasternal lymphoscintigraphy before treatment planning. The mean depth and lateral position of the internal mammary nodes were 1.8. ± 0.9 cm and 2.4 ± 0.9 cm respectively. Thirteen per cent of the nodes would have been undertreated by the standard tangential technique used at our institution. Six of 15 patients whose treatment plans were examined retrospectively had at least 1 lymph node undertreated by the standard tangential tec hnique. Thus, although standard tangential portals provide adequate coverage for the internal mammary lymph nodes in a majority of patients, parasternal lymphoscintigraphy can insure complete coverage of this lymph node group.

Between January, 1967 and July, 1980, 176 women who were referred to the Joint Center for Radiation Therapy (JCRT) for definitive breast irradiation underwent low axillary dissection. A typical operative technique is described. The dissection stops short of the axillary vein although the vein is usually visualized. One hundred thirty-two axillae were thought to be N 0 or N 1a . Forty-six axillae were felt to be N. Seventeen percent of the T 1 N 0 patients had pathologically positive nodes. Twenty-seven percent of the T 2 N 0 patients had positive nodes. When 5 or less nodes were removed at axillary sampling the incidence of nodal involvement was very low. There were no differences in nodal positivity when comparing upper quadrant to lower or central lesions. Lateral lesions appeared to have higher positivity rates compared with either medial or central lesions. Ninety-four percent of axillae with N 1b lesions were pathologically confirmed. The complication rate for this procedure was low. There were 5 transient non-surgical complications and 1 cellulitis resulting in a frozen shoulder, which required corrective surgery. There were no cases of moderat or severe arm edema. Axillary sampling is compared to axillary dissection as a diagnostic procedure. Axillary sampling may underestimate the true pathologic positive rate, but diagnostic accuracy appears excellent if level 1 and 2 nodes are sampled.

Treatment with a perfluorochemical emulsion combined with breathing a 95% or 100% oxygen atmosphere has been shown to be an effective adjuvant to radiation therapy in several animal tumor systems. Similarly, the addition of treatment with a perfluorochemical emulsion combined with breathing a high oxygen atmosphere has been shown to improve the response of several animal tumor systems to treatment with BCNU. We now report results of the use of the perfluorochemical emulsion, Fluosol-DA, and carbogen breathing with single dose radiation treatment, BCNU and combined drug and radiation treatment in intracranially implanted 9L gliosarcoma. The median enhancement in life span produced by Fluosol-DA and carbogen breathing in addition to radiation was 2 days at 10 Gy and 6 days at 20 Gy compared to radiation treatment alone. In the group receiving 20 Gy with Fluosol-DA and carbogen breathing, 2 of 20 lived 120 days. Treatment with a single intraperitoneal injection of BCNU (10 mg/kg) on day 7 post tumor cell implantation produced an increase in life span of 2 days compared to untreated control animals. The combination of drug treatment with Fluosol-DA and carbogen breathing produced an increase in life span of 26 days, which was significantly different from BCNU treatment with air breathing (p less than 0.001). Finally, when BCNU and Fluosol-DA and carbogen were combined with radiation treatment (20 Gy), an increase in life span of nearly 85 days compared to untreated controls was produced, with 47% (9 or 19) surviving 120 days. These results suggest that this combination might be effective in the treatment of malignant brain tumors.

The perfluorochemical emulsion, Fluosol-DA, combined with breathing a 95% oxygen/5% carbon dioxide atmosphere enhances the response of several rodent tumors. B6D2F1/J mice bearing Lewis lung tumors, measuring 50-100 mm3 were treated with 4, 8 and 12 ml/kg of Fluosol-DA intravenously each morning. Three Gy fractions twice per day were employed and carbogen breathing was maintained 1 hr prior to and during each X ray treatment. The dose modifying factors were 1.42 +/- 0.16 at 4 ml/kg, 1.85 +/- 0.23 at 8 ml/kg, and 2.17 +/- 0.34 at 12 ml/kg. In a second experiment, a single dose of Fluosol-DA (12 ml/kg) was administered on day 1 to B6D2F1/J male mice, bearing established subcutaneous Lewis lung tumors, as described above. X rays were delivered in 2, 3, or 4 Gy fractions once per day for five days. The dose modifying effect was 2.60 +/- 0.54. The effect of this treatment program was the same as that seen with single dose radiation. These experiments demonstrate that Fluosol-DA need not be administered with every fraction to produce an improved treatment outcome with fractionated X rays.