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To survey radiation oncology residents on perceptions of diversity, equity, inclusion, and belonging in their residency training programs.A 23-item survey was developed by the Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee (ARRO EISC) resident members and faculty advisors and sent to all residents from ACGME accredited programs. The survey was divided into 4 sections: Institutional Culture, Support and Resources, Interview and Recruitment, and Experiences of Bias. The survey was sent individually to residents from all ACGME accredited radiation oncology programs.The survey was issued to 757 residents. 319 residents completed the survey, for a response rate of 42%. All post-graduate years (PGY) and geographic regions were represented. Significant racial, ethnic, and gender differences were present in survey response patterns. White residents (94%, 164/174) and male residents (96%, 186/194) were more likely to strongly agree/agree that they were treated with respect by their colleagues and their co-workers than other racial groups (p0.005) or gender groups (p0.008). Only 3% (5/174) of white residents strongly agreed/agreed that they were treated unfairly because of their race/ethnicity, while 31% (5/16) of Black residents and 10% (9/94) of Asian residents strongly agreed/agreed (p.0001). Similarly, Hispanic residents were more likely to strongly/agree (24%, 5/21) than non-Hispanic residents (7%, 20/298; p=0.003). Regarding mentorship, there were no differences by gender or ethnicity. There were differences by race in residents reporting that they had a supportive mentor (p=0.022), with residents 89% (154/174) of white residents who strongly agreed/agreed, 88% (14/16) of Black residents, and 91% of Asian residents (86/94).This survey reveals that experiences of support, mentorship, inclusion, and bias vary significantly among radiation oncology residents based on race, ethnicity and gender. Radiation oncology has opportunity for growth to ensure an equitable experience for all residents.

Purpose Racial and ethnic minorities in the state of Washington experience higher cancer mortality relative to whites. We sought to characterize differences in travel distance to radiation therapy (RT) facilities in Washington by race and ethnicity with a special focus on non-Hispanic American Indians and Alaska Natives as a contributor to limited access and cancer disparities. Methods and Materials Geocoded mortality data from Washington Department of Health (2011-2018) were used to identify decedents with mortality related to all-causes, all cancers, and cancers likely requiring access to RT. This was determined from optimal RT usage estimates by diagnosis. RT facility locations were ascertained from the Directory of Radiation Therapy Centers and confirmed. Distance from decedents’ address listed on death certificates to nearest RT facility was calculated. Generalized mixed models were used for statistical analysis. Results We identified 418,754 deaths; 109,134 were cancer-related, 60,973 likely required RT. Among decedents with cancers likely requiring RT, non-Hispanic American Indians and Alaska Natives decedents would have had to travel 1.16 times (95% confidence interval [CI], 1.09-1.24) farther from their residences to reach the nearest treatment facility compared with non-Hispanic whites. This association existed in metro counties but was more pronounced in nonmetro counties (1.39 times farther; 95% CI, 1.22-1.58). In addition, Hispanics would have had to travel 1.11 times farther (95% CI, 1.06-1.16) to reach the nearest facility compared with non-Hispanic whites, primarily due to differences in urban counties. Decedents in nonmetro counties lived on average 35 miles (SD = 29) from RT centers and non-Hispanic American Indians and Alaska Natives in nonmetro counties 53 miles (SD = 38). Compared with non-Hispanic white decedents, those who were non-Hispanic black, non-Hispanic Asian, and non-Hispanic Native Hawaiian decedents lived closer to RT facilities. Conclusions We observed significant disparities in access to RT facilities in Washington, specifically for non-Hispanic American Indians and Alaska Natives and rural decedents. The findings call for initiatives to improve access to critical cancer treatment services for these underserved populations with known disparities in cancer deaths.

Purpose To characterize the participation of radiation oncology (RO) in reporting quality metrics through the Centers for Medicare and Medicaid Services’ (CMS) Hospital Compare database and to describe the association of hospital characteristics with RO-specific quality metrics. Methods and Materials Data from the CMS Hospital Compare, International Atomic Energy Agency’s Directory of Radiotherapy Centre, 2010 US Census, and CMS Inpatient Prospective Payment System were linked to create an integrated data set of geographic information, facility characteristics, and quality measures, focusing on the use of external beam radiation therapy (EBRT) for bony metastases. Results Of 4829 hospitals in the Hospital Compare database, 2030 had access to radiation therapy. Among these, 814 (40%) reported on the rate of guideline-concordant EBRT for bony metastases, a RO-specific quality measure. A total of 33,614 eligible cases of bony metastases treated with EBRT were sampled. Participation in quality reporting varied significantly by geography, population type, teaching status, hospital ownership, hospital type, and hospital size. The median rate of guideline-concordant palliative EBRT utilization was 89%. Nine percent of 814 centers had a compliance rate of less than 50%. On multivariable analysis, increasing number of cases sampled (odds ratio 0.93, P = .028), increasing hospital star-rating, and above-average patient experience rating (odds ratio 0.58, P = .024) remained significantly associated with decreased odds of falling into the lowest quartile of guideline-concordant EBRT utilization. Conclusions RO participation in a large, national quality improvement effort is nascent and reveals potential quality gaps between hospitals offering palliative EBRT for bone metastases. More robust RO-specific quality measures are needed.

Purpose/Objective(s) Racial and ethnic minorities in Washington State (WA) experience higher cancer mortality relative to whites. We sought to characterize differences in travel distance as a marker for access to radiation therapy (RT) facilities in WA and one possible contributing factor to cancer disparities. Materials/Methods Geocoded mortality data from the WA Department of Health (2011-2018) were used to identify decedents with mortality related to all causes, all cancers, and cancers likely requiring access to RT (defined as estimated RT usage rate > 50% by anatomical subsite corresponding to ICD-9 or 10 code). Race was defined per US Office of Management and Budget 1997 standard and ethnicity as Hispanic or non-Hispanic. RT facility locations were identified from the Directory of Radiotherapy Centers and validated by internet search or phone calls. Road network distance from decedent's residence to nearest RT facility was calculated on a geographic information platform. Generalized mixed models were used for statistical analysis. Results We identified 109,134 cancer-related deaths of which 60,973 likely required RT. Among decedents with cancers likely requiring RT, non-Hispanic (NH) American Indian/Alaskan Native (AI/AN) decedents would have had to travel 1.16 times (95% CI 1.09-1.24) farther to reach the nearest treatment facility compared to NH whites. This association existed in metro counties but was more pronounced in non-metro and rural counties, where NH AI/ANs would have had to travel 1.39 times farther compared to NH whites (95% CI 1.22 – 1.58). This translated to an average of 83 miles (SD = 22) for NH AI/AN in rural areas to travel to RT centers whereas NH Whites in rural areas would have had to travel on average 59 miles (SD = 28). Hispanics would have had to travel 1.11 times farther to reach the nearest facility compared to NH whites (95% CI 1.06 – 1.16), primarily due to differences in urban areas. NH African American, NH Asian, and NH Native Hawaiian decedents lived closer to RT facilities compared to the NH white decedents. Based on our findings, we estimated that expanding the federal “safe harbor” restrictions on health systems providing transportation from 50 to 75 miles could open up needed services for 96% of rural NH AI/ANs. Conclusion NH AI/ANs and rural decedents experience stark disparities in access to RT facilities in WA state. The findings call for creative initiatives to improve access to critical cancer treatment services to combat racial, ethnic and rural disparities in cancer deaths. In depth analysis of local barriers to access for minority communities is necessary to devising practical solutions such as advocating for policy change for “safe harbor” restrictions.

PURPOSE/OBJECTIVE(S) To investigate radiation oncology (RO) program directors' (PDs) attitudes and practices regarding racial and ethnic diversity, equity and inclusion (DEI) and to better understand their potential impact on underrepresented in medicine (UIM) residents in RO. MATERIALS/METHODS A 28-item IRB-approved survey was developed using the validated Ethnic Harassment Experiences Scale and the Daily Life Experiences subscale, as well as input from DEI leaders in RO. Apart from demographics, questions were either True/False or graded on a Likert scale. The Likert-scaled questions are reported as agreement (strongly agree and agree) or disagreement (strongly disagree or disagree). The survey was administered using an online survey platform to PDs from the 90 ACGME-accredited programs. Descriptive statistics were used for data analysis. RESULTS The response rate was 71% (64/90). Demographics: 59% were male and 41% female. 66% were White, 25% Asian, < 2% Black and < 2% Hispanic. Institutional Culture and Beliefs: Most (75%, N = 48) reported at least one UIM faculty and 52% had a UIM faculty in a leadership role. 42% responded that they had a department DEI director. A minority (17%, N = 11) agreed "I believe that people from UIM backgrounds have equal access to quality tertiary education.... in the US." The majority (97%, N = 62) agreed "My program values residents from UIM backgrounds." Support and Resources: Majority (78%, N = 50) agreed "My program has resources in place to assist/provide support for resident physicians from UIM backgrounds," and a minority (19%, N = 12) agreed "My program has supported a UIM resident to apply for an NIH Diversity Supplement award." Interview and Recruitment: Most PDs (53%) had not taken part in activities aimed at recruiting UIM residents and 17% had interviewed no UIM applicants in the past 5 years for residency. In response to "How many total UIM students has your department matriculated?" 19% (N = 12) did not provide an answer, 20% (N = 13) answered unsure/did not know and 6% (N = 4) had matriculated zero UIM applicants. Resident experiences of Racism: 17% (N = 11) agreed "UIM residents in my program have reported incidents of racism to me," and 28% (N = 18) agreed "I believe that UIM residents in my program have been treated differently because of their race/ethnicity by faculty, staff, co-residents or patients." CONCLUSION Our survey results show that most (75%) RO PDs believe that UIM persons do not have equal access to tertiary education in the US (17% disagreed and 8% were neutral), but that UIM residents are supported in their department (78%). Most PDs reported that they do not participate in specific activities aimed at recruiting UIM residents, with nearly 1 in 5 programs reporting no interviews of UIM applicants in the last 5 years, and over one quarter of programs acknowledging differential treatment based on race/ethnicity. These data suggest a potential disconnect between DEI perceptions and activities among RO PDs that may be addressed through increased awareness and tailored programs.

PURPOSE This study examines the relationship between dose to corneal substructures and incidence of corneal toxicity within 6 months of proton beam therapy (PBT) for uveal melanoma. We aim to develop clinically meaningful dose constraints that can be used to mitigate corneal toxicity. METHODS AND MATERIALS Ninety-two patients were treated with PBT between 2015 and 2017 and evaluated for grade 2+ (GR2+) intervention-requiring corneal toxicity in our prospectively maintained database. Most patients were treated with 50 Gy (relative biological effectiveness [RBE]) in 5 fractions, and all had complete six-month follow-up. Analyses included Mann-Whitney, χ2, Fisher exact, and receiver operating curve tests to identify risk factors for GR2+ toxicity. Bivariate logistic regression was used to identify independent dose-volume histogram (DVH) predictors of toxicity after adjustment for the most important clinical risk factor. RESULTS The 6-month PBT GR2+ corneal toxicity rate was 10.9%, with half of patients experiencing grade 2 toxicity and half experiencing grade 3 toxicity, with no grade 4 events. Patients with anterior chamber tumors had a higher risk (58.3%) for toxicity than those with posterior tumors (0%) or posterior tumors extending past the equator (25%, P

Purpose The indications for treatment of brain metastases from non-small cell lung cancer (NSCLC) with stereotactic radiosurgery (SRS) remain controversial. We studied patterns, predictors, and cost of SRS use in elderly patients with NSCLC. Methods and Materials Using the Surveillance, Epidemiology, and End Results-Medicare (SEER-Medicare) database, we identified patients with NSCLC who were diagnosed with brain metastases between 2000 and 2007. Our cohort included patients treated with radiation therapy and not surgical resection as initial treatment for brain metastases. Results We identified 7684 patients treated with radiation therapy within 2 months after brain metastases diagnosis, of whom 469 (6.1%) cases had billing codes for SRS. Annual SRS use increased from 3.0% in 2000 to 8.2% in 2005 and varied from 3.4% to 12.5% by specific SEER registry site. After controlling for clinical and sociodemographic characteristics, we found SRS use was significantly associated with increasing year of diagnosis, specific SEER registry, higher socioeconomic status, admission to a teaching hospital, no history of participation in low-income state buy-in programs (a proxy for Medicaid eligibility), no extracranial metastases, and longer intervals from NSCLC diagnosis. The average cost per patient associated with radiation therapy was 2.19 times greater for those who received SRS than for those who did not. Conclusions The use of SRS in patients with metastatic NSCLC increased almost 3-fold from 2000 to 2005. In addition, we found significant variations in SRS use across SEER registries and socioeconomic quartiles. National practice patterns in this study suggested both a lack of consensus and an overall limited use of the approach among elderly patients before 2008.

Purpose To evaluate outcomes of patients treated for aggressive non-Hodgkin lymphoma (NHL) with combined modality therapy based on [ 18 F]fluoro-2-deoxy-2-d-glucose positron emission tomography (FDG-PET) response. Methods and Materials We studied 59 patients with aggressive NHL, who received chemotherapy and radiation therapy (RT) from 2001 to 2008. Among them, 83% of patients had stage I/II disease. Patients with B-cell lymphoma received R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone)-based chemotherapy, and 1 patient with anaplastic lymphoma kinase-negative anaplastic T-cell lymphoma received CHOP therapy. Interim and postchemotherapy FDG-PET or FDG-PET/computed tomography (CT) scans were performed for restaging. All patients received consolidated involved-field RT. Median RT dose was 36 Gy (range, 28.8-50 Gy). Progression-free survival (PFS) and local control (LC) rates were calculated with and without a negative interim or postchemotherapy FDG-PET scan. Results Median follow-up was 46.5 months. Thirty-nine patients had negative FDG-PET results by the end of chemotherapy, including 12 patients who had a negative interim FDG-PET scan and no postchemotherapy PET. Twenty patients were FDG-PET-positive, including 7 patients with positive interim FDG-PET and no postchemotherapy FDG-PET scans. The 3-year actuarial PFS rates for patients with negative versus positive FDG-PET scans were 97% and 90%, respectively. The 3-year actuarial LC rates for patients with negative versus positive FDG-PET scans were 100% and 90%, respectively. Conclusions Patients who had a positive interim or postchemotherapy FDG-PET had a PFS rate of 90% at 3 years after combined modality treatment, suggesting that a large proportion of these patients can be cured with consolidated RT.

Purpose: Given the excellent prognosis for patients with benign meningiomas, treatment strategies to minimize late effects are important. One strategy is proton radiation therapy (RT), which allows less integral dose to normal tissue and greater homogeneity than photon RT. Here, we report the first series of proton stereotactic radiosurgery (SRS) used for the treatment of meningiomas. Methods and Materials: We identified 50 patients with 51 histologically proven or image- defined, presumed-benign meningiomas treated at our institution between 1996 and 2007. Tumors of =}2 mm from the optic apparatus were eligible for treatment. Indications included primary treatment (n = 32), residual tumor following surgery (n = 8), and recurrent tumor following surgery (n = 10). The median dose delivered was 13 Gray radiobiologic equivalent (Gy[RBE]) (range, 10.0-15.5 Gy[RBE]) prescribed to the 90% isodose line. Results: Median follow-up was 32 months (range, 6-133 months). Magnetic resonance imaging at the most recent follow-up or time of progression revealed 33 meningiomas with stable sizes, 13 meningiomas with decreased size, and 5 meningiomas with increased size. The 3-year actuarial tumor control rate was 94% (95% confidence interval, 77%-98%). Symptoms were improved in 47% (16/ 34) of patients, unchanged inmore » 44% (15/34) of patients, and worse in 9% (3/34) of patients. The rate of potential permanent adverse effects after SRS was 5.9% (3/51 patients). Conclusions: Proton SRS is an effective therapy for small benign meningiomas, with a potentially lower rate of long-term treatment-related morbidity. Longer follow-up is needed to assess durability of tumor control and late effects.« less

Conclusions: ADT+RT is associated with reduced PCS and overall mortality in real-world clinical practice, consistent with findings from two RCTs. ADT+RT is also associated with reduced mortality in screen-detected and elderly patient subgroups not represented in the RCTs. Author Disclosure: J.E. Bekelman: None. N. Mitra: None. E. Handorf: None. R. Uzzo: None. S. Hahn: None. D. Polsky: None. K. Armstrong: None.