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Increased demand for Gamma Knife (GK) radiosurgery treatment necessitated the installation of a second treatment machine to continue providing lifesaving treatment in a timely manner. The addition of a second machine brought with it the potential to double treatment volume, but the department was unable to allocate additional pre and post procedural space. Workflow and scheduling of patients was evaluated to ensure streamlined operations during the rollout of the additional machine. The objective of the Continuous Improvement (CI) project was to minimize the incidence of treatments surpassing 6:00 PM. A cross functional team (represented by nursing, radiation therapists, radiation oncologists, surgeons, and physicists) employed A3 methodology to develop a current state process map for the different treatment modalities used in GK. Using the process map, the team constructed a proposed scheduling guideline that accounted for an increased patient volume without additional pre/post procedural space. Data were collected from the Brain Tumor Institute database for 325 patients regarding procedure type and duration, patient zip code, and number of days surpassing 6:00 PM. This information was used to develop a GK sample patient population. The CI process involved creating a visual representation to convey patient flow through the GK department using a poster board and patient tokens. Procedure times were generated by a randomized normal distribution of the GK sample population, and used in scenarios of varying capacity, complexity, and timing of pre-procedure imaging. The simulation included having the team complete a pre-planning huddle to determine the flow of the day that included patient order and arrival times. The simulation progressed patients through the day in 30-minute intervals while generating randomized unplanned delays formulated from clinician feedback. The proposed scheduling guideline was simulated at 60% capacity with mild complexity and 50% of imaging completed prior to the treatment day. A subsequent simulation was conducted at 100% capacity with moderate complexity and no imaging completed prior. This resulted in five modifications to the guideline and both simulations completing prior to 6:00 PM. Following the go-live, the number of patients treated in GK increased from 113 in 2021 to 157 in 2022 between January 1st and February 24th. The number of days that treatments surpassed 6:00 PM during the respective time periods reduced from 4 to 2, representing a 50% year over year reduction, despite a volume increase of 39%. Utilization of a simulation activity to evaluate a proposed scheduling guideline provided a tangible experience with optimizing workflow and efficiency. This allowed the CI team to gain a practical understanding of the impacts of adding a second treatment machine prior to the new machine's implementation. [ABSTRACT FROM AUTHOR]

Patients' understanding of radiation therapy (RT) and data regarding optimal approaches to patient education (PE) within radiation oncology (RO) are limited. We aimed to evaluate PE practices of radiation oncologists and interprofessional RT care team members to inform recommendations for delivering inclusive and accessible PE. An anonymous survey was administered to all Radiation Oncology Education Collaborative Study Group members (10/5/22-11/23/22). Respondent demographics, individual practices/preferences, and institutional practices were collected. Qualitative items explored strategies, challenges, and desired resources for PE. Descriptive statistics summarized survey responses. The Fisher exact test compared PE practices by respondent role and PE timing. Thematic analysis was used for qualitative responses. One hundred thirteen Radiation Oncology Education Collaborative Study Group members completed the survey (28.2% response rate); RO attendings comprised 68.1% of respondents. Most practiced in an academic setting (85.8%) in North America (80.5%). Institution-specific materials were the most common PE resource used by radiation oncologists (67.6%). Almost half (40.2%) reported that their PE practices differed based on clinical encounter type, with paper handouts commonly used for in-person and multimedia for telehealth visits. Only 57.7% reported access to non-English PE materials. PE practices among radiation oncologists differed according to RT clinical workflow timing (consultation versus simulation versus first RT, respectively): one-on-one teaching: 88.5% versus 49.4% versus 56.3%, P <.01, and paper handouts: 69.0% versus 28.7% versus 16.1%, P <.01. Identified challenges for PE delivery included limited time, administrative barriers to the development or implementation of new materials or practices, and a lack of customized resources for tailored PE. Effective strategies for PE included utilization of visual diagrams, multimedia, and innovative education techniques to personalize PE delivery/resources for a diverse patient population, as well as fostering interprofessional collaboration to reinforce educational content. Radiation oncologists and interprofessional RO team members engage in PE, with most using institution-specific materials often available only in English. PE practices differ according to clinical encounter type and RT workflow timing. Increased adoption of multimedia materials and partnerships with patients to tailor PE resources are needed to foster high-quality, patient-centered PE delivery. [ABSTRACT FROM AUTHOR]

In this Pediatric Normal Tissue Effects in the Clinic (PENTEC) vision paper, challenges and opportunities in the assessment of subsequent neoplasms (SNs) from radiation therapy (RT) are presented and discussed in the context of technology advancement. The paper discusses the current knowledge of SN risks associated with historic, contemporary, and future RT technologies. Opportunities for research and SN mitigation strategies in pediatric patients with cancer are reviewed. Present experience with radiation carcinogenesis is from populations exposed during widely different scenarios. Knowledge gaps exist within clinical cohorts and follow-up; dose-response and volume effects; dose-rate and fractionation effects; radiation quality and proton/particle therapy; age considerations; susceptibility of specific tissues; and risks related to genetic predisposition. The biological mechanisms associated with local and patient-level risks are largely unknown. Future cancer care is expected to involve several available RT technologies, necessitating evidence and strategies to assess the performance of competing treatments. It is essential to maximize the utilization of existing follow-up while planning for prospective data collection, including standardized registration of individual treatment information with linkage across patient databases. [ABSTRACT FROM AUTHOR]

Purpose: To clarify the feasibility and effectiveness of intra-arterial CT angiography (IACTA) for treatment planning of arteriovenous malformation radiosurgery.Methods and Materials: A CT scanner installed in an angiographic examination room was used. Helical IACTA was performed in 22 patients during continuous intra-arterial infusion of contrast medium via the internal carotid or vertebral artery, and dynamic IACTA was performed in 20 of these patients with reconstruction at 0.2-s intervals. The dynamic IACTA was repeated for each 3- or 5-mm increment to encompass the nidus. Subtractions were performed in postembolization cases. A retrospective review of IACTA was performed to assess the effectiveness of dynamic scans.Results: No complications related to the angiographic procedure or CT imaging were detected. High contrast enhancement was obtained for both helical and dynamic IACTA. In 18 of the 20 cases (90%), draining veins were separated from the nidus by using the enhancement patterns, and in 13 cases (65%), feeding arteries were separated.Conclusion: Dynamic IACTA added important information for target-volume determinations. Conventional CT and MRI could be omitted from the protocol, and the period that patients wore the frame was substantially shortened. We conclude that IACTA is a practical and useful method for radiosurgical treatment planning of arteriovenous malformations. [Copyright &y& Elsevier]

To assess delays in treatment initiation of chemoradiation or radiation alone for patients with advanced stage cervical cancer in Botswana. Females with locally advanced cervical cancer (stages IB2-IVB) were prospectively enrolled in an observational cohort study from 2015 to 2019. We evaluated delays at 30, 60, 90, 120, 150, and 180 or greater days between the date of diagnosis and treatment initiation. Factors associated with overall survival were modeled with multivariable Cox proportional hazards regression (aHR). Associations between delays in cervical cancer treatment initiation were evaluated via univariable logistic regression. Among the 556 patients included (median age = 47.9 years), 386 (69.4%) were females living with HIV with a median CD4 count of 448.0 cells/μL (IQR, 283.0-647.5 cells/μL) at diagnosis. Most patients had stages 2 (38.1%) or 3 (34.5%) cervical cancer. Early-stage patients experienced longer delays in treatment initiation compared to late-stage patients (P =.033). Early-stage patients with delays ≥90 days and pathology diagnosis between 2016 and 2019 (aHR, 0.34; P <.001) versus <90 days had a decreased risk of mortality, and those with delays ≥90 days and pathology diagnosis before 2016 (aHR, 5.67; P =.022) versus <90 days had an increased risk of mortality. Late-stage patients with delays ≥120 days and pathology diagnosis between 2018 and 2019 (aHR, 1.98; P =.025) versus <120 days had an increased risk of mortality. Early-stage patients with pathology diagnosis between 2016 and 2019 (odds ratio, 2.32; P =.043) versus before 2016 were more likely to experience delays ≥90 days, and late-stage patients who traveled >100 km to the treatment facility (odds ratio, 2.83; P <.001) versus <100 km were more likely to experience delays ≥120 days. Delays in care are common in Botswana, particularly for those living farther from the treatment clinic and at advanced stages. This paper is among the first to show an association between treatment delays and worsened overall survival at advanced stages of cervical cancer, highlighting the need for interventions to help patients receive timely care in global settings. [ABSTRACT FROM AUTHOR]

In 2021, the Advanced Practice Radiation Therapy Working Group (APRTWG) was established in the United States as a grassroots alliance of multidisciplinary radiation oncology professionals—radiation therapists, physicians, dosimetrists, and administrators—located across the country, interested in studying and establishing the Advanced Practice Radiation Therapist (APRT) level of practice in the United States. The APRT model has shown success in the United Kingdom, Canada, Australia, Singapore, and other countries, documenting the value of the APRT to the quality and advancement of clinical care. In the United States, the APRTWG seeks to coordinate activities, align resources, and drive the national agenda to collectively develop and define novel models of care using APRT in line with the evolving needs of patients and the radiation therapy profession. This environmental scan aims to examine the context of radiation oncology medical practice in the United States to inform pathways ahead for a proposed APRT model through a Political, Economic, Social, Technological, Environmental, and Legal (PESTEL) analysis. A literature search was conducted to understand the chronological timeline of the development of APRT during the past 25 years. Items that included the activities, scope of practice, and implementation of APRT nationally and internationally were identified. Papers describing advanced practitioner roles that are commonly found in the multidisciplinary team in radiation oncology both in the United States and internationally, such as physician assistants and nurse practitioners, were excluded. Despite the environmental scan outcome, it is acknowledged that data collation and analysis was not as robust as that anticipated by undertaking a systematic review. Papers were identified by the lead author that aligned with each of the PESTEL factors. Defined broadly, a new care model can adjust how health services are delivered by incorporating best practices in patient care for a specific population, person, or patient cohort. As patients enter different stages of their disease, the purpose of a new model is to provide individuals with the right care, at the right time, by the right team, in the right place. It is clear that the opportunity for positive change and impact on the current state of practice in radiation oncology exists. The environmental scan findings demonstrate the complexities associated with implementing APRT in the United States, with multifactorial political, environmental, societal, technological, economic, and legal aspects to consider. The APRTWG will continue to lead and participate in such activities to demonstrate and identify APRT role opportunities in the United States and drive the nationwide implementation of the APRT level of practice in this country. [ABSTRACT FROM AUTHOR]

FLASH radiation therapy (FLASH-RT), delivered with ultrahigh dose rate (UHDR), may allow patients to be treated with less normal tissue toxicity for a given tumor dose compared with currently used conventional dose rate. Clinical trials are being carried out and are needed to test whether this improved therapeutic ratio can be achieved clinically. During the clinical trials, quality assurance and credentialing of equipment and participating sites, particularly pertaining to UHDR-specific aspects, will be crucial for the validity of the outcomes of such trials. This report represents an initial framework proposed by the NRG Oncology Center for Innovation in Radiation Oncology FLASH working group on quality assurance of potential UHDR clinical trials and reviews current technology gaps to overcome. An important but separate consideration is the appropriate design of trials to most effectively answer clinical and scientific questions about FLASH. This paper begins with an overview of UHDR RT delivery methods. UHDR beam delivery parameters are then covered, with a focus on electron and proton modalities. The definition and control of safe UHDR beam delivery and current and needed dosimetry technologies are reviewed and discussed. System and site credentialing for large, multi-institution trials are reviewed. Quality assurance is then discussed, and new requirements are presented for treatment system standard analysis, patient positioning, and treatment planning. The tables and figures in this paper are meant to serve as reference points as we move toward FLASH-RT clinical trial performance. Some major questions regarding FLASH-RT are discussed, and next steps in this field are proposed. FLASH-RT has potential but is associated with significant risks and complexities. We need to redefine optimization to focus not only on the dose but also on the dose rate in a manner that is robust and understandable and that can be prescribed, validated, and confirmed in real time. Robust patient safety systems and access to treatment data will be critical as FLASH-RT moves into the clinical trials. [ABSTRACT FROM AUTHOR]

Purpose: Taste loss is a major cause of morbidity in patients undergoing head-and-neck irradiation. The relationship between the time course and the degree of taste disorder was studied in both acute and late phases. Methods and Materials: Taste ability was measured by the taste threshold for the four basic tastes using a filter paper disc method in patients before, during, and after radiotherapy. The subjects were divided into two groups. In Group A, the radiation fields included most of the tongue (n = 100), and in Group B the radiation fields did not include the tip of the tongue (n = 18). Results: In Group A, there was a significant impairment of the threshold of all four basic tastes at 3 weeks after starting radiotherapy (RT), and this impairment remained at 8 weeks (p < 0.05). This was not seen in Group B. In Group A, there was no significant difference in the patterns of taste sensitivity change between the high-dose (>20 Gy) and low-dose (≤20 Gy) groups. In the late phase, recovery of taste loss was seen in both groups since 4 months after completing RT. Conclusions: Unless the anterior part of the tongue was irradiated, taste loss was not observed during RT. When the anterior part of the tongue was irradiated, a difference by radiation dose was not observed in the taste loss pattern. Additionally, radiation-induced taste dysfunction appears to be a temporal effect. [Copyright &y& Elsevier]

Consistency of nomenclature within radiation oncology is increasingly important as big data efforts and data sharing become more feasible. Automation of radiation oncology workflows depends on standardized contour nomenclature that enables toxicity and outcomes research, while also reducing medical errors and facilitating quality improvement activities. Recommendations for standardized nomenclature have been published in the American Association of Physicists in Medicine (AAPM) report from Task Group 263 (TG-263). Transitioning to TG-263 requires creation and management of structure template libraries and retraining of staff, which can be a considerable burden on clinical resources. Our aim is to develop a program that allows users to create TG-263–compliant structure templates in English, Spanish, or French to facilitate data sharing. Fifty-three premade structure templates were arranged by treated organ based on an American Society for Radiation Oncology (ASTRO) consensus paper. Templates were further customized with common target structures, relevant organs at risk (OARs) (eg, spleen for anatomically relevant sites such as the gastroesophageal junction or stomach), subsite- specific templates (eg, partial breast, whole breast, intact prostate, postoperative prostate, etc) and brachytherapy templates. An informal consensus on OAR and target coloration was also achieved, although color selections are fully customizable within the program. The resulting program is usable on any Windows system and generates template files in practice-specific Digital Imaging and Communications In Medicine (DICOM) or XML formats, extracting standardized structure nomenclature from an online database maintained by members of the TG-263U1, which ensures continuous access to up-to-date templates. We have developed a tool to easily create and name DICOM radiation therapy (DICOM-RT) structures sets that are TG-263–compliant for all planning systems using the DICOM standard. The program and source code are publicly available via GitHub to encourage feedback from community users for improvement and guide further development. [ABSTRACT FROM AUTHOR]

A series of radiobiological models were developed to study tumor control probability (TCP) for stereotactic body radiation therapy (SBRT) of early-stage non-small cell lung cancer (NSCLC) per the Hypofractionated Treatment Effects in the Clinic (HyTEC) working group. This study was conducted to further validate 3 representative models with the recent clinical TCP data ranging from conventional radiation therapy to SBRT of early-stage NSCLC and to determine systematic optimal fractionation regimens in 1 to 30 fractions for radiation therapy of early-stage NSCLC that were found to be model-independent. Recent clinical 1-, 2-, 3-, and 5-year actuarial or Kaplan-Meier TCP data of 9808 patients from 56 published papers were collected for radiation therapy of 2 to 4 Gy per fraction and SBRT of early-stage NSCLC. This data set nearly triples the original HyTEC sample, which was used to further validate the HyTEC model parameters determined from a fit to the clinical TCP data. TCP data from the expanded data set are well described by the HyTEC models with α/β ratios of about 20 Gy. TCP increases sharply with biologically effective dose and reaches an asymptotic maximal plateau, which allows us to determine optimal fractionation schemes for radiation therapy of early-stage NSCLC. The HyTEC radiobiological models with α/β ratios of about 20 Gy determined from the fits to the clinical TCP data for SBRT of early-stage NSCLC describe the recent TCP data well for both radiation therapy of 2 to 4 Gy per fraction and SBRT dose and fractionation schemes of early-stage NSCLC. A steep dose response exists between TCP and biologically effective dose, and TCP reaches an asymptotic maximum. This feature results in model-independent optimal fractionation regimens determined whenever safe for SBRT and hypofractionated radiation therapy of early-stage NSCLC in 1 to 30 fractions to achieve asymptotic maximal tumor control, and T2 tumors require slightly higher optimal doses than T1 tumors. The proposed optimal fractionation schemes are consistent with clinical practice for SBRT of early-stage NSCLC. [ABSTRACT FROM AUTHOR]

Research in radiation oncology often involves manual review and entry of large volumes of patient information into data repositories. This is labor intensive, costly, and may divert effort of learners (e.g. students and residents) away from more educational experiences. We hypothesize that we could use artificial intelligence (AI) to develop software to complete complex tasks related to data screening, cleaning, and entry into research databases. AI with ChatGPT4 was queried in an iterative process to build executable software using Python programming language and spreadsheet software macros to meet the data extract needs for two IRB-approved research projects. No patient data was shared with AI. In Project 1, paper questionnaires filled out by hand during clinic visits were obtained to collect patient and physician reported outcomes in the use of prostate radiotherapy. In Project 2, patient data from numerous global institutions were submitted to be included in a meta-analysis of individual patient data of hepatocellular carcinoma. Data were to be manually checked for completeness and inconsistencies, then comments were generated to be returned to the sender with requests to correct any remaining deficiencies. For both projects, we quantified the time taken to create the AI-derived software. For Project 1, where students have been employed over prior years and some have used time-tracking software to log their work, we quantified the time/cost that is predicted to be saved by avoiding manual data extraction. A radiation oncologist (TY), with experience using a programming environment (and no experience with Python or building spreadsheet software macros), used ChatGPT4 to build software to complete all required tasks for both Project 1 and 2 (Table 1). For Project 1, ≈40 hours of development produced software to digitize human markings on patient and physician reported outcomes into tabular form. In prior years, undergraduate and medical students have performed these tasks at a rate of ≈2-4 minutes/page with a departmental cost of ≈$0.7/page. Software generated by ChatGPT4 performs the same task at a rate of 1.6 seconds per page and can be run in perpetuity without cost. For Project 2, ≈35 hours of development were required to build a spreadsheet software macro to review and identify missing data, inconsistencies (e.g., incompatible dates), or unexpected variables (e.g., out-of-range laboratory results), as well as suggest comments to be returned to the sender. The macro was found to make no errors and is currently being used in lieu of hiring a research assistant. We were able to use AI to create software that can extract data accurately from paper forms and also review and clean large datasets with entry into registries to facilitate radiation oncology research. [ABSTRACT FROM AUTHOR]

Our study aims to examine factors associated with a successful CT simulation on first attempt in a cohort of prostate cancer patients treated with radiation therapy at a tertiary cancer center. We included adult patients with prostate cancer undergoing CT simulation for pelvic radiation and requiring bladder and bowel preparation. Convenience sampling targeting 230 consecutive, consenting patients will be recruited over 6-8 months, to allow a multivariable logistic model with 12 pre-specified variables, assuming a 50% success rate of CT simulation. Patients answered questions regarding their preparation experience. We extracted CT simulation and scheduling information from patient charts. We also collected basic demographic data. The survey included questions regarding the type of consultation, bowel/bladder preparation instructions, previous treatments, ESAS-r-cancer questions to assess constipation and diarrhea, English as first language, and an open-text question for feedback. The AUA (American Urological Association) symptom score questionnaire was also included to assess urinary function. Successful CT simulation was defined as a CT planning scan that was successfully completed on the first attempt on/off the CT couch. A descriptive analysis was completed for all baseline variables. Multivariable logistic regression was used to evaluate factors associated with successful simulation. To date, we have accrued 221 patients. The mean age was 70 years, majority with Stage 3 disease (57%) and treated with external beam radiotherapy alone (67%). 73 (33%) patients had a successful CT simulation. Certain factors showed clinically meaningful associations with successful CT simulation, including in-person consult (vs virtual) [OR 1.4 (95% 0.6-3.4)], as was providing both verbal and paper instructions (vs none) [OR 1.7 (95% CI = 0.65-4.5)]. We found a lower-than-expected rate of successful CT simulations. However, these results provide a better understanding of factors that may impact successful CT simulation in patients with prostate cancer. One might infer that in-person visits and providing both paper and verbal instructions improved the success rate. To improve successful CT simulation on the first attempt and reduce the need for repeated appointments, further enhancements in provider-patient interaction and bladder/bowel prep instructions are needed. This study will hopefully help guide strategies to improve efficiency, communication, and patient experience. [ABSTRACT FROM AUTHOR]

As the survival rates of childhood cancer improve, it becomes increasingly important to study the impact of multi-modality therapies on long-term health. Radiotherapy has been implicated as a contributor to late toxicities such as second malignant neoplasms and cardiovascular disease; however, there are still significant gaps in knowledge. Indeed, survivors presenting with late health effects today were treated before the widespread availability of 3D imaging and radiotherapy planning. However, without 3D organ dosimetry, it is difficult to translate the knowledge gained from past treatments into the dose tolerance criteria needed for improving outcomes for patients treated today. The National Wilms Tumor Study (NWTS) provides a unique opportunity to bridge this gap. This paper describes the methods, workflow, and results of a multi-year effort to reconstruct radiotherapy organ doses for the NWTS cohort in support of late effects research. We reconstructed 3D organ doses for 4716 pediatric patients in the NWTS cohort. As CT images were not available for the NWTS patients, computational phantoms were selected from a body-size dependent phantom library to use as surrogate anatomy. Each patient was matched to a phantom in the library based on gender, height, and weight at age of Wilms tumor diagnosis. A DICOM CT image set and structure file for the matched phantom was then imported into a treatment planning system (TPS) for reconstruction of the radiotherapy fields according to paper medical records. The radiotherapy planning was performed by an experienced medical physicist under the supervision of a radiation oncologist familiar with protocols used during the NWTS trials. As the accuracy of the TPS is limited in the out-of-field region, Monte Carlo radiation transport calculations were also performed to improve the organ dose estimates. All calculations were performed on the NIH high-performance computing cluster. The patients were treated with a variety of photon energies: 4 MV (23%), 6 MV (48%), 10 MV (3%), Co-60 (23%), and other (3%). The most common treatment fields were left and right-flank, abdomen, and chest. The Monte Carlo dose calculations took approximately ~100 CPU hours (wall clock time ~2 hours) for a typical patient, resulting in approximately 0.5 million CPU hours in total for the cohort. Mean organ dose and dose-volume metrics were computed for more than 100 organs or tissues. This study represents the first time Monte Carlo methods have been directly applied on a large scale to reconstruct organs doses for an epidemiological cohort. The organ doses for the NWTS cohort will provide valuable information for developing dose tolerance criteria for mitigating radiotherapy toxicity. [ABSTRACT FROM AUTHOR]

The statistical technique of multiple regression, commonly referred to as "multivariable regression," is often used in clinical research to quantify the relationships between multiple predictor variables and a single outcome variable of interest. The foundational theory underpinning multivariable regression assumes that all predictor variables are independent of one another. In other words, the effect of each independent variable is measured by its contribution to the regression equation while all other variables remain unchanged. In the presence of correlations between two or more variables, however, it is impossible to change one variable without a consequent change in the variable(s) it is linked to. This condition, known as "multicollinearity," can introduce errors into multivariable regression models by affecting estimates of the regression coefficients that quantify the relationship between individual predictor variables and the outcome variable. Errors that arise due to violations of the multicollinearity assumption are of special interest to radiation oncology researchers. Because of high levels of correlation among variables derived from points along individual organ dose-volume histogram (DVH) curves, as well as strong intercorrelations among dose-volume parameters in neighboring organs, dosimetric analyses are particularly subject to multicollinearity errors. For example, dose-volume parameters for the heart are strongly correlated not only with other points along the heart DVH curve but are likely also correlated with dose-volume parameters in neighboring organs such as the lung. In this paper, we describe the problem of multicollinearity in accessible terms and discuss examples of violations of the multicollinearity assumption within the radiation oncology literature. Finally, we provide recommendations regarding best practices for identifying and managing multicollinearity in complex data sets. [ABSTRACT FROM AUTHOR]

According to the most recent report of the American Cancer Society, the 5-year overall survival for pancreatic and lung cancer is respectively 44% and 63% for localized lesions, respectively, highlighting the need for improved tumor control [1]. The FLASH effect, recently discovered and being investigated in the context of a real implementation in the clinical workflow, has a clear potential to contribute to this challenge. Promising radiobiological results have already been obtained with low energy electron beams (6 MeV), which has stimulated our interest in studying the potential of VHEE (70-130 MeV) with the aim of quantifying the main dosimetric advantages compared to the current state of the art clinical solutions (VMAT, at conventional rates). By applying the FLASH effect to the VHEE plans, it is possible to quantify the organ-at-risk sparing and the possible increase in target prescriptions to improve tumor control. In this paper, we investigate the comparison between VMAT and VHEE and the potential increase in prescribing to improve overall survival for these challenging diseases, taking into account the FLASH effect. The selected cancers for the dosimetric comparison are: pancreatic adenocarcinoma and NSCLC. For pancreatic cancer, 3 patients with primary neoplasia were enrolled for stereotactic tumor ablation. Radical radiotherapy was chosen aiming to induce tumor necrosis. In this case, the main limitation is imposed by duodenal sparing: the maximum dose should not exceed a total of 35 Gy in 0.1 cm^3 in 5 treatment sessions to avoid serious adverse events for the patients. The 2 selected lung cancer cases are medically inoperable early stage I-II NSCLC primary neoplasms. Current RTOG guidelines recommend three, four or five-fraction SBRT. For all the patients, we have planned a treatment using an in-house developed treatment planning system that uses dose maps derived from FRED software. The prescription used for VMAT pancreatic cases is less than 7 Gy for 5 fractions due to the duodenal sparing. Comparing the VHEE results for these cases with the FLASH model applied, it can be seen that the duodenal sparing allows a dose escalation up to 8 Gy in 5 fractions. For the lung cases, the VHEE plans with the FLASH model applied show a sparing effect on the high dose region around the CTV. When compared to the conventional VMAT schedule, the VHEE FLASH irradiation of lung cancer can reduce the number of sessions and increase the dose per fraction: the first case studied showed that it will be possible to go from 12 Gy in 4 fractions to 15 Gy in 3 fractions achieving the same level of toxicity. For a clinical translation of the presented in silico results, radiobiological experiments on human tissues and a better understanding of FLASH activation in a clinical setting are needed. The results obtained suggest a high potential for FLASH electron irradiation and strongly support research efforts in this area. [1] American Cancer Society: Cancer Facts and Figures 2024. [ABSTRACT FROM AUTHOR]

Proton radiography is an imaging method using proton beam instead of X ray to get patient image. Water equivalent path length (WEPL) information can be directly got in proton radiograph, which is critical to proton therapy. Deep learning has been widely applied in medical image field due to its powerful feature extraction capability. However, proton radiography is a frontier medical image technology, the sample size of proton image dataset is too small to use to train deep learning network. Computed tomography (CT) is the most common examination method in clinic. In this paper, we use an improved cycle generative adversarial network (CycleGAN) to convert unpaired and uncalibrated lung CTs into proton CTs to expand the sample size of lung proton CTs dataset to make it more suitable for deep learning network training. We selected 3D CT data from 53 lung cancer patients and 4D proton CT data including 10 different phases from 1 lung cancer patient for preprocessing. Firstly, all the data were sliced into 2D data and cropped to appropriate sizes, and then high-quality images were filtered. The training dataset included unpaired and uncalibrated 832 CT slice images and 1185 proton CT slice images. We constructed a CycleGAN to demonstrate the possibility of using it to expand proton CTs through CTs. Subsequently, we added a sobel operator convolutional layer to CycleGAN encoder to extract edge and detail features. A structural similarity (SSIM) loss was added in loss function to make generated proton CT structure more similar to that of CT. In addition, convolutional layers with 1 kernel size were used to replace upsampling and downsampling layer, to make generated proton CTs style feature closer to that of real proton CTs. Finally, 15 CT slice images were randomly selected from rest patient CT as testing dataset to test the performance of above CycleGANs and generated proton CTs were evaluated. The Frechet Inception Distance (FID) score and Turing like test score of proton CT generated by original CycleGAN was 255.50 and 2.63, respectively. The proton CTs generated by the CycleGAN which was added a sobel operator convolutional layer in generator and SSIM loss in the loss function had a 220.00 score for FID and a 2.90 score for Turing like tests. After updating upsampling and downsampling layer, the FID score of generated proton CT decreased to 188.22, and its Turing like test score increased to 4.10. The Turing like test score was significantly improved after used improved CycleGAN. Even if the FID score didn't decrease significantly, this improvement also made generated proton CT style feature, especially grayscale values closer to real proton CTs. The improved CycleGAN had feasibility and effectiveness in expanding proton CTs. It can generate proton CTs that are similar to real samples in terms of structure, detail information, style features, etc., laying the foundation for the application of artificial intelligence in proton CT. [ABSTRACT FROM AUTHOR]

The randomness of radiation interaction with matter and the statistical fluctuation of cellular dose further confirm the sensitivity of microscopic energy deposition to target volume and shape at subcellular level. Numerous studies have demonstrated the applicability of Monte Carlo method in quantifying cellular scale dose and its distribution. The highly irregular morphological changes between different cell types resulted in the emergence of the cell curved surface model. It can more accurately describe the cell morphology and structure, including the spatial position relationship of nucleus and cytoplasm, more accurately model the cell surface shape and topological structure, and improve the accuracy of cell dose distribution estimation by Monca simulation. The purpose of this study is to explore the construction of biophysical cell model for the application of radiation therapy and the mechanism of biological effects in glioma cells. The main work of this study is as follows: By applying radiation dosimetry theory and combining advanced image analysis and numerical analysis techniques, a curved surface model of real brain glioma cells was constructed to simulate the dose distribution of single cells and community cells under different doses in real irradiation environment. Monte Carlo simulation and radiobiology experiments were carried out to obtain the results of radiation physics and radiobiology experiments. Analyze and compare the construction of a cellular scale dose and effect database. The dose estimation results of glioma cell curved surface model presented in this paper show that the dose deposited in the nucleus of a single glioma cell after X-ray irradiation is about 70% of the dose deposited in the external radiation, and the dose distribution of community cells is Gaussian, which accords with the randomness of dose deposition. Radiobiological results showed that the damage of T98G cells increased with the increase of dose, and the apoptosis rate reached the highest at 48 h under 2 Gy irradiation and gradually decreased, which may be related to repair gene Rad 51. Based on the microscopic characteristics and dose distribution of tumor cells, the biological effects of radiation on tumor cells (apoptosis, iron death, coke death, etc.) can be predicted according to the dose-response model at cellular scale. From a macro perspective, understanding the dose distribution of tumor cells, based on dose-response relationship information, can help optimize the design of radiation therapy plans, assess the risk of treatment course, and predict the effect of radiation therapy. The proposed cell surface model further expands the digital model library of human cells, and contributes to the in-depth development of cell microdosimetry, which is between radiobiology and radiophysics, and has the characteristics of both. It can enable us to combine physics and biology, and may reveal a new field of science and application. [ABSTRACT FROM AUTHOR]

In the complex field of radiotherapy (RT), ensuring patient safety is paramount. Recognizing the critical need for disseminating knowledge on potential failure modes (FMs) in RT, our study introduces i-SART (intelligent Safety Assistant in RT), a web application empowered by AI, aiming to promote proactive risk management and patient safety awareness. The objective of this work is to describe i-SART's development and deployment strategy and discuss its potential implications. The i-SART design is based on the Failure Modes and Effects Analysis methodology (FMEA) and the AAPM TG100, whilst integrating AI techniques to engage RT professionals in an interactive learning process. I-SART is built upon a database populated with potential FMs in the RT process and associated techniques, including MR-guided Adaptive RT, extracted from 10 papers and safety reports. The application, developed using Python 3.9 and the Django REST framework, features two user roles: administrator and user. Secure information transfer was ensured through JSON Web Token authentication. MySQL relational database was chosen for persistent user and FM information storage. The user interface of i-SART was created using Vue.js, an interpreted computer programming language-based framework. An AI-driven chatbot facilitates discussions about FMs and safety measures. Experiments with AI techniques such as Markov Chains and Generative Adversarial Networks were conducted to generate synthetic FMs. This is a collaborative effort between two European Universities. The application collects data and organizes a database of potential FMs and their attributes (causes, effects, severity and mitigation strategies) in RT procedures. Initially, 728 FMs were collected which were then reduced to 419 after the removal of duplicates and ambiguities. The application provides users with functionalities for searching, filtering, and sorting FMs, as well as contributing new FMs for continuous database growth. The AI-driven chatbot is anticipated to enhance user engagement and knowledge dissemination. The experiments with AI techniques for synthetic FMs resulted in limited outcomes due to the small training dataset. I-SART's effectiveness will soon be evaluated by users and stakeholders. I-SART is a promising conversational tool for enhancing patient safety in RT through proactive risk management. Future work involves expanding the database and exploring integration with other risk management methodologies. We anticipate i-SART to drive further research in integrating AI techniques in RT risk management and providing a substantial dataset for machine learning applications, FMs predictions and synthetic FMs generation. [ABSTRACT FROM AUTHOR]

Incarceration rates in the United States are the highest in the world. Cancer risk is higher among incarcerated persons in the United States than nonincarcerated. Incarcerated women experience high cancer rates relative to incarcerated males. Health literacy is associated with increased screening, yet there is minimal published information on cancer screening literacy among women who are incarcerated in United States prisons. Decreased health literacy in combination with limited self-advocacy may impact justice-involved women's cancer screening. We conducted a survey of incarcerated persons in Wisconsin's largest prison for females, Taycheedah Correctional Institution (TCI), on their familiarity with cancer screening. A 31-item paper survey was distributed to all incarcerated individuals at TCI. The survey measured respondents' knowledge and attitudes towards breast, cervical, and colon cancer screening, and collected demographic data including age and self-reported race/ethnicity. Of the estimated 830 possible participants (2023 reported TCI population), 661 surveys were returned for a nearly 80% response rate. Self-reported race/ethnicity was 68% White/Caucasian, 17% Black/African American, 8% American Indian/Alaskan Native, 5% Latinx, and 1% Asian. Almost all respondents were within the age range for cervical cancer screening based on USPSTF recommendations, and about half were within the range for breast and colon cancer screening. Overall familiarity for breast cancer screening was 89.3%, for cervical cancer was 85.2%, and for colon cancer was 76.8%. Knowledge generally increased as age increased, and as duration of incarceration decreased. White respondents had the most overall knowledge, while American Indian/Alaskan Native and Asian respondents had the least. In this assessment of cancer screening knowledge among incarcerated women, overall familiarity with cancer screening was high, with highest rates for breast cancer and lowest rates for colon cancer. There were differences in familiarity between populations with different lengths of incarceration, between age groups, and between racial/ethnic groups. These differences highlight high-risk incarcerated subpopulations that may benefit from intervention to increase knowledge. Future research should assess screening experiences during incarceration, including measuring any racial/ethnic differences in reported desire for and actual receipt of screening. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to characterize retracted studies within the field of radiation oncology.Methods and Materials: Computerized searches were performed in Ovid MEDLINE, PubMed, Ovid EMBASE, and the Cochrane Library up to May 2017 looking for retracted studies using the terms "retraction note," "retracted note," "withdrawn" and "radiotherapy," and "radiation oncology." Additional studies were identified by hand-searching 10 discipline-specific journals. Two authors independently screened papers and then extracted author demographics, journal characteristics, and retraction-specific variables.Results: Of the 58 studies identified, the most common reasons for retraction were misconduct (43%), methodological error (21%), authorship issues (5%), unknown causes (5%), and journal (administrative) errors (3%). A total of 13 systematic reviews or protocols (22%) were withdrawn from the Cochrane Library for being out-of-date or redundant. All but one retracted study and retraction notice were available in portable document format. Of the 57 retrieved papers, 79% were identified as retracted via in-text notations or watermarks. Overall median time to retraction was 44 months (interquartile range, 11-98 months). However, 42 studies (72%) were still cited after retraction notices were published.Conclusions: A retracted study within the field of radiation oncology remains a relatively uncommon event. Although promising, our data suggest that the majority of these retracted articles continue to be cited as valid research. As such, there is still a need for clinicians to remain vigilant with their academic rigor and good clinical research practices. There is an urgent need for publication houses to foster universal publishing standards along with discipline-specific retraction guidelines. [ABSTRACT FROM AUTHOR]

In the United States, lung cancer is the leading cause of cancer death. Between 2010 and 2016, the non-small cell lung cancer (NSCLC) 5-year overall survival rate was 26.5%. The National Comprehensive Cancer Network (NCCN) guidelines described the recommended management of NSCLC. Stereotactic body radiation therapy (SBRT) has emerged as the optimal treatment for nonoperative NSCLC with excellent 3-year local control of 90%. However, there exists uncertainty over the optimal fractionation schedule between daily and nonconsecutive fractionation schedules. A meta-analysis was performed using relevant literature from PubMed to identify studies comparing daily and nonconsecutive fractionation schedules for SBRT on NSCLC patient populations. Odds ratios were calculated, and forest plots were constructed for the toxicities. Weighted averages were calculated for the median overall survival (OS). The inclusion criteria to select eligible studies: (a) patients receiving SBRT for early-stage NSCLC dosages of 45-60 Gray over 3-8 fractions; (b) studies must include data pertaining to both daily and nonconsecutive fractionation schedules; (c) studies may be retrospective, single-institution, multi-institution, controlled studies, or meta-analyses; (d) studies conducted after 2000. The exclusion criteria to remove eligible studies: (a) one-armed studies analyzing only one of daily or nonconsecutive; (b) studies not analyzing post-operative toxicities. Our systematic review identified 5 suitable papers, which analyzed 916 patients of which 439 received daily fractions and 477 received nonconsecutive fractions. Our analysis concluded the median overall survival for the daily fractionation block (32.93 months) was less than nonconsecutive fractionation block (37.77 months). Amongst toxicities, cough OR is 1.03 (95% CI: 0.24, 4.31; p = 0.49), dyspnea OR is 0.81 (95% CI: 0.08, 8.31; p = 0.47), chest wall pain OR is 0.9 (95% CI: 0.14, 5.66; p = 0.92)., pneumonitis OR is 0.15 (95% CI: 0.05, 0.46; p = 0.47), and general pulmonary toxicity ORs are 0.40 (95% CI: 0.14, 1.10; p = 0.20), 2.57 (95% CI: 0.46, 14.47; p = 0.14), and 2.42 (95% CI: 0.53, 10.99; p = 0.2) for Grades 1, 2, and 3-5, respectively. There was no significant difference in the likelihoods. SBRT is an effective and well tolerated treatment for NSCLC. To our knowledge, this study of 916 patient is the first systemic review to determine the optimal fractionation schedule using existing studies. This meta-analysis provides evidence that there is no potential survival advantage associated with nonconsecutive fractionation, both daily and nonconsecutive schedules exhibit similar safety profiles in terms of post-operative toxicities. Clinicians should consider these findings when making decisions about the fractionation schedule for SBRT in early-stage NSCLC, emphasizing the need for a personalized approach that balances efficacy and safety considerations for individual patients. [ABSTRACT FROM AUTHOR]

To describe the use of teletherapy QA capacity, QA protocols, and patient safety incident reporting systems in LMICs. An electronic survey on QA practices was distributed to 220 medical physicists (MP) in 22 LMICs by contacts and the non-profit BIO Ventures for Global Health. Answers from each clinic's most experienced respondent were summarized with descriptive statistics. The Teletherapy QA Capacity (TQC), defined as the ratio of the number of QA devices/tests (Array detector, film, EPID, ion chamber, solid water phantom, water tank, diode, TBI/TSET phantom, front pointer, Winston-Lutz, graph paper, ruler, laser localization, optical, and/or collimator indicator) to the number of machines, was calculated for each clinic. Surveys were initiated by 119 MP and completed by 67 MP (34% response rate) from 50 clinics in 16 countries (76% represented). Of the 50 MP responses analyzed, 58% worked in government/academic settings, and 6% were trainees. QA devices/tests used in ≥70% of clinics included film, EPID, ion chambers, solid water phantoms, water tanks, rulers, and laser, optical and collimator checks. The mean number of QA devices/tests used per clinic was 10 (range 4-14). The mean number of teletherapy units per clinic was 1.7 (range 1-5). The mean clinic TQC was 7.4 (range 1.3-14). Local QA protocols were used in 24%/38% of clinics/ countries, and AAPM or IAEA protocols were used in 94%/94%, respectively. One clinic had no protocols. Safety incidents were documented in a clinic-wide system in 82%/81% of clinics/countries, hospital-wide system in 52%/69%, and the IAEA Safety in Radiation Oncology (SAFRON) database in 26%/44%, respectively. The TQC value is a novel, simple method to relate strengths and gaps in the treatment triad of teletherapy capacity, QA capacity, and patient outcomes. Most surveyed MP follow international QA guidelines and document safety incidents; feasibility and fidelity should be investigated further. [ABSTRACT FROM AUTHOR]

Patient-reported outcome (PRO) collection and intervention improves disease outcomes. In our urban public hospital radiation oncology department, we created a digital "care companion" (CC) program embedded in the health system electronic medical record (EMR) to provide breast cancer (BC) radiation therapy (RT) patient education and collect PRO. We hypothesized that CC would be used by a majority of patients who had activated the mobile EMR app. A multidisciplinary team (physicians, nurses, and information technology) oversaw CC. Because the EMR did not have an existing CC module for RT, we created a first-of-its-kind program using established and validated content. CC included weekly education, PROs at multiple timepoints during and after RT, reminder messages, and videos. Patients were eligible for the program if they had a diagnosis of BC undergoing RT, were English-literate, and had a smartphone. All patients received usual care consisting of paper-based educational materials before RT start. Patients were enrolled in CC through the EMR before the first RT fraction and instructed to download the mobile EMR app. PROs came from two source surveys: 1) National Cancer Institute PRO-CTCAE Custom Survey of 36 questions relevant to BC, and 2) EORTC-QLQ BR23 comprising 23 BC-related items. Patients completed skin reaction and pain scales weekly during RT. Educational materials were "tasked" to patients during and after RT. Reminder messages were sent by email. Nurses also verbally reminded patients about CC during clinic visits. CC ended 90 days after RT. We measured monthly patient Engagement and Task Compliance. "Engagement" is percentage of patients interacting with a task and either skipping or completing it within a specific time window (1 week for PRO surveys, 3 days for other tasks). "Task compliance" is the percentage of a specific assigned educational or PRO task that is completed each month. A total of 56 BC patients were enrolled in CC from 9/6/2023 to 2/28/2024; 40 completed the program and 16 remain enrolled. Median age was 58 years (range = 29-85). 89% of enrolled patients activated the EMR chart by app or web browser. Engagement was 21.6% on average per month (range = 6 to 38%). Average monthly task compliance ranged from 2% (for PRO-CTCAE) to 6% (for Skin and Pain scales), with monthly high of 19% in January (skin/pain scales). Throughout our hospitals, patient logins to the EMR chart after activating an account remain low at 10-11% monthly. In our urban public hospital population, a novel patient-facing BC care companion EMR program had low engagement in its first six months, despite most patients activating their EMR chart. Digital interventions suffer from high dropout or disengagement. To improve usage, next steps include demonstrating CC task completion to patients in clinic, changing automatic reminders to be text-based, and surveys to understand patient reasons for disengagement. PROs will be reported after longer follow up. [ABSTRACT FROM AUTHOR]

In the realm of cancer care, the toll extends beyond physical and emotional strain to include substantial financial burdens. This paper embarks on an exploration of financial toxicity among cancer patients, employing observational study methods to delve into the determinants shaping these economic challenges. By uncovering key factors, we aim to inform targeted interventions to alleviate the financial burden associated with cancer treatment. The study was conducted at single cancer institute over a nine-month period, from May 2023 to January 2024, involving 250 cancer patients. Financial toxicity was assessed using the COST scale, while quality of life was evaluated using the WHO BREF scale. Statistical analysis, including the Wald's method of logistic regression analysis, was utilized to identify determinants affecting financial toxicity among the participants. The subjects, predominantly female (52.00%), had a mean age of 54.94 years (±13.51 SD). A portion of 30.40% presented with metastatic conditions, while 59.60% exhibited ECOG scores of 3 or 4. Regarding financial toxicity, 26.8% encountered Grade 1, 60.8% Grade 2, and 5.6% Grade 3, with the remaining subjects reporting no financial toxicity. The analysis unveiled statistically significant correlations between financial toxicity and education (p = 0.000), annual family income (p = 0.044), functioning scale (p = 0.000), and symptom scale (p = 0.039). The study reveals a high prevalence of financial toxicity among cancer patients, predominantly Grade 2. Significant correlations were found between financial toxicity and education, annual income, physical functioning, and symptom severity, emphasizing the need for interventions addressing socioeconomic disparities to alleviate financial burden and enhance patient well-being. [ABSTRACT FROM AUTHOR]

Patient understanding of radiotherapy (RT) processes and data regarding optimal approaches to patient education (PE) within radiation oncology (RO) are limited. Our objective was to evaluate PE practices and preferences of interprofessional RO providers to inform recommendations for delivering inclusive, accessible, and patient-centered education. An anonymous 17-item online survey, approved by an ethics review board, was administered to all members of the Radiation Oncology Education Collaborative Study Group (ROECSG) between 10/5/22 to 11/23/22. Respondent demographics, provider practices/preferences, and institutional practices were collected. Qualitative items explored key strategies, challenges, and desired resources for PE. Descriptive statistics summarized survey responses. Fisher's exact test compared PE practices by provider role and PE timing. Thematic analysis was used for qualitative responses. A total of 123 ROECSG members, including RO attendings (64%), RO trainees (21%), medical physicists (7%), physician assistants/nurses (2%), and radiation therapists (2%), completed the survey (31% response rate). Most practiced in an academic setting (86%) in North America (82%). The most common PE resources used were custom created institution-specific (61%) and electronic health system generated materials (38%). PE was delivered primarily by one-on-one teaching (72%), paper handouts (69%), and organizational websites (21%) (e.g., RTanswers.org). Almost half (41%) reported that PE practices differed based on type of clinical encounter, for example paper handouts for in-person visits and multimedia for virtual visits. The majority (86%) stated that their institution has disease site-specific PE materials, with nearly all having breast cancer materials (91%). Only 58% reported access to non-English PE materials. RO attendings/trainees were more likely than other team members to deliver PE at consultation (98% vs 71%, p = 0.03). PE practices amongst radiation oncologists differed according to the timing along the RT care path (consultation vs simulation vs first fraction, respectively): one-on-one teaching: 89% vs 49% vs 56%, p<0.01 and paper handouts: 69% vs 28% vs 16%, p<0.01. Key PE strategies included incorporating multimedia resources, personalizing delivery, and repetition at multiple timepoints by the interprofessional team. Limited time, inadequate administrative support, and lack of customized resources were identified as challenges in PE delivery. Interprofessional RO providers engage in PE, with most utilizing institution-specific materials. PE practices differ according to the type of clinical encounter and timing in the RT care path. Increased adoption of multimedia materials and partnerships with patients to tailor PE resources based on language, learning styles, and cultural preferences are needed to foster high-quality, patient-centered PE delivery. [ABSTRACT FROM AUTHOR]

The objective of this study was to determine the impact of the COVID-19 pandemic on academic productivity in oncology as measured by conference abstracts, journal publications and individual authorship trends. Using a reference time frame of 2018 to 2022, we obtained data on the number of abstracts and articles submitted and published from a selection of oncology conferences and journals. To assess individual authorship patterns, we randomly selected 200 articles from 2018 (i.e., the 'index paper') and tracked publications over subsequent years for the first or last authors. Linear time-trend analyses and independent two-sample t-tests were used to assess changes in academic productivity over time, and univariable and multivariable linear regression were used to analyze individual factors predictive of publication rates, including gender, continent, specialty, MD vs. non-MD, and career status (early if within 5 years of training completion vs. late for all others). Data on submitted and published abstracts were available from 5 and 7 conferences, respectively. Both abstract categories demonstrated decreasing values over time but not statistically significant: conference submissions decreased from 15,308 in 2018 to 13,623 in 2022, (p = 0.11), and published abstracts decreased from 13,111 to 11,848, respectively (p = 0.16). Journal submissions were available from 6 journals and increased from 14,142 in 2018 to a peak of 20,241 in 2020 (2018 vs. 2020: p<0.001), and then declined to 15,650 in 2021. Journal publications from 10 journals showed no clear trends over time (p = 0.64). For the author-level analysis, of the 200 authors randomly selected, the majority were male (66.5%), from North America (55.5%), with an MD degree (80.9%, 131/162) and late career (86.6%, 129/149). Most common specialties included surgery (29%), radiation oncology (18.5%), epidemiology/public health (11%) and medical oncology (10%). For articles authored per year, there was no linear trend detected (p = 0.51), although mean number of publications per author peaked in 2020/2021 (papers/year for 2018-2022: 18.1, 18.1, 20.1, 21.2, 19.6). On univariable analysis, factors significantly associated with increasing publication rates were male gender, last author position on index paper, late career status, MDs, speciality of surgery or public/health epidemiology, and authors from Asia (all p<0.01). On multivariable analysis, factors remaining significantly predictive were late career status, MDs, specialty of surgeons or public health/epidemiologists, and authors from Asia (all p<0.01). Conference submissions and publications trended downward from 2018 to 2022. Journal submissions peaked overall in 2020, but did not translate to increases in journal publication rates. Disparities in publication trends were found, based on speciality and geographic regions, including a negative impact on early-career researchers. [ABSTRACT FROM AUTHOR]

Patients undergoing curative (chemo)radiotherapy ((C)RT) for head and neck cancer (HNC) who experience or are at risk of developing dysphagia are often provided with pre-treatment swallow exercises (SE), in line with consensus opinion for best practice. Evidence of SE efficacy is limited, with adherence cited as a confounding factor. We evaluated SE adherence in our patient group with the aim of proposing opportunities for improvement. A 16 item questionnaire was developed with input from patients, speech and language therapists (SLTs) and oncologists, including quantitative and qualitative questions covering demographics, patient reported swallow function, understanding of and confidence with SE, frequency of completion, and resources that could improve adherence. The questionnaire was offered in paper or electronic format (Civica Software) to patients who completed (C)RT over a 3-month period. All patients had received swallow exercises as per our standard protocol with advice to complete them 7-10 times per day, supported by a written leaflet and regular SLT review during treatment. Of 39 patients who completed (C)RT, 90% (n=35) completed the questionnaire; 51% (n=18) treated with primary (C)RT and 46% (n=16) post-operative (C)RT. Swallowing difficulties were reported by 31% (n=11) pre-(C) RT, rising to 71% (n=25) at end of treatment. Almost all (94%, n=33) stated they understood the rationale for SE. Frequency of completion was variable (Table 1). Treatment toxicities were reported as barriers to adherence by 51% (n=18). Over a third of patients (37%, n=13) felt only somewhat, slightly or not at all confident they were completing SE correctly. Regarding resources that would improve adherence, a leaflet with written instructions and pictures or diagrams was selected most frequently (46%, n=16), a website/app with videos was also popular (29%, n=10). 80% (n=28) planned to continue SE after treatment. 83% (n=29) rated their overall experience of SE and advice as either good or very good. A questionnaire offers a simple way to obtain a snapshot view of current experience, and our high response rate suggests results are reliable. Our findings suggest that our current recommendation of SE completion 7-10 times per day is not achievable for most patients; a change in recommendation to 3-5 times per day is supported by recent evidence and encourages self-efficacy. At least a third of patients lacked confidence in completing SE, and we are focusing on this by developing new pictorial, online and video resources. Our survey indicated high overall satisfaction with our current service despite variable adherence. Future work will evaluate the impact of service improvements on patient outcomes. [ABSTRACT FROM AUTHOR]

In a developing country like India, large fungating breast cancers are not uncommon. This causes much deterioration in the quality of life attributed to the pain, growth of maggots, bleeding and discharge from the tumor. Surgery is often not feasible, and chemotherapy hardly brings any response in such aggressive lesions. Our initial results were presented in the last two consecutive ASTRO conferences. Our first paper showed the feasibility and safety of extreme hypo-fractionated radiotherapy (8 Gy weekly x 5 fractions) while the second one compared the toxicity and response outcomes of 40 Gy (8 Gy weekly x 5 fractions) versus 24 Gy (8 Gy x 3). This paper presents the long-term local control and survival rates between the two groups. A total of 54 patients were enrolled in the study. 24 patients received 5 fractions of weekly 8 Gy to the involved breast, while 30 patients received 3 fractions of the same dose. Early and late toxicities were assessed using RTOG toxicity criteria and Harvard 4-point cosmesis respectively. All patients were planned with tangential photon beams, ensuring that the lungs and the heart are outside our treatment field. Out of the fifty-four patients, 45 (83%) patients were upfront metastatic, while the remaining were unresectable post-neoadjuvant chemotherapy. Thirty-eight (70%) of the patients were hormone receptor-negative, 23 (42%) patients were Her 2 Neu positive which were almost equally distributed between both arms. Overall, 44 patients (81%) had extensive skin involvement including ulcerations, fungating mass, extensive peud' orange and satellite nodules. All these patients were treated with bolus over the skin. The median largest size was 8cm (3.3cm-16cm). 25 patients (46%) succumbed to their disease, within a year of treatment, as expected in such an aggressive cohort. As reported earlier, 52% of the patients had greater than grade 2 dermatitis in the 40 Gy arm versus none of the patients who had dermatitis grade 2 or above in the 24 Gy arm (p=0.051). Again, as reported earlier, the cosmesis was significantly worse in the 40 Gy arm with 25 % of patients reporting fair or poor cosmesis as compared to none in the 24 Gy arm (p=0.052). Nine (37%) progressed in the 40 Gy arm, versus 16 (53%) in the 24 Gy arm with a median progression-free survival of 11.3months versus 13.6 months, favoring the arm with 40 Gy (p=0.04). There was a trend to increased overall survival in the 40 Gy arm (25 months versus 18 months), although this was not statistically significant (p=0.5). This unique study compares two novel high doses of palliative radiotherapy for fungating, unresectable and chemo-resistant malignancies of the breast. The 24 Gy regimen can be safely used, with minimal concerns of toxicity and cosmesis. Although the toxicities and deterioration of cosmesis were higher for the 40 Gy arm, the statistically significant local disease control may warrant the use of this higher dose which may be individualized based on the size and nature of the lesion. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to determine whether prophylactic gabapentin usage in patients undergoing definitive concurrent chemotherapy and radiation therapy (chemoRT) for oropharyngeal cancer (OPC) improves treatment-related oral mucositis pain, opioid use, and feeding tube (FT) placement.Methods and Materials: This double-blind, randomized phase 3 study for patients with locally advanced OPC undergoing chemoRT randomly allocated patients to prophylactic gabapentin (600 mg thrice daily) or placebo. The primary endpoint was change in Patient-Reported Oral Mucositis Symptom (PROMS) scores over the entire treatment period (baseline to 6 weeks post-radiation therapy [RT] follow-up) with higher scores indicating worse outcomes. Opioid requirements, FT placement, and other patient-reported quality of life (QOL) metrics (Functional Assessment of Cancer Therapy-Head and Neck [FACT-HN] and Patient-Reported Outcomes version of the National Cancer Institute Common Terminology Criteria for Adverse Events [PRO-CTCAE]) were assessed. Lower scores suggested poorer QOL with the FACT-HN questionnaire, and higher scores suggested worse outcomes with the PRO-CTCAE questionnaire. Questionnaires were administered at baseline, weekly during RT, and at 6 weeks post-RT follow-up. Repeated measures analysis of variance was used to detect differences in PROMS scores and change in opioid use from baseline. Wilcoxon rank sum tests were used to compare averages for the other secondary endpoints. A P value less than .05 was considered statistically significant.Results: Treatment arms were well balanced overall, including T and N staging and dosimetric variables. There were 58 patients analyzed. No significant difference was found in PROMS scores (mean 29.1, standard deviation [SD] 22.5 vs 20.1, SD 16.8 for gabapentin vs placebo, respectively, P = .11). The FACT-HN functional well-being index had a significant decrease in scores from baseline to follow-up in the gabapentin arm (median -6, interquartile range [IQR] -10.0 to -0.5 vs -1, IQR -5.5 to 3.0, P = .03). PRO-CTCAE scores increased significantly at follow-up for gabapentin (median 6.5, IQR 3.5-11.8 vs 1, IQR -2.0 to 6.0, P = .01). There was no significant difference in average or change in opioid use. FT placement was significantly higher in the gabapentin arm (62.1% vs 20.7%, P < .01).Conclusions: This study suggests that prophylactic gabapentin is not effective in improving treatment-related oral mucositis symptoms in a select population of patients with OPC undergoing definitive chemoRT. [ABSTRACT FROM AUTHOR]

Purpose: Extramural venous invasion (EMVI) is recognized as a poor prognostic factor in rectal cancer. There are well-documented limitations associated with pathology detection of EMVI, including variable reporting and the inability to use it preoperatively to guide neoadjuvant treatment. Magnetic resonance imaging (MRI)-detected EMVI (mrEMVI) has been proposed as an imaging biomarker. This review assesses the prognostic significance of mrEMVI on survival outcomes and whether regression of mrEMVI after neoadjuvant therapy is associated with improvements in survival.Methods and Materials: An electronic search was carried out using MEDLINE and EMBASE databases using the search terms "rectum," "cancer,", "MRI," and "outcomes." A systematic review and meta-analysis were carried out in accordance with Preferred Reporting for Systematic Reviews and Meta-Analyses guidelines using Review Manager software. A qualitative review was performed.Results: A total of 7399 articles were identified, of which 33 were relevant to the review question. After a qualitative assessment, 20 articles were included in the meta-analysis. Baseline mrEMVI positivity is associated with significantly worsened overall survival (hazard ratio [HR] 1.84; 95% confidence interval [CI], 1.33-2.54; P = .0001) and significantly worsened disease-free survival (HR 2.41; 95% CI, 2.02-2.89; P < .00001). After neoadjuvant treatment, a positive mrEMVI status is associated with a significantly worsened overall and disease-free survival. Only 3 papers specifically looked at mrEMVI regression, but the results show that persistent mrEMVI-positive status after treatment is associated with significantly worsened disease-free survival compared with a change in mrEMVI from positive to negative (HR 1.93; 95% CI, 1.39-2.68; P < .0001). A subgroup analysis of MRI-detected lymph node metastases showed no significant association with survival, with a hazard ratio of 1.33 (95% CI, 0.98-1.80; P = .06).Conclusion: mrEMVI is significantly associated with worsened survival outcomes, both at baseline and after neoadjuvant treatment. Additionally, there is evidence that regression of mrEMVI after neoadjuvant treatment is associated with improved survival compared with mrEMVI persistence. The findings of this review emphasize the need for accurate and consistent reporting of mrEMVI status before and after neoadjuvant treatment and support the inclusion of mrEMVI into staging systems preferentially over lymph node metastases. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this critical review is to summarize the literature specific to single-fraction stereotactic radiosurgery (SRS) and multiple-fraction stereotactic radiation therapy (SRT) for postoperative brain metastases resection cavities and to present practice recommendations on behalf of the ISRS.Methods and Materials: The Medline and Embase databases were used to apply the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach to search for manuscripts reporting SRS/SRT outcomes for postoperative brain metastases tumor bed resection cavities with a search end date of July 20, 2018. Prospective studies, consensus guidelines, and retrospective series that included exclusively postoperative brain metastases and had at minimum 100 patients were considered eligible.Results: The Embase search revealed 157 manuscripts, of which 77 were selected for full-text screening. PubMed yielded 55 manuscripts, of which 23 were selected for full text screening. We deemed 8 retrospective series, 1 phase 2 prospective study, 3 randomized controlled trials, and 1 consensus contouring paper appropriate for inclusion. The data suggest that SRS/SRT to surgical cavities with prescription doses of 30 to 50 Gy equivalent effective dose (EQD) 210, 50 to 70 Gy EQD25, and 70 to 90 EQD22 are associated with rates of local control ranging from 60.5% to 91% (median, 80.5%). Randomized data suggest improved local control with single-fraction SRS compared with observation and improved cognitive outcomes compared with whole-brain radiation therapy (WBRT). The toxicity of SRS/SRT in the postoperative setting was limited and is reviewed herein.Conclusions: Although randomized data raise concern for poorer local control after resection cavity SRS than WBRT, these findings may be driven by factors such as conservative prescription doses used in the SRS arm. Retrospective studies suggest high rates of local control after single-fraction SRS and hypofractionated SRT for postoperative brain metastases. With a superior neurocognitive profile and no survival disadvantage to withholding WBRT, the ISRS recommends SRS as first-line treatment for eligible postoperative patients. Emerging data suggest that fractionated SRT may provide superior local control compared with single-fraction SRS, in particular, for large tumor cavity volumes/diameters and potentially for patients with a preoperative diameter greater than 2.5 cm. [ABSTRACT FROM AUTHOR]

Purpose: Our purpose was to develop a deep learning-based computed tomography (CT) perfusion mapping (DL-CTPM) method that synthesizes lung perfusion images from CT images.Methods and Materials: This paper presents a retrospective analysis of the pulmonary technetium-99m-labeled macroaggregated albumin single-photon emission CT (SPECT)/CT scans obtained from 73 patients at Queen Mary Hospital in Hong Kong in 2019. The left and right lung scans were separated to double the size of the data set to 146. A 3-dimensional attention residual neural network was constructed to extract textural features from the CT images and reconstruct corresponding functional images. Eighty-four samples were randomly selected for training and cross-validation, and the remaining 62 were used for model testing in terms of voxel-wise agreement and function-wise concordance. To assess the voxel-wise agreement, the Spearman's correlation coefficient (R) and structural similarity index measure between the images predicted by the DL-CTPM and the corresponding SPECT perfusion images were computed to assess the statistical and perceptual image similarities, respectively. To assess the function-wise concordance, the Dice similarity coefficient (DSC) was computed to determine the similarity of the low/high functional lung volumes.Results: The evaluation of the voxel-wise agreement showed a moderate-to-high voxel value correlation (0.6733 ± 0.1728) and high structural similarity (0.7635 ± 0.0697) between the SPECT and DL-CTPM predicted perfusions. The evaluation of the function-wise concordance obtained an average DSC value of 0.8183 ± 0.0752 for high-functional lungs (range, 0.5819-0.9255) and 0.6501 ± 0.1061 for low-functional lungs (range, 0.2405-0.8212). Ninety-four percent of the test cases demonstrated high concordance (DSC >0.7) between the high-functional volumes contoured from the predicted and ground-truth perfusions.Conclusions: We developed a novel DL-CTPM method for estimating perfusion-based lung functional images from the CT domain using a 3-dimensional attention residual neural network, which yielded moderate-to-high voxel-wise approximations of lung perfusion. To further contextualize these results toward future clinical application, a multi-institutional large-cohort study is warranted. [ABSTRACT FROM AUTHOR]

Radiation Oncology (RO) programs report that an applicant's research productivity during medical school is an important consideration in the residency match process, motivating medical students to seek out research opportunities. Unfortunately, many of these students lack basic research skills impairing their ability to contribute to a research project. To address this problem, we co-designed a short asynchronous virtual education in research (SAVER) program which consists of short educational video trainings. With three medical students currently involved in research, we brainstormed 29 skills required for successful research and searched YouTube to identify what existing educational videos were already freely accessible. We then evaluated each topic based on two criteria: 1) the importance of the skill in contributing to a research team and 2) how novel a new video on the topic would be if it were created. Skills that were deemed more essential to a medical student's ability to contribute to the productivity of a research team were ranked higher on a 0 to 3 scale. Topics for which there were few high-quality YouTube videos were ranked higher on a 0 to 2 scale. The scores were then summed, and the video topics were ranked by their score. This process identified the following ten topics for SAVER videos: time management, IRB proposals, authorship rules, biostatistics, performing a literature search, using citation software, performing chart review in an EMR, creating a research survey, submitting a paper to a journal, submitting an abstract to a conference. Our next steps are to begin creating these videos. We will evaluate their quality through pre- and post-training surveys completed by the students and assessments of research skills completed by their research mentors. We anticipate an improvement in the competency and productivity of medical student researchers as measured by survey data completed by them and their faculty mentors as well as more publications and abstracts. This work highlights the importance of co-designing a medical student research training program in improving the productivity and competency of medical student researchers. It also identifies and fills existing research education gaps by drawing on the experience of medical student researchers to curate a tailored curriculum that can efficiently prepare them for residency. Finally, it provides faculty research mentors with a resource to which they can direct prospective mentees and trust that they will be prepared to contribute upon completion. [ABSTRACT FROM AUTHOR]

Neuroendocrine neoplasms (NEN) are a diverse group of rare tumors. The most common primary sites are gastrointestinal tract and lung, though these neoplasms can occur throughout the body. Neuroendocrine neoplasms of the head and neck are rare, with those of the oropharynx being especially uncommon. Case studies and small series make up most of the literature on oropharyngeal neuroendocrine tumors, and there is no clear consensus on how to treat these unique cancers. Therefore, we aim to explore the current literature describing neuroendocrine neoplasms of the oropharynx. A comprehensive search of several databases including Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Web of Science, and Scopus from inception to May 19, 2021 was conducted. Inclusion criteria included diagnosis of neuroendocrine neoplasm of the tonsil, base of tongue, soft palate, or posterior pharyngeal wall with histopathology available for review. Cases with distant metastatic disease at presentation, review papers, large database studies, papers not in English, papers without outcomes of interest reported, and conference abstracts were excluded. Information including patient demographics, symptoms at presentation, radiologic findings, diagnostic approach, treatment approach, and outcomes were recorded. The search resulted in 1,154 papers. After title and abstract screening, 93 papers qualified for full review, with 28 were included ultimately in our review. In these papers, 52 unique cases were identified. The average age at presentation was 62 years. Of the patients identified, 73% were male (n=38), 25% were female (n=13), and 2%were unspecified (n=1). The most common site was the tonsil at 36% (n= 21). This was followed by 35% in the tongue base (n=18), 17% in the oropharynx (unspecified) (n=10), 2% in the soft palate (n=1), and 3% unknown primary sites (n=2). The most common histology was small cell neuroendocrine carcinoma at 45% (n= 26). HPV status was reported in 24 patients, with 75% being HPV positive (n=18) and 25% HPV negative (n=6). Treatment modalities varied, with definitive therapy being the most common, in 19 cases. Neuroendocrine neoplasms of the head and neck are a rare subtype of oropharyngeal cancer, and there is limited data available to drive treatment. More work is needed to elucidate guidelines for how to treat these rare tumors. [ABSTRACT FROM AUTHOR]

Purpose: Reirradiation for locally recurrent nasopharyngeal carcinoma (NPC) is challenging because prior radiation dose delivered in the first course is often close to the tolerance limit of surrounding normal structures. A delicate balance between achieving local salvage and minimizing treatment toxicities is needed. However, high-level evidence is lacking because available reports are mostly retrospective studies on small series of patients. Pragmatic consensus guidelines, based on an extensive literature search and the pooling of opinions by leading specialists, will provide a useful reference to assist decision-making for these difficult decisions.Methods and Materials: A thorough review of available literature on recurrent NPC was conducted. A set of questions and preliminary draft guideline was circulated to a panel of international specialists with extensive experience in this field for voting on controversial areas and comments. A refined second proposal, based on a summary of the initial voting and different opinions expressed, was recirculated to the whole panel for review and reconsideration. The current guideline was based on majority voting after repeated iteration for final agreement.Results: The initial round of questions showed variations in clinical practice even among the specialists, reflecting the lack of high-quality supporting data and the difficulties in formulating clinical decisions. Through exchange of comments and iterative revisions, recommendations with high-to-moderate agreement were formulated on general treatment strategies and details of reirradiation (including patient selection, targets contouring, dose prescription, and constraints).Conclusion: This paper provides useful reference on radical salvage treatment strategies for recurrent NPC and optimization of reirradiation through review of published evidence and consensus building. However, the final decision by the attending clinician must include full consideration of an individual patient's condition, understanding of the delicate balance between risk and benefits, and acceptance of risk of complications. [ABSTRACT FROM AUTHOR]

Purpose: Dose-volume data for injury to carotid artery and other major vessels in stereotactic body radiation therapy (SBRT)/SABR head and neck reirradiation were reviewed, modeled, and summarized.Methods and Materials: A PubMed search of the English-language literature (stereotactic and carotid and radiation) in April 2018 found 238 major vessel maximum point doses in 6 articles that were pooled for logistic modeling. Two subsequent studies with dose-volume major vessel data were modeled separately for comparison. Attempts were made to separate carotid blowout syndrome from other bleeding events (BE) in the analysis, but we acknowledge that all except 1 data set has some element of BE interspersed.Results: Prior radiation therapy (RT) dose was not uniformly reported per patient in the studies included, but a course on the order of conventionally fractionated 70 Gy was considered for the purposes of the analysis (with an approximately ≥6-month estimated interval between prior and subsequent treatment in most cases). Factors likely associated with reduced risk of BE include nonconsecutive daily treatment, lower extent of circumferential tumor involvement around the vessel, and no surgical manipulation before or after SBRT.Conclusions: Initial data pooling for reirradiation involving the carotid artery resulted in 3 preliminary models compared in this Hypofractionated Treatment Effects in the Clinic (HyTEC) report. More recent experiences with alternating fractionation schedules and additional risk-reduction strategies are also presented. Complications data for the most critical structures such as spinal cord and carotid artery are so limited that they cannot be viewed as strong conclusions of probability of risk, but rather, as a general guideline for consideration. There is a great need for better reporting standards as noted in the High Dose per Fraction, Hypofractionated Treatment Effects in the Clinic introductory paper. [ABSTRACT FROM AUTHOR]

Purpose: To research the fiducial-based, real-time tracking intrafraction (during the fraction [intra-]) and interfraction (between fractions [inter-]) tumor respiration amplitude, motion trajectory, and prediction error and quantify their relationships for different types of motion trajectories during Cyberknife-based stereotactic ablation radiotherapy.Methods and Materials: Twelve patients with liver tumors were treated using a Cyberknife system, and 58 fractions were involved in this study. Real-time target motion tracking data were extracted and transformed from the robot coordinate system into the patient coordinate system by the rotation matrix. Only the time sessions of the beam on were studied according to the data information generated from the Cyberknife motion tracking system. The motion correlation model between the external marker signal and internal fiducial position was built to present the type of motion trajectory.Results: Using the correlation model as a function of external marker signal and internal fiducial position, we knew 4 motion trajectories mainly existed for liver cancer patients as follows: perfect linearity (group I), simple linearity (group II), hysteresis (group III), and area respiratory (group IV) patterns. More than half of the patients had a linear breathing trajectory. Analyzing all patients together, the intra-amplitudes were slightly less than those of the inter-amplitudes. The amplitude from large to small was in the superior-inferior, left-right and anterior-posterior directions, regardless of inter- and intra-amplitudes. Then, patients with a larger peak-to-peak have a larger standard deviation of amplitude and a larger amplitude in all fractions/sessions. The prediction errors of the linear motion trajectory were generally less than 1 mm. The prediction errors of the regular hysteresis breathing model were smaller than those of the irregular hysteresis model. Scattered breathing would result in a larger tracking error, such as the area respiratory trajectory. It was logical that prediction errors were larger for patients who showed much variation in their breathing amplitude.Conclusions: This paper showed that the liver motion trajectory model included perfect linearity, sample linearity, hysteresis, and area. The linear motion trajectory presented the minimum tracking error and the best stability, and the hysteresis and area trajectory were the worst. Therefore, breathing management, including respiration training, control, and evaluation of motion trajectory in all directions, was significantly necessary during liver SABR treatment. [ABSTRACT FROM AUTHOR]

Purpose: Radiation therapy (RT) after breast-conserving surgery reduces locoregional recurrences and improves survival but may cause late side effects. The main purpose of this paper was to investigate long-term side effects after whole breast RT in a randomized clinical trial initiated in 1991 and to report dose-volume data based on individual 3-dimensional treatment plans for organs at risk.Methods and Materials: The trial included 1187 patients with T1-2 N0 breast cancer randomized to postoperative tangential whole breast RT or no further treatment. The prescription dose to the clinical target volume was 48 to 54 Gy. We present 20-year follow-up on survival, cause of death, morbidity, and later malignancies. For a cohort of patients (n = 157) with accessible computed tomography-based 3-dimensional treatment plans in Dicom-RT format, dose-volume descriptors for organs at risk were derived. In addition, these were compared with dose-volume data for a cohort of patients treated with contemporary RT techniques.Results: The cumulative incidence of cardiac mortality was 12.4% in the control group and 13.0% in the RT group (P = .8). There was an increase in stroke mortality: 3.4% in the control group versus 6.7% in the RT group (P = .018). Incidences of contralateral breast cancer and lung cancer were similar between groups. The median Dmean (range) heart dose for left-sided treatments was 3.0 Gy (1.1-8.1), and the corresponding value for patients treated in 2017 was 1.5 Gy (0.4-6.0).Conclusions: In this trial, serious late side effects of whole breast RT were limited and less than previously reported in large meta-analyses. We observed no increase in cardiac mortality in irradiated patients. Doses to the heart were a median Dmean of 3.0 Gy for left-sided RT. The observed increase in stroke mortality may partly be secondary to cardiac side effects, complications to anticoagulant treatment, or to chance, rather than a direct side effect of tangential whole breast irradiation. [ABSTRACT FROM AUTHOR]

Purpose: Current incidence methods for reporting mild or moderate symptoms capture the (first) occurrence of an event and do not allow distinguishing between patients who suffer from long-lasting versus transient morbidity. This paper introduces a new methodological approach that identifies cancer survivors who have clinically relevant, long-lasting symptoms (patients with late, persistent, substantial and treatment-related symptoms, [LAPERS]).Methods and Materials: LAPERS can be evaluated in patients with baseline information and at least 3 late follow-up assessments after treatment. LAPERS identifies individual patients with a given symptom that is substantial (above a predefined clinically relevant threshold) and must be present in at least half of the follow-ups. Baseline morbidity is accounted for by requiring the median of the late symptom score to be worse than the baseline condition. The LAPERS approach was applied to 4 relevant patient-reported genito-urinary/gastrointestinal symptoms within the prospective, longitudinal EMBRACE study (An intErnational study on MRI-guided BRachytherapy in locally Advanced CErvical cancer, www.embracestudy.dk). LAPERS was compared with crude incidence and prevalence rates.Results: Within the EMBRACE cohort, 651/1044 patients (62%) had baseline and long-term follow-up available (median follow-up: 42 months). There was a considerable gap between LAPERS, crude incidence, and prevalence rates. The proportion of patients with LAPERS events was 3.8-4.8 times lower than crude incidences. The highest prevalence rates across follow-up times were 1.8-2.6 times lower than crude incidences.Conclusions: These findings indicate limitations of incidence methods for reporting substantial patient-reported symptoms because a considerable proportion of patients with symptoms do not experience them persistently over time, as they may fluctuate or get successfully treated. In contrast, the LAPERS method for longitudinal analysis identifies patients with clinically relevant, long-lasting symptoms. [ABSTRACT FROM AUTHOR]