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ObjectiveThe current study examined whether compliance with anti-pandemic measures during the COVID-19 pandemic relates to (a) importance of the fulfillment of core psychological needs, namely, relationship, self-esteem, efficacy, and pleasure; (b) coping behavior styles, namely, surrender, self-soothing, divert attention, and confrontation; and (c) worries or concerns beyond COVID-19 which may impair wellbeing.MethodsThis study used a cross-sectional design and online survey data from responses to a structured questionnaire developed within the theoretical framework of schema-based psychotherapy on psychological needs and coping behavior styles from 740 participants in Central Europe and West Africa.ResultsAnalysis indicated that people with the psychological needs of “pleasure” and “efficacy” and the coping style of “surrender” were more likely to comply with anti-pandemic measures. We also found that people with the coping style of “confrontation” were less likely to comply. There were no statistically significant relationships between compliance and “relationship,” “self-esteem,” “self-soothing,” “divert attention,” and “existential concerns.”DiscussionOur findings indicate that how likely a given individual is to comply with prescribed pandemic countermeasures varies based on their specific psychological needs and behavior styles. Therefore, to control contagion during a pandemic, authorities must recognize the relevance of human need fulfillment and their behavior styles and accordingly highlight and encourage admissible and feasible actions. The findings demonstrate that some individual differences in core psychological needs and coping behavior patterns predict compliance behavior.

Purpose: To investigate dose differences between the planning CT (pCT) and dose calculated on pre-treatment verification CBCTs using DIR and dose summation for cervical cancer patients., Methods: Cervical cancer patients treated at our institution with 45 Gy EBRT undergo a pCT and 5 CBCTs, once every five fractions of treatment. A free-form intensity-based DIR in MIM was performed between the pCT and each CBCT using the "Merged CBCT" feature to generate an extended FOV-CBCT (mCBCT). DIR-generated bladder and rectum contours were adjusted by a physician, and dice similarity coefficients (DSC) were calculated. After deformation, the investigated doses were (1) recalculated in Eclipse using original plan parameters (ecD), and (2) deformed from planning dose (pD) using the deformation matrix in MIM (mdD). Dose summation was performed to the first week's mCBCT. Dose distributions were compared for the bladder, rectum, and PTV in terms of percent dose difference, dose volume histograms (DVHs), and gamma analysis between the calculated doses., Results: For the 20 patients, the mean DSC was 0.68 ± 0.17 for bladder and 0.79 ± 0.09 for rectum. Most patients were within 5% of pD for D2cc (19/20), Dmax (17/20), and Dmean (16/20). All patients demonstrated a percent difference > 5% for bladder V45 due to variations in bladder volume from the pCT. D90 showed fewer differences with 19/20 patients within 2% of pD. Gamma rates between pD and ecD averaged 94% for bladder and 94% for rectum, while pD and mdD exhibited slightly better performance for bladder (93%) and lower for rectum (85%)., Conclusion: Using DIR with weekly CBCT images, the MIM deformed dose (mdD) was found to be in close agreement with the Eclipse calculated dose (ecD). The proposed workflow should be used on a case-by-case basis when the weekly CBCT shows marked difference in organs-at-risk from the planning CT., (© 2024 The Author(s). Journal of Applied Clinical Medical Physics published by Wiley Periodicals, LLC on behalf of The American Association of Physicists in Medicine.)

Purpose: Patients with conjunctival squamous cell carcinoma that present with persisting disease or recurrence following topical chemotherapy and/or surgery especially when invading the sclera are challenging to treat. Herein, we describe the use of high-dose-rate (HDR), FDA-cleared, yttrium-90 ( 90 Y) plaque brachytherapy for such lesions., Observation: Three cases of invasive conjunctival squamous cell carcinoma that had exhibited a poor response or recurrence following topical chemotherapy and/or surgery are described. As treatment, HDR 90 Y beta-radiation was applied to the tumor and margins for a single, continuous duration. In contrast to low-dose-rate (LDR) plaque, HDR 90 Y brachytherapy did not require episcleral sutures, amniotic membrane buffering of the cornea, a Gunderson flap, outpatient dwell time, or second surgery. Radiation safety was improved by eliminating LDR-implant related post-operative radiation exposure to health care personnel, the community, family, and pets. Follow-up examination at one month revealed complete tumor resolution in all patients. At last follow-up (8, 11 and 18 months) all patients remained clinically tumor-free as confirmed by slit-lamp biomicroscopy, anterior segment optical coherence tomography, and high-frequency ultrasound imaging. There were no acute complications (e.g., corneal edema, iridocyclitis, scleropathy, keratopathy or cataract)., Conclusion and Importance: 90 Y brachytherapy demonstrated efficacy as a single-surgery, minimally invasive, outpatient irradiation for squamous carcinoma of the ocular surface. While short-term results were promising, long-term follow-up monitoring for side-effects and recurrence are essential., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier Inc.)

Purpose: The aim of this work was to report the effect of mismatch repair (MMR) status on outcomes of patients with stage I-II endometrioid endometrial adenocarcinoma (EEC) who receive adjuvant radiation therapy., Methods and Materials: This is a multi-institutional retrospective cohort study across 11 institutions in North America. Patients with known MMR status and stage I-II EEC status postsurgical staging were included. Overall survival (OS) and recurrence-free survival (RFS) rates were estimated via the Kaplan-Meier method. Univariable and multivariable analyses were performed via Cox proportional hazard models for RFS and OS. Statistical analyses were conducted using SPSS version 27., Results: In total, 744 patients with a median age at diagnosis of 65 years (IQR, 58-71) were included. Most patients were White (69.4%) and had Federation of Obstetrics and Gynecology 2009 stage I (84%) and Federation of Obstetrics and Gynecology grade 1 to 2 (73%). MMR deficiency was reported in 234 patients (31.5%), whereas 510 patients (68.5%) had preserved MMR. External beam radiation therapy with or without vaginal brachytherapy was delivered to 186 patients (25%), whereas 558 patients (75%) received vaginal brachytherapy alone. At a median follow-up of 43.5 months, the estimated crude OS and RFS rates for the entire cohort were 92.5% and 84%, respectively. MMR status was significantly correlated with RFS. RFS was inferior for MMR deficiency compared with preserved MMR (74.3% vs 88.6%, P < .001). However, no difference in OS was seen (90.8% vs 93.2%, P = .5). On multivariable analysis, MMR deficiency status was associated with worse RFS (hazard ratio, 1.86; P = .001) but not OS., Conclusions: MMR status was independently associated with RFS but not OS in patients with early-stage EEC who were treated with adjuvant radiation therapy. These findings suggest that differential approaches to surveillance and/or treatment based on MMR status could be warranted., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Studies support the existence of psychosomatic phenomena that enable critically ill patients to postpone death until a specific event. We assessed for this effect in cancer by examining variability in deaths at the month and weekend levels using the National Center for Health Statistics database. We found that deaths from cancer were not uniformly distributed temporally. There was a relative 3.3% difference death rate between the peak on Saturday and nadir on Monday, and relative 10.2% difference in rate of death between the peak of deaths in January and nadir in February. The "weekend effect" could be present in 1 in 200 cancer deaths and the "holiday effect" in 1 in 100 cancer deaths. Temporal variation may reflect a small portion of patients are able to "hold on" for a limited amount of time. This uneven distribution of cancer deaths highlights the importance of improving communication and facilitating end-of-life discussions.

Background: The health-care industry is a substantial contributor to global greenhouse gas emissions, yet the specific environmental impact of radiotherapy, a cornerstone of cancer treatment, remains under-explored. We aimed to quantify the emissions associated with the delivery of radiotherapy in the USA and propose a framework for reducing the environmental impact of oncology care., Methods: In this multi-institutional retrospective analysis and simulation study, we conducted a lifecycle assessment of external beam radiotherapy (EBRT) for ten anatomical disease sites, adhering to the International Organization for Standardization's standards ISO 14040 and ISO 14044. We analysed retrospective data from Jan 1, 2017, to Oct 1, 2023, encompassing patient and staff travel, medical supplies, and equipment and building energy use associated with the use of EBRT at four academic institutions in the USA. The primary objective was to measure the environmental impacts across ten categories: greenhouse gases (expressed as kg of carbon dioxide equivalents [CO 2 e]), ozone depletion, smog formation, acidification, eutrophication, carcinogenic and non-carcinogenic potential, respiratory effects, fossil fuel depletion, and ecotoxicity. Human health effects secondary to these environmental impacts were also estimated as disability-adjusted life years. We also assessed the potential benefits of hypofractionated regimens for breast and genitourinary (ie, prostate and bladder) cancers on US greenhouse gas emissions using an analytic model based on the 2014 US National Cancer Database for fractionation patterns and patient commute distances., Findings: We estimated that the mean greenhouse gas emissions associated with a standard 25-fraction EBRT course were 4310 kg CO 2 e (SD 2910), which corresponded to 0·0035 disability-adjusted life years per treatment course. Transit and building energy usage accounted for 25·73% (1110 kg CO 2 e) and 73·95% of (3190 kg CO 2 e) of total greenhouse gas emissions, respectively, whereas supplies contributed only 0·32% (14 kg CO 2 e). Across the other environmental impact categories, most of the environmental impact also stemmed from patient transit and energy use within facilities, with little environmental impact contributed by supplies used. Hypofractionated treatment simulations suggested a substantial reduction in greenhouse gas emissions-by up to 42% for breast and 77% for genitourinary cancer-and environmental impacts more broadly., Interpretation: This comprehensive lifecycle assessment of EBRT delineates the environmental and secondary health impacts of radiotherapy, and underscores the urgent need for sustainable practices in oncology. The findings serve as a reference for future decarbonisation efforts in cancer care and show the potential environmental benefits of modifying treatment protocols (when clinical equipoise exists). They also highlight strategic opportunities to mitigate the ecological footprint in an era of escalating climate change and increasing cancer prevalence., Funding: Mount Zion Health Fund., Competing Interests: Declaration of interests CLT has received honoraria from Clinically Sustainable Consulting and financial support from Vizient, and has held leadership roles with the New York University Stern School of Business Center for Sustainable Business, the Centre for Sustainable Healthcare, EyeSustain, and Mass General Center for Climate and Health. JC has been a paid consultant for Stryker and Guidepoint, has received honoraria from Gynecologic Oncology Group Foundation, has received compensation in exchange for services and expertise from KM Pharmaceutical Consulting and Merck, and is member of the American Brachytherapy Society. SSY has received research support grants from EMD Serono and Bristol-Myers Squibb, royalties from UpToDate and Springer, and honoraria from the American Society of Radiation Oncology and Elsevier. All other authors declare no competing interest., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Vulvar cancer is annually diagnosed in an estimated 6,470 individuals and the vast majority are histologically squamous cell carcinomas. Vulvar cancer accounts for 5% to 8% of gynecologic malignancies. Known risk factors for vulvar cancer include increasing age, infection with human papillomavirus, cigarette smoking, inflammatory conditions affecting the vulva, and immunodeficiency. Most vulvar neoplasias are diagnosed at early stages. Rarer histologies exist and include melanoma, extramammary Paget's disease, Bartholin gland adenocarcinoma, verrucous carcinoma, basal cell carcinoma, and sarcoma. This manuscript discusses recommendations outlined in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for treatments, surveillance, systemic therapy options, and gynecologic survivorship.

The NCCN Guidelines for Cervical Cancer provide recommendations for all aspects of management for cervical cancer, including the diagnostic workup, staging, pathology, and treatment. The guidelines also include details on histopathologic classification of cervical cancer regarding diagnostic features, molecular profiles, and clinical outcomes. The treatment landscape of advanced cervical cancer is evolving constantly. These NCCN Guidelines Insights provide a summary of recent updates regarding the systemic therapy recommendations for recurrent or metastatic disease.

Purpose: The global cervical cancer burden is disproportionately high in low- and middle-income countries (LMICs), and outcomes can be governed by the accessibility of appropriate screening and treatment. High-dose-rate (HDR) brachytherapy plays a central role in cervical cancer treatment, improving local control and overall survival. The American Brachytherapy Society (ABS) and Indian Brachytherapy Society (IBS) collaborated to provide this succinct consensus statement guiding the establishment of brachytherapy programs for gynecological malignancies in resource-limited settings., Methods and Materials: ABS and IBS members with expertise in brachytherapy formulated this consensus statement based on their collective clinical experience in LMICs with varying levels of resources., Results: The ABS and IBS strongly encourage the establishment of HDR brachytherapy programs for the treatment of gynecological malignancies. With the consideration of resource variability in LMICs, we present 15 minimum component requirements for the establishment of such programs. Guidance on these components, including discussion of what is considered to be essential and what is considered to be optimal, is provided., Conclusions: This ABS/IBS consensus statement can guide the successful and safe establishment of HDR brachytherapy programs for gynecological malignancies in LMICs with varying levels of resources., (Copyright © 2023 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To design, manufacture, and validate a female pelvic phantom for multi-modality imaging (CT, MRI, US) to benchmark a commercial needle tracking system with application in HDR gynecological (GYN) interstitial procedures., Materials and Methods: A GYN needle-tracking phantom was designed using CAD software to model an average uterus from a previous patient study, a vaginal canal from speculum dimensions, and a rectum to accommodate a transrectal ultrasound (TRUS) probe. A target volume (CTV HR ) was designed as an extension from the cervix-uterus complex. Negative space molds were created from modeled anatomy and 3D printed. Silicone was used to cast the anatomy molds. A 3D printed box was constructed to house the manufactured anatomy for structural integrity and to accommodate the insertion of a speculum, tandem, needles, and TRUS probe. The phantom was CT-imaged to identify potential imperfections that might impact US visualization. Free-hand TRUS was used to guide interstitial needles into the phantom. The commercial tracking system was used to generate a 3D US volume. After insertion, the phantom was imaged with CT and MR and the uterus and CTV HR dimensions were verified against the CAD model., Results/conclusions: The manufactured phantom allows for accurate visualization with multiple imaging modalities and is conducive to applicator and needle insertion. The phantom dimensions from the CAD model were verified with those from each imaging modality. The phantom is low cost and can be reproducibly manufactured with the 3D printing and molding processes. Our initial experiments demonstrate the ability to integrate the phantom with a commercial tracking system for future needle tracking validation studies., (© 2023 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, LLC on behalf of The American Association of Physicists in Medicine.)

Purpose: In this prospective trial, we aim to determine whether fluorodeoxyglucose positron emission tomography and computed tomography (PET/CT)-based adaptive radiation therapy (ART) improves dosimetry outcomes for patients treated with definitive radiation for locally advanced vulvar cancer., Methods and Materials: Patients were enrolled in 2 sequential institutional review board-approved prospective protocols for PET/CT ART from 2012 to 2020. Patients were planned with pretreatment PET/CT to 45 to 56 Gy in 1.8 Gy/fraction, followed by a boost to gross disease (nodal and/or primary) to a total of 64 to 66 Gy. Intratreatment PET/CT was obtained at 30 to 36 Gy, and all patients were replanned to the same dose goals with revised organ at risk (OAR), gross tumor volume, and planned target volume contours. Radiation therapy consisted of either intensity modulated radiation therapy or volumetric modulated arc therapy. Toxicity was graded by Common Terminology Criteria for Adverse Events, version 5.0. Local control, disease-free survival, overall survival, and time to toxicity were estimated using the Kaplan-Meier method. Dosimetry metrics for OARs were compared using the Wilcoxon signed rank test., Results: Twenty patients were eligible for analysis. Median follow-up among surviving patients was 5.5 years. Local control, disease-free survival, and overall survival at 2 years were 63%, 43%, and 68%, respectively. ART significantly reduced the following OAR doses: bladder, maximum dose (D max ; median reduction [MR], 1.1 Gy; interquartile range [IQR], 0.48-2.3 Gy; P < .001) and D 2cc (MR, 1.5 Gy; IQR, 0.51-2.1 Gy; P < .001); bowel, D max (MR, 1.0 Gy; IQR, 0.11-2.9 Gy; P < .001), D 2cc (MR, 0.39 Gy; IQR, 0.023-1.7 Gy; P < .001), and D 15cc (MR, 0.19 Gy; IQR, 0.026-0.47 Gy; P  = .002); and rectal, mean dose (MR, 0.66 Gy; IQR, 0.17-1.7 Gy; P  = .006) and D 2cc (MR, 0.46 Gy; IQR, 0.17-0.80 Gy; P  = .006). No patients experienced any grade ≥3 acute toxicities. There were no reported late grade ≥2 vaginal toxicities. Lymphedema at 2 years was 17% (95% confidence interval, 0%-34%)., Conclusions: Doses to bladder, bowel, and rectum were significantly improved with ART, though the median magnitudes were modest. Which patients benefit most from adaptive treatment is a matter for future investigation., (© 2023 The Author(s).)

Objective: To report the impact of race on clinical outcomes in patients with stage IIIC endometrial carcinoma., Materials and Methods: A retrospective multi-institutional study included 90 black and 568 non-black patients with stage IIIC endometrial carcinoma who received adjuvant chemotherapy and radiation treatments. Overall survival (OS) and recurrence-free survival (RFS) were calculated by the Kaplan-Meier method. Propensity score matching (PSM) was conducted. Statistical analyses were conducted using SPSS version 27., Results: The Median follow-up was 45.3 months. black patients were significantly older, had more nonendometrioid histology, grade 3 tumors, and were more likely to have >1 positive paraaortic lymph nodes compared with non-black patients (all P <0.0001). The 5-year estimated OS and RFS rates were 45% and 47% compared with 77% and 68% for black patients versus non-black patients, respectively ( P <0.001). After PSM, the 2 groups were well-balanced for all prognostic covariates. The estimated hazard ratios of black versus non-black patients were 1.613 ( P value=0.045) for OS and 1.487 ( P value=0.116) for RFS. After PSM, black patients were more likely to receive the "Sandwich" approach and concurrent chemoradiotherapy compared with non-black ( P =0.013) patients., Conclusions: Black patients have higher rates of nonendometrioid histology, grade 3 tumors, and number of involved paraaortic lymph nodes, worse OS, and RFS, and were more likely to receive the "Sandwich" approach compared with non-black patients. After PSM, black patients had worse OS with a nonsignificant trend in RFS. Access to care, equitable inclusion on randomized trials, and identification of genomic differences are warranted to help mitigate disparities., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Müllerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers. This selection from the NCCN Guidelines for Uterine Neoplasms focuses on the diagnosis, staging, and management of pure endometrioid carcinoma. The complete version of the NCCN Guidelines for Uterine Neoplasms is available online at NCCN.org.

Purpose: Climate change is one of the direst health threats that humanity faces. We aim to estimate the carbon dioxide (CO 2 ) emissions associated with the energy usage from linear accelerator (LINAC)-based external beam radiation therapy (EBRT) for the most common cancer diagnoses., Methods and Materials: We identified patients with the 4 most common cancer types treated with curative-intent EBRT. Beam-on time for each fraction was extracted from the treatment planning system and averaged over each site and treatment modality. The power was multiplied by the beam-on time in hours to yield kilowatt hours (kWh). Using the US Environmental Protection Agency Greenhouse Gas Equivalencies calculator, we converted the kWh into estimates of CO 2 -equivalent emissions for the average US power grid. Idle time of the LINAC was estimated via Varian Medical Systems., Results: A total of 10 patients were included for each of the following modalities: conventionally fractionated for prostate cancer (28 fractions [fx]), prostate stereotactic body radiation therapy (SBRT) (5 fx), 15- and 5-fx regimens for early-stage breast cancer, 3- and 5-fx SBRT regimens for early-stage lung cancer, conventional EBRT (30 fx) for locally advanced lung cancer, and short- (5 fx) and long-course (25-28 fx) for rectal cancer. The modality with the lowest and highest carbon emissions per course, on average, was prostate SBRT (2.18 kg CO 2 ; interquartile range, 1.92-2.30) and conventional treatment for prostate cancer (17.34 kg CO 2 ; interquartile range, 10.26-23.79), respectively. This corresponds to CO 2 -equivalent emissions of driving an average of 5.4 miles and 41.2 miles in a standard vehicle, respectively. "Standby" mode for a LINAC TrueBeam and Clinac IX uses 112 kWh and 64.8 kWh per day, respectively., Conclusions: We have estimated CO 2 emissions arising from direct energy usage of a LINAC for 4 common cancers treated with EBRT. "Standby" mode of a LINAC uses the most energy per day. Comprehensive studies are warranted to minimize the environmental effects of health and cancer care., (© 2023 The Authors.)

Purpose: Patients with primary or metastatic brain tumors often require intensive end-of-life care, for which place of death may serve as a quality metric. Death at home or hospice is considered a more "ideal" location. Comprehensive information on place of death of people with brain tumors is lacking., Methods: Using CDC Wonder Database data, those who died in the USA from a solid cancer from 2003 to 2016 were included and place of death for those with primary brain, brain metastases, and solid non-brain tumors were compared. Multivariate logistic regression tested for disparities in place of death., Results: By 2016, 51.1% of patients with primary brain tumors and 45.2% with brain metastases died at home. 15.9% of patients with primary brain tumors and 23.6% with brain metastases died in the hospital. Black patients were least likely to die at home or hospice. For patients with primary brain tumors, being married (OR = 2.25 (95%CI 2.16-2.34), p < 0.01) and having an advanced degree (OR = 1.204 (95%CI 1.15-1.26), p < 0.01) increased odds of home/hospice death; older age (OR = 0.50 (95%CI 0.46-0.54), p < 0.01) decreased odds for home/hospice death. For patients with brain metastases, being married (OR = 2.19 (95%CI 2.11-2.26), p < 0.01) increased odds of home/hospice death and male sex (OR = 0.87 (095%CI .85-0.89), p < 0.01) and older age (OR = 0.59 (95%CI 0.47-0.75), p < 0.01) decreased odds of home/hospice death., Conclusion: Disparities exist in place of death in the brain tumor population. Focused interventions are indicated to increase the utilization of hospice in those with metastatic cancer, under-represented minority groups, and the elderly population., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Brachytherapy is an essential component of the cervical cancer treatment paradigm as it contributes to improved clinical outcomes and overall survival. Yet brachytherapy remains globally underutilized, with disparities in access at both national and international levels., Areas Covered: The review explores current brachytherapy utilization practices and efforts being undertaken to address barriers to implementation in low-, middle-, and high-income countries, and how these efforts are projected to impact future brachytherapy access. The content presented is based on a review of published literature and the authors' collective clinical experiences., Expert Opinion: There exists a tremendous opportunity to expand access to essential brachytherapy services for women with cervical cancer. Many national and international brachytherapy efforts exist; yet it remains imperative that such focused efforts continue to grow and provide further access to this critical treatment modality for women in need worldwide.

Stereotactic body radiotherapy (SBRT, also referred to as stereotactic ablative radiotherapy (SABR)) has been used in the treatment of primary and metastatic solid tumors, and increasingly so in gynecologic oncology. This review article aims to summarize the current literature describing the utility of SBRT in the primary, recurrent, and limited metastatic settings for gynecologic malignancies. The use of SBRT in both retrospective and prospective reports has been associated with adequate control of the treated site, particularly in the setting of oligometastatic disease. It is not, however, recommended as an alternative to brachytherapy for intact disease unless all efforts to use brachytherapy are exhausted. While phase I and II trials have established the relative safety and potential toxicities of SBRT, there remains a dearth of phase III randomized evidence, including the use of immunotherapy, in order to better establish the role of this technique as a method of improving more global outcomes for our patients with gynecologic cancers., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To evaluate the impact of prophylactic paraortic lymph node (PALN) radiation therapy (RT) on clinical outcomes in patients with International Federation of Obstetrics and Gynecology 2018 stage IIIC1 endometrial cancer (EC)., Methods and Materials: A multi-institutional retrospective study included patients with International Federation of Obstetrics and Gynecology 2018 stage IIIC1 EC lymph node assessment, status postsurgical staging, followed by adjuvant chemotherapy and RT using various sequencing regimens. Overall survival (OS) and recurrence-free survival (RFS) rates were estimated by the Kaplan-Meier method. Univariable and multivariable analysis were performed by Cox proportional hazard models for RFS/OS. In addition, propensity score matching was used to estimate the effect of the radiation field extent on survival outcomes., Results: A total of 378 patients were included, with a median follow-up of 45.8 months. Pelvic RT was delivered to 286 patients, and 92 patients received pelvic and PALN RT. The estimated OS and RFS rates at 5 years for the entire cohort were 80% and 69%, respectively. There was no difference in the 5-year OS (77% vs 87%, P = .47) and RFS rates (67% vs 70%, P = .78) between patients treated with pelvic RT and those treated with pelvic and prophylactic PALN RT, respectively. After propensity score matching, the estimated hazard ratios (HRs) of prophylactic PALN RT versus pelvic RT were 1.50 (95% confidence interval, 0.71-3.19; P = .28) for OS and 1.24 (95% confidence interval, 0.64-2.42; P = .51) for RFS, suggesting that prophylactic PALN RT does not improve survival outcomes. Distant recurrence was the most common site of first recurrence, and the extent of RT field was not associated with the site of first recurrence (P = .79)., Conclusions: Prophylactic PALN RT was not significantly associated with improved survival outcomes in stage IIIC1 EC. Distant metastasis remains the most common site of failure despite routine use of systemic chemotherapy. New therapeutic approaches are necessary to optimize the outcomes for women with stage IIIC1 EC., (Copyright © 2021 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

The NCCN Guidelines for Uterine Neoplasms provide recommendations for diagnostic workup, clinical staging, and treatment options for patients with endometrial cancer or uterine sarcoma. These NCCN Guidelines Insights focus on the recent addition of molecular profiling information to aid in accurate diagnosis, classification, and treatment of uterine sarcomas.

Purpose: Our purpose was to evaluate the effect of sequence and type of adjuvant therapy for patients with stage IIIC endometrial carcinoma (EC) on outcomes., Methods and Materials: In a multi-institutional retrospective cohort study, patients with stage IIIC EC who had surgical staging and received both adjuvant chemotherapy and radiation therapy (RT) were included. Adjuvant treatment regimens were classified as adjuvant chemotherapy followed by sequential RT (upfront chemo), which was predominant sequence; RT with concurrent chemotherapy followed by chemotherapy (concurrent); systemic chemotherapy before and after RT (sandwich); adjuvant RT followed by chemotherapy (upfront RT); or chemotherapy concurrent with vaginal cuff brachytherapy alone (chemo-brachy). Overall survival (OS) and recurrence-free survival (RFS) rates were estimated by the Kaplan-Meier method., Results: A total of 686 eligible patients were included with a median follow-up of 45.3 months. The estimated 5-year OS and RFS rates were 74% and 66%, respectively. The sequence and type of adjuvant therapy were not correlated with OS or RFS (adjusted P = .68 and .84, respectively). On multivariate analysis, black race, nonendometrioid histology, grade 3 tumor, stage IIIC2, and presence of adnexal and cervical involvement were associated with worse OS and RFS (all P < .05). Regardless of the sequence of treatment, the most common site of first recurrence was distant metastasis (20.1%). Vaginal only, pelvic only, and paraortic lymph node (PALN) recurrences occurred in 11 (1.6%),15 (2.2 %), and 43 (6.3 %) patients, respectively. Brachytherapy alone was associated with a higher rate of PALN recurrence (15%) compared with external beam radiation therapy (5%) P < .0001., Conclusions: The sequence and type of combined adjuvant therapy did not affect OS or RFS rates. Brachytherapy alone was associated with a higher rate of PALN recurrence, emphasizing the role of nodal radiation for stage IIIC EC. The vast proportion of recurrences were distant despite systemic chemotherapy, highlighting the need for novel regimens., (Copyright © 2021 Elsevier Inc. All rights reserved.)

To investigate the feasibility of the log-demons deformable image registration (DIR) method to correct eddy current and field inhomogeneity distortions while preserving diffusion tensor information. Diffusion-weighted images (DWIs) are susceptible to distortions caused by eddy current and echo-planar imaging (EPI) gradients. We propose a post-acquisition correction algorithm using the log-demons DIR technique for eddy current and field inhomogeneity distortions of DWI. The new correction technique was applied to DWI acquired using a diffusion phantom and the multiple acquisitions for standardization of structural imaging validation and evaluation (MASSIVE) brain database. This method is compared to previous methods using cross-correlation, mutual information (MI). In the phantom study, the log-demons algorithm reduced eddy current and field inhomogeneity distortions while preserving diffusion tensor information when compared to affine and demon's registration techniques. Analysis of the tensor metrics using percent difference and the root mean square of the apparent diffusion coefficient and fractional anisotropy found that the log-demons algorithm outperforms the other algorithms in terms of preserving diffusion information. In the MASSIVE study, the average MI of all slices increased for both eddy current and field inhomogeneity distortion correction. The average absolute differences of all slices between corrected images with opposing gradients were also on average decreased. This work indicates that the log-demons DIR algorithm is feasible to reduce eddy current and field inhomogeneity distortions while preserving quantitative diffusion information.

Objectives: People living with HIV (PLWH) have increased risk for cancer and worse cancer-specific survival. We explored the emotional burden of cancer and HIV as a potential driver of cancer mortality., Research Approach: Semi-structured qualitative interviews with PLWH and cancer., Participants: 27 PLWH who had either completed cancer treatment, were currently undergoing treatment, or experienced challenges in completing treatment., Methodological Approach: An inductive qualitative approach using the constant comparative method., Findings: Participants drew strong parallels between being diagnosed with HIV and cancer. Many described HIV-related stigma that hindered social support. Cancer treatment side effects were a major challenge, impacting treatment adherence for both cancer and HIV., Implications for Psychosocial Providers: There is a need for convenient, affordable, and visible services to support PLHIV as they navigate cancer care. Services should be tailored to the unique needs of this population by addressing HIV-related stigma, building social support, and fostering resilience.

Competing Interests: Declaration of Competing Interest Christina Annunziata (American Society of Clinical Oncology representative): MaxCyte, Medivir, and Precision Biologics (research), Horizon Pharma and Merck (provided drugs for clinical trial); Sushil Beriwal: Eisai, Institute of Education, and Via Oncology (honoraria), Varian (consultant), XOFT (DSMB); Matthew Harkenrider: AstraZeneca (advisory board [ended]), Varian (advisory board [ended]); Christine Holschneider (Society of Gynecologic Oncology representative): UpToDate (honoraria); Mitchell Kamrava: Augmenix (speakers bureau); Lilie Lin: AstraZeneca (research); Jyoti Mayadev: AstraZeneca (consultant), Varian (advisory board); Marc Morcos: Elekta (travel); Daniel Petereit: (American Brachytherapy Society representative and president): BMS Foundation (research and salary support), Irving A Hansen Memorial Foundation (patient funding), Ralph Lauren Pink Pony Foundation (board member); Beth Erickson: Elekta (research and travel); and Junzo Chino, Akila Viswanathan, Emma Fields, Jane Fitch (patient representative), Eric Leung, and Chika Nwachukwu reported no disclosures.

Purpose: As the utilization of brachytherapy procedures continues to decline in clinics, a need for accessible training tools is required to help bridge the gap between resident comfort in brachytherapy training and clinical practice. To improve the quality of intracavitary and interstitial high-dose-rate brachytherapy education, a multimaterial, modular, three-dimensionally printed pelvic phantom prototype simulating normal and cervical pathological conditions has been developed., Methods and Materials: Patient anatomy was derived from pelvic CT and MRI scans from 50 representative patients diagnosed with localized cervical cancer. Dimensions measured from patients' uterine body and uterine canal sizes were used to construct a variety of uteri based off of the averages and standard deviations of the subjects in our study. Soft-tissue anatomy was three-dimensionally printed using Agilus blends (shore 30 and 70) and modular components using Vero (shore 85)., Results: The kit consists of four uteri, a standard bladder, a standard rectum, two embedded gross tumor volumes, and four clip-on gross tumor volume attachments. The three anteverted uteri in the kit are based on the smallest, the average, and the largest dimensions from our patient set, whereas the retroverted uterus assumes average dimensions., Conclusions: This educational high-dose-rate gynecological pelvic phantom is an accessible and cost-effective way to improve radiation oncology resident training in intracavitary/interstitial brachytherapy cases. Implementation of this phantom in resident education will allow for more thorough and comprehensive physician training through its ability to transform the patient scenario. It is expected that this tool will help improve confidence and efficiency when performing brachytherapy procedures in patients., (Copyright © 2020 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Purpose: People living with HIV are less likely to receive cancer treatment and have worse cancer-specific survival, yet underlying drivers of this disparity have minimally been explored. We investigated cancer care barriers from the perspective of patients living with HIV and cancer (PLWHC) to inform future interventions, reduce disparities, and improve outcomes. Methods: We conducted in-depth semistructured interviews with 27 PLWHC. The interview guide explored perceptions of the cancer care experience, treatment decision making, and barriers to cancer treatment. Interview data were analyzed using the constant comparative method of qualitative analysis. Results: Study participants were predominantly men ( n =22, 81%) with a median age of 56 years and median annual income of $24,000. Among those who experienced challenges with cancer treatment adherence, barriers included debilitating side effects of cancer treatment, stigma surrounding HIV, issues with coping and mental health, the financial burden of cancer care, and challenges with care accessibility. Despite these challenges, participants indicated that their past experiences of coping with HIV had prepared them to accept and address their cancer diagnosis. Resiliency and social support were key facilitators for cancer treatment adherence. Conclusion: This qualitative study of PLWHC in the United States found that a cancer diagnosis created a substantial added stress to an already challenging situation. Health- and stigma-related stressors impacted patients' ability to fully complete cancer treatment as prescribed. There is a need for improved provider communication and mental health support for PLWHC to ensure equitable access to and completion of cancer treatment., Competing Interests: No competing financial interests exist., (© Kelsey L. Corrigan et al. 2020; Published by Mary Ann Liebert, Inc.)

A percentage of long-term cancer survivors who receive pelvic irradiation will develop treatment-related late effects, collectively termed pelvic radiation disease. Thus, there is a need to prevent or ameliorate treatment-related late effects in these patients. Modern radiotherapy methods can preferentially protect normal tissues from radiation toxicities to permit higher doses to targets. However, concerns about chronic small bowel toxicity, for example, still constrain the prescription dose. This provides strong rationale for considering adding pharmacologic mitigators. Implementation of modern targeted radiotherapy methods enables delivery of focused radiation to target volumes, while minimizing dose to normal tissues. In prostate cancer, these technical advances enabled safe radiation dose escalation and better local tumor control without increasing normal tissue complications. In other pelvic diseases, these new radiotherapy methods have not resulted in the low probability of normal tissue damage achieved with prostate radiotherapy. The persistence of toxicity provides rationale for pharmacologic mitigators. Several new agents could be readily tested in clinical trials because they are being or have been studied in human patients already. Although there are promising preclinical data supporting mitigators, no clinically proven options to treat or prevent pelvic radiation disease currently exist. This review highlights therapeutic options for prevention and/or treatment of pelvic radiation disease, using pharmacologic mitigators. Successful development of mitigators would reduce the number of survivors who suffer from these devastating consequences of pelvic radiotherapy. It is important to note that pharmacologic mitigators to ameliorate pelvic radiation disease may be applicable to other irradiated sites in which chronic toxicity impairs quality of life., (©2020 American Association for Cancer Research.)

Purpose: This guideline reviews the evidence and provides recommendations for the indications and appropriate techniques of radiation therapy (RT) in the treatment of nonmetastatic cervical cancer., Methods: The American Society for Radiation Oncology convened a task force to address 5 key questions focused on the use of RT in definitive and postoperative management of cervical cancer. These questions included the indications for postoperative and definitive RT, the use of chemotherapy in sequence or concurrent with RT, the use of intensity modulated radiation therapy (IMRT), and the indications and techniques of brachytherapy. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength., Results: The guideline recommends postoperative RT for those with intermediate risk factors, and chemoradiation for those with high-risk factors. In the definitive setting, chemoradiation is recommended for stages IB3-IVA, and RT or chemoradiation is conditionally recommended for stages IA1-IB2 if medically inoperable. IMRT is recommended for postoperative RT and conditionally recommended for definitive RT, for the purposes of reducing acute and late toxicity. Brachytherapy is strongly recommended for all women receiving definitive RT, and several recommendations are made for target dose and fractionation, the use of intraoperative imaging, volume-based planning, and recommendations for doses limits for organs at risk., Conclusions: There is strong evidence supporting the use of RT with or without chemotherapy in both definitive and postoperative settings. Brachytherapy is an essential part of definitive management and volumetric planning is recommended. IMRT may be used for the reduction of acute and late toxicity. The use of radiation remains an essential component for women with cervical cancer to achieve cure., (Copyright © 2020 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)