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The use of neoadjuvant chemotherapy (NAC) in patients with operable breast cancer allows for assessment of treatment response and subsequent tailoring of adjuvant therapy. Data are limited with respect to outcomes among patients with a heavy residual tumor burden after NAC. We report outcomes in patients who had exceptionally poor responses to NAC: those with9 involved nodes after NAC or with 5 cm or more of residual disease in the breast.Between June 2014 and April 2020, 1511 patients with breast cancer received NAC followed by surgery at our institution. Poor responders, defined as those with positive nodes or residual tumor in the breast, were identified for analysis. Patients were further classified into 3 groups for comparison purposes: (1) 1 to 3 positive nodes; (2) 4 to 9 positive nodes; or (3)9 positive nodes and/or5 cm of residual tumor, which was defined as high-volume residual (HVR). Recurrence and survival outcomes were compared based on residual disease burden after NAC.Among 934 poor responders, 539 patients had 1 to 3 positive nodes (ypN1), 215 had 4 to 9 positive nodes (ypN2), and 180 had HVR disease. Specifically, 118 had9 positive nodes (HVR), and 62 patients had5 cm of residual tumor in the breast. With a median follow-up of 31 months (interquartile range, 18-46), the 5-year overall survival rate was 88% among ypN1, 76% among ypN2, and 72% among patients with HVR disease (P.001). The 5-year distant recurrence-free survival and locoregional recurrence incidences were 82% and 7.6% among ypN1 versus 67% and 8.4% among ypN2 versus 53% and 12% among HVR, respectively.Our work suggests that patients with HVR disease are at high risk for locoregional and distant recurrence as well as death, despite best available standard-of-care treatment. Intensification of locoregional therapies and/or alternative adjuvant systemic treatment may improve outcomes in these poor responders.

PURPOSE: Compared with conventional external-beam radiation therapy (cEBRT) for patients with breast cancer (BC) and prostate cancer (PC), shorter radiation regimens may be associated with lower treatment noncompletion rates. We assess disparities in receipt of shorter radiation regimens and treatment noncompletion for BC and PC. PATIENTS AND METHODS: The 2004-2017 National Cancer Database was queried for adjuvant cEBRT or hypofractionated EBRT (hEBRT) for nonmetastatic BC; and definitive cEBRT, moderate hypofractionation (mEBRT), or stereotactic body radiotherapy (SBRT) for localized PC. Multivariable logistic regression identified factors associated with treatment noncompletion and receipt of shorter regimens. FINDINGS: We identified 170,386 men with PC (median age [interquartile range], 70 [64-75] years; Black, 17.5%; White, 82.5%) and 306,846 women with BC (61 [52-69] years; Black, 12.3%; White, 87.7%). Among patients who received cEBRT for PC, Black men had higher treatment noncompletion rates compared with White (14.1% v 13.0%; odds ratio [95% CI] 1.07 [1.03 to 1.12]; P < .001). In contrast, treatment noncompletion was not disparate with SBRT (Black 1.6% v White 1.3%; 1.20 [0.72 to 2.00], P = .49) or mEBRT (Black 9.0% v White 7.1%; 1.05 [0.72 to 1.54], P = .79). From 2004 to 2017, SBRT (0.07% to 11.8%; 1.32 [1.31 to 1.33]) and mEBRT (0.35% to 9.1%; 1.27 [1.25 to 1.28]) increased (both P < .001); however, Black men were consistently less likely to receive SBRT (7.4% v White, 8.3%; 0.84 [0.79 to 0.89], P < .001). Among women with BC, there were no racial differences in treatment noncompletion; however, hEBRT was associated with lower treatment noncompletion rates (1.0% v cEBRT 2.3%; 0.39 [0.35 to 0.44], P < .001). Although hEBRT for BC increased (0.8% to 35.6%) between 2004 and 2017, Black women were less likely to receive hEBRT (10.4% v 15.3%; 0.78 [0.75 to 0.81], P < .001). INTERPRETATION: Black patients were consistently less likely to receive hypofractionated radiation for PC or BC, despite evidence suggesting that shorter regimens may lower rates of treatment noncompletion with similar oncologic outcomes.

Although mentorship has been associated with promotion, job satisfaction, and retention, data are limited on the mentorship experience of clinical- versus research-track physicians as well as feasibility and relative priority of formal program components.Within a single-institution, multi-site, academic network, we implemented a Radiation Oncology AcaDemic Mentorship Program (ROADMAP) for junior faculty. Validated surveys assessing mentee satisfaction were distributed at baseline and 1 year. The statistical analysis included Wilcoxon rank sum and signed tests. Mentees assessed the likelihood to recommend each program component (10-point Likert-type scale), and means with standard error (SE) are reported.Among 42 eligible junior faculty, 36 (86%) opted into the program. The median time since residency was 2.5 years (interquartile range, 1.75-5.25) on the clinical track (n = 12) and 3 years (interquartile range, 2.75-5.00) on the research track (n = 24). At baseline, research-track physicians reported higher satisfaction with mentoring than physicians on the clinical track (2.92 vs 2.16; P = .02). Among 32 physicians completing 1 year, overall satisfaction with mentoring increased compared with baseline (2.72 vs 3.87; P.001), which persisted on subset analysis for both clinical- (2.16 vs 4.03; P.001) and research-track physicians (2.99 vs 3.77; P = .005). At 1 year, 28 mentees (88%) opted to continue the program. Program components were rated 8.25 (SE, 0.37) for mentor-mentee pairings, 7.22 (SE, 0.39) for goal setting, 6.84 (SE, 0.47) for administrative support, 6.69 (SE, 0.44) for peer mentoring, and 6.53 (SE, 0.45) for steering committee oversight. Ratings of peer mentoring were not associated with track (P = .59) or years in practice (P = .29).Clinical-track physicians may be less satisfied with mentorship than research-track faculty. However, all junior faculty, regardless of track, appeared to benefit from formalizing dyadic mentor-mentee relationships, goal setting, and peer mentoring. Further work is needed to determine the role of mentorship in addressing physician burnout.

OBJECTIVE: Patient experience scores are increasingly important in measuring quality of care and determining reimbursement from payers, including the Hospital Value Based Purchasing Program and the Radiation Oncology Model. However, the role of bias in patient experience scores in oncology is unknown, raising the possibility that such payment structures may inadvertently perpetuate bias in reimbursement. Therefore, we characterized patient-, physician-, and practice-level predictors of patient experience scores in patients undergoing radiation therapy. METHODS: We retrospectively reviewed patient experience surveys for radiation oncology patients treated at two large multi-site academic cancer centers. The outcome was responses on four survey questions. Co-variates included self-reported patient demographics, physician characteristics, practice setting characteristics, and wait time rating linked to each survey. We fitted multivariable ordinal regression models to identify predictors of receiving a higher score on each of the survey questions. RESULTS: 2,868 patients completed surveys and were included in the analysis. Patient experience scores were generally high, with >90% of respondents answering 5/5 on the 4 survey items. Physician gender was not associated with any measured patient experience outcomes (all p-values>0.4). Independent predictors of higher score included a wait-time experience classified as “good” as compared to “not good” (all q-values

Purpose/Objective(s) Local breast cancer recurrences and new primary breast cancers are an increasingly common clinical challenge without clear treatment guidelines. To date, photon reirradiation (reRT) has not been widely adopted due to concerns for toxicities. Proton beam therapy (PBT) can optimize normal tissue sparing and may allow for safer delivery of a second definitive radiotherapy (RT) course. We hypothesize salvage PBT reRT can be safely delivered, and we present clinical outcomes and toxicities of patients with recurrent or new primary non-metastatic breast cancer who received prior RT and PBT reRT. Materials/Methods In an IRB-approved retrospective study, all consecutive patients with recurrent or new primary non-metastatic breast cancer treated with breast or chest wall (CW) RT and PBT reRT from a single institution were identified. Patient and tumor characteristics, treatment parameters, clinical outcomes and toxicities were collected. Distant metastasis-free survival (DMFS) and overall survival (OS) were defined from PBT reRT start to date of distant recurrence, death or last follow-up and estimated using Kaplan-Meier methodology. Results Forty-six consecutive patients were assessed. Eight patients (17.4%) were reirradiated to an intact breast, 13 (28.3%) to CW without reconstruction, 20 (43.5%) to CW with reconstruction, and 5 (10.9%) to regional lymph nodes (LN) alone. PBT reRT was delivered with uniform (70%) or pencil beam (30%) scanning PBT. Median first course dose was 60Gy (45-66Gy); median PBT reRT dose was 50.4Gy (RBE) (40-66.6Gy); median cumulative dose was 108.9Gy2, a/b = 3(RBE) (95.0-168.8 Gy2, a/b = 3 (RBE)). When regional LN were retreated, median first course dose was 50.4 Gy (48.6-66.6Gy) and median PBT reRT dose was 50 Gy2, a/b = 3 (46.7-66.0Gy2, a/b = 3). Four patients had significant brachial plexus overlap with cumulative doses up to 99.0 Gy. At a median follow-up of 21 months, there were no local or regional recurrences; 8 patients (17%) developed distant recurrence, of whom three died. Estimated 3-year DMFS and OS were 60% and 88%, respectively. Grade 3 acute toxicities were limited exclusively to RT dermatitis (30.4%). Grade 3 late toxicities occurred in 4 patients (8.7%) (3 capsular contracture requiring surgical intervention, 1 breast pain requiring mastectomy). Two patients developed rib fracture. No cases of neuropathies, skin ulceration or other acute or late grade ≥3 toxicities occurred. Conclusion In the largest series to date of PBT reRT for breast cancer recurrence or new primary after prior definitive breast or CW RT, PBT reRT provided excellent locoregional control with a low rate of high-grade toxicities limited to target tissue not amenable to sparing from full reRT dose. These data are encouraging and suggest PBT reRT may provide patients with a relatively safe and highly effective salvage option. Longer follow-up and additional patients are needed to correlate composite normal tissue doses with toxicities and assess long-term outcomes.

We aimed to develop and study the implementation of a remote system for toxicity assessment and management of acute side effects of breast radiation using electronic patient-reported outcomes (ePROs).A response-adapted Patient-Reported Outcomes Common Terminology Criteria for Adverse Events-based assessment for breast radiation toxicity was administered weekly during and for 8 weeks after radiation from June 2019 to July 2020. The care team received alerts when "severe" symptoms were reported by patients, who were then contacted. Treatment, clinic, and sociodemographic characteristics were abstracted from patient records. A subsample of patients and care team members was qualitatively interviewed at follow-up.Overall, 5787 assessments were sent to 678 patients, of whom 489 (72%) completed 2607 assessments (45%). Moderate or greater toxicity was reported by 419 responders (86%; 95% CI, 82%-89%). Clinician alerts for severe toxicity were generated for 264 assessments among 139 unique patients, of which 83% occurred posttreatment. The proportion of surveys that prompted an alert was significantly higher after treatment (219 [13%]) than during treatment (45 [5%]) (P.001). Survey completion rates in the posttreatment period were higher among patients undergoing partial breast irradiation than postmastectomy radiation (incidence rate ratio, 0.70; 95% CI, 0.60-0.81) (P.001) despite these patients experiencing less severe toxicity. Interviews (15) found that patients had a positive experience with ePROs, although many thought the primary purpose was for research rather than symptom management.With the majority of toxicity occurring after breast radiation has ended, remote symptom monitoring with ePROs appears to fill a gap in clinical practice, particularly for patients undergoing shorter courses of radiation. It is important to properly onboard patients and explain that the purpose of ePROs is to aid clinical care. Further research is needed to determine whether the costs associated with ePROs can be offset by reducing routine clinic visits and whether this approach is acceptable and appropriate.

PURPOSE ATM, a gene that controls repair of DNA double-strand breaks, confers an excess lifetime risk of breast cancer among carriers of germline pathogenic variants (PV). ATM PV homozygotes are particularly sensitive to DNA damage caused by ionizing radiation. Consequently, there is concern that adjuvant radiotherapy (RT) may cause excess morbidity among heterozygous carriers of ATM PV. We evaluated the tolerability of breast RT among carriers of ATM germline variants. METHODS Of 167 patients with ATM germline variants presenting to our institution with breast cancer, 91 received RT. Treatment-related toxicity was ascertained from medical records and graded across organ systems. Toxicities grade > 2 were recorded from the end of treatment to last evaluable follow-up and were analyzed according to ATM variant pathogenicity. RESULTS Of 91 evaluable carriers of ATM variants, with a median follow-up of 32 months following RT, 25% (n = 23) harbored a PV, whereas 75% (n = 68) harbored a variant of uncertain significance (VUS). Prevalence of grade ≥ 2 toxicity unrelated to post-mastectomy reconstruction among patients with ATM PV was: 32% at the end of treatment ( v 34% for VUS carriers), 11% at 1 year of follow-up ( v 4% for VUS carriers), and 8% at the last follow-up ( v 13% for VUS carriers), consistent with previous studies of RT among unselected populations. No grade 4 or 5 toxicities were observed. ATM variant pathogenicity was not associated with local toxicity, contralateral breast cancer, or secondary malignancy in this limited cohort of patients who received breast RT. CONCLUSION We found no evidence of excess RT-associated toxicity among carriers of pathogenic ATM germline variants. Breast-conserving therapy and adjuvant RT may be safely considered among appropriately selected carriers of ATM germline variants.

Background:The COVID-19 pandemic has transformed cancer care with the rapid expansion of telemedicine, but given the limited use of telemedicine in oncology, concerns have been raised about the quality of care being delivered. We assessed the patient experience with telemedicine in routine radiation oncology practice to determine satisfaction, quality of care, and opportunities for optimization.Patients and Methods:Patients seen within a multistate comprehensive cancer center for prepandemic office visits and intrapandemic telemedicine visits in December 2019 through June 2020 who completed patient experience questionnaires were evaluated. Patient satisfaction between office and telemedicine consultations were compared, patient visit-type preferences were assessed, and factors associated with an office visit preference were determined.Results:In total, 1,077 patients were assessed (office visit, n=726; telemedicine, n=351). The telemedicine-consult survey response rate was 40%. No significant differences were seen in satisfaction scores between office and telemedicine consultations, including the appointment experience versus expectation, quality of physician’s explanation, and level of physician concern and friendliness. Among telemedicine survey respondents, 45% and 34% preferred telemedicine and office visits, respectively, and 21% had no preference for their visit type. Most respondents found their confidence in their physician (90%), understanding of the treatment plan (88%), and confidence in their treatment (87%) to be better or no different than with an office visit. Patients with better performance status and who were married/partnered were more likely to prefer in-person office visit consultations (odds ratio [OR], 1.04 [95% CI, 1.00–1.08];P=.047, and 2.41 [95% CI, 1.14–5.47];P=.009, respectively). Patients with telephone-only encounters were more likely to report better treatment plan understanding with an office visit (OR, 2.25; 95% CI, 1.00–4.77;P=.04).Conclusions:This study is the first to assess telemedicine in routine radiation oncology practice, and found high patient satisfaction and confidence in their care. Optimization of telemedicine in oncology should be a priority, specifically access to audiovisual capabilities that can improve patient–oncologist communication.

ImportanceDespite federal initiatives encouraging the enrollment of individuals from racial and ethnic minority groups in US clinical trials, no studies to date have specifically examined demographic disparities among participants in phase 1 drug development trials for patients with metastatic cancer.ObjectiveTo assess trends in the enrollment of patients from racial and ethnic minority groups in US phase 1 therapeutic drug trials for metastatic cancer from 2000 to 2018.Design, Setting, and ParticipantsIn this cross-sectional study, ClinicalTrials.gov was queried in July 2021 to identify completed phase 1 drug trials for metastatic cancer in the US from January 1, 2000, to December 31, 2018, with published results, yielding 221 phase 1 trials with 8309 participants aged 18 years or older with metastatic solid tumors. Proportions of each racial and ethnic group of trial participants were compared with that from the North American Association of Central Cancer Registries’ Cancer in North America (CiNA) database. Statistical analysis was performed from July 12, 2021, to March 15, 2022.Main Outcomes and MeasuresFor each racial and ethnic group, the difference between trial and CiNA proportions was examined using a 2-sample test for equality of proportions with continuity correction.ResultsThe 8309 phase 1 trial participants (4198 men [50.5%]; median age, 59 years) included 23 American Indian or Alaska Native participants (0.3%), 371 Asian or Pacific Islander participants (4.5%), 514 Black participants (6.2%), 401 of 5076 Hispanic or Latinx participants (7.9%), and 7154 White participants (86.1%). Industry funded 165 of the 221 trials (74.7%). White patients were overrepresented overall compared with the corresponding CiNA cohort (7154 of 8309 [86.1%] vs 4 113 096 of 4 891 486 [84.1%]; difference, 2.0 percentage points; P P = .23) to 2012-2018 (trials, 4374 of 5063 [86.4%]; CiNA, 1 735 077 of 2 090 775 [82.9%]; difference, 3.5 percentage points; P Conclusions and RelevanceIn this cross-sectional study of participants in phase 1 clinical trials of drugs for metastatic cancer, worsening disparities were observed over time in the accrual of patients from racial and ethnic minority groups. These findings may represent widening inequalities in access to trial sites and worsening systemic biases. More efforts are needed to diversify phase 1 cancer drug trials to improve equity in access to new treatments and to ensure that safety and efficacy findings from early drug trials are generalizable across populations.

ImportanceFemale oncologists often spend their childbearing years in training and establishing careers, with many later experiencing fertility issues when starting a family. Physician fertility and family planning are rarely discussed during training. Attitudes among female oncologists regarding family planning are unknown.ObjectivesTo understand barriers to family planning as well as the association of fertility treatment with career decisions and to assess experiences of pregnancy-based discrimination among female oncologists.Design, Setting, and ParticipantsIn this survey study, a novel 39-item questionnaire was distributed to US female oncologists from May 7 to June 30, 2020, via email and social media channels. Questions regarding factors associated with family planning, maternity leave, and discrimination were included.Main Outcomes and MeasuresThe distribution of survey responses was compared by oncology subspecialty. Multivariable logistic regression was performed to determine independent variables for discrimination experienced during maternity leave.ResultsResponses were collected from 1004 female oncologists. Most respondents (847 [84.4%]) were married, and 713 (71.0%) were currently working full-time. A total of 351 oncologists (35.0%) worked in radiation oncology, 344 (34.3%) in medical oncology, 186 (18.4%) in surgical oncology, and 91 (9.1%) in pediatric oncology. A total of 768 respondents (76.5%) had children, and of these, 415 (41.3%) first gave birth during postgraduate training, and 275 (27.4%) gave birth in years 1 to 5 as an attending physician. Almost all respondents (951 [94.7%]) stated that their career plans were at least somewhat associated with the timing of when to start a family. Having a supportive partner was the most commonly cited positive association with family planning (802 [79.9%]), while long work hours and heavy workload (669 [66.6%]) were the most common negative factors. One-third (318 [31.7%]) had miscarried, and 315 (31.4%) reported difficulty with infertility that required fertility counseling and/or treatment; 660 (65.7%) thought fertility preservation should be discussed with women during medical school and/or residency. One-third (312 [31.1%]) reported experiencing discrimination during pregnancy, and 332 (33.1%) stated they experienced discrimination for taking maternity leave. On multivariable logistic regression, having more than 1 child was associated with increased likelihood of experiencing discrimination during maternity leave (2 children: odds ratio, 1.62 [95% CI, 1.10-2.39]; P = .02; ≥3 children: odds ratio, 1.84 [95% CI, 1.14-2.95; P = .01).Conclusions and RelevanceIn this survey study of female oncologists, 1 in 3 reported experiencing infertility and 1 in 3 stated they experienced discrimination during pregnancy and/or for taking maternity leave. Systemic changes are necessary to ensure women are supported and able to advance equitably in the field.

Clinician generated segmentation of tumor and healthy tissue regions of interest (ROIs) on medical images is crucial for radiotherapy. However, interobserver segmentation variability has long been considered a significant detriment to the implementation of high-quality and consistent radiotherapy dose delivery. This has prompted the increasing development of automated segmentation approaches. However, extant segmentation datasets typically only provide segmentations generated by a limited number of annotators with varying, and often unspecified, levels of expertise. In this data descriptor, numerous clinician annotators manually generated segmentations for ROIs on computed tomography images across a variety of cancer sites (breast, sarcoma, head and neck, gynecologic, gastrointestinal; one patient per cancer site) for the Contouring Collaborative for Consensus in Radiation Oncology challenge. In total, over 200 annotators (experts and non-experts) contributed using a standardized annotation platform (ProKnow). Subsequently, we converted data into NIfTI format with standardized nomenclature for ease of use. In addition, we generated consensus segmentations for experts and non-experts using the STAPLE method. These standardized, structured, and easily accessible data are a valuable resource for systematically studying variability in segmentation applications.

OBJECTIVEContouring Collaborative for Consensus in Radiation Oncology (C3RO) is a crowdsourced challenge engaging radiation oncologists across various expertise levels in segmentation. A challenge in artificial intelligence (AI) development is the paucity of multi-expert datasets; consequently, we sought to characterize whether aggregate segmentations generated from multiple non-experts could meet or exceed recognized expert agreement.MATERIALS AND METHODSParticipants who contoured ≥1 region of interest (ROI) for the breast, sarcoma, head and neck (H&N), gynecologic (GYN), or gastrointestinal (GI) challenge were identified as a non-expert or recognized expert. Cohort-specific ROIs were combined into single simultaneous truth and performance level estimation (STAPLE) consensus segmentations. STAPLEnon-expert ROIs were evaluated against STAPLEexpert contours using Dice Similarity Coefficient (DSC). The expert interobserver DSC (IODSCexpert) was calculated as an acceptability threshold between STAPLEnon-expert and STAPLEexpert. To determine the number of non-experts required to match the IODSCexpert for each ROI, a single consensus contour was generated using variable numbers of non-experts and then compared to the IODSCexpert.RESULTSFor all cases, the DSC for STAPLEnon-expert versus STAPLEexpert were higher than comparator expert IODSCexpert for most ROIs. The minimum number of non-expert segmentations needed for a consensus ROI to achieve IODSCexpert acceptability criteria ranged between 2-4 for breast, 3-5 for sarcoma, 3-5 for H&N, 3-5 for GYN ROIs, and 3 for GI ROIs.DISCUSSION AND CONCLUSIONMultiple non-expert-generated consensus ROIs met or exceeded expert-derived acceptability thresholds. 5 non-experts could potentially generate consensus segmentations for most ROIs with performance approximating experts, suggesting non-expert segmentations as feasible cost-effective AI inputs.

PURPOSE: Community-academic partnerships have the potential to improve access to clinical trials for under-represented minority patients who more often receive cancer treatment in community settings. In 2017, the Memorial Sloan Kettering (MSK) Cancer Center began opening investigator-initiated clinical trials in radiation oncology in targeted community-based partner sites with a high potential to improve diverse population accrual. This study evaluates the effectiveness of a set of implementation strategies for increasing overall community-based enrollment and the resulting proportional enrollment of Hispanic patients on trials on the basis of availability in community-based partner sites. METHODS: An interrupted time series analysis evaluating implementation strategies was conducted from April 2018 to September 2021. Descriptive analysis ofHispanic enrollment on investigator-initiated randomized therapeutic radiation trials open at community-based sites was compared with those open only at themain academic center. RESULTS: Overall, 84 patients were enrolled in clinical trials in the MSK Alliance, of which 48 (56%) identified as Hispanic. The quarterly patient enrollment pre- vs postimplementation increased from 1.39 (95% CI, –3.67 to 6.46) to 9.42 (95% CI, 2.05 to 16.78; P5 .017). In the investigator-initiated randomized therapeutic radiation trials open in the MSK Alliance, Hispanic representation was 11.5% and 35.9% in twometastatic trials and 14.2% in a proton versus photon trial. Inmatched trials open only at the main academic center, Hispanic representation was 5.6%, 6.0%, and 4.0%, respectively. CONCLUSION: A combination of practice-level and physician-level strategies implemented at community-based partner sites was associated with increased clinical trial enrollment, which translated to improved Hispanic representation. This supports the role Q:2 of strategic community-academic partnerships in addressing disparities in clinical trial enrollment.

Evidence suggests that cancer treatment-related toxic effects are underreported by clinicians. We sought to compare patient- and clinician-reported acute toxic effects among patients undergoing radiation therapy for primary breast cancer and to determine factors associated with patient-clinician discordance.Patient responses from a weekly Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events based assessment were matched to clinician assessments of acute toxic effects during treatment. Weighted κ statistics were used to evaluate agreement between patient and clinician assessments. Linear regression, logistic regression, and generalized estimating equation models were used to identify covariates associated with discordance.Overall, 842 patient-clinician assessment pairs from 376 unique patients were analyzed. Total symptom burden score was higher for patients than clinicians (4.7 vs 2.3, P.01). Dermatitis, pruritis, pain, and edema items were classified as having minimal agreement (κ of 0.25, 0.23, 0.20, and 0.25, respectively). Fatigue (κ 0.17) and psychosocial (0.03) patient-clinician pairs were found to have no agreement. The linear regression demonstrated that assessments by patients who identified as Black or African American were associated with a 0.13-point decrease in discordance (95% confidence interval, -0.25 to -0.01), while time from the start of treatment was associated with increased discordance (95% confidence interval, 0.07-0.12).For patients undergoing breast radiation therapy, discordance in patient and clinician symptom reporting is high and increases as treatment progresses. The mechanism of reduced discordance among Black or African American patients warrants further investigation. Prospective studies are needed to determine whether interventions for lower severity symptoms, which are commonly overlooked by clinicians, can reduce symptom burden and improve patient quality of life during radiation therapy.

We aimed to assess contouring-related practices among US radiation oncologists and explore how access to and use of resources and quality improvement strategies vary based on individual- and organization-level factors.We conducted a mixed methods study with a sequential explanatory design. Surveys were emailed to a random 10% sample of practicing US radiation oncologists. Participating physicians were invited to a semi-structured interview. Kruskal-Wallis and Wilcoxon rank-sum tests and a multivariable regression model were used to evaluate associations. Interview data were coded using thematic content analysis.Survey overall response rate was 24%, and subsequent completion rate was 97%. Contouring-related questions arise in ≥50% of clinical cases among 73% of respondents. Resources accessed first include published atlases (75%) followed by consulting another radiation oncologist (60%). Generalists access consensus guidelines more often than disease-site specialists (P = 0.04), while eContour.org is more often used by generalists (OR 4.3, 95% CI 1.2-14.8) and younger physicians (OR 1.33 for each 5-year increase, 95% CI 1.08-1.67). Common physician-reported barriers to optimizing contour quality are time constraints (58%) and lack of access to disease-site specialists (21%). Forty percent (40%, n = 14) of physicians without access to disease-site specialists indicated it could facilitate the adoption of new treatments. Almost all (97%) respondents have formal peer review, but only 43% have contour-specific review, which is more common in academic centres (P = 0.02).Potential opportunities to improve radiation contour quality include improved access to disease-site specialists and contour-specific peer review. Physician time must be considered when designing new strategies.

Purpose For patients with long bone metastases who undergo orthopedic stabilization surgery followed by radiotherapy (RT), it is unclear what extent of hardware coverage by the radiation field is needed for optimal tumor control. Methods and Materials Long bone metastases treated with surgical intervention followed by radiation between August 2011 to May 2019 from a single institution were reviewed. Local recurrence, defined as any in-bone recurrence, was identified by chart review. Accompanying demographic and treatment characteristics were recorded. Statistical analysis to evaluate factors associated with tumor recurrence included univariate analysis, multivariate analysis, and propensity score matching. Results Among 138 patients with 145 long bone metastases undergoing postoperative RT with a median follow-up of 29.5 months, 36 bone metastases experienced a local recurrence. Most patients (92%) were treated with conventional RT and the median delivered dose was 30 Gy (interquarile range, 20-30 Gy). On univariate analysis, whole hardware RT field coverage and higher dose (biologically effective dose 10 ≥39 Gy) were associated with reduced local recurrence (0.44 hazard ratio [HR]; 95% confidence interval [CI], 0.22%-0.86%; P = .017; 0.5 HR; 95% CI, 0.26%-0.96%; P = .038, respectively). Covariates of time from surgery to RT start, histology of primary tumor (categorized as resistant vs sensitive), intramedullary hardware placement, reaming procedure, and margin status did not reach statistical significance. To adjust for confounding effects, we also conducted a propensity score matched analysis which confirmed that whole hardware coverage was statistically associated with a decreased risk of recurrence on the matched dataset (0.24 HR; 95% CI, 0.07%-0.84%; P = .026). Conclusions In this analysis of mostly patients undergoing conventional radiation, coverage of the whole hardware was associated with reduced local recurrence for patients with long bone metastases, consistent with prior reports. Investigation of approaches to further reduce local recurrence, such as preoperative stereotactic radiation, may be warranted.

Purpose Local therapy for patients with nonspine bone metastases is evolving, with data supporting the use of single-fraction treatments, and more recently, showing possible benefit from stereotactic body radiation therapy (SBRT). However, the rate of local salvage therapy (LST) after each technique has not been characterized in real-world clinic settings where patients are selected at physician discretion. We examined rates of LST in patients with nonspine bone metastases. Methods and Materials We reviewed records of RT for nonspine bone metastases at our institution from January 1, 2016, to December 31, 2018. We defined LST as the first occurrence of RT or surgery for oncologic progression to a bone metastasis after initial RT. Cumulative incidence functions for retreatment were generated. We conducted multivariate analysis to identify variables associated with LST. Results A total of 1754 patients were analyzed, with median follow-up of 16.2 months (range, 0-36.8 months). Of all episodes of RT, 51.5% were multifraction external beam radiation therapy (EBRT), 7.0% were single-fraction EBRT, and 41.4% were SBRT. Altogether, 88 patients (5.0%) required LST, with an incidence at 6 months of 2.5%. Incidence of LST at 6 months was 2.1% for SBRT, 5.3% for single-fraction conventional regimens, and 2.4% for multifraction conventional regimens (P = .26). Patients of younger age, who had a higher Karnofsky performance status, and/or who had lesions in the pelvis had a higher risk of retreatment. Conclusions In this large institutional cohort, the rate of LST was low, with no difference between RT techniques. The findings indicated that SBRT for patients at high risk for treatment failure may reduce the rate of retreatment overall. When treatment modality was selected based on patient characteristics, rates of LST were lower than when treatment was randomly selected.

Purpose/Objective(s) We hypothesize that there is an oligoprogressive state in metastatic cancer, in which disease control can be improved with local therapy to progressive lesions only. This study therefore evaluated the impact of stereotactic body radiotherapy (SBRT) to sites of oligoprogression in patients with metastatic non-small-cell lung cancer (NSCLC) and breast cancer with 1-5 progressive lesions. Materials/Methods We enrolled patients with metastatic NSCLC or breast cancer who received ≥ 1 line of systemic therapy and had oligoprogressive lesions amenable to SBRT. There was no upper limit of non-progressive lesions. Oligoprogression was defined as Response Evaluation or Positron Emission Tomography Response Criteria in Solid Tumors documented progression ≤ 5 individual lesions. Stratification factors included number of progressive sites (1 vs. 2-5), prior systemic therapy (immunotherapy vs. other), primary tumor (NSCLC vs. breast), and tumor marker status (driver mutation and hormone receptor status). Patients were randomized 1:1 between SBRT to all progressive sites plus palliative standard of care (SOC) vs. palliative SOC only. Systemic therapy was per physician's discretion. The primary endpoint was progression-free survival (PFS). We used a randomized phase II design with a one-sided alpha of 0.05 and a power of 0.80, yielding a target accrual of 160 patients. PFS was compared using one-sided stratified log-rank test. One interim analysis was planned. Results From January 2019 to May 2021, 102 patients were randomized - 58 NSCLC (30 in the SBRT arm) and 44 breast (22 in each arm). Median age was 67. Most patients (75%) had > 1 site of oligoprogression and 47% had > 5 total metastatic lesions. Fifty-five (54%) patients received immunotherapy. The majority of NSCLC (86%) did not harbor an actionable driver mutation and 32% of breast cancer were triple negative. Baseline factors were balanced between arms. At a median follow-up of 51 weeks, 71 patients progressed and 30 died. Median PFS was 22 weeks in the SBRT arm vs. 10 weeks in the palliative SOC arm (p=0.005). This was driven entirely by the PFS benefit from SBRT in the NSCLC patients (44 weeks with SBRT vs. 9 weeks with SOC; p=0.004). No difference in median PFS was seen in the breast cohort (18 weeks with SBRT vs. 17 weeks with SOC; p=0.5). In multivariable Cox model inclusive of stratification factors, age, sex, lines of systemic therapy, and change of systemic therapy, the PFS benefit of SBRT remained substantial in the NSCLC cohort (Hazard Ratio: 0.38; 95% CI: 0.18-77; p=0.007). Grade ≥2 adverse events occurred in 8 patients in the SBRT arm, including 1 grade 3 pneumonitis. Conclusion Inthis pre-planned interim analysis of the first and largest randomized trial of radiotherapy for oligoprogressive metastatic NSCLC and breast cancer, we demonstrated the benefit of SBRT to sites of oligoprogression on overall PFS, meeting the primary endpoint. The mechanism of the differential benefits between NSCLC and breast cohorts merits further evaluation.

Purpose/Objective(s) Accelerated partial breast irradiation (APBI) following breast conserving surgery offers a convenient and well-tolerated adjuvant radiotherapy option in comparison to whole breast irradiation. While several APBI regimens exhibit excellent disease control among appropriately selected patients, patient-reported outcomes and toxicity assessments may vary. We sought to describe patient-reported acute toxicity as a function of salient dosimetric parameters, during and after an APBI regimen of 40 Gy in 10 once-daily fractions. Materials/Methods From June 2019 to July 2020 patients undergoing APBI were assigned a weekly, response adapted, PRO-CTCAE-based acute toxicity assessment. Symptoms assessed included pain, fatigue, breast enlargement, skin toxicity, and psychosocial concerns. Patients reported acute toxicity during treatment, and for up to 8-weeks following treatment. Socio-demographic characteristics and dosimetric treatment parameters were collected. Descriptive statistics were used to summarize patient-reported outcomes and corresponding dosimetric measures. Results Overall, 55 patients who received APBI (40 Gy in 10 fractions administered once-daily) completed more than one assessment during or after treatment. A total of 351 assessments were included in this analysis. Median patient age was 59 (range 37-78), and median planning target volume (PTV) was 210cc (range 64-580cc). Median PTV:ipsilateral breast volume ratio was 0.17 (range 0.05-0.44) and median maximum hotspot dose was 112% (range 108-115%). Breast V20 Gy ranged from 16% to 65% with a median of 45%. When queried weekly, 22% of patients reported moderate breast enlargement at least once, occurring at a median of 3 weeks after the initiation of treatment. More commonly, 71% reported maximum skin toxicity of moderate to very severe (42% moderate, 22% severe, 5% very severe) arising at a median of 3 weeks after the initiation of treatment. Furthermore, 70% of patients reported maximum fatigue as moderate to severe (42% moderate, 15% severe), and 44% patients reported maximum pain in the radiated area as moderate to very severe. Median time to first report of any moderate to very severe symptom was 10 days (IQR 6-27 days). By 8 weeks following APBI, 9 patients (16%) reported residual moderate symptoms and none endorsed severe or very severe symptoms. Conclusion Weekly assessments during and after APBI revealed that several patients experienced severe or very severe toxicities by their estimation, but that these universally resolved by 8 weeks following treatment at which point a minority endorsed moderate symptoms. Depending on toxicity type, peak effect could be noted as early as 1 week from the initiation of treatment for fatigue, or as late as 4 weeks for skin toxicity. More comprehensive evaluations among larger cohorts will help to define the precise dosimetric parameters that correspond to each outcome of interest.

Purpose/objective(s) Although clinical trial enrollment is critical to development of new cancer therapies, Materials/methods All patients enrolled on radiation oncology therapeutic clinical trials at community-based partner sites from Q2 2018 - Q1 2021 were included in this analysis. Guided by Expert Recommendation for Implementing Change (ERIC), strategies to increase trial enrollment were implemented prior to Q2 2020, and included: 1) altered incentive structure (per-patient cost paid to partner site, leaderboards), 2) building a coalition of physicians in metastatic disease, and 3) practice facilitation. An interrupted time series analysis included a two-tailed student's t-test to compare mean trial enrollments per quarter pre- and post-implementation. Protocol deviations were assessed in quality assurance (QA) review. Results Among 52 total patients enrolled in community-based, partner sites, 28 (54%) identify as Black or Hispanic. The number of clinical trials open to enrollment pre- and post-implementation was 5 vs. 8, respectively, while the number of patients enrolled was 6 vs. 46, respectively, representing an overall increase in mean number of quarterly patient enrollments from 1 to 11 (P Conclusion These implementation strategies were associated with increased therapeutic trial enrollment in community-based partner sites. With high variation in enrollment between physicians and prior research suggesting limited impact of site-level financial incentives, qualitative research will further investigate non-financial incentives and other facilitators to clinical trial enrollment within community-academic partnerships. Over-representation of minority patients further supports the benefit of enrolling patients on clinical trials in the community-based setting.

PURPOSE/OBJECTIVE(S) The use of neoadjuvant chemotherapy (NAC) in patients with operable breast cancer allows for assessment of treatment response, and subsequent tailoring of adjuvant therapy. While there is robust evidence demonstrating worse prognosis with residual disease versus path CR after NAC, there is little data regarding outcomes among patients with a heavy residual tumor burden after NAC. We report outcomes in patients who have exceptionally poor responses to NAC-those with > 9 nodes after NAC or with 5 cm or more of residual disease in the breast. MATERIALS/METHODS Between 06/2014 and 04/2020, 1511 patients received NAC followed by surgery at our institution. Poor responders, defined as those with positive nodes or residual tumor in the breast, were identified for analysis. Those with 1-3 positive nodes after NAC were used as a comparison cohort. Recurrence and survival outcomes were compared based on residual disease burden after NAC. Clinicopathologic parameters were summarized with descriptive statistics. Overall survival and recurrence-free survival estimates were calculated using Kaplan Meier methodology. RESULTS Among 517 poor-responders, 315 patients had 1-3 positive nodes (N1a), 108 had 4-9 positive nodes (N2a), and 62 had > 9 positive nodes (high-volume residual, HVR); 32 patients with > 5cm of residual tumor in the breast were categorized as HVR. With a median follow-up of 39 months (IQR 27-50), the 5-year overall survival rate was 90% among N1a, 72% among N2a, and 78% among HVR patients (P = 0.003). The 5-year distant recurrence-free survival and local recurrence-free survival rates were 87%/87% among N1a vs. 59%/71% among N2a vs. 68%/75% among HVR (P < 0.001 and P = 0.009), respectively. 5-year local-regional and distant recurrence cumulative incidence rates, stratified by residual disease burden and by breast cancer subtype, are shown in Table 1. CONCLUSION Our work confirms that patients with high-volume residual are at high risk for LR and distant recurrence as well as death, despite best available standard-of-care treatment. ypN2a patients appear to perform as bad as HVR patients in terms of DM and death, but better in terms of local-regional recurrence. Triple-negative patients with residual disease had high rates of recurrence and death compared to other subtypes. Treatment intensification efforts are urgently needed.

e13650 Background: Studies suggest that oncology patients are satisfied and sometimes prefer telehealth over an in-person visit; however, data are scarce on when patients find telehealth helpful. Such information would be key in understanding how telehealth can be optimally integrated into cancer care delivery. This study aims to identify factors that influence patient experience of telehealth among a multidisciplinary head and neck oncology population. Methods: From Mar 2020 to Dec 2020, we surveyed head and neck oncology patients at a comprehensive cancer center and 6 satellite sites in New York and New Jersey. We assessed patient experience of telehealth versus in-person visit (primary outcome) and their satisfaction with telehealth (secondary outcome). We conducted multivariate regression to analyze covariates that may influence their experience and satisfaction. Covariates included patient factors (age, gender, race, marital status, primary language, home state, home distance from center, current location at home or clinic), clinical factors (diagnosis, performance status, receiving chemotherapy or radiation), physician factors (profession, current location at main or regional campus), visit factors (type, length, billing level, month, first telehealth visit or not), and a technological factor (device type). Results: Among 1,071 completed surveys (response rate 24.0%), 551 first-unique surveys were analyzed. Surveyed patients were predominantly 60 years or older (64.1%), white (88.3%), married (73.8%), and lived within 50 miles from our cancer center (76.1%). Majority had diagnoses of head and neck cancers (65.7%), followed by thyroid cancers (23.8%), and skin cancers (10.5%). While most patients would recommend telehealth (82.4%), only half reported telehealth the same or better compared to in-person visits (55.7%), whereas the other half reported not as good or unsure (44.3%). In multivariate analyses, patients who found telehealth the same or better than in-person visits were more likely to have thyroid cancers (adjusted odds ratios [aOR]: 2.18, CI 95% 1.44 - 3.36) and have visits from July to December (aOR 1.61, CI 95% 1.14 - 2.27). Satisfaction with telehealth was higher among patients with thyroid cancers (aOR: 2.58, CI 95% 1.20 - 6.41), on visits when patients were at home (aOR 3.48, CI 95% 1.37 - 8.42) and when physicians were on campus (aOR 1.73, CI 95% 1.00 - 2.99). Conclusions: Patient experience with telehealth is diverse among the head and neck oncology population; while one-half found telehealth the same or better compared to in-person visits, the other half found it not as good or unsure. More favorable telehealth experience among patient subgroups highlights the multidisciplinary nature of head and neck oncology and improved acceptance of telehealth over time. Future research to optimize patient experience is needed to ensure successful integration of telehealth in head and neck oncology practices.

This cross-sectional study uses data from the Centers for MedicareMedicaid Services to assess the use of professional society guideline-nonconcordant radiotherapy in patients at the end of life.

PURPOSE/OBJECTIVE(S) Perineural invasion (PNI) is a pathologic finding observed across a spectrum of solid tumors, typically with adverse prognostic implications. Little is known about how the presence of PNI influences locoregional recurrence (LRR) among breast cancers. We evaluated the association between PNI and LRR among an unselected, broadly representative cohort of breast cancer patients, and among a propensity-score matched cohort. MATERIALS/METHODS We ascertained breast cancer patients seen at our institution from 2008 to 2019 for whom PNI status and salient clinicopathologic features were available. Fine-Gray regression models were constructed to evaluate the association between PNI and LRR, accounting for age, tumor size, nodal involvement, estrogen receptor (ER), progesterone receptor (PR), HER2 status, histologic tumor grade, presence of lymphovascular invasion (LVI), and receipt of chemotherapy and/or radiation. Analyses were then refined by comparing PNI-positive patients to a PNI-negative cohort defined by propensity score matching. RESULTS Among 8,864 invasive breast cancers, 1384 (15.6%) were noted to harbor PNI. At a median follow-up of 6.3 years, 428 locoregional recurrence events were observed yielding a 7-year LRR of 7.1% (95% CI 5.5-9.1) for those with PNI and 4.7% (95% CI 4.2-5.3; P = 0.01) for those without. On univariate analysis throughout the entire cohort, presence of PNI was significantly associated with an increased risk of LRR (HR 1.39, 95% CI 1.08 - 1.78, P < 0.01). Accounting for differences in salient clinicopathologic and treatment parameters by multivariable Fine-Gray regression modeling, the association between PNI and LRR was potentiated (HR = 1.57, 95% CI 1.2 - 2.07, P = 0.001). We further conducted propensity score matching to balance clinicopathologic parameters and treatments between the two groups (PNI vs not), again showing a similar significant association between PNI and LRR (HR = 1.46, 95% CI 1.03 - 2.08, P = 0.034). CONCLUSION PNI is significantly associated with LRR following the definitive treatment of invasive breast cancer. The excess risk conferred by PNI is similar in magnitude to that observed with LVI, or by ER/PR negativity. Breast cancer prognostication and therapeutic decision-making should consider the presence of PNI among other salient risk factors. Larger studies among more uniform breast cancer presentations may elucidate the extent to which these findings apply across breast cancer subtypes and stages.

PURPOSE/OBJECTIVE(S) Cancer patients are at elevated risk of suicide due to additional disease-specific factors relating to cancer and its treatments. Given that cancer survivorship in the United States continues to improve, evaluating the risk and identifying factors associated with suicide among cancer survivors is warranted. MATERIALS/METHODS This population-based study examined the National Center for Health Statistics Multiple-Cause Mortality data for adult cancer survivors aged ≥ 20 with suicide and self-inflicted injury as the underlying cause and malignant neoplasm as a contributing cause of death. Associations with death by suicide were assessed with multivariable logistic regression for demographic and comorbid factors, and univariate logistic regression for anatomic site of cancer stratified by sex. Trends in suicide rates of non-cancer and cancer survivors were assessed with Pearson's correlation coefficient. RESULTS Among 12,180,902 adult cancer survivors, 6,254 (0.051%) deaths were by suicide. Male sex, White race, being not married, and having a high school education or higher, were associated with increased odds of suicide. Cancer survivors with a documented history of substance use disorder (OR [95% CI], 0.35 [0.31-0.39], P < .001) or chronic medical condition (0.36 [0.34-0.39], P < .001) had decreased odds, while history of depressive disorder had significantly increased odds of suicide (97.44 [90.61-104.78], P < .001), compared to those without the respective comorbidity. Survivors of head and neck, female breast, or genitourinary cancers had increased likelihood of death by suicide compared to those of thoracic sites (Table). Over the study period, the suicide rate of those without a history of cancer increased (r = 0.95, P < .0005) while the overall suicide rate of cancer survivors decreased (r = -0.60, P = 0.005). Specifically, suicide rates decreased for thoracic, gastrointestinal, genitourinary, and head and neck cancers, with the largest decline in multiple, metastatic, not otherwise specified sites (r = -0.67, P = 0.001). CONCLUSION Among adult cancer survivors, suicide risk varies with sociodemographic status, comorbid conditions, and anatomic cancer site. Although the suicide rate of cancer survivors has declined overall, further research is needed to develop interventions in high-risk cancer patients, particularly those with a history of depression, to mitigate suicide risk and improve survivorship care.

Purpose/objective(s) We have previously demonstrated high patient satisfaction with telemedicine during the COVID-19 pandemic. During the relaxation of pandemic restrictions, patients are now offered a choice of in person or remote visits. Here we report on the experience of a cohort of patients treated with radiotherapy who opted for fully remote providers. Materials/methods At the time of new visit consultation scheduling, patients were offered fully remote management if availability of onsite providers was limited. Additionally, after initial consultation with the treating oncologist, if patients expressed preference for treatment at a regional facility different from the oncologist's primary site, they were offered treatment at the preferred site with fully remote on-treatment visits, without transfer of care to an onsite provider. Potentially harmful patient safety events and "near-misses" were prospectively collected with an in-house quality improvement reporting system. Patient satisfaction surveys assessing several domains of the patient experience (including appointment logistics, patient-physician communication, and overall impressions) were distributed to patients before, during and after treatment. Results From 10/2020 to 2/2021, a total of 192 patients treated to 208 sites opted for fully remote management. 50% were male, 50% female. 61% of patients had metastatic disease. Sites treated included prostate (10%), breast (7%), thoracic (7%), head and neck (2%), gastrointestinal (25%), and other sites including bone, soft tissue and brain (49%). There were 46 minor (no harm or near-miss) patient safety events reported, of which 85% were unrelated to patient condition or physician communication and included events associated with treatment planning, orders, prescriptions and delivery. Minor events related to patient condition and patient scheduling/communication comprised 9% and 6% of events, respectively. There was 1 temporary harm event of patient decompensation in the department requiring activation of emergency services. The safety event rate per patient was similar between this cohort and non-remotely managed patients treated during the same period. The telemedicine survey response rate was 32%. Patient satisfaction with telehealth visits remained high with 98% of experiences across all domains rated as Good to Very Good. 90% of patients either preferred telehealth or expressed no preference with the in person vs. fully remote visits. Conclusion Treatment with fully remote providers is safe and feasible, with no serious patient events and minimal need for onsite care. We observed high patient satisfaction, consistent with our previously reported outcomes for telemedicine visits. These findings support the continuation of fully remote management for select patients in the post-COVID era, which can only continue if the current remote/telehealth exemption is continued beyond the emergency period.

Purpose/Objective(s) Local therapy for patients with non-spine bone metastases is evolving, with recent data suggesting that stereotactic body radiotherapy (SBRT) may improve pain response in the palliative setting. However, the rate of local salvage therapy (LST) after SBRT compared to conventional RT is unknown. We therefore characterized rates and risk factors for LST in patients with non-spine bone metastases. Materials/Methods We reviewed records of all courses of RT for non-spine bone metastases at our institution from 1/1/2016 to 12/31/2018. LST was defined as the first occurrence of either RT or surgery for progression to a bone metastasis following initial RT. Functions of the cumulative incidence of re-treatment were generated for each RT technique. We identified associations with various predictors using the Fine and Gray method for competing risk regression. Results Of the 1,754 patients included, 2,648 bone metastases were treated with RT and analyzed with a median follow up of 15 months (IQR = 6.4 – 25.0 months). 51% of episodes were multi-fraction EBRT, 10% were single fraction EBRT, and 39% were SBRT. Of the treated metastases, 120 (4.5%) episodes required LST (median time to LST = 6.2 months, range = 0.3-35.6 months), with a cumulative incidence at 6 and 12 months of 2.4% and 3.9%, respectively. Cumulative incidence of re-treatment at 6 months was 2.6% for SBRT, 3.5% for single-fraction conventional, and 2.1% for multi-fraction conventional regimens (P = 0.76). On multivariable analysis, younger age, higher Karnofsky performance status (KPS), and location of the metastasis in the pelvis had higher hazard of re-treatment (Table 1). There was no significant difference in hazard of LST among RT techniques (P = 0.44), nor was there a significant interaction between RT technique and radioresistant histology (P = 0.33). Conclusion In our large institutional cohort, the rate of LST was low, with no difference between RT techniques. Our results suggest that judicious selection of patients at high risk for eventual treatment failure (i.e., those with longer expected survival) for SBRT may reduce the rate of retreatment rate in the population. When patients are appropriately selected for single fraction conventional RT, such as those who are older or have poor KPS, rates of LST remain low. Further studies to validate our findings are warranted to help clinicians to select the appropriate treatment technique for patients with bone metastases.

Purpose/Objective(s) The delivery of safe and effective radiation therapy relies on accurate target delineation, particularly in the era of highly conformal treatment techniques. Contouring resources can improve accuracy but are fragmented and underused. We report the 5-year development and usage outcomes of a free, online, easily accessible web-based interactive contouring atlas. Materials/Methods eContour ( https://econtour.org ) was developed using modern web technologies, including HTML5, Python, and an interpreted computer programming language, to interactively display images and contours from real patient cases. The viewer has standard tools for image manipulation, contour display, image overlays, and radiation dose distribution. Information from evidence-based guidelines and clinical pearls are summarized and presented next to each case. Mixpanel software was used to collect web usage statistics, including user demographics, geography, and case views. Results In the first 5 years of operation (February 1, 2016 to February 1, 2021), a total of 22,889 users registered on eContour. Users represented a total of 146 countries, with the largest cohort from the United States (7,096, 31%). Other countries with > 700 registered users included Spain, India, Brazil, China, and Russia. The majority of registered users (58%) reported their profession as physicians, including 10,869 practicing radiation oncologists (47%) and 2,583 resident physicians (11%). There are 3,107 users who identified as physicians and were geographically within the US. The remaining users identified as radiation therapists (10%), dosimetrists (10%), medical physicists (8.7%), and medical students (6.6%). As of February 2021, a total of 65 cases have been developed covering 9 disease sites. The most commonly viewed disease site was head and neck (23% of all case views), followed by gynecological, gastrointestinal, and breast cancer. The most commonly viewed cases include pre-operative rectal cancer, head and neck organs-at-risk, and intact prostate cancer. Over 5 years, usage of eContour has increased both in terms of total users and case views. Total users have grown > 600% since 2017; 3,613 (2017), to 12,248 (2019), to 22,889 cumulative total users (2021). In the fourth quarter of 2020, eContour averaged 1,018 case views per weekday. Since the onset of the COVID pandemic, usage of eContour has accelerated. Annual case views increased 56% year-over-year from 2019 to 2020 (147,846 to 230,304 views) as compared to essentially stable from 2018 to 2019 (144,769 to 147,846). Conclusion With approximately 5,000 radiation oncologists in the US, we estimate 60% of US radiation oncologists are registered users. Growth in users and web site traffic over the first 5 years of eContour show its strong potential to increase the use of evidence-based contouring information at the point of care.

Purpose/objective(s) Palliative radiation therapy (RT) can be an effective tool for bone metastases. NCCN guidelines recommend imaging every 3 months after RT for spine metastases (SM), yet no standard surveillance guidelines exist after RT for non-spine bone metastases (NSBM). We sought to evaluate factors associated with radiation oncology-specific follow-up after palliative RT. Materials/methods In a large single-institution retrospective cohort analysis, we identified all patients receiving RT for bone metastases by ICD-10 codes and RT prescription from 2017-2019. Demographic, clinical, and RT data were collected. Overall survival (OS) was calculated using Kaplan-Meier analysis. Factors associated with urgent care (UC) evaluation and radiation oncology follow-up were evaluated with multivariable logistic regression among patients surviving or followed to 3 months post-RT. Results Overall, 3082 patients (39% NSBM, 61% SM) received RT for bone metastases. Within 3 months of RT, 49% had radiation oncology follow-up, 79% underwent imaging, and 27% were seen in the UC. For patients with NSBM, follow-up CT was most common (55%) while for SM, MRI and CT were common (both 54%). Median OS was 10.0 months for SM (95% CI 8.9-11.0) and 13.5 months for NSBM (95% CI 11.5-15.5), with 1343 (71%) SM patients and 923 (77%) NSBM patients surviving to > = 3 months post-RT. Of the 2266 3-month survivors (41% NSBM, 59% SM), 1619 (71%) had radiation oncology follow-up, with higher performance status (OR 2.1, 95% CI 1.44-3.05) and younger patients ( Conclusion After RT for bone metastases, most patients had radiation oncology-specific surveillance, which was associated with younger age and improved performance status. Most patients survived to 3 months post-RT, with a substantial minority receiving a second RT course. Patients with NSBM had longer survival and different time-to-follow-up compared to SM, highlighting the need for further clarification on what the optimal follow-up should be for NSBM. Race was a predictor of UC visits, likely reflecting health disparities that require further investigation. These data support radiation oncology specific follow-up after RT, particularly among younger patients and those with higher performance status with specific attention to racial disparities.

249 Background: The objective of this study was to assess contouring-related quality improvement practices employed by radiation oncologists in the United States (US) and to identify individual and organizational factors associated with use. Methods: We conducted a mixed methods study with a sequential explanatory design. A survey was developed with domains assessing individual and organizational demographic characteristics, clinical decision support strategies, and quality assurance and improvement processes. Study invitations were sent to a random 10% sample of practicing US radiation oncologists. After survey completion, physicians were invited to participate in a 30-minute audio-recorded semi-structured interview. Kruskal-Wallis and Wilcoxon rank-sum tests were used to evaluate associations between participant characteristics and survey responses. Interview data were coded using thematic content analysis. Results: The web-based survey response rate was 24% (115/482), and we completed 15 interviews. 72% of survey respondents report that contouring-related questions arise in at least half of cases in routine patient care, and the resources they access first are cooperative group guidelines and contouring atlases (e.g. RTOG/NRG) (75%) followed by consulting another radiation oncologist (60%). The most frequent barriers to optimizing quality of contours and treatment plans are time constraints (58%) and lack of access to disease site specialists (22%). About half (54%) of respondents do not have access to on-site disease site specialists. A majority of survey respondents (75%) believe having access to disease site specialists to review image-based radiation treatment-related questions would be helpful, and 40% indicated it could facilitate adoption of new radiation treatments. Seven interviewees mentioned engaging with out-of-network sub-specialists by phone, text or email. Five interviewees without access to sub-specialists mentioned a formalized system for consultation could be helpful. While almost all (97%) respondents report having a formal process for peer review, only 44% have contour-specific peer review. Academic centers/university setting and higher number of colleagues are factors associated with increased access to contour-specific peer review (p = 0.02 and p = 0.001). Clinical pathway use was reported by 18% of survey respondents, and interviews revealed concerns related to physician autonomy (i.e. ability to individualize treatment recommendations). Conclusions: This study identifies two potential opportunities to improve the radiation treatment quality from the physician’s perspective– improved access to disease site specialists and contour-specific peer review. Research is needed to test the acceptability and effectiveness of these strategies. Time and resource constraints must be considered when designing quality improvement efforts.

Importance Many patients with metastatic cancer receive high-cost, low-value care near the end of life. Identifying patients with a high likelihood of receiving low-value care is an important step to improve appropriate end-of-life care. Objective To analyze patterns of care and interventions during terminal hospitalizations and examine whether care management is associated with sociodemographic status among adult patients with metastatic cancer at the end of life. Design, Setting, and Participants This retrospective, population-based cross-sectional study used data from the Healthcare Cost and Utilization Project to analyze all-payer, encounter-level information from multiple inpatient centers in the US. All utilization and hospital charge records from national inpatient sample data sets between January 1, 2010, and December 31, 2017 (n = 58 761 097), were screened. The final cohort included 21 335 patients 18 years and older at inpatient admission who had a principal diagnosis of metastatic cancer and died during hospitalization. Data for the current study were analyzed from January 1, 2010, to December 31, 2017. Exposures Patient demographic characteristics, patient insurance status, hospital location, and hospital teaching status. Main Outcomes and Measures Receipt of systemic therapy (including chemotherapy and immunotherapy), receipt of invasive mechanical ventilation, emergency department (ED) admission, time from hospital admission to death, and total charges during a terminal hospitalization. Results Among 21 335 patients with metastatic cancer who had terminal hospitalizations between 2010 and 2017, the median age was 65 years (interquartile range, 56-75 years); 54.0% of patients were female; 0.5% were American Indian, 3.3% were Asian or Pacific Islander, 14.1% were Black, 7.5% were Hispanic, 65.9% were White, and 3.1% were identified as other; 58.2% were insured by Medicare or Medicaid, and 33.2% were privately insured. Overall, 63.2% of patients were admitted from the ED, 4.6% received systemic therapy, and 19.2% received invasive mechanical ventilation during hospitalization. Racial and ethnic minority patients had a higher likelihood of being admitted from the ED (Asian or Pacific Islander patients: odds ratio [OR], 1.43 [95% CI, 1.20-1.72]; P