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There are no agreed upon measures to comprehensively determine the quality of radiation oncology (RO) care delivered for prostate cancer. Consequently, it is difficult to assess the implementation of scientific advances and adherence to best practices in routine clinical practice. To address this need, the US Department of Veterans Affairs (VA) National Radiation Oncology Program established the VA Radiation Oncology Quality Surveillance (VA ROQS) Program to develop clinical quality measures to assess the quality of RO care delivered to Veterans with cancer. This article reports the prostate cancer consensus measures.The VA ROQS Program contracted with the American Society for Radiation Oncology to commission a Blue Ribbon Panel of prostate cancer experts to develop a set of evidence-based measures and performance expectations. From February to June 2021, the panel developed quality, aspirational, and surveillance measures for (1) initial consultation and workup, (2) simulation, treatment planning, and delivery, and (3) follow-up. Dose-volume histogram (DVH) constraints to be used as quality measures for definitive and post-prostatectomy radiation therapy were selected. The panel also identified the optimal Common Terminology Criteria for Adverse Events, version 5.0 (CTCAE V5.0), toxicity terms to assess in follow-up.Eighteen prostate-specific measures were developed (13 quality, 2 aspirational, and 3 surveillance). DVH metrics tailored to conventional, moderately hypofractionated, and ultrahypofractionated regimens were identified. Decision trees to determine performance for each measure were developed. Eighteen CTCAE V5.0 terms were selected in the sexual, urinary, and gastrointestinal domains as highest priority for assessment during follow-up.This set of measures and DVH constraints serves as a tool for assessing the comprehensive quality of RO care for prostate cancer. These measures will be used for ongoing quality surveillance and improvement among veterans receiving care across VA and community sites. These measures can also be applied to clinical settings outside of those serving veterans.

Radical cystectomy with bilateral pelvic lymphadenectomy and trimodality bladder-sparing therapy or TMT, are both curative options for patients with nonmetastatic muscle invasive bladder cancer. Patients should be afforded the opportunity for a multidisciplinary evaluation with equipoise in discussing these options for eligible patients. We discuss the barriers to broader acceptance and utilization of TMT and encourage support of clinical trials of TMT.

Extracorporeal Membrane Oxygenation (ECMO) is associated with significant mortality. Provision of high-quality end-of-life (EOL) care for patients supported on ECMO entails specific physiological, pharmacological, and technical considerations. Limited guidance exists for clinicians on delivery of optimal EOL care on ECMO. In this article, we review the unique aspects of EOL care as they apply to ECMO support and propose a pragmatic, interdisciplinary framework for compassionate ECMO discontinuation in children and adults. The goal of compassionate ECMO discontinuation (CED) is to allow natural death from the underlying disease process while delivering high-quality EOL care to ensure a good death experience for patients and their families. The CED approach includes: 1) a family meeting to define goal-concordant EOL care and prepare families and patients for the dying process; 2) clinical preparation, including symptom management and discontinuation of other life-sustaining therapies; 3) technical aspects which necessarily vary according to patient factors and the circuit and cannulation strategy; and 4) bereavement support. The proposed CED considerations and checklist may serve as tools aiding provision of comprehensive, quality, individualized patient- and family-centered care for children and adults dying despite ECMO support. A structured CED may enhance EOL experiences for patients, family, and staff by providing a respectful and dignified death experience. Future research is required to determine feasibility and effectiveness of the framework, which must be adapted to the patient and institutional setting.

Purpose Primary mediastinal B cell lymphoma (PMBCL) is a highly curable subtype of non-Hodgkin lymphoma that is diagnosed predominantly in adolescents and young adults. Consequently, long-term treatment-related morbidity is critical to consider when devising treatment strategies that include different chemoimmunotherapy strategies with or without radiation therapy. Furthermore, adaptive approaches using the end-of-chemotherapy (EOC) positron emission tomography (PET)/computed tomography (CT) scanning may help to determine which patients may benefit from additional therapies. We aimed to develop evidence-based guidelines for treating these patients. Methods and Materials We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline using the PubMed database. The ARS expert committee, composed of radiation oncologists, hematologists, and pediatric oncologists, developed consensus guidelines using the modified Delphi framework. Results Nine studies met the full criteria for inclusion based on reporting outcomes on patients with primary mediastinal B cell lymphoma with EOC PET/CT response scored with the 5-point Deauville scale. These studies formed the evidence for these guidelines in managing patients with PMBCL according to the EOC PET response, including after a 5-point Deauville scale of 1 to 3, 4, or 5, and for patients with relapsed and refractory disease. The expert group also developed guidance on radiation simulation, treatment planning, and plan evaluation based on expert opinion. Conclusions Various treatment approaches exist in the management of PMBCL, including different chemoimmunotherapy regimens, the use of consolidative radiation therapy, and adaptive approaches based on EOC PET/CT response. These guidelines can be used by practitioners to provide appropriate treatment according to different disease scenarios.

In the past decade, behavioral science has seen the introduction of beneficial reforms to reduce false positive results. Serving as the motivational backdrop for the present research, we wondered whether these reforms might have unintended negative consequences for researchers’ behavior and emotional experiences. In an experiment simulating the research process, Study 1 (N = 449 researchers) suggested that engaging in a pre-registration task impeded the discovery of an interesting but non-hypothesized result. Study 2 (N = 400 researchers) indicated that relative to confirmatory research, researchers found exploratory research more enjoyable, motivating, and interesting; and less anxiety-inducing, frustrating, boring, and scientific. These studies raise the possibility that emphasizing confirmation can shift researchers away from exploration, and that such a shift could degrade the subjective experience of conducting research. Study 3 (N = 314 researchers) introduced a scale to measure “prediction preoccupation”—the feeling of heightened concern over, and fixation with, confirming predictions.

OBJECTIVES To evaluate the complications and oncologic outcomes of orthotopic ileal neobladder reconstruction (ONB) following pelvic radiotherapy (RT) compared to patients with no prior pelvic RT. METHODS Our institutional database was queried for all patients with pT0-4bN0-3M0 urothelial carcinoma of the bladder who underwent radical cystectomy with curative intent and ONB between 1990 and 2018. We then queried this cohort for patients who had prior pelvic RT (>3900 cGy) and compared baseline characteristics, perioperative complications, and recurrence free survival between patients with and without prior pelvic RT. RESULTS One thousand eight hundred and forty-six patients matched our inclusion criteria; 34 had prior pelvic RT with a median dose of 6280 cGy. Prior RT targeted the bladder, prostate, and cervix in 27, 6, and 1 patient, respectively. Median time from RT to cystectomy was 15.5 months. Patients with prior RT had a longer time from diagnosis to cystectomy, more frequently had ≥5 TURBT and neoadjuvant chemo, and less frequently had multifocal disease. Perioperative complications including operative time, estimated blood loss, days hospitalized, as well as 30- and 90-day complication rates, were not statistically different. There was no statistical difference in recurrence free survival between the 2 groups (P = .48). CONCLUSION ONB in highly selected patients with prior pelvic RT is feasible with statistically similar perioperative complication rates compared to ONB without prior RT.

PurposePatients who receive radiation therapy (RT) for prostate cancer are routinely positioned through radiographic means. We set out to establish a data-driven process that defines bladder volume required to meet V40/65 constraints using daily bladder ultrasound (US) and comparative cone beam CT (CBCT) before placing a patient on the treatment table.Methods and materialsThis was a single institution retrospective study of 20 patients (390 CBCT scans) who received postprostatectomy RT. Each patient received a daily US before treatment. CBCT alignment was performed 3 times a week. The bladder and rectum were contoured on each CBCT and a session dose was recorded. A mixed-effect model was used to estimate trajectory slopes of radiation exposure with organs-at-risk volume increase. Slope differences by V40/65 for prostate fossa (PF) and pelvic lymph nodes (PF/pLN) were tested using a 3-way-interaction term with Bonferroni correction.ResultsFor the 20 patients, 10 received treatment to PF and 10 received RT to the PF/pLN. Predefined bladder constraints were V65 < 50%, V40 < 70%, and rectal constraints were V65 < 35%, V40 < 55%. The CBCT bladder volume (76-578 cm3) was greater than the pretreatment bladder US (87-466 cm3) due to volume filling between measurements (r = 0.8 ± 0.05). Mixed model detected a statistically significant 3-way interaction (P < .01) for bladder volume and V40/65. Both PF and PF/pLN patients showed improvement in V40/65 with an increase in bladder volume. For PF patients, bladder constraints were met when the US volume was >108 cm3 and for PF/pLN patients when the US bladder volume was >200 cm3. Rectal filling showed no association with CBCT volume.ConclusionsDaily US of the bladder before postprostatectomy RT allows for dosimetric predictions before daily treatment. This should translate into fewer CBCT for the patient and improved machine throughput. This technique is easy to institute and ensures organs-at-risk volumetric constraints are met based on daily US measurements.

Purpose Stereotactic body radiotherapy (SBRT) in the post-prostatectomy setting is investigational. A major concern is the deformable prostate bed clinical target volume (CTV) and the closely juxtaposed organs-at-risk (OARs). We report a volumetric and dosimetric analysis of kilovoltage cone-beam CT (CBCT) data from the first 18 patients enrolled on a phase II trial of post-prostatectomy SBRT. With instructions on bladder filling and rectal preparation, we hypothesized acceptable CTV coverage while minimal overdosing to OARs could be achieved. Methods All patients received 5 fractions of 6–6.8 Gy to the prostate bed. CBCT were taken prior to and halfway through each fraction. CTV and OARs were contoured for each CBCT. Changes in inter- and intra-fraction volume and dose were calculated. Relative changes in CTV V95%, bladder V32.5 Gy, and rectal V32.5 Gy and V27.5 Gy were evaluated. Results Interfraction CTV volume remained stable, with median change +5.69% (IQR −1.73% to +9.84%). CTV V95% exhibited median change −0.74% (IQR −9.15% to −0.07%). Volumetric and dosimetric changes were minor from interfraction rotation and intrafraction motion. CTV V95% was ≥93% in 13 of 18 (72%) patients; in the remaining five, median change was −14.09% (IQR −16.64% to −13.56%). Interfraction CTV volume change was significantly larger among patients with CTV V95% Conclusions With specific bladder and rectum filling protocols, CTV underdosing and overdosing to bladder and rectum are avoided in majority of patients. Changes in CTV shape may account for the underdosing that may be observed.

Objectives Some hospitals have invested in robotic surgery platforms to stimulate the uptake of minimally invasive surgery (MIS) and offer its benefits to more patients. The objectives were to determine the clinical and financial effects, as well as the policy implications, of a robotics program in an academic gynecologic oncology division over time. Methods Patients treated for endometrial, cervical, and ovarian cancer within a gyn-oncology division between 2003 and 2016 were included in the current study. Clinical outcomes were described in function of surgical approach (laparotomy, laparoscopy, and robotic surgery) and tumor site. The net present value and the return on investment of the robotics program were approximated using previously reported treatment costs from our center. Results The use of MIS soared from a high of 15% to 91% before and after the introduction of robotics in December 2007, respectively. Across all tumor sites, MIS procedures were associated with diminished blood loss and a shorter hospital stay (p Conclusions Robotic surgery was instrumental in catalyzing the shift from open surgery to MIS and amplifying the number of patients who benefited from less invasive surgery. Continued investments in robotics and the digitization of surgery could help further drive innovation and expand its applications.