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Background In meeting input data requirements for a system dynamics (SD) model simulating the radiotherapy (RT) process, the number of patient care pathways (RT workflows) needs to be kept low to simplify the model without affecting the overall performance. A large RT department can have more than 100 workflows, which results in a complex model structure if each is to be handled separately. Here we investigated effects on model performance by reducing the number of workflows for a model of the preparatory steps of the RT process. Methods We created a SD model sub-structure capturing the preparatory RT process. Real data for patients treated in 2015-2016 at a modern RT department in Sweden were used. RT workflow similarity was quantified by averaged pairwise utilization rate differences (%) and the size of corresponding correlation coefficients (r). Grouping of RT workflows was determined using two accepted strategies (80/20 Pareto rule; merging all data into one group) and a customized algorithm with r≥0.75:0.05:0.95 as criteria for group inclusion by two strategies (A1 and A2). Number of waiting patients for each grouping strategy were compared to the reference of all workflows handled separately. Results There were 128 RT workflows for 3209 patients during the studied period. The 80/20 Pareto rule resulted in 14/8/21 groups for curative/palliative/disregarding treatment intent. Correspondingly, A1 and A2 resulted in 7-40/≤4-36/7-82 groups depending on r cutoff. Results for the Pareto rule and A2 at r≥85 were comparable to the reference. Conclusions The performance of a simulation model over the RT process will depend on the grouping strategy of patient input data. Either the Pareto rule or the grouping of patients by resource use can be expected to better reflect overall departmental effects to various changes than when merging all data into one group. Our proposed approach to identify groups based on similarity in resource use can potentially be used in any setting with variable incoming flows of objects which go through a multi-step process comparable to RT where the aim is to reduce the complexity of associated model structures without compromising with overall performance.

Background The aim of this study was to adapt the instrument and evaluate the psychometric properties of the Swedish version of the Swallowing Quality of Care questionnaire (S-SWAL-CARE) in patients with oropharyngeal dysphagia. Methods Translation and adaptation of the original SWAL-CARE into Swedish was performed according to established international guidelines. Field testing was performed using 100 patients with oropharyngeal dysphagia due to multiple reasons such as head and neck cancer and neurologic/neuromuscular disease, who had undergone swallowing evaluation within 6 months prior to the study. The patients answered the S-SWAL-CARE, the Quality from the Patient’s Perspective (QPP) and the Swallowing Quality of Life (SWAL-QOL). Test–retest was performed in 20% of the participants. The reliability and validity of the S-SWAL-CARE were assessed by Pearson correlation coefficient and Cronbach’s alpha as well as convergent and discriminative validity, respectively. Results The field testing of the S-SWAL-CARE resulted in sufficient reliability, with Cronbach’s alpha values exceeding 0.90 for all domains. All items correlated strongly to their own domain, with weaker correlations to the other domains, indicating proper scale structure. Results also indicate sufficient convergent and discriminant validity when tested for association to the QPP domains and the SWAL-QOL Total score. The test–retest reliability of the S-SWAL-CARE demonstrated sufficient intraclass correlation coefficient (ICC) for the General advice domain (0.73) and Clinical advice domain (0.82). The ICC for the Patient satisfaction domain was lower (0.44). Conclusion The S-SWAL-CARE can be considered a reliable and valid tool to assess the dysphagia-related quality of care in a mixed Swedish dysphagia patient population.

Highlights • RT staff generally enjoyed their work and was positive to change. • An important key to enjoy work/perform well was willingness to cooperate. • Organizational issues, shortage of time and lack of staff were current concerns. • Contouring was the most critical bottleneck in the RT workflow. • Small departments were less affected by work-related problems., Background The radiotherapy (RT) community faces great challenges to meet the growing cancer incidence, especially regarding workload and recruitment of personnel. Workflow-related issues affect involved professions differently since they have specific expertise and various roles in the workflow. To obtain an objective understanding of the current working situation and identify workflow bottle necks in RT, we conducted a national survey on this topic in 2018. Materials and Methods All 17 (photon-based) RT departments in Sweden were invited to participate in the study, which targeted both managers and employees in RT. Descriptive statistics were calculated for each profession and for small, medium and large departments (2/3–4/≥5 linacs). Results Altogether, 364 filled-in questionnaires were returned (32/332 managers/employees; 94% response rate). Managers reported a general need for more staff (all professions). Small departments reported no problems with waiting times (0/3); whereas 2/3 of medium and large departments did (medium: 5/8, large: 2/3). All professions had a positive attitude towards working in RT (mean = 86%, 0/100%=negative/positive attitude). Organizational issues were ranked highest among reoccurring events that were most frustrating/had most negative effect on the work environment. The most severe workflow-related problems were reported to originate at contouring. Conclusion Future efforts to improve the modern RT workflow need to focus on how to make positive mechanisms at small departments useful in larger settings. Our data also reveal that strong leadership and improved routines at contouring are warranted by all RT professions to reduce frustration related to organizational issues and to increase work effectivity.

A fundamental problem in radiotherapy is the variation of organ at risk (OAR) volumes. Here we present our initial experience in engaging a large Radiation Oncology (RO) community to agree on national guidelines for OAR delineations. Our project builds on associated standardization initiatives and invites professionals from all radiotherapy departments nationwide. Presently, one guideline (rectum) has successfully been agreed on by a majority vote. Reaching out to all relevant parties in a timely manner and motivating funding agencies to support the work represented early challenges. Population-based data and a scalable methodological approach are major strengths of the proposed strategy.

Objectives To explore an understanding of medical doctors' entire process of specialty choice with a focus on the influence of personal experiences and personality traits on choices made. Methods A qualitative study was performed. Semi-structured individual interviews were conducted with medical doctors undergoing their specialty training in Sweden about their experiences and personalities. The transcribed interviews were analyzed with an inductive content analysis approach. Results A total of 15 medical doctors participated. Three themes were identified using content analysis: To be invited or not, to fit in or not and to contribute or not. Furthermore, the results refute that specialty choice is a long-term, complex process. Conclusions First, the importance of being invited to the specialty choice was stressed by the doctors, especially in their early years when they needed to feel valued and trusted. Secondly, the need to fit in was essential to make a sustainable career choice. Finally, the doctors' expressed a will to contribute to the medical field of their chosen specialty. The interviews showed that specialty choice is a long-term, complex process; therefore, one implication for the healthcare sector would be to target the entire chain of medical education to improve recruitment strategies for those specialties with recruitment difficulties. More studies are needed to understand better how positive and negative encounters within the healthcare sector can influence young doctors' specialty choice.

Objectives: Evaluation of the degree of concordance between an artificial intelligence (AI) program and radiologists in assessing malignant lesions in screening mammograms. Methods: The study population consisted of all consecutive cases of screening-detected histopathologically confirmed breast cancer in females who had undergone mammography at the NU Hospital Group (Region Västra Götaland, Sweden) in 2018 to 2019. Data were retrospectively collected from the AI program (lesion risk score in percent and overall malignancy risk score ranging from 1 to 10) and from medical records (independent assessments by two radiologists). Ethical approval was obtained. Results: Altogether, 120 females with screening-detected histopathologically confirmed breast cancer were included in this study. The AI program assigned the highest overall malignancy risk score 10 to 86% of the mammograms. Five cases (4%) were assigned an overall malignancy risk score ≤5. Lack of consensus between the two radiologists involved in the initial assessment was associated with lower overall malignancy risk scores (p = 0,002). Conclusion: The AI program detected a majority of the cancerous lesions in the mammograms. The investigated version of the program has, however, limited use as an aid for radiologists, due to the pre-calibrated risk distribution and its tendency to miss the same lesions as the radiologists. A potential future use for the program, aimed at reducing radiologists’ workload, might be to preselect and exclude low-risk mammograms. Although, depending on cut-off score, a small percentage of the malignant lesions can be missed using this procedure, which thus requires a thorough risk–benefit analysis. Advances in knowledge: This study conducts an independent evaluation of an AI program’s detection capacity under screening-like conditions which has not previously been done for this program.

Health care is a complex system with multiprofessional staff and multiple patient care pathways. Time pressure and minimal margins for error make it challenging to implement new policies or procedures, no matter how desirable. Changes in health care also requires the participation of the staff. System dynamics (SD) simulations can lead to shared systems understanding and allows for the development and testing of new scenarios in silico before implementing solutions. However, research shows that the actual implementation rate of simulations is low. This paper presents a reanalysis of a successful change project in health care combining SD principles with basic action research (AR) premises. The analysis was done by a multidisciplinary research group using qualitative methodology and identifies that a fruitful combination of AR inquiry and SD modelling potentially can improve implementation rates. publishedVersion

Background and purpose: In uterine cervical cancer tumour spread reaching the para-aortic lymph nodes is the most significant independent pre-treatment predictor of progression-free survival. When introducing [18F]fluorodeoxyglucose-positron emission tomography (FDG-PET)/computed tomography (CT) in our clinic for patients with advanced cervical cancer planned for definitive radiochemotherapy, the purpose of this study was to quantify to what extent the added information lead to changes in radiotherapy planning. Material and methods: We included 25 consecutive patients with cervical cancer stages IB2 – IIIB planned for definitive radiochemotherapy between November 2010 and May 2012. The patients were examined both with magnetic resonance imaging (MRI) and FDG-PET/CT before treatment and after four weeks of treatment. Results: In 11/24 (46%) of the patients the FDG-PET/CT before treatment provided additional diagnostic information leading to changes in treatment planning compared to information from MRI. Seven of these eleven patients (64%) were alive and without evidence of disease at four-year follow-up. The MRI detected pelvic tumour spread not seen on the FDG-PET/CT in 2/24 patients. The disease-free four-year survival was 59%. Conclusions: Additional diagnostic information from FDG-PET/CT changed treatment strategy in almost half of the patients and may have increased chances of survival in this limited group of patients with locally advanced uterine cervical cancer. We recommend both modalities for nodal detection. Keywords: Cervical cancer, Nodal spread, Radiochemotherapy, FDG-PET/CT, MRI

PURPOSE/OBJECTIVE(S) Although radiation-induced side-effects affecting mastication functionality have been studied in head and neck cancer (HNC) radiotherapy (RT), dose constraints for the associated structures are rarely included during treatment plan optimization. Previous research has identified several radiation dose relationships with mean dose thresholds around 30-40 Gy for masseter muscles, 40-50 Gy for pterygoid muscles, and 15-60 Gy for temporomandibular joint (TMJ) relating to a 10% trismus risk post RT. The purpose of this work was to use a multi-criteria optimization (MCO) approach to investigate to what extent doses to these structures can be lowered without violating existing clinical treatment goals in inverse planning of HNC RT. MATERIALS/METHODS This exploratory treatment planning study used data from 22 HNC patients treated to 68 Gy without mastication-structure-sparing intent in 2017-2019 at one institute in Sweden. Original volumetric-modulated arc therapy (VMAT) plans were re-activated in the treatment planning system and masseter muscles, pterygoid muscles (medial and lateral), and TMJ were consistently delineated according to a previously reported delineation manual4. Re-planning was done using the MCO function of the treatment planning system with the resulting dose distribution normalized to match the clinical target volume (CTV T) mean dose of the clinical treatment plan. Dose differences between MCO and clinical plans were not allowed to exceed 2 Gy for any original clinical treatment goal unless tolerance doses had been substantially exceeded in the clinical treatment plan. To what extent dose to mastication structures could be lowered without violating existing clinical treatment goals were quantified by group and by patient. RESULTS Altogether, there were 334 clinical treatment goals in the clinical treatment plans (median = 15, range: 7-24 per patient, depending on tumor location), which easily could be met in the corresponding MCO plans. Mean doses to the mastication structures were in most cases below proposed tolerance doses in the clinical plan but could on average be further reduced between 3-5 Gy in the MCO plans (Table). Of the 25/88 patient reductions below 5 Gy (28%), 18/25 (72%) were for the masseter (n = 8) and medial pterygoid (n = 10) muscles. CONCLUSION With modern RT, it seems possible to reduce the dose to mastication structures below proposed trismus dose tolerance thresholds for most HNC patients without violating clinical treatment goals. Focusing on masseter and medial pterygoid muscle doses may prove to give the largest benefit in individual cases.

Purpose/Objective(s) Successful delivery of radiotherapy (RT) relies on correct and consistent definition of organs at risk (OAR). Artificial intelligence (AI) auto-segmentation based on deep learning (DL) is emerging as a means to reduce variability of OARs. Knowledge about how auto-segmentation tools perform on standardized datasets is limited. Our aim is to evaluate the quality of rectal volumes defined by an existing DL auto-contouring algorithm on a standardized dataset for rectal volumes in prostate cancer RT as proposed by the Swedish STRONG guidelines for male pelvis [1][2][3]. [1] Olsson et al. PhIRO 2019:11:88 [2] Gay et al. IJROBP 2012:83:e353 [3] Salembier et al. RO 2018:127:49 Materials/Methods DICOM-RT datasets for 19 patients extracted from a treatment planning system at one institution in Sweden was used. The patients were treated for prostate cancer in 2018-2019 using 15 MV photon beams to total doses of 50-70Gy@2-3Gy/fraction. Rectal volumes were defined on planning CT images clinically (clinical), according to proposed standard (reference), and auto-contoured using the existing version of the MVision software. The degree of variation between volumes was investigated. Statistics included dose volume histogram metrics, the Jaccard index, and the Dice similarity coefficient with comparisons between groups based on hypothesis testing with a two-sided P-value≤0.05 indicating a statistically significant difference. Results The clinical and the MVision DVH points were in general closer to each other than to the points of the reference DVH. Clinical and MVision volumes were also somewhat larger than the reference volume (83cc and 84cc versus 80cc; P > > 0.05). Overall, mean doses were 0.8/0.9Gy lower for clinical/MVision compared with the reference (21.9 ± 5.1/21.8 ± 5.1Gy versus 22.7 ± 5.9Gy; P > > 0.05) whilst maximum doses were similar for all (67.8-67.9 ± 4.3). Both overlap metrics were similar for volume comparisons between MVision and reference and for MVision and clinical but somewhat higher for clinical and reference (Jaccard index/Dice coefficient: 0.74/0.85 versus 0.73/0.83 versus 0.90/0.95, respectively). Differences were primarily found in cranio-caudal direction between any two data sets. Conclusion This is the first systematic comparison of an auto-contouring algorithm's performance on a standardized OAR dataset in RT. Our results need to be confirmed on a larger patient cohort, but indicate that the MVision algorithm did very well since the size of identified differences generally was small both with respect to clinical and to reference volumes. However, to increase the use of AI-algorithms for clinical studies and research, retraining them on standardized reference datasets has the potential to improve performance further.

Dysphagia is a common and severe toxicity after oncological treatment of head and neck cancer (HNC). The study aim was to investigate relationships between patient-reported dysphagia and clinically measured swallowing function in HNC after modern curative radiotherapy with or without chemotherapy to identify possible alarm symptoms for clinically manifest dysphagia. Patients with tumors of the tonsil, base of tongue, hypopharynx, and larynx treated in 2007–2015 were assessed for dysphagia post-treatment by telephone interview and videofluoroscopy (VFS). A study-specific categorized symptom score was used to determine patient-reported dysphagia (DESdC = presence of Drinking, Eating, Swallowing difficulties, and Coughing when eating/drinking (any combination); scores between 0 and 4 with 0 = no symptom); the penetration–aspiration scale (PAS) to determine swallowing function by VFS. Swallowing difficulties were defined as DESdC ≥ 1 and PAS ≥ 2. Relationships between clinically relevant cut-offs for DESdC and PAS were determined by Pearson’s correlation coefficient (Pr). Swallowing difficulties according to DESdC were reported by 89% of the patients and according to PAS by 60% at a median of 7 months post-treatment. Averaged correlations between DESdC score 1/2/3/4 and PAS were 0.16/0.10/0.27/0.18. Almost one in two patients with DESdC score ≥3 had severe swallowing difficulties according to PAS. Correlations between individual DESdC:s were highest for swallowing and eating (Pr = 0.53) and lowest for swallowing and coughing (Pr = 0.11). Our data suggest that if a patient reports having swallowing difficulties, it is likely that he or she also has eating difficulties but not necessarily coughing problems when eating/drinking. However, if all these three symptoms are reported, it is likely that the patient will present with moderate or severe impaired swallowing function according to PAS and thus should be referred for further evaluation and treatment.

Objectives To identify temporal patterns of patient-reported trismus during the first year post-radiotherapy, and to study their associations with maximal interincisal opening distances (MIOs). Design Single institution case series. Setting University hospital ENT clinic. Participants One hundred ninety six subjects who received radiotherapy (RT) for head and neck cancer (HNC) with or without chemotherapy in 2007-2012 to total dose of 64.6/68 Gy in 38/34 fractions, respectively. All subjects were prospectively assessed for mouth-opening ability (Gothenburg Trismus Questionnaire (GTQ), and MIO) pre-RT and at 3, 6, and 12 months after RT. Main outcome measures Correlations between temporally robust GTQ-symptoms and MIO as given by Pearson's correlation coefficients (Pr); temporally robust GTQ-symptom domains as given by factor analysis; rates of trismus with respect to baseline by risk ratios (RRs). Results Four temporally robust domains were identified: Eating (3-7 symptoms), Jaw (3-7), Pain (2-5), and Quality of Life (QoL, 2-5), and included 2-3 persistent symptoms across all post- RT assessments. The median RR for a moderate/severe (>2/>3) cut-off was the highest for Jaw (3.7/3.6) and QoL (3.2/2.9). The median Pr between temporally robust symptoms and MIO post-radiotherapy was 0.25-0.35/0.34-0.43/0.24-0.31/0.34-0.50 for Eating/Jaw/Pain/QoL, respectively. Conclusions Mouth-opening distances in HNC patients post-RT can be understood in terms of associated patient-reported outcomes on trismus-related difficulties. Our data suggest that a reduction in MIO can be expected as patients communicate their mouth-opening status to interfere with private/social life, a clinical warning signal for emerging or worsening trismus as patients are being followed after RT. This article is protected by copyright. All rights reserved.

Highlights • Majority of DARS investigated for radiation-induced late dysphagia in HNC. • Epiglottis (E) and submandibular glands (SG) have previously not been reported as critical for dysphagia. • Reduced epiglottic inversion may explain the importance of E dose. • Interplay between xerostomia and dysphagia may explain the importance of SG dose. • Potential DVH thresholds to reduce dysphagia: E V60 = 60% and contralateral SG V60 = 17%, Background and purpose Dysphagia is a common, severe and dose-limiting toxicity after oncological treatment of head and neck cancer (HNC). This study aims to investigate relationships between radiation doses to structures involved in normal swallowing and patient-reported as well as clinically measured swallowing function in HNC patients after curative (chemo-) radiation therapy (RT) with focus on late effects. Materials and methods Patients (n = 90) with HNC curatively treated with RT ± chemotherapy in 2007–2015 were assessed for dysphagia post-treatment by telephone interview and videofluoroscopy (VFS). A study-specific symptom score was used to determine patient-reported dysphagia. The Penetration-Aspiration Scale (PAS) was applied to determine swallowing function by VFS (PAS ≥ 4/ ≥ 6 = moderate/severe dysphagia). Thirteen anatomical structures involved in normal swallowing were individually delineated on the patients’ original planning CT scans and associated dose-volume histograms (DVHs) retrieved. Relationships between structure doses and late toxicity were investigated through univariable and multivariable logistic regression analysis (UVA/MVA) accounting for effects by relevant clinical factors. Results Median assessment time was 7 months post-RT (range: 5–34 months). Mean dose to the contralateral parotid gland and supraglottic larynx as well as maximum dose to the contralateral anterior digastric muscle predicted patient-reported dysphagia (AUC = 0.64–0.67). Mean dose to the pharyngeal constrictor muscle, the larynx, the supraglottic larynx and the epiglottis, as well as maximum dose to the contralateral submandibular gland predicted moderate and severe dysphagia by VFS (AUC = 0.71–0.80). Conclusion The patients in this cohort were consecutively identified pre-treatment, and were structurally approached and assessed for dysphagia after treatment at a specific time point. In addition to established dysphagia organs-at-risk (OARs), our data suggest that epiglottic and submandibular gland doses are important for swallowing function post-RT. Keeping DVH thresholds below V60 = 60% and V60 = 17%, respectively, may increase chances to reduce occurrence of severe late dysphagia. The results need to be externally validated in future studies.

Purpose To develop an infrastructure for structured and automated collection of interoperable radiation therapy (RT) data into a national clinical quality registry. Materials and methods The present study was initiated in 2012 with the participation of seven of the 15 hospital departments delivering RT in Sweden. A national RT nomenclature and a database for structured unified storage of RT data at each site (Medical Information Quality Archive, MIQA) have been developed. Aggregated data from the MIQA databases are sent to a national RT registry located on the same IT platform (INCA) as the national clinical cancer registries. Results The suggested naming convention has to date been integrated into the clinical workflow at 12 of 15 sites, and MIQA is installed at six of these. Involvement of the remaining 3/15 RT departments is ongoing, and they are expected to be part of the infrastructure by 2016. RT data collection from ARIA®, Mosaiq®, Eclipse™, and Oncentra® is supported. Manual curation of RT-structure information is needed for approximately 10% of target volumes, but rarely for normal tissue structures, demonstrating a good compliance to the RT nomenclature. Aggregated dose/volume descriptors are calculated based on the information in MIQA and sent to INCA using a dedicated service (MIQA2INCA). Correct linkage of data for each patient to the clinical cancer registries on the INCA platform is assured by the unique Swedish personal identity number. Conclusions An infrastructure for structured and automated prospective collection of syntactically interoperable RT data into a national clinical quality registry for RT data is under implementation. Future developments include adapting MIQA to other treatment modalities (e.g. proton therapy and brachytherapy) and finding strategies to harmonize structure delineations. How the RT registry should comply with domain-specific ontologies such as the Radiation Oncology Ontology (ROO) is under discussion.

Purpose: To identify imaged regions in which dose is associated with radiation-induced trismus after head and neck cancer radiation therapy (HNRT) using a novel image-based data mining (IBDM) framework. Methods and Materials: A cohort of 86 HNRT patients were analyzed for region identification. Trismus was characterized as a continuous variable by the maximum incisor-to-incisor opening distance (MID) at 6 months after radiation therapy. Patient anatomies and dose distributions were spatially normalized to a common frame of reference using deformable image registration. IBDM was used to identify clusters of voxels associated with MID (P ≤.05 based on permutation testing). The result was externally tested on a cohort of 35 patients with head and neck cancer. Internally, we also performed a dose-volume histogram–based analysis by comparing the magnitude of the correlation between MID and the mean dose for the IBDM-identified cluster in comparison with 5 delineated masticatory structures. Results: A single cluster was identified with the IBDM approach (P s = −0.36, –0.35, −0.32; P =.001,.001,.002, respectively). External validation confirmed an association between mean dose to the IBDM cluster and MID (R s = −0.45; P =.007). Conclusions: IBDM bypasses the common assumption that dose patterns within structures are unimportant. Our novel IBDM approach for continuous outcome variables successfully identified a cluster of voxels that are highly associated with trismus, overlapping partially with the ipsilateral masseter. Tests on an external validation cohort showed an even stronger correlation with trismus. These results support use of the region in HNRT treatment planning to potentially reduce trismus.

Purpose The aims of this study were to systematically review tolerance doses for late distinct gastrointestinal (GI), genitourinary (GU), and sexual dysfunction (SD) symptoms after external beam radiation therapy (EBRT) alone and treatments involving brachytherapy (BT) for prostate cancer after Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) and ultimately to perform quantitative syntheses of identified dose/volume tolerances represented by dose-volume histogram (DVH) thresholds, that is, statistically significant (P ≤ .05) cutoff points between symptomatic and asymptomatic patients in a certain study. Methods and Materials PubMed was scrutinized for full-text articles in English after QUANTEC (January 1, 2010). The inclusion criteria were randomized controlled trials, case-control studies, or cohort studies with tolerance doses for late distinct symptoms ≥3 months after primary radiation therapy for prostate cancer (N > 30). All DVH thresholds were converted into equivalent doses in 2-Gy fractions (EQD2α/β) and were fitted with a linear or linear-quadratic function (goodness of fit, R2). The review was registered on PROSPERO (CRD42016042464). Results From 33 identified studies, which included 36 to 746 patients per symptom domain, the majority of dose/volume tolerances were derived for GI toxicity after EBRT alone (GI, 97 thresholds; GU, 8 thresholds; SD, 1 threshold). For 5 symptoms (defecation urgency, diarrhea, fecal incontinence, proctitis, and rectal bleeding), relationships between dose/volume tolerances across studies (R2 = 0.93 [0.82-1.00]), and across symptoms, leading to a curve for overall GI toxicity (R2 = 0.98), could be determined. For these symptoms, mainly rectal thresholds were found throughout low and high doses (10 Gy ≤ equivalent dose in 2-Gy fractions using α/β = 3Gy (EQD23) ≤ 50 Gy and 55 Gy ≤ EQD23 ≤ 78 Gy, respectively). For BT with or without EBRT, dose/volume tolerances were also mainly identified for GI toxicity (GI, 14 thresholds; GU, 4 thresholds; SD, 2 thresholds) with the largest number of DVH thresholds concerning rectal bleeding (5 thresholds). Conclusions Updated dose/volume tolerances after QUANTEC were found for 17 GI, GU, or SD symptoms. A DVH curve described the relationship between dose/volume tolerances across 5 GI symptoms after EBRT alone. Restricting treatments for EBRT alone using the lower boundaries of this curve is likely to limit overall GI toxicity, but this should be explored prospectively. Dose/volume tolerances for GU and SD toxicity after EBRT alone and after BT with or without EBRT were scarce and support further research including data-sharing initiatives to untangle the dose/volume relationships for these symptoms.

Background: To present an overview of patient-reported sexual toxicity in sexually active long-term prostate cancer survivors treated with radiation therapy. Methods: We used patient-reported outcomes from a study-specific questionnaire surveying symptoms after prostate cancer radiation therapy. Data from 518 men treated at the Sahlgrenska University Hospital in Sweden from 1993 to 2006 were analysed. The men had undergone primary or salvage external beam radiation therapy (EBRT) or EBRT combined with high-dose rate brachytherapy (BT). We also used information from 155 non-treated reference men from the general population with no history of prostate cancer, matched for age and residency. Results: Median time from treatment to follow-up was 5 years (range: 1–14 years). Among the 16 investigated symptoms on erectile function, libido, orgasm, and seminal fluid, 9 symptoms in the primary EBRT group and 10 in both the salvage EBRT and the EBRT+BT groups were statistically significantly more prevalent in survivors than in reference men. Erectile dysfunction was influenced by both age and time to follow-up, whereas symptoms relating to orgasm and seminal fluid were influenced by time to follow-up only. Not being sexually active was almost one and a half times as common in survivors as in reference men. Conclusions: The presented symptom profiles can help to develop personalized therapy for prostate cancer through a better understanding of which radiation-induced toxicities to be addressed in the clinic and can also assist in identifying suitable interventions for existing symptoms.

Background and purpose With modern radiotherapy technology we have the means to substantially reduce late gastrointestinal toxicities after radiation therapy for prostate cancer. However, there is still a lack of knowledge regarding the spectrum of patient-reported gastrointestinal symptoms after such treatment. Materials and methods We conducted a cross-sectional study using a study-specific questionnaire to survey gastrointestinal symptoms 2–14years after prostate cancer radiation therapy. We included 985 men treated between 1994 and 2006 with primary (EBRT) or salvage (POSTOP) external beam radiation therapy or EBRT and high-dose rate brachytherapy (EBRT BT). We also included 350 non-irradiated population-based controls randomly matched 1:3 for age and area of residence. Results Survey participation rate was 89% (874/985) for survivors and 73% (243/332) for controls. We found significant increased prevalence ratios for 13/34 symptoms in the primary EBRT group, 10/34 symptoms in the EBRT BT group and 9/34 symptoms in the POSTOP group, several of which have not been described previously. Bother due to these symptoms increased with increasing symptom intensity and was highest for fecal leakage and defecation urgency. Conclusions Our results can be used to inform clinical evaluation and future studies of long-term gastrointestinal toxicity after radiotherapy for prostate cancer.

Initial Experience with Introducing National Swedish Guidelines for CT- and MRI-based Delineation of Organs at Risk in Radiotherapy : The STRONG Project

Purpose. To study if partnership modifies the effect of gastrointestinal symptoms on quality of life after radiation therapy for prostate cancer. Material and methods. Using a study-specific questionnaire we conducted a cross-sectional follow-up of the occurrence gastrointestinal symptoms and quality of life after radiation therapy for prostate cancer. We obtained information from 874 prostate cancer survivors treated with radiation therapy at the Sahlgrenska University Hospital, Sweden between 1994 and 2006. In this paper we describe how partnership status affects the association between gastrointestinal symptoms and quality of life. Results. We found that unpartnered men with gastrointestinal symptoms reported a lower quality of life than unpartnered men without such symptoms. Unpartnered men with symptoms had an excess risk of low quality of life compared with unpartnered men without symptoms for those experiencing altered composition of stools, prevalence ratio 3.8 (95% CI 1.1–13.1), leakage, 3.6 (1.3–10.1), sensory bowel symptoms, 4.5 (1.6–12.8), and for urgency, 4.2 (1.2–15.1). We also found that unpartnered men with symptoms had an excess risk of low quality of life compared with partnered men with symptoms for those experiencing altered composition of stools, prevalence ratio 2.9 (95% CI 1.4–5.8), leakage 2.8 (1.2–6.4), sensory bowel symptoms 3.4 (1.5–7.4), urgency 2.6 (1.2–5.8), and for any gastrointestinal symptom 2.5 (1.3–4.9). Conclusion. Unpartnered men may represent a group that is specifically vulnerable to the distressful effects of gastrointestinal symptoms after radiation therapy for prostate cancer.

Purpose To investigate how treatment-related and non-treatment-related factors impact urethral pain among long-term prostate cancer survivors. Methods and materials Men treated for prostate cancer with radiation therapy at the Sahlgrenska University Hospital in Goteborg, Sweden from 1993 to 2006 were approached with a study-specific postal questionnaire addressing symptoms after treatment, including urethral burning pain during urination (n=985). The men had received primary or salvage external-beam radiation therapy (EBRT) or EBRT in combination with brachytherapy (BT). Prescribed doses were commonly 70 Gy in 2.0-Gy fractions for primary and salvage EBRT and 50 Gy plus 2×10.0 Gy for EBRT+BT. Prostatic urethral doses were assessed from treatment records. We also recruited 350 non-pelvic-irradiated, population-based controls matched for age and residency to provide symptom background rates. Results Of the treated men, 16% (137 of 863) reported urethral pain, compared with 11% (27 of 242) of the controls. The median time to follow-up was 5.2 years (range, 1.1-14.3 years). Prostatic urethral doses were similar to prescription doses for EBRT and 100% to 115% for BT. Fractionation-corrected dose and time to follow-up affected the occurrence of the symptom. For a follow-up≥3 years, 19% of men (52 of 268) within the 70-Gy EBRT+BT group reported pain, compared with 10% of men (23 of 222) treated with 70 Gy primary EBRT (prevalence ratio 1.9; 95% confidence interval 1.2-3.0). Of the men treated with salvage EBRT, 10% (20 of 197) reported urethral pain. Conclusions Survivors treated with EBRT+BT had a higher risk for urethral pain compared with those treated with EBRT. The symptom prevalence decreased with longer time to follow-up. We found a relationship between fractionation-corrected urethral dose and pain. Among long-term prostate cancer survivors, the occurrence of pain was not increased above the background rate for prostatic urethral doses up to 70 Gy3.

To analyze the relationship between mean radiation dose to the bowels and the anal-sphincter and occurrence of 'defecation into clothing without forewarning', a specific and serious fecal incontinence symptom after gynecological radiotherapy. Additional potential risk factors associated with the symptom are explored.Data were collected for 519 eligible gynecological cancer survivors, treated with pelvic radiotherapy, with a median follow-up of 5.8 years, using a study-specific questionnaire and medical records. Correlations between defecation into clothing without forewarning and mean dose to organs at risk; the anal-sphincter region, the rectum, the sigmoid and the small intestines were investigated, also taking other risk factors into account.Twelve percent reported having had the symptom at least once in the preceding six months. Mean doses 50 Gy to the anal-sphincter region, the rectum, the sigmoid and the small intestines were related to the occurrence of the symptom. Significantly associated risk factors were deliveries with high birth weight, heart failure and lactose and/or gluten intolerance. After adjusting for these factors, mean doses 50 Gy to the anal-sphincter region, the sigmoid and the small intestines remained related to the occurrence of the symptom.Mean doses to the bowels and anal-sphincter region are related to the risk of defecation into clothing without forewarning in long-term gynecological cancer survivors treated with pelvic radiotherapy. Further radiobiological modeling may distinguish which organ(s) contribute most to development of the symptom.

Background and purpose Radiotherapy (RT) induced genitourinary (GU) morbidity is typically assessed by physicians as single symptoms or aggregated scores including symptoms from various domains. Here we apply a method to group patient-reported GU symptoms after RT for localized prostate cancer based on their interplay, and study how these relate to urinary bladder dose. Materials and methods Data were taken from two Scandinavian studies ( N =207/276) including men treated with external-beam RT (EBRT) to 78/70Gy (2Gy/fraction; median time-to-follow-up: 3.6–6.4y). Within and across cohorts, bladder dose–volume parameters were tested as predictors for GU symptom domains identified from two study-specific questionnaires (35 questions on frequency, incontinence, obstruction, pain, urgency, and sensory symptoms) using univariate and multivariate logistic regression analysis (MVA) with 10-fold cross-validation. Performance was evaluated using Area Under the Receiver Operating Characteristic Curve (A z ). Results For the identified Incontinence (2–5 symptoms), Obstruction (3–5 symptoms), and Urgency (2–7 symptoms) domains, MVA demonstrated that bladder doses close to the prescription doses were the strongest predictors for Obstruction (A z : 0.53–0.57) and Urgency (A z : 0.60). For Obstruction , performance increased for the across cohort analysis (A z : 0.61–0.64). Conclusions Our identified patient-reported GU symptom domains suggest that high urinary bladder doses, and increased focus on both obstruction and urgency is likely to further add to the understanding of GU tract RT responses.

SummaryBackground: In the field of radiation oncology, the use of extensive patient reported outcomes is increasingly common to meas -ure adverse side effects after radiotherapy in cancer patients. Factor analysis has the potential to identify an optimal number of latent factors (i.e., symptom groups). However, the ultimate goal of treatment response modeling is to understand the relationship between treatment variables such as radiation dose and symptom groups resulting from FA. Hence, it is crucial to identify clinically more relevant symptom groups and improved response variables from those symptom groups for a quantitative analysis. Objectives: The goal of this study is to design a computational method for finding clinically relevant symptom groups from PROs and to test associations between symptom groups and radiation dose. Methods: We propose a novel approach where exploratory factor analysis is followed by confirmatory factor analysis to determine the relevant number of symptom groups. We also propose to use a combination of symptoms in a symptom group identified as a new response variable in linear regression analysis to investigate the relationship between the symptom group and dose-volume variables. Results: We analyzed patient-reported gastrointestinal symptom profiles from 3 datasets in prostate cancer patients treated with radiotherapy. The final structural model of each dataset was validated using the other two datasets and compared to four other existing FA methods. Our systematic EFA-CFA approach provided clinically more relevant solutions than other methods, resulting in new clinically relevant outcome variables that enabled a quantitative analysis. As a result, statistically significant correlations were found between some dose- volume variables to relevant anatomic structures and symptom groups identified by FA. Conclusions: Our proposed method can aid in the process of understanding PROs and provide a basis for improving our understanding of radiation-induced side effects.

Risk structures for radiation-induced trismus in head and neck cancer

The aim of this study was to investigate what bowel organ and delivered dose levels are most relevant for the development of 'emptying of all stools into clothing without forewarning' so that the related dose-responses could be derived as an aid in avoiding this distressing symptom in the future.Of the 77 gynecological cancer survivors treated with radiotherapy (RT) for gynecological cancer, 13 developed the symptom. The survivors were treated between 1991 and 2003. The anal-sphincter region, the rectum, the sigmoid and the small intestines were all delineated and the dose-volume histograms were exported for each patient. The dose-volume parameters were estimated fitting the data to the Relative Seriality (RS), the Lyman and the generalized Equivalent Uniform Dose (gEUD) model.The dose-response parameters for all three models and four organs at risk (OARs) were estimated. The data from the sigmoid fits the studied models best: D50 was 58.8 and 59.5 Gy (RS, Lyman), γ50 was 1.60 and 1.57 (RS, Lyman), s was 0.32, n was 0.13 and a was 7.7 (RS, Lyman, gEUD). The estimated volume parameters indicate that the investigated OARs behave serially for this endpoint. Our results for the three models studied indicate that they have the same predictive power (similar LL values) for the symptom as a function of the dose for all investigated OARs.In our study, the anal-sphincter region and sigmoid fit our data best, but all OARs were found to have steep dose-responses for 'emptying of all stools into clothing without forewarning' and thus, the outcome can be predicted with an NTCP model. In addition, the dose to the four studied OARs may be considered when minimizing the risk of the symptom.

Torture is common today and is practised in over 100 countries according to Amnesty International. A substantial number of refugees coming to Europe have been tortured including females. Documentation of physical injuries due to torture is done by forensic pathologists often in collaboration with psychiatrists. In Sweden, the majority of torture documentations is done by an organization (KTC) which have specialized in documenting torture, and in short-term therapy of refugees and other crime victims suffering from post-traumatic stress. From the KTC archives of 500 documented alleged torture victims, the records of 63 females were studied separately. Age, nationality, asylum motive, social situation, torture methods, number of injuries, and sequels to torture were among the variables studied. Female torture victims differed from their male counterparts studied previously in the following: (i) The most common reason for seeking asylum was persecution because of the political activity of their husbands or some other close relative. (ii) Rape often both anal and vaginal, several times, and by different persons, was reported by 76% of the women. Physical abuse by use of blunt force was alleged by 95% but (iii) other types of force and specific torture methods was reported infrequently. (iv) A high frequency of PTSD -- 87% was diagnosed.

Aim The involvement of various penile structures in radiotherapy (RT)-induced sexual dysfunction among prostate cancer survivors remains unclear and domains beyond erectile dysfunction such as orgasm, and pain have typically not been considered. The purpose of this study was to investigate sexual dysfunction post-RT for localized prostate cancer and to examine whether radiation dose to different penile structures can explain these symptoms. Methods We investigated sexual dysfunction in two treated prostate cancer cohorts and in one non-pelvic-irradiated cohort, 328 sexually active men part of an unselected, population-based study conducted in 2008. The treated subjects were prescribed primary/salvage external-beam RT to 70 Gy@2.0 Gy/fraction. Absorbed RT doses (Dmean and Dmax) of the corpora cavernosa (CC), the penile bulb (PB), and the total penile structure (CC + PB) were related to 13 patient-reported symptoms on sexual dysfunction by means of factor analysis (FA) and logistic regression. Results Three distinct symptom domains were identified across all cohorts: “erectile dysfunction” (ED, two to five symptoms), “orgasmic dysfunction” (OD, two to four symptoms), and “pain” (two to three symptoms). The strongest predictor for ED symptoms was CC + PB Dmax (P = 0.001–0.03), CC and PB Dmean predicted OD symptoms equally well (P = 0.03 and 0.02–0.05, respectively), and the strongest predictor for pain symptoms was CC + PB Dmean (P = 0.02–0.03). Conclusion Sexual dysfunction following RT was separated into three main domains with symptoms related to erectile dysfunction, orgasmic dysfunction, and pain. Chances for intact sexual functionality may be increased if dose to the total penile structure can be restricted for these domains in the planning of RT.

BACKGROUND: Alzheimer's disease biomarkers are important for early diagnosis in routine clinical practice and research. Three core CSF biomarkers for the diagnosis of Alzheimer's disease (Aβ42, T-tau, and P-tau) have been assessed in numerous studies, and several other Alzheimer's disease markers are emerging in the literature. However, there have been no comprehensive meta-analyses of their diagnostic performance. We systematically reviewed the literature for 15 biomarkers in both CSF and blood to assess which of these were most altered in Alzheimer's disease. METHODS: In this systematic review and meta-analysis, we screened PubMed and Web of Science for articles published between July 1, 1984, and June 30, 2014, about CSF and blood biomarkers reflecting neurodegeneration (T-tau, NFL, NSE, VLP-1, and HFABP), APP metabolism (Aβ42, Aβ40, Aβ38, sAPPα, and sAPPβ), tangle pathology (P-tau), blood-brain-barrier function (albumin ratio), and glial activation (YKL-40, MCP-1, and GFAP). Data were taken from cross-sectional cohort studies as well as from baseline measurements in longitudinal studies with clinical follow-up. Articles were excluded if they did not contain a cohort with Alzheimer's disease and a control cohort, or a cohort with mild cognitive impairment due to Alzheimer's disease and a stable mild cognitive impairment cohort. Data were extracted by ten authors and checked by two for accuracy. For quality assessment, modified QUADAS criteria were used. Biomarker performance was rated by random-effects meta-analysis based on the ratio between biomarker concentration in patients with Alzheimer's disease and controls (fold change) or the ratio between biomarker concentration in those with mild cognitive impariment due to Alzheimer's disease and those with stable mild cognitive impairment who had a follow-up time of at least 2 years and no further cognitive decline. FINDINGS: Of 4521 records identified from PubMed and 624 from Web of Science, 231 articles comprising 15 699 patients with Alzheimer's disease and 13 018 controls were included in this analysis. The core biomarkers differentiated Alzheimer's disease from controls with good performance: CSF T-tau (average ratio 2·54, 95% CI 2·44-2·64, p

Background and purpose To investigate the dose-response relation between the dose to the vagina and the patient-reported symptom ‘absence of vaginal elasticity’ and how time to follow-up influences this relation. Materials and methods The study included 78 long-term gynecological cancer survivors treated between 1991 and 2003 with external beam radiation therapy. Of those, 24 experienced absence of vaginal elasticity. A normal tissue complication model is introduced that takes into account the influence of time to follow-up on the dose-response relation and the patient’s age. The best estimates of the dose-response parameters were calculated using Probit, Probit-Relative Seriality (RS) and Probit-time models. Log likelihood (LL) values and the Akaike Information Criterion (AIC) were used to evaluate the model fit. Results The dose-response parameters for ‘absence of vaginal elasticity’ according to the Probit and Probit-time models with the 68% Confidence Intervals (CI) were: LL=−39.8, D50 = 49.7 (47.2–52.4) Gy, γ 50 = 1.40 (1.12–1.70) and LL = −37.4, D50 = 46.9 (43.5–50.9) Gy, γ 50 = 1.81(1.17–2.51) respectively. Conclusions The proposed model, which describes the influence of time to follow-up on the dose-response relation, fits our data best. Our data indicate that the steepness of the dose-response curve of the dose to the vagina and the symptom ‘absence of vaginal elasticity’ increases with time to follow-up, while D50decreases. • Alevronta E, Avall-Lundqvist E, Al-Abany M, et al. Time-dependent dose-response relation for absence of vaginal elasticity after gynecological radiation therapy. Radiother Oncol 2016. http://dx.doi.org/10.1016/j.radonc.2016.02.013 .

Background Medical students' choice of their future specialty is influenced by several factors, including working conditions and type of patient relations. The aim of this study was to investigate the association between the choice of specialty and personality traits. Methods This is a cross-sectional questionnaire-based study of 399 alumni from Karolinska Institutet Medical School who were assumed to undergo specialty training at the time of the survey in 2013. The Big Five Inventory was used to assess the personality traits extraversion, agreeableness, conscientiousness, neuroticism and openness to experience. Medical specialties were categorised as primary care, psychiatry, internal medicine and surgical and hospital service specialties. Adjustments were made for demographic factors and the method of selection for medical school admission. Results The response rate was 72% (n=289, of which 262 were in training to become specialists). Among these, surgeons scored lower in agreeableness than physicians in primary care, internal medicine and hospital services. Psychiatrists and hospital service physicians showed lower conscientiousness compared with surgeons. Conclusions We found distinctive differences in personality traits between medical specialties even after adjusting for other potential explanatory variables. Since there are differences between specialties, for example, surgeons and psychiatrists, this supports previous findings that personality may affect medical students' specialty choice also in a Swedish setting.

When pooling retrospective data from different cohorts, slice thicknesses of acquired computed tomography (CT) images used for treatment planning may vary between cohorts. It is, however, not known if varying slice thickness influences derived dose-response relationships. We investigated this for rectal bleeding using dose-volume histograms (DVHs) of the rectum and rectal wall for dose distributions superimposed on images with varying CT slice thicknesses. We used dose and endpoint data from two prostate cancer cohorts treated with three-dimensional conformal radiotherapy to either 74 Gy (N = 159) or 78 Gy (N = 159) at 2 Gy per fraction. The rectum was defined as the whole organ with content, and the morbidity cut-off was Grade ≥2 late rectal bleeding. Rectal walls were defined as 3 mm inner margins added to the rectum. DVHs for simulated slice thicknesses from 3 to 13 mm were compared to DVHs for the originally acquired slice thicknesses at 3 and 5 mm. Volumes, mean, and maximum doses were assessed from the DVHs, and generalized equivalent uniform dose (gEUD) values were calculated. For each organ and each of the simulated slice thicknesses, we performed predictive modeling of late rectal bleeding using the Lyman-Kutcher-Burman (LKB) model. For the most coarse slice thickness, rectal volumes increased (≤18%), whereas maximum and mean doses decreased (≤0.8 and ≤4.2 Gy, respectively). For all a values, the gEUD for the simulated DVHs were ≤1.9 Gy different than the gEUD for the original DVHs. The best-fitting LKB model parameter values with 95% CIs were consistent between all DVHs. In conclusion, we found that the investigated slice thickness variations had minimal impact on rectal dose-response estimations. From the perspective of predictive modeling, our results suggest that variations within 10 mm in slice thickness between cohorts are unlikely to be a limiting factor when pooling multi-institutional rectal dose data that include slice thickness variations within this range.

Background. When evaluating late toxicity after combined external beam radiation therapy (EBRT) and high-dose rate brachytherapy (HDR BT) prostate cancer treatments, it is important that the composite dose distribution is taken into account. This can be challenging if organ-at-risk (OAR) dose data are incomplete, i.e. due to a limited ultrasound imaging field-of-view in the HDR BT procedure. This work proposes a method that provides estimates of composite OAR doses for such situations.Material and methods. Original EBRT, simulated HDR BT, and composite dose-volume histograms (DVHs) for 10 pelvic OARs in 30 prostate cancer cases were used for method implementation and evaluation (EBRT: 25 × 2.0 Gy + BT: 2 × 10.0 Gy). The proposed method used information from the EBRT DVH to estimate OAR BT doses (with or without fractionation correction). Coefficients of determination (R2) were calculated for linear relationships between several EBRT DVH parameters and a BT DVH parameter of interest. The largest R2 value decided the relationship that best predicted the BT DVH parameter. The composite dose value was then calculated by adding the EBRT DVH and the estimated BT DVH parameter values and was compared to the reference composite value (in 1200 OAR/patient/parameter cases).Results. The linear relationships had an average R2 of 0.68 (range 0.42–0.88). Only one ninth of the 1200 estimated composite DVH values differed more than 2 Gy from their reference values.Conclusion. Given a successful implementation, the proposed method only requires original or simulated BT plan data for a subset of patients to estimate composite doses for large study populations in a time-efficient manner. This can assist in evaluating radiation-induced late toxicity in multimodality treatments with limited OAR dose data.

Background: The objective of this study is to provide comprehensive overviews of patient-reported urinary symptoms for long-term prostate cancer survivors treated with radiation therapy and for untreated, healthy men. Methods: We performed a population-based cross-sectional study using a study-specific postal questionnaire assessing symptoms among 1007 men consecutively treated at the Sahlgrenska University Hospital, Göteborg, Sweden from 1993–2006 (primary or salvage external beam radiation therapy (EBRT) or EBRT and high-dose rate brachytherapy). We also randomly recruited 350 non-pelvic-irradiated matched control men from the Swedish Total Population Register. Symptom prevalence and prevalence ratios were computed. Results: Survey participation rate was 89% (874/985) for eligible survivors and 73% (243/332) for eligible controls. Median time from treatment to follow-up was 5 years (range, 1–14 years). Among the 21 investigated symptoms reflecting obstruction, frequency, urgency, pain and incontinence, we found significantly higher prevalence compared with controls for 9 symptoms in the EBRT group, 10 in the EBRT+brachytherapy group and 5 in the salvage EBRT group. The prevalence for a majority of the symptoms was stable over time. Conclusion: The presented toxicity profiles provide a thorough understanding of patient-reported urinary symptoms that can assist in developing personalised therapy for prostate cancer.

This study was conducted to investigate the association of long-term gastrointestinal and urinary symptoms with perceived fecal or urine body odor after radiation therapy for prostate cancer and its effect on survivors' quality of life.We used a study-specific questionnaire to measure the occurrence of long-term gastrointestinal and urinary symptoms, the perception of fecal or urine body odor, and quality of life (QoL) 2 to 14 years after radiation therapy for prostate cancer. The questionnaire was sent to 895 eligible survivors who assessed symptom occurrence and QoL in the previous 6 months.We received a filled-in questionnaire from 874 (89 %) men. For the long-term gastrointestinal symptoms, 11/13 were associated with the perception of fecal body odor. For the long-term urinary symptoms, 11/11 were associated with the perception of urine body odor. Men who perceived fecal or urine body odor had a lower quality of life, a lower physical health, and more frequent feelings of depression compared with those who did perceive such body odor.Long-term gastrointestinal and urinary symptoms after prostate irradiation are associated with the perception of fecal or urine body odor leading to a reduced quality of life.Disabling body odor after pelvic irradiation needs to be acknowledged in the clinic. Interventions to prevent long-term symptoms may serve the benefit of avoiding fecal or urine body odor after radiation therapy for prostate cancer.