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Surface mould brachytherapy (SMBT) is ideal in treating superficial skin cancer over the curved surface of the nasal ala. We describe the process of initiating and optimizing SMBT treatment at our institution including clinical workflow, generation of three dimensional (3D) printed custom applicators, and clinical outcomes. Planning CT scans were used to acquire images for delineating target volumes. The applicator was designed with customized catheter positioning (3–5mm from target) to cover target volume while sparing dose to organs at risk (OAR) such as adjacent skin and nasal mucosa. Applicators were 3D printed, with transparent resin to aid visualization of underlying skin. Dosimetric parameters evaluated included CTV D90, CTV D0.1cc, and D2cc to OARs. Clinical outcomes assessed were local control, acute and late toxicity (Common Terminology Criteria for Adverse Events v5.0 [CTCAEv5.0]), and cosmesis (Radiation Therapy Oncology Group [RTOG]). Ten patients were treated with SMBT with a median followup of 17.8 months. Dose prescription was 40 Gy in 10 daily fractions. Mean CTV D90 was 38.5 Gy (range 34.7–40.6), mean CTV D0.1cc 49.2 Gy (range 45.6–53.5), which was <140% of the prescription dose in all patients. Treatment was well tolerated, with acceptable Grade 2 acute, Grade 0–1 late skin toxicity, and good-excellent cosmesis for all patients. Two patients experienced local failure, and both underwent surgical salvage. SMBT was successfully planned and delivered for superficial nasal BCC using 3D printed custom applicators. Excellent target coverage was achieved while minimizing dose to OAR. Toxicity and cosmesis rates were good-excellent. [ABSTRACT FROM AUTHOR]

Brachytherapy (BT) is ideally suited for treatment of non-melanoma skin cancers (NMSC) in patients who are not surgical candidates, by providing a high superficial dose while sparing underlying organs at risk. Our centre provides BT treatment for NMSCs covering large areas or extending over irregular or curved surfaces with custom three dimensional (3D) printed surface mould applicators. We sought to optimize the clinical workflow for treatment with 3D-printed surface applicators while expanding the role of our BT dedicated radiation therapists (BrachyRT). Patients receiving BT for NMSC require 2 CT simulation (CT SIM) appointments for applicator fabrication and treatment planning, followed by 10 daily treatments. An updated quality check list process was developed in MOSAIQ to coordinate CT SIM and treatment appointments, and to track progress of applicator design, contouring and treatment planning. Pre-planning huddles between BrachyRT, CT SIM staff, a BT physicist, and a radiation oncologist were introduced to support inter-professional discussion to identify ideal patient positioning and immobilization for applicator design based on clinical photos. BrachyRT were present at both scheduled simulation appointments to provide patient education and assist in positioning. Detailed clinical photos were acquired at each appointment by CT SIM staff in conjunction with BrachyRT and uploaded to MOSAIQ to inform patient position and applicator placement for treatment. BrachyRT received specialized training to perform applicator QA, digitize applicator source paths and to develop and evaluate customized skin BT treatment plans using a teach one, do one learning model. Training cases were developed by the BrachyRT team lead to further guide independent learning as required. Responsibility for daily patient education and side effect management during treatment appointments was transferred from nursing to BrachyRT due to their intimate knowledge and understanding of the process, and to support nursing workload challenges. Design, fabrication and treatment with custom 3D-printed surface mould applicators is resource intensive, taking 5-8 weeks to complete. Effective treatment relies on reproducing patient positioning and precise applicator placement, which is a challenge with such a complex and multi-step process. Optimizing our workflow to include standard interprofessional communication, documentation and intentional BrachyRT involvement with both CT SIM and treatment appointments helps to mitigate these challenges. In addition, patients are provided with improved continuity of care in the education and side effect management they receive throughout their simulations and treatment. Participation in applicator QA and treatment planning represents a significant expansion in role and aligns with BrachyRT practice in prostate and gynecological BT. Since optimizing our clinical workflow with BrachyRT playing an integral role throughout, our BT team has completed treatment on 16 NMSC patients using 3D-printed custom surface mould applicators. Ongoing prospective analysis of CT SIM and treatment delivery time data will further evaluate and validate this workflow and identify opportunity for any future efficiencies. Patient reported outcomes are being collected for this cohort and will inform development of a BT specific side effect print resource that is being developed. [ABSTRACT FROM AUTHOR]

Background: Historically, radiation to skin cancers for the lower legs has been avoided due to the perceived increased risk of radiation toxicity (poor wound healing, radiation necrosis). However, there is a paucity of published data regarding this perceived risk. Purpose: The objective was to review the risk of poor wound healing/radiation necrosis occurring post radiation and to determine rates of complete response (CR), partial response (PR), and progressive disease after radiation therapy Materials and methods: A retrospective review of patients treated with radiation for skin cancer below the knee was undertaken from January 1, 2013 to May 31, 2018. Results: A total of 25 patients with 39 below the knee skin sites were treated with radiation. Mean follow-up time was 19 months (range 3 months–7.2 years). Crude CR, PR and progression rates for the treated lesions were 65%, 19%, and 16% respectively. Four out of 23 (17%) patients developed Grade 3 skin toxicity. There were no grades 4 or 5 toxicities. Conclusions: For patients not eligible for surgery, radiation therapy is an option with a moderate chance of complete response (65%) and a 17% risk of poor wound healing/radiation necrosis. [ABSTRACT FROM AUTHOR]

Purpose: Radiotherapy-induced nausea and vomiting is a common side effect of radiotherapy. It is well-established that nausea and vomiting have a negative impact on quality of life, but the relative influence of each of symptom is infrequently reported. This study aimed to compare the effects of nausea and vomiting on quality of life in cancer patients receiving palliative radiotherapy.Methods: The Functional Living Index-Emesis (FLIE) is a quality of life questionnaire developed in the chemotherapy-induced nausea and vomiting setting. The FLIE consists of 18 questions, half of which address nausea and half of which address vomiting. Three prospective studies on the efficacy of various anti-emetic medications conducted at our center used the FLIE to assess radiotherapy-induced nausea and vomiting at various time points during and after palliative radiotherapy. FLIE data from these three studies were combined for the present analysis. Univariate and multivariate analyses were conducted to assess the relationships between nausea and vomiting, time of FLIE completion, and patient-reported quality of life.Results: Nausea and vomiting scores both decreased patients' quality of life. Multivariate modeling showed that both symptoms significantly influenced patients' ability to enjoy meals. Nausea was also associated with increased hardship for the patient, while vomiting imposed more difficulty on the patients' loved ones.Conclusions: Nausea and vomiting both significantly influence quality of life. Nausea seems to impact the patient more directly, whereas vomiting affects those closest to the patient. [ABSTRACT FROM AUTHOR]

Bone metastases below the knee are rare, but when they occur they often present challenges to the patient's mobility and ability to perform activities of daily living. We report the case of a 54-year-old woman who presented with tibial and lung metastases at the time of her diagnosis of an endometrial adenocarcinoma. The patient was treated with radiation therapy, surgery to stabilize the tibia, and systemic chemotherapy. Although treatment was initially effective in palliating symptoms, at the time of the most recent follow-up, 19 months after her initial diagnosis, the patient's pain had returned to her left tibia. Because of the limited number of similar cases reported in the literature, the prognosis for patients with endometrial carcinoma presenting with below-the-knee bone metastases is not well understood. [ABSTRACT FROM AUTHOR]

Purpose: To identify symptom clusters in advanced cancer patients attending a palliative radiotherapy clinic using the Edmonton Symptom Assessment System (ESAS).Methods: Principal component analysis (PCA), exploratory factor analysis (EFA), and hierarchical cluster analysis (HCA) were used to identify symptom clusters among the nine ESAS items using scores from each patient's first visit.Results: ESAS scores from 182 patients were analyzed. The PCA identified three symptom clusters (cluster 1: depression-anxiety-well-being, cluster 2: pain-tiredness-drowsiness, cluster 3: nausea-dyspnea-loss of appetite). The EFA identified two clusters (cluster 1: tiredness-drowsiness-loss of appetite-well-being-pain-nausea-dyspnea, cluster 2: depression-anxiety). The HCA identified three clusters similar to the PCA with an exception of the loss of appetite item being classified under cluster 1 rather than 3. Two to three symptom clusters were identified using three analytical methods, with similar patterns reported in the literature. Particular groups of items co-occurred consistently across all three analyses: depression and anxiety; nausea and dyspnea; as well as pain, tiredness, and drowsiness.Conclusion: Three similar symptom clusters were identified in our patient population using the PCA and HCA; whereas, the EFA produced two clusters: one physical and one psychological cluster. Given the implications of symptom clusters in the management of quality of life, clinicians should be aware of these clusters to aid in the palliative treatment of patients. [ABSTRACT FROM AUTHOR]

Purpose: Dyspnea is a debilitating symptom commonly experienced by advanced cancer patients that can lead to negative effects on function and quality of life (QOL). The present study aims to determine the relationship between dyspnea and other Edmonton Symptom Assessment System (ESAS) symptoms in palliative cancer patients referred to a radiotherapy clinic.Methods: The presence and severity of dyspnea was measured using the ESAS. All patients that visited a palliative radiotherapy clinic between 1999 to 2002 and 2006 to 2009 and completed the ESAS were included. ESAS scores and other demographic and clinical information were extracted from a prospectively collected database. Statistical tests including chi-squared tests, Spearman correlations, and multivariate analysis were conducted to explore the relationship between dyspnea, other ESAS items, and other demographic factors. Kaplan-Meier overall survival curves were generated based on dyspnea severity.Results: One thousand three hundred forty-four patients were included in the dyspnea analysis; reported moderate or severe dyspnea. Dyspnea severity was significantly associated with eight other ESAS interference severities (p < 0.001). Upon multivariate analysis, greater severity of dyspnea was significantly related to higher ESAS scores for tiredness, nausea, depression, anxious, drowsiness, and poor appetite (p < 0.05). The actuarial median survival time was 6.57 months (95% CI 5.91-7.29 months). There were highly significant differences in overall survival between those with none, mild, and moderate dyspnea (p < 0.0001).Conclusion: Cancer patients often experience dyspnea along with a multitude of other symptoms. Moderate and severe dyspnea should be assessed and optimally managed to reduce functional and QOL debilitations. As presence of increased dyspnea severity is associated with worse overall survival, interventions should occur at the end of life to reduce symptom burden in palliative patients. [ABSTRACT FROM AUTHOR]

Aims Quality of life ( QOL) is important for advanced cancer patients. Brief questionnaires are advantageous to reduce patient burden. In large clinical trials, statistically significant small changes can be achieved; however, whether such change is clinically relevant is unknown. The purpose of this study was to determine the minimal important differences ( MID) of the European Organisation for Research and Treatment of Cancer quality of life core 15 palliative questionnaire ( EORTC QLQ- C15- PAL). Methods Patients undergoing palliative radiotherapy completed the EORTC QLQ-C15- PAL at baseline and 1 month later. Anchor and distribution-based assessments were employed to determine the MID associated with this instrument. The anchor of overall QOL was used to determine meaningful change. Results In all, 276 patients were included in MID calculation. Mean age was 65 years and primary lung, breast or prostate cancers were most common. Statistically significant MID for improvement was seen in emotional functioning and pain (20.9 and 15.6, respectively). MID for deterioration required a 20.4, 24.5, 17.1 and 23.0 change in physical functioning, fatigue, pain and appetite loss, respectively, to constitute meaningful change. Distribution-based estimates of MID were closest to the standard error of measurement. MID for brain and bone metastases patients yielded MID larger than previously determined in the incorporation of all patients. Conclusion Meaningful change in the EORTC QLQ-C15- PAL is important for clinicians to determine the impact of treatment on the QOL of patients and can aid in determining the sample size required for clinical trials. Future studies should investigate MID in subgroups using symptom-specific modules. [ABSTRACT FROM AUTHOR]

In 1996, the Toronto Sunnybrook Regional Cancer Centre developed the Rapid Response Radiotherapy Program (RRRP). The objective of this clinic is to consult, simulate, plan, and treat patients with palliative radiotherapy on the same day. In 2004, the RRRP initiated a program to provide clinical and research experience to undergraduate students interested in health sciences. The purpose of this study is to review the 10-year (2004-2013) experience of the RRRP and to examine whether the goals of the student program have been met. Students who worked in the RRRP from 2004 to 2013 were contacted to complete a short survey regarding their overall experience with the program and their current endeavors. Student accomplishments were collected from an internal database as well as PubMed. Descriptive statistics were used to analyze results. A total of 54 students from ten postsecondary institutions have worked in the RRRP; 29 were from the University of Waterloo undergraduate co-op program. In total, 214 articles with first authorship from students were published, 93 (43%) of which can be found on PubMed. Other accomplishments include 40 book chapters, 58 invited presentations, and 99 awards cumulatively. Qualitative data regarding student perspectives of their experience in the RRRP were also analyzed. Over the past 10 years, the RRRP has achieved its goal of providing quality medical and research experience to students interested in the health sciences. Using the responses of past and present students, we hope to continue to shape our program and provide unique opportunities to future students. [ABSTRACT FROM AUTHOR]

Superior vena cava syndrome (SVCS) is a well-recognized manifestation of obstruction of the superior vena cava. It is clinically striking but rarely requires emergency treatment. Nowadays SVCS is most commonly due to external compression by malignancy or intrinsic thrombus due to an indwelling catheter. A tissue diagnosis is needed to guide diagnosis and treatment. An aggressive multimodality approach to investigation, support and treatment is indicated. Radiotherapy and intravascular stents are effective methods of achieving immediate symptom relief. The presence of SVCS does not reduce the probability of cure of the underlying malignancy and should not compromise the choice of appropriate treatment. A significant proportion (10-20%) survives over 2 years. [ABSTRACT FROM AUTHOR]

The majority of lung cancer patients have locally advanced or metastatic disease at diagnosis. Many of patients with locally advanced or metastatic lung cancer are treated with palliative intent to help relieve symptoms and improve quality of life. This article summarizes some of our experience with palliative thoracic RT for NSCLC at the Rapid Response Radiotherapy Program (RRRP). [ABSTRACT FROM AUTHOR]

Purpose: Whole brain radiotherapy (WBRT) is a treatment strategy used commonly to relieve burdensome symptoms and improve quality of life (QOL) in patients with multiple brain metastases. The purpose of this study is to determine changes in fatigue score following WBRT as it is a common symptom experienced in this population. Methods: Fatigue and overall QOL scores were collected prospectively in patients for up to 3 months post-WBRT by several questionnaires at different times including the following: Edmonton Symptom Assessment System (ESAS), Brain Symptom and Impact Questionnaire (BASIQ), Spitzer Questionnaire, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), EORTC brain module (EORTC QLQ-BN20 + 2), EORTC QLQ-C15-PAL, and Functional Assessment of Cancer Therapy-General (FACT-G). Questionnaires were grouped for analysis by Wilcoxon Signed Rank test according to the scale of ranking into 0-10, 1-4, and 0-4. Results: Thirty-six patients were interviewed with the ESAS or BASIQ. The median age was 65 years old, and median Karnofsky Performance Status (KPS) was 70. There was a significant increase in fatigue score from baseline to month 1 ( p = 0.02), and months 2 and 3 had no significant change. There was a significant correlation between fatigue and overall QOL score at baseline and month 1 ( p = 0.01, p < 0.0001), respectively. Two hundred and twenty-eight patients were surveyed with Spitzer, C15-PAL, BN20 + 2, QLQ-C30, or FACT-G. Median age was 64 years old and median KPS was 80. Compared to baseline, fatigue score was significantly higher at month 1 ( p < 0.0001) and month 2 ( p = 0.001), with no significant change at month 3. Significant correlation was found between fatigue and overall QOL at baseline, months 1, 2 ( p < 0.0001), and 3 ( p = 0.0009). For all groups, there was no significant change in fatigue score between patients with or without dexamethasone (Dx), except for the fatigue changed score of the group with scale 0-4. Conclusions: Fatigue was significantly increased from baseline to month 1 in all patients, and most patients experienced no difference in fatigue if they were receiving Dx. Increased fatigue was significantly related with decreased overall QOL. [ABSTRACT FROM AUTHOR]

Purpose: The aims of this study were to determine whether symptom clusters in patients with bone metastases varied when derived using three different statistical methods and to compare the presentation of symptom clusters over time in responders and nonresponders to palliative radiation treatment (RT). Methods: Secondary analysis of a previously reported data set compiled using the brief pain inventory from 348 patients with bone metastases. Hierarchical cluster analysis (HCA) and exploratory factor analysis (EFA) were performed to identify symptom clusters at baseline, 1, 2, and 3 months following radiation treatment. Clusters derived were compared with the findings obtained using principal component analysis (PCA) in our previous study. The total patient sample was further separated into two subgroups: responders and nonresponders to RT. PCA, HCA, and EFA identified symptom clusters experienced by each subgroup at the same time points as before. Results: Little correlation was observed in the symptom cluster findings of PCA, EFA, and HCA in the total patient sample. Absolute consensus among all three statistical methods was never reached at any assessment time point in the present study. Varying patterns of symptom cluster presentation over time were observed in the responders versus nonresponders subgroups regardless of the analytical method employed. A core cluster of symptoms composed of worst pain, general activity, walking ability, normal work, and enjoyment of life frequently presented in the same cluster. Conclusion: The presence and composition of symptom clusters derived varied depending on which statistical analysis method was employed. A key step in attaining consistency in symptom cluster research necessitates the utilization of a common method. [ABSTRACT FROM AUTHOR]

Introduction: Advanced cancer patients present with a variety of physical and psychological symptoms. Fatigue is one such symptom which reduces overall quality of life and is difficult to manage. The purpose of this study was to report the presence, severity, and correlating factors of fatigue in advanced cancer patients attending an outpatient palliative radiotherapy clinic. Materials/methods: Patients referred to the Rapid Response Radiotherapy Program between January 1999 and October 2009 completed the Edmonton Symptom Assessment System (ESAS) prior to consultation. Demographic information including age, Karnofsky Performance Status (KPS), gender, and primary cancer sites were collected. Ordinal logistic regression analysis was conducted to determine relationships between demographic information, other ESAS items, and levels of fatigue. Multivariate ordinal logistic regression analysis was used to determine the most significant predictors of fatigue. A p value of <0.05 was considered statistically significant. Results: A total of 1,397 patients completed the ESAS prior to consultation. Median age was 68 years (range, 21-95), median KPS was 60 (range, 10-100), and slightly more males completed the ESAS (53.0%). Common primary cancers were of the lung (35.8%), breast (20.7%), and prostate (17.7%). Only 179 (12.8%) patients reported no fatigue; the majority of patients reported moderate (31.8%) or severe (34.4%) fatigue. A low KPS ( p < 0.0001), being female ( p = 0.0056), or being referred for bone metastases ( p = 0.0185) significantly correlated with higher levels of fatigue. Patients with a genitourinary primary cancer ( p = 0.0078) and/or referred for malignant spinal cord compression ( p = 0.0004) reported less fatigue. All other ESAS items were significantly related to fatigue. The most significant predictors of fatigue were pain ( p < 0.0001, odds ratio (OR) = 1.07), nausea ( p = 0.0010, OR = 1.10), depression ( p < 0.0001, OR = 1.10), drowsiness ( p < 0.0001, OR = 1.33), dyspnea ( p = 0.0003, OR = 1.08), and overall well-being ( p < 0.0001, OR = 1.19). Conclusion: Moderate fatigue was reported in over 66% of our advanced cancer patients prior to radiotherapy. Since radiotherapy inherently causes fatigue, proactive and multidisciplinary management is required for these patients. Similar rates of fatigue severity, in lengthier, fatigue-specific tools, suggest that the ESAS may be a good tool for screening the advanced cancer population. [ABSTRACT FROM AUTHOR]

Introduction. Merkel cell carcinoma is a rare form of non-melanoma skin cancer of neuroendocrine origin. Optimal management of patients is controversial and the role of radiotherapy is unclear. Purpose. The purpose of this study was to review the efficacy of RT in the treatment of both local and distant metastatic disease from MCC. Methods. A literature search was conducted in MEDLINE (1946--January Week 1 2012) and Embase (1980-2012Week 2). Articles of interest analyze the efficacy of radiotherapy for treatment of metastatic MCC and did not exclude case reports. Results. All articles except one focusing on the role of radiotherapy were of retrospective origin or case series. Significant limitations applied in all studies due to limited sample sizes and the retrospective nature of these studies. Radiotherapy improves locoregional control in the adjuvant setting, and many series suggest an improvement in overall survival. In cases where surgery is not possible, definitive radiotherapy may be an as-efficacious alternative. The radiosensitive nature of MCC coupled with existing reports suggests that treatment via current protocols for other primary tumors is adequate. Conclusion. Further studies should be conducted prospectively to clarify the true role of radiotherapy in metastatic MCC. [ABSTRACT FROM AUTHOR]

Purpose: Multiple randomized controlled trials have demonstrated the equivalence of multifraction and single-fraction (SF) radiotherapy for the palliation of painful bone metastases (BM). However, according to previous surveys, SF schedules remain underused. The objectives of this study were to determine the current patterns of practice internationally and to investigate the factors influencing this practice. Methods and Materials: The members of three global radiation oncology professional organizations (American Society for Radiology Oncology [ASTRO], Canadian Association of Radiation Oncology [CARO], Royal Australian and New Zealand College of Radiologists) completed an Internet-based survey. The respondents described what radiotherapy dose fractionation they would recommend for 5 hypothetical cases describing patients with single or multiple painful BMs from breast, lung, or prostate cancer. Radiation oncologists rated the importance of patient, tumor, institution, and treatment factors, and descriptive statistics were compiled. The chi-square test was used for categorical variables and the Student t test for continuous variables. Logistic regression analysis identified predictors of the use of SF radiotherapy. Results: A total of 962 respondents, three-quarters ASTRO members, described 101 different dose schedules in common use (range, 3 Gy/1 fraction to 60 Gy/20 fractions). The median dose overall was 30 Gy/10 fractions. SF schedules were used the least often by ASTRO members practicing in the United States and most often by CARO members. Case, membership affiliation, country of training, location of practice, and practice type were independently predictive of the use of SF. The principal factors considered when prescribing were prognosis, risk of spinal cord compression, and performance status. Conclusion: Despite abundant evidence, most radiation oncologists continue to prescribe multifraction schedules for patients who fit the eligibility criteria of previous randomized controlled trials. Our results have confirmed a delay in the incorporation of evidence into practice for palliative radiotherapy for painful bone metastases. [Copyright &y& Elsevier]

Background: The primary objective of this study was to assess whether there was an improvement in quality of life for patients with brain metastases as measured 1 and 2 months after a course of whole-brain radiotherapy. The secondary objective was to assess the level of agreement between patient and proxy quality of life scores. Methods and materials: Sixty patients with brain metastases and their proxy completed the Functional Assessment of Cancer Therapy-Brain (FACT-BR) questionnaire independently. Proxies were given instructions to answer from the patient’s perspective. Quality-of-life assessments were conducted at baseline, 1 month, and 2 months after completion of whole-brain radiotherapy. Paired t tests with Bonferroni adjustment for multiple comparisons were calculated to detect significant differences in global quality-of-life scores. Lin's concordance correlation coefficient measured agreement between patient and proxy quality-of-life ratings. Results: No significant difference was detected in overall quality of life after whole-brain radiotherapy. At 2 months after whole-brain radiotherapy, there was a trend toward worsening general and brain specific quality-of-life scores. There was poor concordance between patients and their proxies for all quality-of-life domains at baseline. Conclusion: At 2 months after whole-brain radiotherapy, there was a trend toward worsening general and brain specific quality-of-life scores. Proxy rating of patients’ quality of life showed poor concordance at baseline. [ABSTRACT FROM AUTHOR]

Background: Admission into medical schools or other health-related professional schools has become increasingly competitive. As a result, many undergraduate students aspiring to become health care professionals volunteer or work in a health care setting to better equip themselves for the challenge. While there have been a number of papers written about the experiences of medical and nursing students, there is limited amount of literature regarding the experience of undergraduate students in clinical practice environments. Insight into their perspectives and roles could promote patient care and research. Goal: The purpose of the present qualitative study was to explore and describe the experience of being a clinical research student in an outpatient palliative radiotherapy clinic. Methods: Students who have worked as clinical research assistants at the palliative radiotherapy clinic were first asked to write responses to two open ended questions that were qualitatively analyzed for general themes. Subsequently, students were interviewed using an interview guide with open-ended questions that were related to the themes that emerged from their initial responses. Analysis of the students' responses followed the grounded theory approach. Results: Of the 10 students who participated, 6 are pursuing careers as a medical doctor, 2 are pursuing health-related careers, 1 is in medical school, and I is a doctor. The length of time the students have worked as a clinical research assistant at the clinic ranges from 4 months to 2 years. After analyzing the students' responses, patterns were categorized and 7 themes emerged: (1) the value of patient interaction in inspiring students to pursue medical careers; (2) the changed attitude towards palliative patients and clinical research; (3) the lack of educational preparation for the skills and knowledge needed for this position; (4) the importance of being challenged with opportunities that are unfound outside of an academic hospital; (5) developing an appropriate and realistic emotional response to clinical experiences (e.g., death); (6) gaining insight into doctor and patient relationship, and (7) the initial difficulty at finding a niche in a health care setting where research comes secondary to patient care. Conclusion: Working as a research assistant is more than "just a job" for many undergraduate students. The students in this study consistently reported that through their smiles and tears while working in a tertiary palliative cancer care setting, they developed skills and gained knowledge that would be inaccessible within the classroom setting. This experiential learning is crucial in shaping the character of a future clinician or researcher. [ABSTRACT FROM AUTHOR]

Background: Many randomized trials in the treatment of bone metastases have reported that radiotherapy reduces bone pain and decreases analgesic consumption. However, reporting of other pain-related functional outcomes has been sparse. The primary objective of this study was to prospectively determine changes in pain intensity and its functional interference following palliative radiotherapy for painful bone metastases. Materials and Methods: Patients with symptomatic bone metastases treated with palliative radiotherapy from May 2003 to June 2005 were followed with the Brief Pain Inventory (BPI) at baseline, l, 2, and 3 months after the delivery of radiotherapy. Radiotherapy outcome was assessed using the International Bone Metastases Consensus response definitions. Results: One hundred and ninety-nine patients were treated with palliative radiotherapy. All three pain scores and seven functional interference items at two months showed a significant improvement compared to the baseline. Complete, partial and overall response rates of the 101 patients who completed the BPI assessment at two months were 21%, 45% and 66%, respectively. Conclusions: External beam radiation therapy was found to be effective in palliating pain from bone metastases and reducing pain-related functional interference. Incorporating functional interference outcomes in future clinical trials may improve the assessment of meaningful treatment effect. [ABSTRACT FROM AUTHOR]

Previous treatments of systemic isotretinoin, antibiotics and surgical excision without adjuvant radiotherapy were unsuccessful, and he was ineligible for re-excision given the size of the lesion. A 27-year-old man of African descent presented to our radiotherapy clinic with a 5-year history of a recurrent 15 × 8 × 4 cm keloidal tumour (i.e., acne keloidalis nuchae) on his posterior neck (Figure 1A). [Extracted from the article]

A letter to the editor is presented which discussed a study that explored the prevalence of do-not-resuscitate (DNR) orders in an outpatient palliative radiotherapy clinic.

This survey aimed to document the current practice patterns of postoperative radiotherapy (RT), including vaginal vault brachytherapy (VVB) and external beam radiotherapy (EBRT), in the management of patients with endometrial cancer. A 30-item, multiple choice survey querying RT prescribing practices and planning techniques was distributed electronically to American Brachytherapy Society members in December 2018. Seventy-five surveys from 62 centers were completed. Eighty-nine percent of respondents practiced within the USA or Canada. Most (79%) respondents indicated a preference for recommending adjuvant VVB alone in FIGO Stage IB, Grade 2 margin and lymphovascular space invasion (LVSI) negative disease. For FIGO Stage IB, Grade 3, LVSI-positive disease, most respondents preferred incorporating EBRT either alone (33%) or with VVB (28%). For IIIC1, margin positive disease, VVB in addition to EBRT was most commonly recommended (75%). When planning adjuvant EBRT, 49% utilized CT simulation with both bladder full and empty. Internal target volume was utilized by 53%. Volumetric modulated arc therapy (53%) or intensity-modulated radiotherapy (19%) were commonly used planning techniques. The most common dose prescription was 45 Gy in 25 fractions (57%). When treating with VVB, 49% determined applicator size at the time of brachytherapy. Sixty-four percent planned treatments based on CT imaging with the applicator in situ and 33% repeated CT imaging before each subsequent fraction. The most common prescription was 21 Gy in three fractions prescribed to 0.5 cm depth (43%). This study identified variability in treatment recommendations and in both EBRT and VVB simulation and planning processes in postoperative endometrial cancer. [ABSTRACT FROM AUTHOR]

Interstitial brachytherapy (ISBT) is an effective option for delivering conformal high dose radiation to the target volume with better organ-at risk sparing but is thought to be more invasive and painful than other methods. This study investigated pain levels and opioid consumption in patients who received spinal anesthesia (SA) or general anesthesia (GA) for their ISBT. Patients that underwent ISBT from April 2014 to September 2018 were analyzed from a prospective institutional database. The most prevalent malignancies were cervical (45%), recurrent endometrial (27%) and vaginal (20%) cancers. Baseline patient characteristics, radiation treatment details, anesthesia records, and inpatient charts were obtained. Opioid consumption was quantified as oral morphine equivalent per day (OMEq/day) from implantation until removal. Pain score levels were collected by using an 11-point scoring system. Ninety nine patients received GA and 40 patients received SA as their anesthesia for ISBT. During their first admission, 76 patients (55%) required intravenous opioids. Patients receiving SA had significantly lower mean pain scores on the morning of their procedure 6 (Interquartile range [IQR] 2–8) vs. 0 (IQR: 0–1); p < 0.001]. Pain did not significantly differ between cohorts at any other time. During the first admission, SA patients had a lower median opioid usage of 23 (IQR: 9–47) mg/day compared to GA patients at 38 (IQR: 21–71) mg/day (p = 0.011). No difference in opioid consumption was seen during subsequent admissions. In patients undergoing ISBT, SA provides better immediate pain control post insertion compared to GA. Patients who received SA used lower amounts of opioids during their first ISBT insertion. [ABSTRACT FROM AUTHOR]

Abstract: Background: Identifying the most radiosensitive patient group would have huge clinical implications. Methods: A tissue bank containing skin fibroblasts, whole blood, lymphocytes, plasma and lymphoblastoid cell lines from clinically radiation hypersensitive patients was established from patients in Europe and Canada. Over-reacting individuals had CTCAE3.0 severe acute side effects grade 2 or more occurring at very low radiation doses where these side effects are unexpected or grade 3–4 lasting more than 4weeks after the end of radiotherapy and/or requiring surgical intervention at any time or severe late side effects grade 3–4. Results: Eleven patients have been identified with a mean age of 61.6±8.5years (range 49–74). Two patients were male, 9 female. One patient had non-small cell lung cancer, 6 breast cancer, 2 head and neck cancer, one lymphoma and one meningioma. The mean follow-up time after radiotherapy was 1658±1048days (range 84–3752). Conclusions: The establishment of an international tissue bank of the rare group of patients with extreme hypersensitivity to radiotherapy was proven to be feasible and should enable in-depth molecular studies. [ABSTRACT FROM AUTHOR]

Cervical cancer is a deadly disease and the COVID-19 pandemic has the potential to further impact its lethality. Hypofractionated radiotherapy could mitigate this impact, however robust data in cervical cancer setting still is lacking. Information provided here could help institutions in reducing radiotherapy fractions for cervical cancer patients. [ABSTRACT FROM AUTHOR]

Abstract Purpose Perineal interstitial brachytherapy (P-ISBT) is an important component in the treatment of locally advanced gynecological cancers. However, there are concerns about potential acute complications from catheter needles. The goal is to evaluate the safety of P-ISBT by studying acute complications and radiological organ needle intrusions. Materials and Methods Forty-eight patients with gynecological cancers treated with P-ISBT at a single institution from September 2014 to April 2016 were included in a prospective registry trial. Postoperative adverse events were recorded during inpatient stay and at 6-week followup. Postprocedure CT and MRI images were reviewed by two physicians to record the number of needles intruded into organs. Discrepancies were resolved by a radiologist. Results Median followup time was at least 3 months. Forty-two patients were initially treated with external beam radiation therapy, median dose of 45 Gy. A total of 73 insertions were performed. The median number of needles for first and second insertions was 17 and 19, respectively. Twenty-eight patients had radiological evidence of needle intrusion(s) into at least one pelvic organ. The most commonly intruded organs were large bowel (18 cases) and bladder (18), followed by rectum (12). A total of nine acute toxicities from needle intrusions were found: four hematuria (1 G1, 3 G2); four perineal infections (3 G2, 1 G3); and one vaginal bleeding (G3). No gastrointestinal complications were found. Conclusions Perineal ISBT is an effective treatment for gynecological cancers. Despite occasional radiological catheter intrusions, there are low rates of organ complications. Concern of needle complications from P-ISBT should not be a barrier to adopting this technique for effective treatment. [ABSTRACT FROM AUTHOR]

Background and purpose To estimate the prevalence of neuropathic pain in patients with symptomatic bone metastases referred for palliative radiotherapy. Material and methods A prospective study of patients with symptomatic bone metastases was conducted. Patients referred for palliative radiotherapy completed the Self-Reported Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) questionnaire to assess for neuropathic pain. Patient demographics, medication use, and radiotherapy prescribed were collected. Statistical approaches to identify relationships between the presence of neuropathic and other patient factors were conducted. Results 62 patients completed the S-LANSS and 16 (25.8%) patients had a score suggesting neuropathic pain. Fifty-nine (95.2%) patients received radiotherapy with total of 81 sites treated, the most common sites were spine and pelvis. No statistically significant difference in fractionation was found between patients with and without neuropathic pain. Of the 16 patients with neuropathic pain, only 2 were receiving a neuropathic specific analgesic. No significant difference between demographic factors or radiation treatments between patients with and without neuropathic pain was found. There was no significant difference in worst pain score between these two groups. Conclusions Pain with neuropathic features remains prevalent in a population of patients referred for palliative radiotherapy. More frequent prescription of pain medications targeting neuropathic pain may be warranted in this patient population. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To provide practice guidelines for delineating clinical target volume (CTV) for radiotherapy planning of non melanoma (NMSC) skin cancers. Methods and materials: A prospective, single arm, study. Preoperatively, a radiation oncologist outlined the boundary of a gross lesion, and drew 5-mm incremental marks in four directions from the delineated border. Under local anesthesia, the lesion was excised, and resection margins were assessed microscopically by frozen section. Once resection margins were clear, the microscopic tumor extent was calculated using the presurgical incremental markings as references. A potential relationship between the distance of microscopic tumor extension and other variables was analyzed. Results: A total of 159 lesions in 150 consecutive patients, selected for surgical excision with frozen section assisted assessment of resection margins, were accrued. The distance of microscopic tumor extension beyond a gross lesion varied from 1mm to 15mm, with a mean of 5.3mm. The microscopic tumor extent was positively correlated with the size of gross lesion, histology and number of surgical attempts required to obtain a clear margin. To provide a 95% or greater chance of covering microscopic disease we make the following recommendations for CTV margins; 10mm for BCC less than 2cm, 13mm for BCC greater than 2cm, 11mm for SCC less than 2cm, and 14mm for SCC greater than 2cm. Conclusions: Tumors greater than 2cm and SCC histology required larger margins to adequately cover the microscopic extent of disease. This information is crucial in radiation planning of NMSC. Clinicians should be cautioned, as these guidelines may not offer optimum treatment for patients with extremely large or small lesions. [Copyright &y& Elsevier]

Merkel cell carcinoma of the head and neck (MCCHN) presents a clinical challenge due to its aggressive natural history, unpredictable lymphatic drainage, and high degree of treatment relatedmorbidity. Histological examination of the regional lymph nodes is very important in determining the optimal treatment and is usually achieved by sentinel lymph node biopsy. Radiotherapy plays a critical role in the treatment of most patients with MCCHN. Surgery with adjuvant radiotherapy to the primary tumour site is associated with high local control rates. If lymph nodes are clinically or microscopically positive, adjuvant radiotherapy is indicated to decrease the risk of regional recurrence. The majority of locoregional recurrences occur at the edge or just outside of the radiation field, reflecting both the inherent radiosensitivity of MCC and the importance of relatively large volumes to include "in-transit" dermal lymphatic pathways. When surgical excision of the primary or nodal disease is not feasible, primary radiotherapy alone should be considered as a potentially curative modality and confers good loco-regional control. Concurrent chemoradiotherapy is well tolerated and may further improve outcomes. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the efficacy of palliative radiotherapy (RT) in relieving metastatic bone pain in elderly patients. Methods and Materials: The response to RT for palliation of metastatic bone pain was evaluated from a prospective database of 558 patients between 1999 and 2008. The pain scores and analgesic intake were used to calculate the response according to the International Bone Metastases Consensus Working Party palliative RT endpoints. Subgroup analyses for age and other demographic information were performed. Results: No significant difference was found in the response rate in patients aged ≥65, ≥70, and ≥75 years compared with younger patients at 1, 2, or 3 months after RT. The response was found to be significantly related to the performance status. Conclusion: Age alone did not affect the response to palliative RT for bone metastases. Elderly patients should be referred for palliative RT for their painful bone metastases, regardless of age, because they receive equal benefit from the treatment. [Copyright &y& Elsevier]

Purpose: To examine prospectively patient self-rated symptoms and quality of life (QOL) indicators in patients with brain metastases following whole brain radiotherapy (WBRT). Methods and Materials: Consecutive patients with brain metastases referred for WBRT were approached for this study. Patients were asked to rate their symptoms and QOL using the Spitzer Quality of Life Index questionnaire. Follow-up was at 1, 2, and 3 months following WBRT. Linear regression analysis was used to determine the change in symptom severity over time. Results: Between August 2005 to October 2007, 129 patients with brain metastases were enrolled. The majority of patients (88%) received 20 Gy in five fractions. Median age was 64 years, and median Karnofsky Performance Status at baseline was 70. The most commonly experienced symptoms at baseline were headaches, weakness, balance problems, and fatigue. Thirty-five percent of patients rated neurological functional (NF) status as 1, indicating moderate neurological symptoms and need for assistance. Forty-three percent of patients had stable or decreased fatigue, and 47% had a stable or improved NF status over time (p = 0.0040). Although certain QOL domains improved over time, all other QOL domains and symptom items did not change significantly following WBRT. Conclusion: WBRT may have contributed to symptom stabilization in our study. An alternative goal of WBRT may be the prevention of symptom progression and QOL deterioration. Further research is required to select the most appropriate group of patients with brain metastases who would benefit most from WBRT. [Copyright &y& Elsevier]