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Purpose: In 2015, men undergoing radical prostatectomy in Ontario, Canada were recommended to undergo multidisciplinary care by seeing a radiation oncologist or discussion at multidisciplinary rounds before surgery. The a priori target rate was (76%. We used population-based data to explore factors associated with not receiving multidisciplinary care prior to radical prostatectomy. Materials and Methods: Men who underwent radical prostatectomy for localized prostate cancer in Ontario between 2007 and 2017 were identified using administrative data. Physician billings identified patients who received multidisciplinary care. Multivariable logistic regression was used to predict receipt of multidisciplinary care. Results: A total of 31,485 men underwent radical prostatectomy between 2007 and 2017. Of these patients 28.7% saw a radiation oncologist, 1.2% underwent multidisciplinary discussion and 1.9% had both before surgery. Multidisciplinary care receipt increased from 17.8% in 2007 to 47.8% in 2017 (p <0.001). The odds ratio between the highest and lowest geographic regions was 7.93 (95% CI 6.17e10.18, p <0.001). Lower odds of multidisciplinary care receipt were observed for men further from the nearest cancer center (OR 0.74 per 50 km, 95% CI 0.71e0.78, p <0.001) and higher odds for the highest versus lowest income quintile (OR 1.41, 95% CI 1.29e1.54, p <0.001). Of 128 urologists who performed (10 radical prostatectomies between 2016 and 2017, 29 (22.7%) met the target of having (76% of men seen for multidisciplinary care prior to surgery. Conclusions: Despite increasing utilization, many men do not receive multidisciplinary care prior to radical prostatectomy. While geography and the urologist appear to be the greatest factors predicting multidisciplinary care receipt, these factors are closely intertwined. [ABSTRACT FROM AUTHOR]

Purpose: Medical physics staffing models require periodic review due to the rapid evolution of technology and clinical techniques in radiation oncology. We present an update to a grid‐based physics staffing algorithm for radiation oncology (originally published in 2012) that has been widely used in Canada over the last decade. Materials and Methods: The physics staffing algorithm structure was modified to improve the clarity and consistency of input data. We collected information on clinical procedures, equipment inventory, and teaching activities from 15 radiation treatment centers in the province of Ontario from April 1, 2018, to March 31, 2019. Using these data sets, the algorithm's weighting parameters were adjusted to align the prediction of full‐time equivalent (FTE) personnel with actual staffing levels in Ontario. The algorithm computes FTE estimates for medical physicists, physics assistants, engineering (electrical and mechanical), and information technology (IT) support. The performance of the algorithm was also tested in eight Canadian cancer centers outside of Ontario. Results: The mean difference between the algorithm and actual staffing for the 23 Canadian cancer centers did not exceed 0.5 FTE for any staffing group. The results were slightly better in Ontario than in other provinces, as expected since the algorithm was optimized using Ontario data. There was a linear correlation between the algorithm predictions and the number of annual‐treated cases for physicists, and physicists plus physics assistants. For other staff categories, the algorithm weighting parameters were not significantly altered, except for a reduction in mechanical engineering staff. Comparison with other published models suggests that the updated algorithm should be considered as a minimum recommended staffing level for the clinical support of radiation oncology programs. Conclusions: We support the use of grid‐based physics staffing algorithms that account for clinical workload with flexibility to adapt to local conditions with variable academic and research demands. [ABSTRACT FROM AUTHOR]

Background After surgery for early-stage breast cancer (bca), adjuvant radiotherapy (rt) decreases the risk of locoregional recurrence and death from bca. It is unclear whether delays to the initiation of adjuvant rt are associated with inferior survival outcomes. Methods This population-based retrospective cohort study included a random sample of 25% of all women with stage i or ii bca treated with adjuvant rt in Ontario between 1 September 2001 and 31 August 2002, when, because of capacity issues, wait times for radiation were abnormally long. Pathology reports were manually abstracted and deterministically linked to population-level administrative databases to obtain information about recurrence and survival outcomes. Cox proportional hazards modelling was used to evaluate the association between waiting time and survival outcomes. A composite survival outcome was used to ensure that all possible measurable harms of delay would be captured. The composite outcome, event-free survival, included locoregional recurrence, development of metastatic disease, and bca-specific mortality. Results We identified 1028 women with stage i or ii bca who were treated with breast-conserving surgery and adjuvant rt. For the 599 women who were treated with adjuvant radiation without intervening chemotherapy, a waiting time of 12 weeks or more from surgery to the start of radiation appeared to be associated with worse event-free survival after a median follow-up of 7.2 years (hazard ratio for the composite outcome: 1.44; 95% confidence interval: 0.98 to 2.11; p = 0.07). For the 429 women who received intervening adjuvant chemotherapy, a waiting time of 6 weeks or more from completion of chemotherapy to start of radiation was associated with worse event-free survival after a median follow-up of 7.4 years (hazard ratio: 1.50; 95% confidence interval: 1.00 to 2.22; p = 0.047). Conclusions Delay to the initiation of adjuvant rt after breast-conserving surgery is associated with inferior bca survival outcomes. The good prognosis for patients with early-stage bca limits the statistical power to detect an effect of delay to rt. Given that there is no plausible advantage to delay, we agree with Mackillop that time to initiation of rt should be kept "as short as reasonably achievable." [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to investigate patient engagement (PE) in the development and delivery of Continuing Professional Development (CPD) programs for health care providers within radiation oncology, radiation therapy and medical physics across Canada. This study looked at the current state of PE in CPD programs across Canada and how to address the benefits and barriers to PE to advance these programs., Methods: A quantitative, exploratory survey was conducted among radiation oncologists, radiation therapists and medical physicists across Canada. The questionnaire was developed by a multi-disciplinary team and piloted among interprofessional (IP) faculty with a special interest in patient education. The survey was web-based and disseminated through the Canadian Association of Medical Radiation Technologists (CAMRT) and Canadian Radiation Oncologists (CARO) professional associations., Results: A total of 97 responses were obtained, 43.3% (n = 41) were radiation oncologists 64% (n = 54) were radiation therapists and 2(2%) were medical physicists. There was representation from all provinces, except Newfoundland, with the majority 36% (n = 35) from Ontario. 57% (n = 46) of participants agreed that patients should be involved in CPD, and 11% (n = 9) disagreed. The most agreed-upon barriers are financial costs for patients and clinician bias when selecting patients. The most agreed-upon solutions were improving patient resources and creating training programs for patients. Radiation therapists agreed significantly more (p<0.05) with the potential benefits of PE in CPD, compared to radiation oncologists., Discussion: PE in CPD programs is a novel and controversial topic but is still highly rated and important. We intend to advocate for patients to take an active role in our CPD programs. Further research is warranted., (Copyright © 2023. Published by Elsevier Inc.)

Aims Guidelines recommend the discussion of adjuvant radiotherapy post-prostatectomy for prostate cancer patients with high-risk pathology to consider all of their treatment options. We determine whether patterns of radiotherapy referral and treatment post-prostatectomy reflect guideline-based use in a contemporary prostatectomy cohort. Materials and methods Electronic treatment records were linked to Ontario's cancer registry. Multivariable regression was used to evaluate clinical and health systems factors associated with referral and the use of adjuvant radiotherapy within 6 months post-prostatectomy. Results Among 2663 patients treated with prostatectomy between 1 January 2012 and 30 November 2012, 1261 (47%) were found to have adverse pathology and 492 were referred to radiation oncology ≤6 months post-prostatectomy, of whom 51% received adjuvant radiotherapy. Multivariable analysis showed that patients were more likely to be referred to radiation oncology from a low-volume surgical facility (≤50 versus >50 radical prostatectomy cases, odds ratio 2.50 [1.80–3.48]), if they lived farther from a radiotherapy centre (>50 km versus <10 km, odds ratio 1.73 [1.22–2.46]), if they were seen by radiation oncology preoperatively (odds ratio 1.95 [1.51–2.52]), or if they had adverse pathology: high T-category (pT3b/T4 versus pT2, odds ratio 17.87 [12.14–26.30]; pT3a versus pT2, odds ratio 5.24 [3.95–6.97]), positive margins (non-apex positive versus negative, odds ratio 4.20 [3.19–5.53]; apex only positive versus negative, odds ratio 2.60 [1.71–3.94]) and high Gleason score (8–10 versus ≤6, odds ratio 11.32 [5.37–23.84]; 7 versus ≤6, odds ratio 4.18 [2.16–8.10]). Wide geographic variation in radiotherapy referral rates persisted (range 6–66%; P < 0.0001). After radiotherapy referral, only high T-category (pT3b/T4 versus pT2, odds ratio 5.37 [3.01–9.60]; pT3a versus pT2, odds ratio 2.72 [1.59–4.65]) and non-apex positive margins (odds ratio 2.81 [1.86–4.23]) remained significantly predictive of treatment. Conclusions Variations in referral for a discussion of radiotherapy post-prostatectomy are not mainly explained by patient characteristics. After seeing radiation oncology, treatment decisions correlated most strongly with pathological findings. Understanding the reasons for the tremendous non-clinical variations in care is needed to ensure access to potentially curative radiotherapy post-prostatectomy for high-risk prostate cancer patients. [ABSTRACT FROM AUTHOR]

Purpose: To assess radiation oncology residents’ needs and satisfaction in their first postgraduate year (PGY-1) in the province of Ontario. Methods and Materials: Of 62 radiation oncology residents, 58 who had completed their PGY-1 and were either enrolled or had graduated in 2006 were invited to participate in a 31-item survey. The questionnaire explored PGY-1 residents’ needs and satisfaction in four domains: clinical workload, faculty/learning environment, stress level, and discrimination/harassment. The Fisher’s exact and Wilcoxon nonparametric tests were used to determine relationships between covariate items and summary scores. Results: Of 58 eligible residents, 44 (75%) responded. Eighty-four percent of residents felt that their ward and call duties were appropriate. More than 50% of respondents indicated that they often felt isolated from their radiation oncology program. Only 77% agreed that they received adequate feedback, and 40% received sufficient counseling regarding career planning. More than 93% of respondents thought that faculty members had contributed significantly to their learning experience. Approximately 50% of residents experienced excessive stress and inadequate time for leisure or for reading the medical literature. Less than 10% of residents indicated that they had been harassed or experienced discrimination. Eighty-three percent agreed or strongly agreed that their PGY-1 experience had been outstanding. Conclusions: Most Ontario residents were satisfied with their PGY-1 training program. More counseling by radiation oncology faculty members should be offered to help residents with career planning. The residents might also benefit from more exposure to “radiation oncology” and an introduction to stress management strategies. [Copyright &y& Elsevier]

Background and Purpose: Access to radiotherapy (RT) is a key component of a cancer control strategy. However, radiotherapy utilization (RTU) rates fall short of desired benchmarks in certain Canadian provinces. We aimed to describe provincial variations in RTU across Canada., Materials and Methods: We calculated radiotherapy utilization ratios (RTUR) for each Canadian province from 2016 (RT case counts divided by incidence counts), by cancer type (all cancers, lung, breast, rectal, prostate) and treatment intent (curative, palliative) where data were available. Data were extracted from each provincial RT data repository, cancer registry and/or RT department. We compared RTURs descriptively across provinces and to Ontario benchmarks, and calculated an estimated national RTUR. In provinces with capacity for data linkage, RTURs were compared to a linked (patient-specific) method of calculating utilization, by linking each incident case to whether RT was received within 1 year of diagnosis (RTU-1 yr)., Results: Excluding three provinces that included re-treatments, all-cancer RTURs ranged from 0.31 in Manitoba to 0.40 in Nova Scotia. The national all-cancer RTUR was 0.35, which was comparable to Ontario benchmarks (0.34). Larger variations were seen by cancer type, with an absolute difference in RTURs of 28% for lung cancers, 27% for breast cancers, 21% for rectal cancers, and 18% for prostate cancers. RTURs for nearly all provinces were below established Ontario benchmarks for each cancer type, except prostate cancer. RTURs over-estimated RTU-1 yr by at most 5%, except for prostate cancers where they over-estimated RTU-1 yr by up to 15%., Conclusions: RTU varies by province in Canada, and most notably by cancer subsite. More granular data at the regional level and by healthcare facility is required to further tailor strategies aimed at improving RT access. RTURs also serve as a reasonable surrogate for linked RTU, and both methods can contribute meaningfully to measure RTU depending on the context and data availability., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Management of locally-advanced breast cancer is determined by multiple factors, but in patients without distant metastases often involves neoadjuvant systemic therapy, surgery and radiation. If the primary tumour remains unresectable following systemic therapy, radiotherapy may be used for tumour shrinkage prior to surgery. When metastatic disease is present, locoregional radiotherapy is generally reserved for management of tumour-related symptoms. We reviewed our experience of high-dose radiotherapy for unresected locally-advanced breast cancer., Methods: A retrospective chart review was conducted of patients with unresected locally advanced breast cancer (LABC) receiving external beam radiotherapy to the breast, chest wall and/or regional lymph nodes. Patients were stratified based on the presence of metastatic disease at presentation. Patient demographics, disease characteristics, and treatment outcomes were recorded., Results: Forty-three cases were analyzed between 2004 and 2016. Median follow-up was 25 months from diagnosis and 14 months from completion of radiotherapy. There were 24 cases (56%) with metastatic disease on presentation, and 19 (44%) without. Tumour shrinkage occurred within 3 months of completing radiotherapy in 36 cases (84%). Ulceration and bleeding improved following radiotherapy in 13 (54%) of the 24 applicable cases. Twenty-six patients (60%) developed moist desquamation but none experienced grade 4 or 5 radiation dermatitis. Median locoregional progression-free survival for all patients was 12 months from completion of radiotherapy. Locoregional progression-free survival (P=0.2) and overall survival (OS) (P=0.4) were not significantly different between patients with and without distant metastases at presentation., Conclusions: Radiotherapy provided good response and symptom control in most patients in this study; there is a role for palliative radiotherapy in patients with LABC.

Objective: Radiation Oncology practices can exhibit heterogeneities between and sometimes within institutions. Clinical registries with scope and detail could quantify consistency and distinctives that justify difference. Retrospective, isolated clinical audits are problematic, typically because not all data are captured in charts, while useful prospective clinical registries will have to be practical, efficient and accurate. We tested feasibility of a clinical registry at a critical time-point in the patient's clinical trajectory when treating physicians could have requisite data., Design: This was a prospective and non-randomized observational study. Four centres used a 1-page form to acquire data during a 4-month period. Patients had curative breast, rectum or prostate cancers, or were palliative. Objectives were to demonstrate form completion and to delineate patterns of disease presentation and clinical practice., Results: The 107 cases had 99% complete data, internally consistent within cases and centres. Similar practices were seen for 22 cases with curative rectal and prostate cancer, and 34 palliative cases, but of the 51 curative breast cancer cases those in Africa were with greater Stage, underwent more extensive surgery, were less likely to receive shorter radiation schedules, and were less exposed to Taxane-based chemotherapy regimens., Conclusions: This study demonstrates the feasibility for a simple clinical registry requiring minimal effort by participants. A real-time pan-African registry, operating continually or in regular waves, could provide important knowledge at little cost.

Background: Research regarding the decision to adopt and implement technological innovations in radiation oncology is lacking. This is particularly problematic since these technologies are often complex and rapidly evolving, requiring ongoing revisiting of decisions regarding which technologies are the most appropriate to support. Variations in adoption and implementation decisions for new radiation technologies across cancer centres can impact patients' access to appropriate and innovative forms of radiation therapy. This study examines the key steps in the process of adopting and implementing intensity modulated radiation therapy (IMRT) in publicly funded cancer centres and identifies facilitating or impeding factors., Methods: A multiple case study design, utilizing document analysis and key informant interviews was employed. Four cancer centres in Ontario, Canada were selected and interviews were conducted with radiation oncologists, medical physicists, radiation therapists, and senior administrative leaders., Results: Eighteen key informants were interviewed. Overall, three centres made fair to excellent progress in the implementation of IMRT, while one centre achieved only limited implementation as of 2009. Key factors that influenced the extent of IMRT implementation were categorized as: 1) leadership, 2) training, expertise and standardization, 3) collaboration, 4) resources, and 5) resistance to change., Conclusion: A framework for the adoption and implementation of complex and evolving technologies is presented. It identifies the key factors that should be addressed by decision-makers at specific stages of the adoption/implementation process.

Background: To construct a short prostate cancer radiation late toxicity (PCRT) questionnaire with health-related quality-of-life (HRQoL) domains., Methods: The PCRT was developed by item generation, questionnaire construction (n = 7 experts, n = 8 focus group patients), pilot testing (n = 37), item reduction (n = 100), reliability testing (n = 237), and validity testing (n = 274)., Results: Reliability of the three item-reduced subscales demonstrated intraclass correlation coefficients (CC) of 0.811 (GU), 0.842 (GI), and 0.740 (sexual). Discriminant validity demonstrated Pearson CC of 0.449 (GU-GI), 0.200 (sexual-GU), and 0.09 (sexual-GI). Content validity correlations between PCRT-PCQoL were 0.35-0.78, PCRT-FACT-G(c) were 0.19-0.39, and PCRT-SF-36(R) were 0.03-0.34., Conclusion: We successfully generated a PCRT HRQoL questionnaire including subscales with very good psychometric properties.

Objectives: To determine the current practice of clinicians in the diagnosis and management of osteoporosis among men taking androgen deprivation therapy (ADT), because ADT leads to decreased bone mineral density (BMD) and fractures., Methods: We sent out a survey to Canadian urologists and radiation oncologists. The survey included questions about BMD testing, treatment practices, referral patterns, and risk of osteoporosis., Results: The surveys were returned by 170 of 294 respondents (response rate 58%). Few respondents would obtain a baseline BMD in patients starting ADT. Forty percent would order a repeat BMD test after starting ADT if the baseline BMD were normal or unknown, but more than two thirds would if the baseline BMD showed osteoporosis. In men with a normal BMD starting ADT, respondents recommended weight-bearing exercises (58%), calcium (50%), vitamin D (47%), and bisphosphonate (6%) supplements. In men with osteoporosis at baseline, the use of nonprescription therapies increased slightly and bisphosphonate use increased to 44%. If osteoporosis were diagnosed, 11% would treat the patient themselves. The estimated risk of developing osteoporosis within 1 year of starting ADT with a normal baseline BMD ranged from 0% to 90% (median 20%)., Conclusions: To our knowledge, this is the first survey of its kind. The key findings included that few physicians would order a baseline BMD test, would prescribe bisphosphonates for prevention but almost one half would consider bisphosphonates to treat established osteoporosis, and wide variations exist in the practice patterns and risk perception surrounding ADT-related osteoporosis. Evidence-based guidelines are needed to help physicians deal effectively with osteoporosis prevention and management among men taking ADT.

Background and Purpose: Annual genitourinary radiation oncology meetings aim to assist in the dissemination of knowledge that may affect current practice. We aim to measure changes in practice approaches that have occurred while these meetings have been conducted., Materials and Methods: A previously published survey from 2002 was sent to all genitourinary radiation oncologists in Ontario. Six prostate cancer patient scenarios were used: three definitive (low risk, intermediate risk, high risk), and three post-operative (extracapsular extension, margin positive, slowly rising PSA). There were 21 responders from seven cancer centers., Results: Using biological equivalent dose (BED), there is significant dose escalation in 2005, particularly for intermediate risk patients (mean BED 73.0 Gy2 in 2002 versus 76.1 Gy2 in 2005, p=0.0003). There has been a corresponding move away from the use of neoadjuvant hormones in these patients (2002: 62% versus 2005: 24%, p=0.0097). More accurate prostate localization using fiducials is more common, leading to less use of rectal barium and urethrograms in the simulation process. In the definitive settings there is more utilization of rigid immobilization and more complex treatment delivery including intensity modulated radiotherapy. There is also greater use of multileaf collimation, electronic portal imaging and dose volume histograms in 2005 compared with 2002., Conclusions: There have been significant changes in the way that prostate cancer is managed with radiotherapy in Ontario between 2002 and 2005. Dose escalation and more complex treatment planning is widely evident.

Goals: The rapid response radiotherapy program (RRRP) at Toronto-Sunnybrook Regional Cancer Center (TSRCC) provides quick access to palliative radiotherapy for patients with a life expectancy of less than 12 months. Patients then return to their referring physician for continued oncologic management. After the initial RRRP consultation, we fax an interim consultation report to the referring physician. The purpose of this study was to assess how useful referring physicians perceive this interim report and whether this report needs to be modified to meet their information needs., Methods: Physicians who referred patients to the RRRP and who were faxed an interim consultation report were identified over a 4-month period. These physicians were then faxed a questionnaire that asked how useful the interim report was in patient management, about their satisfaction with the information provided, to critique the report format, and whether the RRRP physician and nurse were easily accessible by telephone., Main Results: Forty physicians referred patients to the RRRP clinic over the 4-month study period. The response rate to our survey was 58% (23/40). The vast majority of physicians (95%) stated that the interim consultation report was useful in patient management. They felt that treatment details were adequately discussed in the report. The report format was perceived to be clear and concise. Referring physicians wished to be informed about any medication changes. RRRP physicians and nurse were perceived to be easily accessible by telephone if needed., Conclusions: Results showed that referring physicians found the faxed interim consultation report useful in patient management. Suggestions were made on how to improve the report, and they will be used to further enhance physician communication and ultimately patient care.

Canadians have been involved in the issues of cancer staging since the inception of the international effort led by the UICC. The seminal roles of Sellers and Bush in furthering the development of the concept of staging and how it relates to a patient's prognosis have served as an example to others in Canada and elsewhere. Canadians have shown a pattern of multidisciplinary representation on staging bodies with epidemiologists, radiation oncologists and surgeons involved in cancer staging over the years. The scope of involvement has ranged from the NCIC Canadian Committee on Cancer Staging to the UICC, FIGO and the AJCC with its expert task forces. The recent consultation initiative to coordinate comprehensive nationwide staging by TNM is considered by the UICC as a potential model for other countries to follow.