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Non-melanoma skin cancer is the most frequently diagnosed cancer in Australia. Recent advances in radiation therapy (RT) allow large convex areas with extensive skin field cancerisation (ESFC) to be treated using volumetric modulated arc therapy (VMAT). RT doses and volumes are planned by radiation oncologists from pre-treatment computed tomography (CT) scans. Changes in limb volume due to the inflammatory response triggered by radiation can affect planned volumes and result in inaccuracies in dosimetry. We present a case study comparing outcomes with and without compression therapy following wide field VMAT to bilateral lower limbs. As edema can affect dosimetry, we hypothesized that edema management using compression therapy would be beneficial in controlling acute edema during RT. In this case when compression was applied during RT, treatment was able to be completed as planned in comparison to RT without compression where additional breaks in treatment were required due to edema and pain. There has been little published research examining edema management during RT for wide field skin cancerisation, however this case suggests further investigation is warranted to examine the potential value of compression therapy and accurate objective measures during VMAT for ESFC.

Magnetic resonance imaging (MRI) is increasingly being integrated into the radiation oncology workflow, due to its improved soft tissue contrast without additional exposure to ionising radiation. A review of MRI utilisation according to evidence based departmental guidelines was performed. Guideline utilisation rates were calculated to be 50% (true utilisation rate was 46%) of all new cancer patients treated with adjuvant or curative intent, excluding simple skin and breast cancer patients. Guideline utilisation rates were highest in the lower gastrointestinal and gynaecological subsites, with the lowest being in the upper gastrointestinal and thorax subsites. Head and neck (38% vs 45%) and CNS (46% vs 67%) cancers had the largest discrepancy between true and guideline utilisation rates due to unnamed reasons and non-contemporaneous diagnostic imaging respectively. This report outlines approximate MRI utilisation rates in a tertiary radiation oncology service and may help guide planning for future departments contemplating installation of an MRI simulator.

Background and purpose Escalating health care costs have led to greater efforts directed at measuring the cost and benefits of medical treatments. The aim of this study was to estimate the costs of 5-year local control and overall survival benefits of radiotherapy for the cancer population in Australia. Materials and Methods The local control and overall survival benefits of radiotherapy at 5-years and optimal number of fractions per course have been estimated for 26 tumour sites for which radiotherapy is indicated. For this study, a hybrid approach that merges features from activity based costing (ABC) and relative value units costing (RVU) were used to provide cost estimates. ABC methodology was used to allocate costs to all radiotherapy activities associated with each patient’s treatment course, while the RVUs represent the cost of each radiotherapy activity relative to the average cost of all activities and were used to achieve a weighted cost allocation. A patient’s journey for the financial year was constructed by consolidating all the radiotherapy activities and their associated costs, and the average cost per activity (fraction) was determined. The cost of radiotherapy per 5-year overall survival and local control was then estimated. Results The estimated population 5-year local control and overall survival benefits of radiotherapy for all cancer were 23% and 6%, respectively. The optimal number of fractions per treatment course if guidelines were followed was 19.4 fractions. The average cost per fraction for all cancer was AU$276. The estimated cost of radiotherapy was AU$23,585 per 5-year local control and AU$86,480 per 5-year overall survival (equivalent to 5 life years) for all cancer. Conclusion The cost of AU$86,480 per 5-year overall survival would translate to AU$17,296 1-year overall survival. Therefore, the cost of radiotherapy is inexpensive if delivered optimally. Policy implications from this study include knowledge about cost to deliver radiotherapy to allow one to quantify the expected benefit at a population level.

Objective To understand how best to support men diagnosed with localised prostate cancer to decide which treatment option best suits their needs, when robotic prostatectomy and radiotherapy are equally appropriate to offer them. Methods Twenty-five men recently diagnosed with localised prostate cancer completed semi-structured interviews asking about information/decision-making needs before and/or after attending a combined clinic in which they consulted a urologist and a radiation oncologist regarding treatment options. Data was transcribed verbatim and thematically analysed. Results Most men preferred robotic prostatectomy pre-combined clinic and chose it afterwards. The thematic analysis revealed four themes: 1) trust in clinicians and the information they provide is critical for treatment choice, 2) perceived fit between treatment characteristics and personal circumstances, 3) additional considerations: specific side effects, socio-emotional and financial factors, and 4) need for tailored information delivery. Robotic prostatectomy was mistakenly believed to provide a more definitive cure than radiotherapy, which was seen as having a lesser lifestyle impact. Conclusions Treatment choice is largely dependent on clinicians’ (mainly urologists’) recommendations. Practice implications Patients need more balanced information about alternatives to robotic prostatectomy earlier in the treatment decision-making process. Referral to a radiation oncologist or combined clinic shortly after diagnosis is recommended.

Decisional conflict and post-treatment decisional regret have been documented in men with localised prostate cancer (LPC). However, there is limited evidence regarding decisional outcomes associated with the choice between robotic-assisted radical prostatectomy (RARP) and radiotherapy, when both treatment options are available in the public health system. There is increasing support for multidisciplinary approaches to guide men with LPC in their decision-making process. This study assessed decisional outcomes in men deciding between RARP or radiotherapy treatment before and after attending a LPC combined clinic (CC).Quantitative longitudinal data were collected from 52 men who attended a LPC CC, where they saw both a urologist and radiation oncologist. Patients completed questionnaires assessing involvement in decision-making, decisional conflict, satisfaction and regret before and after the CC, three months, six months and 12 months post-treatment. Urologists and radiation oncologists also reported their perceptions regarding patients' suitability for, openness to, perceived preferences and appropriateness for each treatment. Data was analysed using paired/independent samples t-tests and McNemar's tests.Most participants (n = 37, 71%) opted for RARP over radiotherapy (n = 14, 27%); one participant deferred treatment (2%). Urologists and radiation oncologists reported low agreement (κ = 0.26) regarding the most appropriate treatment for each patient. Participants reported a desire for high levels of control over their decision-making process (77.5% patient-led, 22.5% shared) and high levels of decisional satisfaction (M = 4.4, SD = 0.47) after the CC. Decisional conflict levels were significantly reduced (baseline: M = 29.3, SD = 16.9, post-CC: M = 16.3, SD = 11.5; t = 5.37, P0.001) after the CC. Mean decisional regret scores were 'mild' at three-months (M = 16.0, SD = 17.5), six-months (M = 18.8, SD = 18.7) and 12-months (M = 18.2, SD = 15.1) post-treatment completion.This is the first Australian study to assess decisional outcomes when patients are offered the choice between RARP and radiotherapy in the public health system. A CC seems to support decision-making in men with LPC and positively impact some decisional outcomes. However, larger-scale controlled studies are needed to confirm these findings.

Introduction Despite 3% of Australians identifying as Indigenous, cutaneous malignancies in these patients, including incidence, risk factors and outcomes have not been investigated. This is despite recognition that cancer outcomes in this population are significantly poorer. Methods We undertook a retrospective case series of Indigenous Peoples who presented to two urban cancer therapy centres for the management of cutaneous malignancies from 2003 to 2017. Risk factors, tumour-specific characteristics, treatments and outcomes were reviewed. Results Twenty-two patients identified as Aboriginal and/or Torres Strait Islander. The median age at presentation was 61 years and the majority were male (63.6%) and had skin phototype III (86.4%). Patients presented with basal cell carcinoma (50%), squamous cell carcinoma (31.8%), melanoma (9.1%) and cutaneous sarcomas (9.1%). The majority (68.2%) presented with stage II or higher disease, and there were high rates of immunosuppression (45.5%). At the time of reporting, 68.2% patients were alive, 18.2% had died from their skin cancers and 13.6% had died from unrelated causes. Conclusion This cohort has demonstrated late-stage presentation of skin cancers, with substantial morbidity and mortality from potentially treatable cutaneous malignancies. This parallels other health conditions in Indigenous Australians and has highlighted the need for improved data collection of Indigenous status to better quantify the epidemiology of skin cancer in this population. There is an imperative to improve skin cancer awareness in this population to allow earlier detection and management to ensure better outcomes.

Introduction This paper reports the key findings of the first survey of recent Radiation Oncology graduates in Australia, New Zealand (ANZ) and Singapore. It explores their experiences in entering the workforce, challenges and perspectives. Methods The survey was conducted in April and May 2016 focusing on graduates from 2013 to 2015. The questions related to relocation, current employment, experiences in finding a job, intentions regarding rural work, job satisfaction and perceptions of the job market. Results The response rate was 80% (66/83). Most respondents (72.7%) commenced and completed their training in the same location. The large majority of respondents (91%) were employed with 51% as consultants, 20% as fellows and 15% as locums. Sixty-four percent of respondents spent more than twelve weeks looking for a consultant position, but this was expected by 80% of respondents. Seventy-three percent of respondents spent more than four weeks looking for a fellowship position, but this was expected by 90%. Twenty seven percent of respondents lived and worked in a rural area with nearly half of respondents who did not work in a rural area, indicating they would consider so if certain conditions were met. The large majority (75%) were satisfied with their current employment with only seven percent reporting dissatisfaction. Respondents felt that the job market was very competitive because of the large number of trainees and better workforce planning was required to ensure a reasonable balance between workforce supply and demand. Some career guidance and mentorship for readiness for the job market was thought to be beneficial. Conclusions This initial survey of recent Radiation Oncology graduates in ANZ and Singapore has revealed the large majority are employed as consultants or fellows, although there is apprehension about a competitive job market. The survey should be repeated on a regular basis to monitor future trends.

Background Radical radiotherapy, with or without concomitant chemotherapy forms the mainstay of organ preservation approaches in mucosal primary head and neck cancer. Despite technical advances in cancer imaging and radiotherapy administration, a significant proportion of patients fail to achieve a complete response to treatment. For those patients who do achieve a complete response, acute and late toxicities remain a cause of morbidity. A critical need therefore exists for imaging biomarkers which are capable of informing patient selection for both treatment intensification and de-escalation strategies. Methods/design A prospective imaging study has been initiated, aiming to recruit patients undergoing radical radiotherapy (RT) or chemoradiotherapy (CRT) for mucosal primary head and neck cancer (MPHNC). Eligible patients are imaged using FDG-PET/CT before treatment, at the end of week 3 of treatment and 12 weeks after treatment completion according to local imaging policy. Functional MRI using diffusion weighted (DWI), blood oxygen level-dependent (BOLD) and dynamic contrast enhanced (DCE) sequences is carried out prior to, during and following treatment. Information regarding treatment outcomes will be collected, as well as physician-scored and patient-reported toxicity. Discussion The primary objective is to determine the correlation of functional MRI sequences with tumour response as determined by FDG-PET/CT and clinical findings at 12 weeks post-treatment and with local control at 12 months post-treatment. Secondary objectives include prospective correlation of functional MRI and PET imaging with disease-free survival and overall survival, defining the optimal time points for functional MRI assessment of treatment response, and determining the sensitivity and specificity of functional MRI sequences for assessment of potential residual disease following treatment. If the study is able to successfully characterise tumours based on their functional MRI scan characteristics, this would pave the way for further studies refining treatment approaches based on prognostic and predictive imaging data. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616000534482 (26 April 2016).

INTRODUCTION AND OBJECTIVES:To understand the decision making process in men diagnosed with localised prostate cancer (LPC) who are attending a combined clinic (CC), deciding between robotic prosta...

INTRODUCTION This paper reports the key findings of the Faculty of Radiation Oncology 2018 workforce census and compares results with previous studies. METHODS The census was conducted in mid-2018 with distribution to all radiation oncologists and trainees listed on the college database in Australia, New Zealand, Singapore and overseas. There were new questions about hours spent on multidisciplinary meetings (MDTS), leadership positions held, management of inpatients, hypofractionation, stereotactic body radiation therapy (SBRT), income type and gynae-oncology work for radiation oncologists. Trainees were asked about time spent on planning and contouring. RESULTS The overall response rate was 69.9% with 67.7% of radiation oncologists and 77.9% of trainees responding. There were 514 radiation oncologists with 60% male and a mean age of 49 years (median = 46 years, range 31-91). The majority of respondents were Caucasian (57.7%) and from New South Wales (29.4%). Sixty-one per cent were subspecialists with breast, SBRT and urological cancers, the most popular areas of interest, and 56% held leadership positions. The majority worked in the public sector (55.7%), but 31.7% worked solely in the private sector with an average working week of 43.4 hours (h) (median = 44, range 2-110). Radiation oncologists spent an average of 3.6 h on MDTS (median = 4 h), 2.2h (median = 2 h) on simulation and 8 h (median = 5 h) on contouring per week. They averaged 245 new patients (median = 250, range 30-695) and 25 inpatients (median = 20) per year. Hypofractionation was used for radical treatment of breast (75%) and prostate cancer (49%). Radiation oncologists were mainly remunerated with a fixed income (53%) with 40% having some incentive-based income. There were 140 trainees with an equal male and female distribution. The large majority (88%) were satisfied with their career and network (83%). Most trainees worked between 36 and 55h per week with 15% having no protected time. Most trainees spent less than 5 hours on planning each week and job availability remained a major concern (90%). CONCLUSIONS The radiation oncologist numbers have increased significantly, but unemployment remains low. Many parameters remain similar to the 2014 census, but new information has been obtained on special interest areas, leadership positions, gynae-oncology, inpatients, hypofractionation use, remuneration and contouring. Trainee numbers remain stable with an increased percentage satisfied with their career with much less concern about oversupply. Protected time remains an issue with contouring time and teaching emerging as a potential issue.

Background This study examined the prognostic significance of human papillomavirus (HPV) in patients with oropharyngeal and oral cavity squamous cell carcinoma (SCC). Methods Tissue microarrays were constructed from oropharyngeal and oral cavity SCC (n = 143). The presence of functional HPV in tumour was determined by combined assessments of p16 immunohistochemistry and HPV in situ hybridisation. Results Oropharyngeal SCC patients presented with more advanced disease in comparison with oral cavity SCC patients (P = 0.001). HPV is present in 60% and 61% of oropharyngeal and oral cavity SCC patients, respectively. HPV-positive oropharyngeal SCC patients with advanced TNM stages displayed better overall and disease-free survival outcomes than HPV-negative patients (P = 0.022 and 0.046, respectively). Such survival differences were not observed in oral cavity SCC. Conclusions HPV is common in both oropharyngeal and oral cavity SCC and is associated with better survival outcome in oropharyngeal SCC but not in oral cavity SCC patients.

To evaluate the prognostic utility of 2-[(18)F] fluoro-2-deoxy-d-glucose positron emission tomography-computed tomography (FDG PET-CT) carried out in the third week (iPET) and after completion (pPET) of definitive radiation therapy in patients with mucosal primary head and neck squamous cell carcinoma (MPHNSCC) and to investigate the optimal visual grading criteria for therapy response assessment.Sixty-nine consecutive patients with newly diagnosed MPHNSCC treated with radical radiation therapy with or without systemic therapy underwent staging. PET-CT, iPET and pPET were included. All PET-CT images were reviewed by using a visual grading system to assess metabolic response for primary tumour: 0 = similar to adjacent background blood pool activity; 1 = more than background but mediastinal blood pool; 2 ≥ mediastinal blood pool andliver; 3 ≥ liver; and 4 ≥ brain. The results were correlated with locoregional recurrence-free survival (LRFS), disease-free survival (DFS) and overall survival, using Kaplan-Meier analysis.The median follow-up was 28 months (range 6-62), the median age was 61 years (range 39-81) and AJCC 7th edition clinical stage II, III and IV were six, 18 and 45 patients, respectively. The optimal threshold for non-complete metabolic response (non-CMR) was defined as focal uptake ≥ liver (grade 3) for iPET and focal uptake ≥ mediastinum (grade 2) for pPET. The 2 year Kaplan-Meier LRFS, DFS and overall survival estimates for primary CMR and non-CMR in iPET were 89.8% versus 71.5% (P = 0.062), 80.1% versus 65.3% (P = 0.132), 79.1% versus 72.1% (P = 0.328) and in pPET 86.2% versus 44.6% (P = 0.0005), 77.6% versus 41.2% (P = 0.006), 81.2% versus 40.6% (P = 0.01), respectively. The negative predictive value (NPV) for LRFS for patients achieving both primary and nodal CMR in iPET was 100%. No locoregional failure was observed in patients with both primary and nodal iPET CMR (P = 0.038), whereas those with nodal iPET CMR had no regional failure (P = 0.033). However, the positive predictive values (PPV) for LRFS and DFS for iPET and pPET were found to be poor: 30% and 36% for iPET and 35% and 39% for pPET, respectively.Standardised criteria using visual assessment are feasible. The metabolic response using visual assessment with standardised interpretation criteria of iPET and pPET can be useful predictors of tumour control. Dose de-escalation can be considered on the basis of a high NPV for iPET. However, the PPV of iPET is poor, indicating that additional discriminative tools are needed.

The aims of this study are to evaluate the prognostic value of metabolic parameters derived from (18) F-FDG PET-CT performed before definitive radiation therapy (RT) (prePET) in patients with mucosal primary head and neck squamous cell carcinoma (MPHNSCC) and to assess the additive prognostic values of FDG PET-CT performed during RT (iPET).One hundred patients with MPHNSCC treated with radical RT underwent staging prePET and iPET performed during the third week of treatment. The maximum standardized uptake value (SUVmax ), metabolic tumour volume (MTV) and total lesional glycolysis (TLG) of primary tumour were analysed for both prePET and iPET, and results were correlated with loco-regional recurrence-free survival (LRFS), disease-free survival (DFS), metastatic failure-free survival (MFFS) and overall survival (OS), using Kaplan-Meier analysis. Optimal cut-offs (OC) for prePET and iPET were derived from Receiver Operating Characteristic curves. Patients with metabolic parameters above/below the individual OC of prePET as well as iPET (i.e. combined prePET and iPET (comPET)) were evaluated against their outcomes.Median age was 61 years (range 39-81), median follow-up of 20 months (range 4-70, mean 27), and AJCC 7th Edition clinical stage II, III and IV were 8, 24 and 68 patients respectively. Metabolic values below individual OC in comPET were found to be associated with statistically significant improvements (P 0.05) in DFS, LRFS and OS. In addition, patients with SUVmax above the OC in comPET were associated with worse MFFS (P = 0.011) and confirmed on both univariate (P = 0.019) and multivariate analyses (P = 0.04).Addition of iPET significantly improves the prognostic values of all three metabolic parameters and can potentially be used in future adaptive local and systemic therapy trials.

Introduction: Inter-observer variability (IOV) in target volume delineation is a source of error in head and neck radiotherapy. Diffusion-weighted imaging (DWI) has been shown to be useful in detecting recurrent head and neck cancer. This study aims to determine whether DWI improves target volume delineation and IOV. Methods: Four radiation oncologists delineated the gross tumour volume (GTV) for ten head and neck cancer patients. Delineation was performed on CT alone as well as fused image sets which incorporated fluorodeoxyglucose (FDG)-positron emission tomography (PET) and magnetic resonance imaging (MRI) in the form of CT/PET, CT/PET/T2W and CT/PET/T2W/DWI image sets. Analysis of the variability of contour volumes was completed by comparison to the simultaneous truth and performance level estimation (STAPLE) volumes. The DICE Similarity Coefficient (DSC) and other IOV metrics for each observer's contour were compared to the STAPLE for each patient and image dataset. A DWI usability scoresheet for delineation was completed. Results: The CT/PET/T2W/DWI mean GTV volume of 13.37 (10.35–16.39)cm was shown to be different to the mean GTV of 10.92 (8.32–13.51)cm when using CT alone (P < 0.001). The GTV DSC amongst observers for CT alone was 0.72 (0.65–0.79), CT/PET was 0.73 (0.67–0.80), CT/PET/T2W was 0.71 (0.64–0.77) and CT/PET/T2W/DWI was 0.69 (0.61–0.75). Conclusion: Mean GTVs with the addition of DWI had slightly larger volumes compared to standard CT and CT/PET volumes. DWI may add supplemental visual information for GTV delineation while having a small impact on IOV, therefore potentially improving target volume delineation.

Background Existing prognostic systems for metastatic cutaneous squamous cell carcinoma of the head and neck (cSCCHN) do not discriminate between the number of involved nodes beyond single versus multiple. This study aimed to determine if the number of metastatic lymph nodes is an independent prognostic factor in metastatic cSCCHN and whether it provides additional prognostic information to the American Joint Committee on Cancer (AJCC) staging. Methods We retrospectively analysed 101 patients undergoing curative intent treatment for metastatic cSCCHN to parotid and/or neck nodes by surgery +/- radiotherapy at Liverpool Hospital, Sydney, Australia. The impact of number of nodal metastases on disease-free survival (DFS) and risk of distant metastases was assessed using multivariate Cox regression. Results The mean number of nodal metastases was 2.5 (range 1-12). On multivariate analysis, increasing number of nodal metastases significantly predicted reduced DFS (hazard ratio 1.17; 95% confidence interval 1.05-1.30; P = 0.004), with a 17% increased risk of recurrence or death for each additional node. This remained significant in multivariate models adjusted for AJCC 8th edition nodal and TNM stages. Number of nodal metastases was also associated with risk of distant metastatic failure (hazard ratio 1.21; 95% confidence interval 1.05-1.39; P = 0.009). Conclusion Increasing number of nodal metastases is associated with decreased DFS and increased risk of distant metastases in metastatic cSCCHN, with a cumulative risk increase with each additional node. It provides additional prognostic information to the AJCC staging, which may be improved by incorporating information on the number of nodal metastases beyond the current single versus multiple distinction.

Background: Caring for patients with head and neck cancer (HNC) can have significant negative psychological and practical impact; however, some carers seem able to cope effectively. Little research has investigated this resilience among carers. Objective: The objective of this study was to investigate the resilience levels among carers of patients with HNC. Methods: Carers (n = 51) from 2 cancer services in New South Wales completed the Resilience Scale (RS), the Head and Neck Information Needs Questionnaire, and the Hospital Anxiety and Depression Scale. Hospital Anxiety and Depression Scale cutoff scores (>8) were used to classify carers with clinically significant levels of anxiety or depression. Results: The majority of carers (67% [34/51]) reported moderately high to high resilience. Rates of anxiety and depression among carers were 27.4% and 9.8%, respectively. Higher resilience scores were significantly correlated with lower anxiety and depression scores, as well as increasing age. Resilience Scale scores were independent of the severity of the HNC. There were no significant correlations between RS scores and Head and Neck Information Needs Questionnaire scores. Finally, increasing RS scores were associated with a decreasing probability of possible anxiety or depression. Conclusions: These results indicate that higher resilience in carers of HNC patients was associated with lower levels of psychological distress. Further investigation into the relationship between resilience and carer psychological wellbeing is warranted. Implications for Practice: If further evidence supports the findings of this study, then investigating ways to build resilience will be an important clinical option for reducing carer morbidity associated with anxiety and depression. The RS could be used to assess resilience levels among carers of HNC patients.

Purpose Treatment planning for IMRT is a complex process that requires additional training and expertise. The aim of this study was to compare and analyze IMRT plans generated by dosimetrists with varying levels of IMRT planning experience. Methods and Materials The computed tomography (CT) data of a patient previously treated with IMRT for left tonsillar carcinoma were used. The patient's preexisting planning target volumes (PTVs) and all organs at risk were provided with the CT data set. Six dosimetrists with variable IMRT planning experience generated IMRT plans according to the department's protocol. Plan analysis included visual inspection and comparison of dose-volume histogram, conformity indices, treatment delivery efficiency, and dose delivery accuracy. Results Visual review of the dose distribution showed that the 6 plans were comparable. However, only the 2 most experienced dosimetrists were able to meet the strict PTV aims and critical structure constraints. The least experienced dosimetrist had the worst planning outcome. Comparison of delivery efficiency showed that the number of segments, total monitor units, and treatment time increased as the IMRT planning experience decreased. Conclusions Dosimetrists with higher levels of IMRT planning experience produced a better quality head and neck IMRT plan. Different planning experience may need to be considered when organizing appropriate departmental resources.

To evaluate the prognostic utility of nodal metabolic parameters derived from FDG PET/CT performed before radiotherapy (prePET) and during the third week of radiotherapy (iPET) in patients with mucosal primary head and neck squamous cell carcinoma (MPHNSCC). This analysis included 75 patients with newly diagnosed locally advanced node-positive MPHNSCC treated with radical radiotherapy and concurrent systemic therapy who underwent prePET and iPET: N1 11 patients, N2a 38, N2b 12, N2c 9, N3 5. The median follow-up was 28 months (9 – 70 months). The maximum and mean standardized uptake values (SUVmax and SUVmean), metabolic tumour volume (MTV) and total lesional glycolysis (TLG) of the index lymph node (node with the highest TLG) and the combined total lymph nodes, and their percentage reductions on iPET were determined, and the results were correlated with 3-year Kaplan-Meier locoregional, regional and distant metastatic failure-free survival (FFS), disease-free survival (DFS) and overall survival (OS). Optimal cut-off values were derived from receiver operating characteristic curves. Cox regression univariate and multivariate analyses with clinical covariates were performed. Based on assessment of residual nodal metabolic burden during treatment, the iPET index node SUVmean (optimal cut-off value 2.95 g/ml) and the total node SUVmean (optimal cut-off value 3.25) were the best independent predictors of outcome in the multivariate analysis: index node SUVmean for DFS and OS p = 0.033 and 0.003, respectively, and the total node SUVmean for locoregional FFS, DFS and OS p = 0.028, 0.025 and 0.014, respectively. Based on the assessment of response rates during treatment, a reduction of more than 50 % in the total node TLG was the best biomarker for locoregional and regional FFS, DFS and OS in the multivariate analysis (p = 0.001, 0.016, 0.001 and 0.004, respectively), and reduction in the total node MTV for locoregional FFS, DFS and OS (p = 0.026, 0.003 and 0.014, respectively). There were no significant correlations between oncological outcomes and prePET nodal parameters. We demonstrated that the index node and total node SUVmean on iPET and a reduction of more than 50 % in MTV and TLG are useful imaging biomarkers, and can potentially identify those patients with MPHNSCC who have a high risk of locoregional metastatic failure and death.

There is increasing use of multiple molecular markers to predict prognosis in human cancer. Our aim was to examine the prognostic significance of cyclin D1 and retinoblastoma (pRb) expression in association with human papillomavirus (HPV) status in oropharyngeal squamous cell carcinoma. Clinical records and specimens of 226 patients with follow-up from 1 to 235 months postdiagnosis were retrieved. Tumor HPV status was determined by HPV E6-targeted multiplex real-time PCR/p16 semiquantitative immunohistochemistry and cyclin D1 and pRb expression by semiquantitative immunohistochemistry. Determinants of recurrence and mortality hazards were modeled using Cox regression with censoring at dates of last follow-up. The HPV-positivity rate was 37% (91% type 16). HPV was a predictor of recurrence, an event (recurrence or death) and death after adjustment for clinicopathological variables. There were inverse relationships between HPV status and cyclin D1 and pRb. On univariate analysis, cyclin D1 predicted locoregional recurrence, event and death and pRb predicted event and death. Within the HPV-positive group, after adjusting for clinicopathological factors, patients with cyclin D1-positive cancers had up to a eightfold increased risk of poor outcome relative to those with cyclin D1-negative tumors. However, within the HPV-negative group, there was only a very small adjusted increased risk. A combination of pRb and HPV did not provide additional prognostic information. Our data provide the first evidence that a combination of HPV and cyclin D1 provides more prognostic information in oropharyngeal cancer than HPV alone. If findings are confirmed, treatment based on HPV and cyclin D1 may improve outcomes.

Summary A multicentre planning study comparing intensity-modulated radiation therapy (IMRT) plans for the treatment of a head and neck cancer has been carried out. Three Australian radiotherapy centres, each with a different planning system, were supplied a fully contoured CT dataset and requested to generate an IMRT plan in accordance with the requirements of an IMRT-based radiation therapy oncology group clinical trial. Plan analysis was carried out using software developed specifically for reviewing multicentre clinical trial data. Two out of the three plans failed to meet the prescription requirements with one misinterpreting the prescription and the third failed to meet one of the constraints. Only one plan achieved all of the dose objectives for the critical structures and normal tissues. Although each centre used very similar planning parameters and beam arrangements the resulting plans were quite different. The subjective interpretation and application of the prescription and planning objectives emphasize one of the many difficulties in carrying out multicentre IMRT planning studies. The treatment prescription protocol in a clinical trial must be both lucid and unequivocally stated to avoid misinterpretation. Australian radiotherapy centres must show that they can produce a quality IMRT plan and that they can adhere to protocols for IMRT planning before using it in a clinical trial.

To evaluate the serial changes and correlations between readout-segmented technique with navigated phase correction diffusion-weighted MRI (DWI), R2*-MRI and (18)F-FDG positron emission tomography (PET) CT performed before and during radiation therapy (RT) in patients with mucosal primary head and neck cancer.The mean apparent diffusion coefficient (ADCmean) from DWI (at b = 50 and 800 s mm(-2)), the mean R2* values derived from T2(*)-MRI, and PET metabolic parameters, including maximum standardized uptake value (SUVmax), metabolic tumour volume (MTV) and total lesional glycolysis (TLG) were measured for the primary tumour. Spearman correlation coefficients were calculated to evaluate correlations between ADCmean, R2*, SUVmax, MTV and TLG. A paired t-test was performed to assess the MRI changes and the slope of serial MRI changes during RT.Pre-treatment scans were performed in 28 patients and mid-treatment scans in 20 patients. No significant correlation was found between ADCmean and either R2* values or PET parameters. There were significant negative correlations of R2* values with pre-treatment PET parameters but not with mid-RT PET parameters: pre-SUVmax (p = 0.008), pre-MTV (p = 0.006) and pre-TLG (p = 0.008). A significant rise in ADCmean was found during the first half (p 0.001) of RT but not in the second half (p = 0.215) of the treatment. There was an increase of the ADCmean values of 279.4 [95% confidence interval (95% CI): 210-348] in the first half of the treatment (Weeks 0-3). However, during the second-half period of treatment, the mean ADC value (Weeks 3-6) was 24.0 and the 95% CI (-40 to 88) included zero. This suggests that there was no significant change in ADC values during the second half of the treatment.A significant negative correlation was found between pre-treatment R2*-MRI and PET parameters. DWI appeared to demonstrate potentially predictable changes during RT.Understanding the correlation and changes that occur with time between potential imaging biomarkers may help us establish the most appropriate biomarkers to consider in future research.

Purpose To evaluate the prognostic value of 18 F-FDG-PET-CT performed prior to (prePET) and during the third week (iPET) of radiation therapy (RT) in nasopharyngeal carcinoma (NPC). Materials and methods Thirty-patients with newly diagnosed loco-regionally advanced NPC treated with radical RT underwent prePET and iPET. The median follow-up was 26months (8–66.9). The maximum-standardised-uptake-value (SUVmax), metabolic-tumour-volume (MTV) and total-lesional-glycolysis (TLG) of the primary tumour (PT), index-node (IN) (lymph node with highest TLG), total-lymph-nodes (TN) and combined primary-tumour and nodal (PTN), and their % reductions in iPET were analysed, and results were correlated with 2-year Kaplan–Meier loco-recurrence-free-survival (LRFS), regional-failure-free-survival (RFFS), distant-metastatic-failure-free-survival (DMFFS), disease-free-survival (DFS), and overall-survival (OS). Optimal-cutoffs (OC) were derived from Receiver-Operating-Characteristic curves. Results For LRFS, the only predictor was reduction in PT MTV by >50%: 95.2% vs. 75.0%, p =0.024. For other treatment outcomes, only nodal or PTN predicted outcomes. The IN SUVmax (pre-PET-OC=10.45g/mL and iPET-OC=8.15) and TLG (prePET-OC=90g and iPET-OC=33.4) were the best predictors of outcome: RFFS (iPET SUVmax/TLG): 100% vs. 50%, p p =0.032; DMFFS (prePET SUVmax/TLG); 100% vs. 51.9%, p =0.004 and 100% vs. 47.6%, p =0.002; DFS (prePET TLG and iPET SUVmax): 87.5% vs. 33%, p =0.045 and 78.7% vs. 20%, p =0.01; and OS (prePET TLG): 100% vs 66.3%, p =0.036. Conclusions We have demonstrated IN of prePET and iPET to be a feasible and potentially useful novel imaging biomarker to predict for patients with NPC who have a high risk of regional or distant metastatic failure. Future work is required to validate our findings in a well-powered, prospective study with a standardised treatment protocol, and their potential use to guide individualised therapy for NPC.

Advanced radiotherapy techniques, such as intensity-modulated radiotherapy, have been reported to reduce toxicities by improving the dose conformity in mucosal primary head and neck cancer (MPHNC). However, to further optimize the therapeutic ratio, details on individual patient and disease characteristics may be necessary to tailor treatments. This is likely to include identifying poor responders for treatment intensification and good responders for de-escalation strategies. Non-invasive, repeatable imaging biomarkers are attractive modalities in both pre-treatment and intra-treatment response prediction with a view to individualized treatment options. This review has assessed the current literature on the prognostic/predictive role of widely available functional imaging (FI) studies such as fMRI(functional magnetic resonance imaging), functional computed tomography (fCT) and positron-emission-tomography(PET). A literature search was carried out using Medline, Embase and PubMed. Studies were included if imaging was undertaken pre and/or during radiotherapy (with or without the addition of chemotherapy and/or surgery). A total of 99 relevant studies were identified: 14 fMRI, 10 fCT, 59 FDG-PET and 16 non-FDG-PET studies. These articles were reviewed to identify imaging parameters demonstrating a correlation with patient outcome or a factor considered to impact on patient outcome and thus likely to be of potential predictive value in MPHNC and associated future radiotherapy treatment directions. Several studies have demonstrated that both pre-treatment and mid-treatment FDG-PET is predictive of outcomes. However, further studies are required to confirm the role of other imaging studies including fMRI and PET using other tracers. There is large heterogeneity within and between published studies, including tumour sites, treatment options, outcome endpoints and parameters assessed. We propose a minimum set of factors that should be reported and make recommendations for studies evaluating the predictive utility in MPHNC.

Summary Orbital rhabdomyosarcoma (RMS) accounts for 10% of childhood RMS and has a relatively good prognosis of up to 85% 5-year survival. Improved survival has led to increased interest in late effects of treatment. The objective of this study was to review the results of treating orbital RMS with multidisciplinary treatment at Women's and Children's Hospital and Royal Adelaide Hospital with emphasis on late effects of treatment. A retrospective review was carried out of all patients with orbital RMS treated with multidisciplinary treatment including radiation therapy and chemotherapy in the two institutions between 1982 and 2002. A total of five patients (age range 5.5-12 years) satisfied the eligibility requirements. Late effects were significant and included facial bone hypoplasia, cataract formation and growth hormone deficiency. Overall survival was 80% (4/5) with mean follow up of 8 years (range 3-13 years). Given the high cure rates achieved, future treatments must aim to maintain the good results but to reduce the high incidence of late effects of treatment. Standardised rating of late toxicity, long-term follow-up clinics, and implementation of modern radiation techniques (3-D conformal radiotherapy, intensity modulated radiotherapy, proton therapy) for patients with orbital RMS are important to improving outcome.

Intravenous contrast-enhanced computed tomography is utilised in radiotherapy lung treatment planning to improve the delineation of the tumour volume and nodal areas. In the resultant CT images, the electron density is increased within the vascular structures of the lung and the overall density in the lung volume may also be increased. As yet, it is unclear whether the change in density affects the accuracy of dose calculations based on this CT data. Two investigations were undertaken. Firstly, contrast-enhancement was simulated using an anthropomorphic phantom. In the second investigation, bulk density corrections were performed in an existing patient dataset. In both investigations, treatment plans were generated using both pre- and post-contrast datasets. The numbers of monitor units calculated in each of the plans were compared, as were the resulting isodose curves, dose volume histograms and physical mean lung doses. The numbers of monitor units calculated from the contrast- and non contrast-enhanced datasets agreed within 2%. The isodose curves and dose volume histograms showed very minor differences in size and shape. With the introduction of contrast agent, the physical mean lung doses calculated remained below the limit recommended for an acceptable plan. These results indicate that the introduction of contrast agent has a minimal dosimetric impact upon lung cancer treatment plans.

BackgroundMen diagnosed with localised prostate cancer (LPC) wanting curative treatment face a highly preference-sensitive choice between prostatectomy and radiotherapy, which offer similar cure rates but different side effects. This study aims to determine the information, decision-making needs and preferences of men with LPC choosing between robotic prostatectomy and standard external beam or stereotactic radiotherapy.Methods and analysisThis study will be conducted at a large public teaching hospital in Australia offering the choice between robotic prostatectomy and radiotherapy from early 2017. Men (20–30) diagnosed with LPC who want curative treatment and meet criteria for either treatment will be invited to participate. In this mixed-methods study, patients will complete semistructured interviews before and after attending a combined clinic in which they consult a urologist and a radiation oncologist regarding treatment and four questionnaires (one before treatment decision-making and three after) assessing demographic and clinical characteristics, involvement in decision-making, decisional conflict, satisfaction and regret. Combined clinic consultations will also be audio-recorded and clinicians will report their perceptions regarding patients’ suitability for, openness to and preferences for each treatment. Qualitative data will be transcribed verbatim and thematically analysed and descriptive statistical analyses will explore quantitative decision-making outcomes, with comparison according to treatment choice.DiscussionResults from this study will inform how to best support men diagnosed with LPC deciding which curative treatment option best suits their needs and may identify the need for and content required in a decision aid to support these men.Ethics and disseminationAll participants will provide written informed consent. Data will be rigorously managed in accordance with national legislation. Results will be disseminated via presentations to both scientific and layperson audiences and publications in peer-reviewed scientific journals.

Rhabdomyosarcoma (RMS) is a malignant soft tissue tumor with skeletal muscle differentiation that can rarely present as a primary cutaneous tumor. There are 3 main subtypes of RMS: embryonal, alveolar, and pleomorphic. Primary cutaneous pleomorphic RMS is extremely rare, there being only 9 reported cases in the literature, 2 of which are radiation induced. We present a case of primary pleomorphic RMS occurring on the sun-damaged skin of the face of an 89-year-old woman. The tumor was diagnosed by histology, immunohistochemistry, and electron microscopy. The patient was treated by surgery and adjuvant radiotherapy. The tumor recurred rapidly after surgical excision. She died 2 months after the diagnosis from complications of treatment, local symptoms of tumor, and concurrent illnesses. Primary cutaneous pleomorphic RMS is a rare tumor of adults and pursues an aggressive clinical course.

Context: Improving the effectiveness of cancer care delivery has become a major focus of research. Objectives: This study assessed the uptake and impact of the Palliative Care Needs Assessment Guidelines and Needs Assessment Tool: Progressive Disease - Cancer (NAT: PD-C) on the outcomes of people with advanced cancer. Methods: Given widely varying survival in people with advanced cancer, an interrupted time series design was used, with data on unmet needs, depression, anxiety, and quality of life collected from 195 patients using telephone interviews every two months, for up to 18 months. Patients completed at least two baseline interviews before health professionals were academically detailed in the use of the Palliative Care Needs Assessment Guidelines and NAT: PD-C. Health professionals completed the NAT: PD-C with patients approximately monthly for the remainder of the study. Changes in patients' outcomes were compared prior to and following the introduction of the NAT: PD-C using general estimating equations. Results: Moderate to high needs across all domains were frequently seen in the preintervention phase. The use of the NAT: PD-C was associated with a significant reduction in health system and information and patient care and support needs. Conclusion: These resources have the potential as an efficient and acceptable strategy for supporting needs-based cancer care. Further work is required to determine their unique contribution to improvements in patient outcomes. © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

In September 2006, the Royal Australian and New Zealand College of Radiologists (RANZCR) endorsed the modified Peer Review Audit Tool (PRAT). We aimed to assess the feasibility of using this tool in a busy radiation oncology department using an electronic medical record (EMR) system, identify areas of compliance and assess the impact of the audit process on patient management. Fortnightly random clinical audit was undertaken by using the revised RANZCR PRAT in the departments of radiation oncology at Liverpool and Macarthur Cancer Therapy Centres (LCTC and MCTC). Following audit of the EMR, treatment plans were audited by peer review. Data were collected prospectively from June 2007 to June 2008. Audits were carried out on 208 patients. Behaviour criteria were well documented in the EMR, but scanning of histology and medical imaging reports did not occur in up to a third of cases. With electronic prescriptions, treatment prescription errors were rare. In total, 8 (3.8%) out of 208 patients had a change to management recommended. Variability in interpretation of PRAT 'protocol/study' criteria was identified. We found that real-time audit is feasible and effective in detecting both issues with documentation in the EMR, and a small number of patients in whom a change to management is recommended. Recommendations have been made in order to continue to improve the audit process including documentation of any changes recommended and whether the recommended change occurred.

Purpose To evaluate the prognostic value of 18F-FDG PET-CT performed in the third week (iPET) of definitive radiation therapy (RT) in patients with newly diagnosed locally advanced mucosal primary head and neck squamous-cell-carcinoma (MPHNSCC). Methodology Seventy-two patients with MPHNSCC treated with radical RT underwent staging PET-CT and iPET. The maximum standardised uptake value (SUVmax), metabolic tumour volume (MTV) and total lesional glycolysis (TLG) of primary tumour (PT) and index node (IN) [defined as lymph node(s) with highest TLG] were analysed, and results were correlated with loco-regional recurrence-free survival (LRFS), disease-free survival (DFS), metastatic failure-free survival(MFFS) and overall survival (OS), using Kaplan-Meier analysis. Results Optimal cutoffs (OC) were derived from receiver operating characteristic curves: SUVmax-PT = 4.25 g/mL, MTVPT = 3.3 cm3, TLGPT = 9.4 g, for PT, and SUVmax-IN = 4.05 g/mL, MTVIN = 1.85 cm3 and TLGIN = 7.95 g for IN. Low metabolic values in iPET for PT below OC were associated with statistically significant better LRFS and DFS. TLG was the best predictor of outcome with 2-year LRFS of 92.7 % vs. 71.1 % [p = 0.005, compared with SUVmax (p = 0.03) and MTV (p = 0.022)], DFS of 85.9 % vs. 60.8 % [p = 0.005, compared with SUVmax (p = 0.025) and MTV (p = 0.018)], MFFS of 85.9 % vs. 83.7 % [p = 0.488, compared with SUVmax (p = 0.52) and MTV (p = 0.436)], and OS of 81.1 % vs. 75.0 % [p = 0.279, compared with SUVmax (p = 0.345) and MTV (p = 0.512)]. There were no significant associations between the percentage reduction of primary tumour metabolic parameters and outcomes. In patients with nodal disease, metabolic parameters below OC (for both PT and IN) were significantly associated with all oncological outcomes, while TLG was again the best predictor: LRFS of 84.0 % vs. 55.3 % (p = 0.017), DFS of 79.4 % vs. 38.6 % (p = 0.001), MFFS 86.4 % vs. 68.2 % (p = 0.034) and OS 80.4 % vs. 55.7 % (p = 0.045). Conclusion The metabolic parameters of iPET can be useful predictors of patient outcome and potentially have a role in adaptive therapy for MPHNSCC. Among the three parameters, TLG was found to be the best prognostic indicator of oncological outcomes.