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Working parents, and a rising number of adults delivering care for ageing relatives, experience numerous challenges in their personal, family, professional and financial lives due to multiple responsibilities. This study describes the experiences of Canadian radiation oncology (RO) parents and family caregivers, reporting challenges that may exist in providing family care with clinical/academic work commitments.Canadian RO's were invited to participate in an anonymous online survey, via RO heads of departments in cancer centres across Canada and to physician members of the Canadian Association of Radiation Oncology between November 2021 and January 2022. The survey focused on demographics, experiences of pregnancy and leave, parenting and adult caregiving responsibilities, and self-care.103 (38%) staff RO completed the survey, 78 (75.7%) identified as having a parental (76, 89.7%) and/or other family caregiver (8, 10.3%) role. 41% were female (59% male), with no difference between gender and number of children (median 2, IQR 1-3, p=0.17). More female respondents took parental leave for their first child compared to male (mean 29 versus 6 weeks, p0.001). 27% of male respondents who started caring for their first child during residency took parental leave compared to 77% (p=0.003) as a staff. The majority of respondents described "always/usually" collegial support for each pregnancy and parental leave. Both genders described parental responsibilities as negatively impacting attendance at conferences (male - 65%, female - 77%, p=0.31) and early/late work-related meetings (male - 76%, female 79%, p=1.0). More female respondents described parental responsibilities as negatively impacting their career (50% vs 29%, p=0.085). 52% of female respondents (vs 26% male respondents, p=0.044) identified a physician mentor or positive role model around parenting issues.Parental and other family caregiving responsibilities are not gender unique in Canadian ROs but competing work and family roles may impact genders differently.

This study sought to report the degree to which postgraduate trainees in radiation oncology perceive their education has been impacted by the COVID-19 pandemic. A cross-sectional online survey was administered from June to July 2020 to trainee members of the Canadian Association of Radiation Oncology (CARO) (n = 203). Thirty-four trainees responded with a 17% response rate. Just under half of participants indicated that COVID-19 had a negative/very negative impact on training (n = 15; 46%). The majority agreed/strongly agreed that they feared family/loved ones would contract COVID-19 (n = 29, 88%), felt socially isolated from friends and family because of COVID-19 (n = 23, 70%), and had difficulty concentrating on tasks because of concerns about COVID-19 (n = 17, 52%). Changes that had a negative/very negative impact on learning included limitations to travel and networking (n = 31; 91%) and limited patient contact (n = 19; 58%). Virtual follow-ups (n = 25: 76%) and in-patient care activities (n = 12; 36%) increased. Electives were cancelled in province (n = 10; 30%), out-of-province (n = 16; 49%), and internationally (n = 15; 46%). Teaching from staff was moderately reduced to completely suppressed (n = 23, 70%) and teaching to medical students was moderately reduced to completely suppressed (n = 27, 82%). Significant changes to radiation oncology training were wrought by the pandemic, and roughly half of trainees perceive that these changes had a negative impact on training. Innovations in training delivery are needed to adapt to these new changes.

Supplementary Data from A Phase II Randomized Trial of Chemoradiation with or without Metformin in Locally Advanced Cervical Cancer

Purpose:Tumor hypoxia is associated with poor response to radiation (RT). We previously discovered a novel mechanism of metformin: enhancing tumor RT response by decreasing tumor hypoxia. We hypothesized that metformin would decrease tumor hypoxia and improve cervical cancer response to RT.Patients and Methods:A window-of-opportunity, phase II randomized trial was performed in stage IB–IVA cervical cancer. Patients underwent screening positron emission tomography (PET) imaging with hypoxia tracer fluoroazomycin arabinoside (FAZA). Only patients with FAZA uptake (hypoxic tumor) were included and randomized 2:1 to receive metformin in combination with chemoRT or chemoRT alone. A second FAZA-PET/CT scan was performed after 1 week of metformin or no intervention (control). The primary endpoint was a change in fractional hypoxic volume (FHV) between FAZA-PET scans, compared using the Wilcoxon signed-rank test. The study was closed early due to FAZA availability and the COVID-19 pandemic.Results:Of the 20 consented patients, 6 were excluded due to no FAZA uptake and 1 withdrew. FHV of 10 patients in the metformin arm decreased by an average of 10.2% (44.4%–34.2%) ± SD 16.9% after 1 week of metformin, compared with an average increase of 4.7% (29.1%–33.8%) ± 11.5% for the 3 controls (P = 0.027). Those with FHV reduction after metformin had significantly lower MATE2 expression. With a median follow-up of 2.8 years, the 2-year disease-free survival was 67% for the metformin arm versus 33% for controls (P = 0.09).Conclusions:Metformin decreased cervical tumor hypoxia in this trial that selected for patients with hypoxic tumor.See related commentary by Lyng et al., p. 5233

Brachytherapy (BT) plays a fundamental role in the treatment of gynecological cancers. Patient education for vaginal self-management and dilator use post-BT involves an interdisciplinary team of healthcare professionals (HCPs) and there is a paucity of post-BT education guidelines. Our objective was to determine the educational needs of gynecological cancer patients surrounding vaginal self-management post-BT and to determine enablers and barriers to the provision of education by HCPs. This cross-sectional study recruited gynecological oncology patients receiving external beam radiotherapy and BT for curative intent. Patients completed a questionnaire to assess their vaginal self-management educational needs, preferred education modality, and desired timing of post-BT education. HCPs were invited to complete a questionnaire to identify enablers and barriers to providing BT education. Twenty patients and 53 HCPs participated. All patients rated each topic as very important/important with information about preventing vaginal stenosis as the most important overall (89%). When asked about topics they addressed during BT education, most HCPs reported that "explaining what vaginal stenosis is and the negative effects of stenosis" was always discussed with patients (N = 37/49, 77%). Barriers to providing post-BT education, including the patients' language and culture, as well as enablers, such as the use of written resources and tools for patients, were identified. Despite a high level of engagement, current education surrounding vaginal self-management post-BT may be inadequate.

The lesbian, gay, bisexual, transgender, queer/questioning and two-spirited, plus (LGBTQ2 +) community experiences cancer-related health disparities and inequities. Our objective was to assess LGBTQ2 + knowledge, attitudes, practices and education interest of healthcare professionals (HCPs), identify opportunities to improve care and inform the development of an HCP education curriculum. This was a mixed methods quality improvement study conducted within a tertiary academic cancer centre. An email was sent to all gynaecologic oncology disease site staff (n = 92) with a secure link to an online survey. We measured respondents' sociodemographic characteristics and LGBTQ2 + knowledge, attitudes, practice behaviours and education interest. Open comments explored HCP experiences and reservations caring for LGBTQ2 + patients and suggestions to improve care. Seventy-five out of ninety-two (82%) HCPs completed the survey, with 7% identifying as LGBTQ2 + . HCPs reported feeling less comfortable (88% vs. 80%, p = 0.031) and knowledgeable (44% vs. 27%, p 0.001) caring for transgender patients compared to LGBQ2 + patients. Most (76%) were unaware whether LGBTQ2 + -specific patient educational materials existed within their institution. Almost all (92% strongly agreed/agreed) were interested in receiving LGBTQ2 + -specific education. Two themes emerged from analysis of open comments: (i) HCPs are concerned of offending LGBTQ2 + individuals because of their lack of knowledge and (ii) HCPs desire LGBTQ2 + -specific health training, specifically in asking pronouns and caring for transgender patients. HCPs report competency gaps in caring for LGBTQ2 + patients with cancer but desire education. In response, we recommend institutions develop an educational curriculum for HCPs improve communication and inclusivity in cancer care.

Patient engagement and education have been mandated across Canadian radiation oncology programs (ROP). Guidance documents include the 2014 Canadian Association of Radiation Oncology (CARO) Radiation Therapy Patient Charter, the 2016 Canadian Partnership for Quality Radiotherapy (CPQR) Patient Engagement Guidelines (PEG) for Canadian Radiation Treatment Programs, and Accreditation Canada’s 2017 refresh of Cancer Care Standards. Since little is known regarding uptake of these guidance statements, Canadian ROP were surveyed to assess current patient engagement and education practices. An e-survey was sent to Canadian ROP (n = 44). The survey focused on awareness and uptake of the CARO Patient Charter, CPQR PEG, and patient education practices. Survey development was guided by these documents and expert consensus, including CARO’s Quality and Standards Patient Education/Engagement working group. Many (71%) responding ROP were familiar with the CARO Patient Charter, while 24% reported use. More than half (53%) of ROP were aware of the CPQR PEG, but approximately third (37%) had previously completed a self-audit. Most (88%) ROP view a pan-Canadian, evidence-based approach to educational materials beneficial and feasible (80%), with the majority (89%) willing to share their best practices across the radiotherapy community. Patient engagement and education are nationally mandated and supported by guidance documents. However, gaps have been identified across ROP for awareness and use of available tools, as well as uptake of their processes critical to quality of care. Understanding current practices will inform CPQR/CARO-supported pan-Canadian initiatives to optimize uptake, including development of CPQR Patient Education Guidance for Canadian Radiation Treatment Programs.

Malignant bowel obstruction (MBO) in patients with advanced gynecologic cancer (GyCa) can negatively impact clinical outcomes and quality of life. Oncology nurses can support these patients with adequate tools/processes.Patients with GyCa with/at risk of MBO endure frequent emergency or hospital admissions, impacting patient care.Optimizing oncology nurses' role to improve care for patients with GyCa with/at risk of MBO, the gynecology oncology interprofessional team collaborated to develop a proactive outpatient nurse-led MBO model of care (MOC).The MBO MOC involves a risk-based algorithm engaging interdisciplinary care, utilizing standardized tools, risk-based assessment, management, and education for patients and nurses. The MOC has improved patient-reported confidence level of bowel self-management and decreased hospitalization. Following education, nurses demonstrated increased knowledge in MBO management.An outpatient nurse-led MBO MOC can improve patient care and may be extended to other cancer centers, fostering collaboration and best practice.

Purpose: Tumor hypoxia is associated with poor response to radiation (RT). We previously discovered a novel mechanism of metformin: enhancing tumor RT response by decreasing tumor hypoxia. We hypothesized that metformin would decrease tumor hypoxia and improve cervical cancer response to RT. Patients and Methods: A window-of-opportunity, phase II randomized trial was performed in stage IB–IVA cervical cancer. Patients underwent screening positron emission tomography (PET) imaging with hypoxia tracer fluoroazomycin arabinoside (FAZA). Only patients with FAZA uptake (hypoxic tumor) were included and randomized 2:1 to receive metformin in combination with chemoRT or chemoRT alone. A second FAZA-PET/CT scan was performed after 1 week of metformin or no intervention (control). The primary endpoint was a change in fractional hypoxic volume (FHV) between FAZA-PET scans, compared using the Wilcoxon signed-rank test. The study was closed early due to FAZA availability and the COVID-19 pandemic. Results: Of the 20 consented patients, 6 were excluded due to no FAZA uptake and 1 withdrew. FHV of 10 patients in the metformin arm decreased by an average of 10.2% (44.4%–34.2%) ± SD 16.9% after 1 week of metformin, compared with an average increase of 4.7% (29.1%–33.8%) ± 11.5% for the 3 controls (P = 0.027). Those with FHV reduction after metformin had significantly lower MATE2 expression. With a median follow-up of 2.8 years, the 2-year disease-free survival was 67% for the metformin arm versus 33% for controls (P = 0.09). Conclusions: Metformin decreased cervical tumor hypoxia in this trial that selected for patients with hypoxic tumor. See related commentary by Lyng et al., p. 5233

To demonstrate the feasibility of treating cervical cancer patients with MRI-guided brachytherapy (MRgBT) using 24 Gy in 3 fractions (F) versus a standard, more resource-intensive regimen of 28 Gy in 4F, and its ability to meet EMBRACE II planning aims.A retrospective review of 224 patients with FIGO Stage IB-IVA cervical cancer treated with 28 Gy/4F (n = 91) and 24 Gy/3F (n = 133) MRgBT between 2016-2021 was conducted. Multivariable linear regression models were fitted to compare dosimetric parameters between the two groups, adjusting for CTVMost patients had squamous cell carcinoma, T2b disease, and were treated with intracavitary applicator plus interstitial needles (96%). The 28 Gy/4F group had higher CTVCervical cancer patients treated with 24 Gy/3F MRgBT had comparable target doses and lower OAR doses compared to those treated with 28 Gy/4F. A less-resource intense fractionation schedule of 24 Gy/3F is an alternative to 28 Gy/4F in cervix MRgBT.

Purpose: To evaluate patient-reported outcomes of adolescents and young adults (AYAs) with breast cancer treated with curative intent. Methods: AYA breast cancer patients (defined as diagnosed between 18 to 39 years of age) treated at a large tertiary cancer centre between January 2014 and December 2016 were identified. Patients routinely complete the validated symptom screening tool, the Edmonton Symptom Assessment System-revised (ESAS-r) prior to their clinical encounter. Scores from diagnosis up to 24 months post-diagnosis were obtained from our internal database, with elevated scores defined as > 4 for each individual symptom (rated 0-10). Patient, clinical and treatment characteristics were extracted from medical records. Descriptive statistics were used to describe patient, clinical and treatment characteristics, and ESAS-r scores. Time to recurrence was calculated from diagnosis to local or regional recurrence, distant metastasis or death (whichever occurred first). Kaplan-Meier survival analysis and log-rank tests were used to compare time to recurrence between women with vs. without elevated symptom scores. Chi-squared test was used to test the change in number of patients with elevated symptom scores over time. Univariable and multivariable logistic regression models were carried out to assess association between various factors and ESAS-r symptoms of depression, anxiety and well-being within 24 months of diagnosis. Results: Among 258 patients identified, 211 (82%) had accompanying ESAS-r and were eligible for analysis. Median follow-up was 3.9 years. Median age at diagnosis was 35 (20-39), most were clinical stage 2/3 at diagnosis (63%), 20% had triple negative disease, 76% received chemotherapy and 81% received radiotherapy. Overall, symptom burden was the highest (scores > 4) for decreased well-being (52%), tiredness (48%) and anxiety (44%). Although symptom burden significantly improved over time, 43%, 38% and 33% of patients, respectively, reported elevated symptoms 24 months post-diagnosis. Multivariable analysis found that elevated anxiety was significantly associated with younger age at diagnosis (p=0.036), receipt of chemotherapy (p=0.01) and presence of long-term toxicity (p=0.0032). Elevated depression, anxiety and well-being were significantly associated with referral to Psychosocial Oncology (p=0.024, p=0.036 and p=0.019, respectively), whereas well-being was also associated with referral to Survivorship Clinic (p=0.043). However, overall rates of referral (24-36%) were much lower than symptom prevalence. There was no association between elevated symptoms and time to recurrence. Conclusion: AYAs diagnosed with breast cancer report high symptom burden that continues to persist up to 24-months post-diagnosis. Patients with elevated psychosocial distress are more likely to be referred to Psychosocial Oncology and Survivorship clinics, indicating that the ESAS-r is a useful screening tool in a real-world setting. However, a gap between symptom burden and intervention exists, providing opportunities for future research. Citation Format: Revathy Krishnamurthy, Tulin Cil, Philippe Bedard, Robin Forbes, Madeline Li, Zhihui (Amy) Liu, Jennifer Croke. Patient-reported outcomes of adolescents and young adults with breast cancer treated with curative intent [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD12-09.

Purpose To design, develop, and evaluate an interactive simulation-based learning tool for treatment plan evaluation for radiation oncology and medical physics residents to address gaps in learning. Methods and Materials We first conducted a needs assessment for optimal learning tool design and case selection. Next, we generated a curated database of cases with clinically unacceptable treatment plans accessible through an in-house developed interactive web-based digital imaging and communications in medicine-radiation therapy viewer. We then developed an interactive user module that allows case selection, learner participation, and immediate feedback, including the final clinically acceptable plan. We pilot tested this case bank learning tool with current radiation oncology and medical physics residents within our institution. Afterward, residents completed an evaluation of tool design, content, and perceived impact on learning and provided suggestions for improvement. Results We generated 70 cases and learning modules for the case bank, encompassing various clinical sites, levels of difficulty, and classified errors. Residents positively endorsed the learning tool, including design, content, and perceived impact on learning. The learning tool’s interactivity was perceived to provide increased educational value compared with other current learning methods. Conclusions We created a high-fidelity simulation platform for treatment plan evaluation linked to a curated case bank. Evaluation of the pilot deployment demonstrated a benefit for resident learning and competency attainment. Future directions include external validation and expansion.

Purpose Mitigation strategies to balance the risk of coronavirus disease 2019 (COVID-19) infection against oncologic risk in patients with breast cancer undergoing radiation therapy have been deployed. To this end, shorter hypofractionated regimens have been recommended where appropriate, with prioritization of radiation therapy by oncologic risk and omission or deferral of radiation therapy for lower risk cases. Timely adoption of these measures reduces COVID-19 risk to both patients and health care workers and preserves resources. Herein, we present our early response and adaptation of breast radiation therapy utilization during the COVID-19 pandemic at a large academic cancer center in Canada. Methods and Materials A state of emergency was announced in Ontario on March 17, 2020, owing to the COVID-19 pandemic. Emergency guidelines were instituted. To examine our response, the number of weekly breast radiation therapy starts, type of breast radiation therapy, and patient age were compared from March 1 to April 30, 2020 to the same period in 2019. Results After the declaration of emergency in Ontario, there was a decrease of 39% in radiation therapy starts in 2020 compared with 2019 (79 vs 129, P < .001). There was a relative increase in the proportion of patients receiving regional nodal irradiation (RNI) in 2020 compared with 2019 (46% vs 29%, respectively), with the introduction of hypofractionated RNI in 2020 (27 of 54 cases, 50%). A smaller proportion of patients starting radiation therapy were aged >50 years in 2020, 66% (78 of 118) versus 83% (132 of 160) in 2019, P = .0027. Conclusions A significant reduction in breast radiation therapy starts was noted during the early response to the COVID-19 pandemic, with prioritization of radiation therapy to patients associated with higher oncologic risk requiring RNI. A quick response to a health care crisis is critical and is of particular importance for higher volume cancer sites where the potential effect on resources is greater.

To evaluate the implementation of a cervix cancer–specific patient-reported outcome measure, the European Organization for Research and Treatment of Cancer Quality of Life Cervical Cancer module (EORTC QLQ-CX24), into gynecologic oncology clinics. This was a prospective, multi-institutional, cross-sectional study involving cervix cancer patients previously treated with curative intent radiotherapy who were attending routine follow-up appointments. Between January 2017 and August 2018, eligible patients were approached to complete the EORTC QLQ-CX24 prior to their clinical encounter and then review it with their oncologist. Patient and oncologist experience was evaluated using Feedback Questionnaires following the encounter. Descriptive statistics were used to summarize the results of the EORTC QLQ-CX24 and Feedback Questionnaires. Open-ended questions within the Feedback Questionnaires were analyzed to identify themes. Eighty-four patients consented to participate in the study. Of these, 80 (95.2%) completed the EORTC QLQ-CX24 and 76 (90.4%) completed both the EORTC QLQ-CX24 and the Feedback Questionnaires. There were high rates of completion for most items within the EORTC QLQ-CX24 (93–98%), except for items pertaining to vaginal symptoms and sexual health (34–35%). All eligible oncologists participated (n = 9). Overall, patients and oncologists positively endorsed use of the questionnaire during clinical encounters. The majority of patients (80%) and oncologists (89%) reported use of the questionnaire improved communication, including discussion of sensitive topics. Interestingly, only a minority of patients and oncologists stated a perceived preference for electronic completion (18% and 44%, respectively). Implementation of the EORTC QLQ-CX24 in gynecologic oncology clinics was feasible and acceptable according to patients and oncologists.

Summary Background BIG 3-07/TROG 07.01 is an international, multicentre, randomised, controlled, phase 3 trial evaluating tumour bed boost and hypofractionation in patients with non-low-risk ductal carcinoma in situ following breast-conserving surgery and whole breast radiotherapy. Here, we report the effects of diagnosis and treatment on health-related quality of life (HRQOL) at 2 years. Methods The BIG 3-07/TROG 07.01 trial is ongoing at 118 hospitals in 11 countries. Women aged 18 years or older with completely excised non-low-risk ductal carcinoma in situ were randomly assigned, by use of a minimisation algorithm, to tumour bed boost or no tumour bed boost, following conventional whole breast radiotherapy or hypofractionated whole breast radiotherapy using one of three randomisation categories. Category A was a 4-arm randomisation of tumour bed boost versus no boost following conventional whole breast radiotherapy (50 Gy in 25 fractions over 5 weeks) versus hypofractionated whole breast radiotherapy (42·5 Gy in 16 fractions over 3·5 weeks). Category B was a 2-arm randomisation between tumour bed boost versus no boost following conventional whole breast radiotherapy, and category C was a 2-arm randomisation between tumour bed boost versus no boost following hypofractionated whole breast radiotherapy. Stratification factors were age at diagnosis, planned endocrine therapy, and treating centre. The primary endpoint, time to local recurrence, will be reported when participants have completed 5 years of follow-up. The HRQOL statistical analysis plan prespecified eight aspects of HRQOL, assessed by four questionnaires at baseline, end of treatment, and at 6, 12, and 24 months after radiotherapy: fatigue and physical functioning (EORTC QLQ-C30); cosmetic status, breast-specific symptoms, arm and shoulder functional status (Breast Cancer Treatment Outcome Scale); body image and sexuality (Body Image Scale); and perceived risk of invasive breast cancer (Cancer Worry Scale and a study-specific question). For each of these measures, tumour bed boost was compared with no boost, and conventional whole breast radiotherapy compared with hypofractionated whole breast radiotherapy, by use of generalised estimating equation models. Analyses were by intention to treat, with Hochberg adjustment for multiple testing. This trial is registered with ClinicalTrials.gov , NCT00470236 . Findings Between June 1, 2007, and Aug 14, 2013, 1208 women were enrolled and randomly assigned to receive no tumour bed boost (n=605) or tumour bed boost (n=603). 396 of 1208 women were assigned to category A: conventional whole breast radiotherapy with tumour bed boost (n=100) or no boost (n=98), or to hypofractionated whole breast radiotherapy with tumour bed boost (n=98) or no boost (n=100). 447 were assigned to category B: conventional whole breast radiotherapy with tumour bed boost (n=223) or no boost (n=224). 365 were assigned to category C: hypofractionated whole breast radiotherapy with tumour bed boost (n=182) or no boost (n=183). All patients were followed up at 2 years for the HRQOL analysis. 1098 (91%) of 1208 patients received their allocated treatment, and most completed their scheduled HRQOL assessments (1147 [95%] of 1208 at baseline; 988 [87%] of 1141 at 2 years). Cosmetic status was worse with tumour bed boost than with no boost across all timepoints (difference 0·10 [95% CI 0·05–0·15], global p=0·00014, Hochberg-adjusted p=0·0016); at the end of treatment, the estimated difference between tumour bed boost and no boost was 0·13 (95% CI 0·06–0·20; p=0·00021), persisting at 24 months (0·13 [0·06–0·20]; p=0·00021). Arm and shoulder function was also adversely affected by tumour bed boost across all timepoints (0·08 [95% CI 0·03–0·13], global p=0·0033, Hochberg adjusted p=0·045); the difference between tumour bed boost and no boost at the end of treatment was 0·08 (0·01 to 0·15, p=0·021), and did not persist at 24 months (0·04 [–0·03 to 0·11], p=0·29). None of the other six prespecified aspects of HRQOL differed significantly after adjustment for multiple testing. Conventional whole breast radiotherapy was associated with worse body image than hypofractionated whole breast radiotherapy at the end of treatment (difference –1·10 [95% CI –1·79 to –0·42], p=0·0016). No significant differences were reported in the other PROs between conventional whole breast radiotherapy compared with hypofractionated whole breast radiotherapy. Interpretation Tumour bed boost was associated with persistent adverse effects on cosmetic status and arm and shoulder functional status, which might inform shared decision making while local recurrence analysis is pending. Funding National Health and Medical Research Council, Susan G Komen for the Cure, Breast Cancer Now, OncoSuisse, Dutch Cancer Society.

Aims: Mentorship during residency guides and supports professional and personal development. Despite this, mentorship programmes within many postgraduate medicine programmes, including radiation oncology, are not standard. The objective of this qualitative study was to carry out a needs assessment to determine the perceived mentorship needs and experiences of radiation oncology residents and faculty.Materials and methods: Radiation oncology residents and faculty from a single university were invited to participate in semi-structured interviews in September 2017. Interviews were audiotaped and transcribed verbatim. An inductive thematic analysis was carried out using NVivo Pro version 11. Data collection occurred until saturation. Codes were derived and a systematic framework was applied to yield emergent themes. Trustworthiness was verified through triangulation and member checking.Results: Twenty interviews (10 residents and 10 faculty) took place between October and December 2017, at which point thematic saturation was achieved. Four major themes emerged: (i) the perceived experiences of residents and faculty with mentorship, (ii) the evolution of mentorship needs during residency training, (iii) the mechanisms of creating mentorship relationships and (iv) peer mentorship.Conclusions: In this study, the perceptions of mentorship from the perspective of radiation oncology residents and faculty were explored. Important areas of alignment and discordance were discovered. These insights will inform the development and implementation of a mentorship programme that can be adapted for use by other oncology training programmes. (C) 2019 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Effective communication between healthcare providers (HCPs) and patients is important for HCP well-being, patient engagement, and health outcomes. Yet, HCPs do not receive adequate communication skills training and report feeling unprepared for difficult conversations. A needs assessment of 64 cancer HCP trainees in Toronto, Canada, found that a majority of trainees rated themselves with low competency in communication skills to support patients through difficult conversations, while nearly all rated these skills as important to their practice. A blended multiprofessional communications program was developed including online theoretical learning and reflective practice in addition to in-person simulation with standardised patient actors. Since communication skills mastery is highly unlikely to occur at the termination of a single training program, the goal of the program was to stimulate participants’ motivational beliefs about difficult conversations communication skills in order to deepen their commitment to learning and mastery. The motivational beliefs assessed included self-efficacy (self-perceived competence), intent to use techniques learned, and confidence in task mastery. After completing the course, participants’ self-perceived competence in dealing with difficult conversations significantly increased by an average of 25 points (p

Purpose: Partial Breast Irradiation (PBI) treats the tumor bed plus a margin in low risk early stage breast cancers, reducing exposure to organs at risk. Randomized trials have shown that PBI with external beam radiotherapy is non-inferior to whole breast irradiation in terms of local control with fewer late normal tissue adverse events. We aimed to determine the proportion of women with early stage breast cancer suitable for external beam PBI at our institution using adapted ASTRO guidelines for accelerated PBI whereby both clinical-pathological factors and visualization of the tumor bed/cavity on planning scans were determined to quantify PBI eligibility. Methods: Patients were identified retrospectively from January 1, 2013 to November 1, 2018 based on age (≥55), tumor size (≤2cm invasive, ≤2.5cm DCIS), nodal negativity and grade (1 or 2). Cases identified were unifocal, lymphovascular invasion negative, ER positive, HER2 negative, with margins ≥2mm (invasive) and ≥3mm (DCIS), no chemotherapy, non-lobular, no extensive intraductal component, no previous/ bilateral cancers and endocrine therapy optional. Planning scans were reviewed to assess for presence of surgical clips and assigned cavity visualization scores (CVS); CVS 1=cavity not visualized, CVS 2=cavity visualized with indistinct margins, CVS 3=cavity visualised with some distinct margins and heterogeneous appearance, CVS 4= cavity visualised with mostly distinct margins and mildly heterogeneous appearance, CVS 5= all cavity margins clearly defined and homogeneous appearance. These features were used to determine if cases were considered radiologically suitable for PBI. Results: Thirty-seven percent (1051/2824) of cases identified were deemed eligible based on age, grade and T1N0/Tis. Of the 1051, 306 (29%) met all the pathologic criteria; the main reasons for exclusion were previous breast cancer, lobular histology, or multifocality. Median age of eligible cases was 65 years (range 55-88 years). The majority (254) had invasive disease (T1mi: 6, T1a: 17, T1b: 98, T1c: 133); 52 had DCIS. There were 169 right-sided and 137 left-sided cases. Endocrine therapy was documented in 55% of cases. CVS (1-5) were: 11%, 22%, 30%, 29%, 8%. Overall, 66% (201/306) of cases were considered radiologically suitable for PBI (of the 201 cases, 97% had CVS ≥3). Seventy-two cases (72/306; 24%) had tumor bed clips, of which, 34 were considered suitable for PBI (91% CVS ≥3; 9% CVS 2). Conclusions: Overall, a low proportion of all patients were eligible for PBI based on clinical features, but two-thirds of eligible cases were suitable for PBI based on CVS score alone. In contrast, the suitability for PBI within the cohort with surgical clip placement was low. Visualization of the tumor bed is essential to safely deliver PBI and is guided by identification of the cavity seroma and/or surgical clips. Development of standard practice guidelines for surgical clip positioning to identify the tumor bed will potentially assist in increasing the proportion of early stage breast cancer patients suitable to receive PBI, even if the CVS is less favorable. Citation Format: Christine Anne Koch, Gemma Corey, Kathy Han, Grace Lee, Tom Purdie, Chris McIntosh, Patricia Lindsay, Fei-Fei Liu, Anthony Fyles, Wilf Levin, Jennifer Croke, Aisling Barry, Danielle Rodin, Nhu Tram Nguyen, Tatiana Conrad. Evaluation of partial breast irradiation suitability in early stage breast cancer patients [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-12-24.

PURPOSE: Malignant bowel obstruction (MBO) is a common and distressing complication in women with advanced gynecologic cancer. A pilot, interprofessional MBO program was launched in 2016 at a large Canadian tertiary cancer center to integrate these patients’ complex care needs across multiple disciplines and support women with MBO. METHOD: Retrospective analysis to evaluate the outcomes of women with advanced gynecologic cancer who were admitted to hospital because of MBO, before (2014 to 2016: baseline group) and after (2016 to 2018) implementation of the MBO program. RESULTS: Of the 169 women evaluated, 106 and 63 were in the baseline group and MBO program group, respectively. Most had ovarian cancer (n = 124; 73%) and had small-bowel obstruction (n = 131; 78%). There was a significantly shorter cumulative hospital length of stay (LOSsum) within the first 60 days of MBO diagnosis in the MBO program group compared with the baseline group (13 v 22 days, respectively; adjusted P = .006). The median overall survival for women treated in the MBO program was also significantly longer compared with the baseline group (243 v 99 days, respectively; adjusted P = .002). Using the interprofessional MBO care platform, a greater proportion of patients received palliative chemotherapy (83% v 56%) and less surgery (11% v 21%) in the MBO program group than in the baseline group, respectively. A subgroup of women (n = 11) received total parenteral nutrition for longer than 6 months. CONCLUSION: Implementation of a comprehensive, interprofessional MBO program significantly affects patient care and may improve outcomes. Unique to this MBO program is an integrated outpatient model of care and education that empowers patients to recognize MBO symptoms for early intervention.

Objective: To evaluate health care professional (HCP) documentation of elevated patient-reported symptoms and subsequent intervention in gynecologic oncology clinics. Methods: This was a retrospective chart review of gynecologic oncology patients within a single institution. Prior to their clinical encounter, patients complete the validated Edmonton Symptom Assessment System revised (ESAS-r) questionnaire. Patients with any ESAS-r symptom score ≥4 (moderate-severe) were eligible for analysis. A stratified sampling method was used: 100 patients were randomly selected with 20 patients per year from 2012 to 2016. Patient, tumor and treatment characteristics were extracted from medical records. Health care provider (HCP) documentation of elevated symptoms and subsequent intervention were evaluated. Descriptive statistics were used to report symptom prevalence, HCP documentation and intervention. Fisher’s exact test evaluated documentation and intervention rates according to symptom severity and total ESAS-r score. Results: Between January 2012 and December 2016, 5849 patients completed the ESAS-r. Symptoms scores were ≥ 4 in 3216 patients (55%). In our sample of 100, ovarian (42%) and endometrial (34%) malignancies were most common. Median age was 55 years (range 47-63). Median ESAS-r score was 24 (range: 5-84), with tiredness being the most prevalent symptom reported by patients. HCP documented at least one elevated symptom in 50 patients (50%), most commonly for pain (71%) and least commonly for nausea (4%). Subsequent interventions were offered to only 32 patients (32%), most commonly for pain (56%). Higher median total ESAS-r score was associated with higher rate of documentation (p=0.004) and higher rate of intervention (pConclusions: A significant proportion of gynecologic oncology patients report symptom that should prompt an intervention. However, HCPs documented symptoms in only half of patients and reported interventions in only one third. These results highlight gaps and opportunities for improving symptom screening and response in the “real-world” setting.

Feedback delivery and training have not been characterized in the context of academic cancer centres. The purpose of this study was to assess the feasibility and utility of a microlearning course based on the R2C2 (Relationship, Reaction, Content, Coaching) feedback model and characterize multidisciplinary healthcare provider (HCP) perspectives on existing feedback practices in an academic cancer centre. Five HCP (two radiation oncologists, one medical oncologist, and two allied health professionals) with supervisory roles were selected by purposive sampling to participate in a prospective longitudinal qualitative study. Each participant completed a web-based multimedia course. Semi-structured one-on-one interviews were conducted with each participant at four time points: pre- and immediately post-course, and at one- and three-months post course. All participants found the course to be time feasible and completed it in 10-20 min. Participants expressed that the course fulfilled their need for feedback training and that its adoption may normalize a feedback culture in the cancer centre. Three themes were identified regarding perceptions of existing feedback practices: (1) hierarchical and interdisciplinary relationships modulate feedback delivery, (2) interest in feedback delivery varies by duration of the supervisory relationship, and (3) the transactionality of supervisor-trainee relationships influences feedback delivery. This study demonstrates the perceived feasibility and utility of a digital microlearning approach for development of feedback competencies in an academic cancer centre, perceptions of cultural barriers to feedback delivery, and the need for organizational commitment to developing a feedback culture.

Purpose The treatment of locally advanced cervical cancer with definitive chemoradiation (CRT) is associated with vaginal toxicity and altered sexual satisfaction. This prospective study assessed patient-reported sexual adjustment, vaginal dosimetry, and physician-reported vaginal toxicity in patients with cervical cancer treated with CRT and MR-guided brachytherapy (BT). Materials and Methods Between 2008 and 2010, International Federation of Gynecologists and Obstetricians stage IB-IVA patients with cervical cancer receiving definitive CRT were enrolled in a feasibility study assessing MR-guided BT. Patients completed the validated sexual adjustment questionnaire (SAQ) before BT (baseline) and during followup. Physician-reported vaginal toxicity was recorded. The International Commission on Radiation Units and Measurements rectovaginal point, mean vaginal dose, and D2cm3 were calculated. Mean SAQ scores at baseline and followup assessments were calculated. Mean time effects were estimated using a linear mixed-effects model. A multivariable linear mixed-effects model was used to examine the association between total and individual scores (repeated measures) and covariates. Results Sixty patients were approached to participate: 29 consented and 27 completed the SAQ at baseline and followup. The diagnosis of cervical cancer and treatment negatively impacted sexual relationships in 61% and 39%, respectively. There were no significant changes in sexual adjustment over time (p = 0.599). There were no associations between sexual adjustment and the International Commission on Radiation Units and Measurements rectovaginal point dose or clinical vaginal involvement. Patients with higher International Federation of Gynecologists and Obstetricians stages (≥IIB) had significantly worse sexual adjustment (p = 0.005). Conclusion CRT and MR-guided BT negatively impacted sexual relationships in patients with cervix cancer; however, there were no significant longitudinal changes in patient-reported sexual adjustment. Worse sexual adjustment may be associated with more advanced disease presentations.

Purpose/Objective(s) Tumor hypoxia is associated with poor response to radiation (RT) and chemotherapy, and worse treatment outcome. We previously discovered a novel mechanism of metformin in a xenograft model: enhancing tumor RT response by inhibiting tumor cell oxygen consumption. Our population-based study showed that cumulative dose of metformin after cervical cancer diagnosis was independently associated with a decreased risk of cervical cancer-specific mortality in diabetic women. Based on the pre-clinical and retrospective data, we hypothesized that metformin would decrease tumor hypoxia and improve tumor response to RT in locally advanced cervical cancer. Materials/Methods A window-of-opportunity, phase II randomized trial was performed in women with stage IB-IVA cervical adenocarcinoma, squamous cell or adenosquamous carcinoma. Patients underwent screening positron emission tomography (PET) imaging with hypoxia tracer fluoroazomycin arabinoside (FAZA). Those with non-hypoxic tumor (no FAZA uptake) were excluded. Patients with FAZA uptake were randomized centrally in a 2:1 ratio (in favor of metformin) to receive either metformin in combination with standard chemoRT or standard chemoRT alone. Metformin was started at 850mg once daily x 3 days, followed by 850mg twice daily throughout the entire duration of external radiotherapy. A second FAZA-PET/CT scan was performed after 1 week of metformin or no intervention in control group, just before start of chemoRT. The hypoxic volume was defined as all voxels within a tumor with standardized uptake values (SUVs) greater than 3 standard deviations (SD) from the mean gluteus maximus muscle SUV value. The hypoxic fraction (HF) was defined as the ratio of the number of hypoxic voxels to the total number of tumor voxels. The primary endpoint was absolute mean change in HF between the two FAZA-PET scans, compared using the Wilcoxon sign rank test. Disease-free survival (DFS) was defined as the duration of time from randomization to the time of relapse or death and compared using the log-rank test. Target accrual was 48 patients; the study was closed early to accrual due to FAZA availability and the COVID-19 pandemic. Results Of the twenty patients who consented, 6 were excluded due to no FAZA uptake and 1 withdrew. The median age of the 13 enrolled patients was 52; 8 (62%) had squamous cell carcinoma and 8 had stage IIB disease. HF of the 10 patients in the metformin arm decreased by an average of 10.2% (from 44.4% to 34.2%) ± SD 16.9% after 1 week of metformin, compared to an average increase of 4.7% (from 29.1% to 33.8%) ± 11.5% for the 3 patients in the control arm (P = 0.027). With a median follow-up of 2.8 years, the 2-year DFS was 67% for the metformin arm vs 33% for control (P = 0.09). Conclusion Metformin decreases cervical tumor hypoxia with a trend towards improved DFS in this trial. A larger confirmatory trial is warranted.

Purpose To determine whether plasma human papillomavirus (HPV) DNA predates clinical recurrence and compare its accuracy with 3-month fluorodeoxyglucose positron emission tomography (FDG-PET) in locally advanced cervical cancer. Methods This prospective multicenter study accrued 23 women with stage IB to IVA cervical cancer planned for definitive chemoradiation therapy (CRT). Plasma HPV DNA was measured serially by digital polymerase chain reaction, and FDG-PET was performed at 3 months post-CRT. Results Of the 19 women with HPV+ cervical cancer included in this analysis, 32% were stage IB, 58% IIB, and 10% IIIB/IVA. Median follow-up was 24 months (range, 18 to 30 months). All patients had detectable plasma HPV DNA before treatment. Six patients had detectable plasma HPV DNA at the end of CRT, and three of them developed metastases at 3 months. Of the 13 patients with undetectable plasma HPV DNA at end of CRT, to date, only one has developed recurrence. Six of those 13 patients had a positive 3-month FDG-PET with no definite residual disease on subsequent imaging or clinical examination to date, and four of these six had undetectable plasma HPV DNA at 3 months. Patients with undetectable plasma HPV DNA at end of CRT had significantly higher 18-month progression-free survival than those with detectable plasma HPV DNA (92% v 50%; P = .02). The area under the receiver operating characteristic curve (accuracy) of 3-month plasma HPV DNA and 3-month FDG-PET imaging for predicting recurrence at 18 months were 77% and 60%, respectively ( P = .008). Conclusion Detectable plasma HPV DNA at end of CRT predates the clinical diagnosis of metastases and is associated with inferior progression-free survival. Moreover, 3-month plasma HPV DNA level is more accurate than 3-month FDG-PET imaging in detecting residual disease. The clinical utility of plasma HPV DNA detection for guiding adjuvant/salvage therapy should be evaluated in future studies.

Background Mentorship fosters professional and personal growth; however, the components essential to program success remain unclear. Our objective was to evaluate and explore the impact of a junior faculty mentorship program within an academic radiation oncology department. Materials and Methods In 2016, our institution implemented a junior faculty mentorship program consisting of: (1) an orientation handbook; (2) faculty development sessions; and (3) direct, one-to-one selection of a mentor. Confidentiality agreements are signed, a goals template is provided, and meeting dates are tracked. Mentors/mentees were invited to participate in a program evaluation using mixed-methodology: a questionnaire followed by a one-on-one semi-structured interview to explore perceptions of the program. Interviews were audiotaped and transcribed verbatim. Descriptive statistics summarized questionnaire results and thematic analysis summarized interview results. Results Eleven junior faculty have selected 10 mentors. Of these, 17 completed the evaluation questionnaire (81%) (7 mentors, 10 mentees; 5 women, 12 men) and 13 were interviewed (62%) (5 mentors, 8 mentees; 3 women, 10 men). The majority (80%) have participated in the program for >2 years. Although most mentees report additional mentors, 30% report this as their sole mentorship relationship. Four themes emerged: (i) Components of an Ideal Mentoring Relationship, (ii) The Value of Mentorship, (iii) Sponsorship, in addition to Mentorship and (iv) Cultivating Departmental Bonds and Boundaries. Conclusion Implementation of a junior faculty mentorship program within an academic radiation oncology department is feasible. Participants expressed satisfaction with most formal program components. Many junior faculty have additional mentors; however, some do not, highlighting the importance of formal programs for professional development.

Feedback delivery and training have not been characterized in the context of academic cancer centres. The purpose of this study was to assess the feasibility and utility of a microlearning course based on the R2C2 (Relationship, Reaction, Content, Coaching) feedback model and characterize multidisciplinary healthcare provider (HCP) perspectives on existing feedback practices in an academic cancer centre. Five HCP (two radiation oncologists, one medical oncologist, and two allied health professionals) with supervisory roles were selected by purposive sampling to participate in a prospective longitudinal qualitative study. Each participant completed a web-based multimedia course. Semi-structured one-on-one interviews were conducted with each participant at four time points: pre- and immediately post-course, and at one- and three-months post course. All participants found the course to be time feasible and completed it in 10–20 min. Participants expressed that the course fulfilled their need for feedback training and that its adoption may normalize a feedback culture in the cancer centre. Three themes were identified regarding perceptions of existing feedback practices: (1) hierarchical and interdisciplinary relationships modulate feedback delivery, (2) interest in feedback delivery varies by duration of the supervisory relationship, and (3) the transactionality of supervisor-trainee relationships influences feedback delivery. This study demonstrates the perceived feasibility and utility of a digital microlearning approach for development of feedback competencies in an academic cancer centre, perceptions of cultural barriers to feedback delivery, and the need for organizational commitment to developing a feedback culture.

Objectives: Optimally caring for oncology patients of culturally and linguistically diverse (CALD) backgrounds poses a unique set of challenges. We aimed to describe CALD gynecologic oncology patient characteristics and distress screening completion in a large, multicultural academic cancer center. Methods: This was a retrospective study of patients with a primary gynecologic malignancy treated in the medical, surgical, or radiation oncology and palliative care clinics at Princess Margaret Cancer Centre (PM), Toronto, Canada, from January 1 to December 31, 2019. Data was generated from electronic health records and other databases. Non-English patients were defined as those who listed a primary language on Electronic Patient Records other than English on initial registration. Edmonton Symptom Assessment System-revised (ESAS-r) was available in various languages, and completion rates were assessed and descriptive statistics performed. Results: In 2019, there were 19,343 patient visits recorded in gynecologic oncology clinics, and 4684 unique patients (mean visits per patient = 4.13). 1656 (8.6%) patient visits were registered as non-English speakers (376 [8.6%] out of 4684 unique patients) comprising more than 40 languages (Figure 1). Most common spoken languages were Mandarin (15.5%), Portuguese (11.6%), Cantonese (10.9%), Spanish (7.8%) and Italian (7.3%). ESAS-r completion rates in the gynecologic oncology clinics were lower in non-English (18.4%) than English (36%; p Download : Download high-res image (80KB) Download : Download full-size image Conclusions: The PM gynecology clinic sees a significant proportion of patients of CALD backgrounds. Completion rates of ESAS-r are significantly lower amongst patients of CALD backgrounds. These results suggest that linguistic sensitivity in assessing and treating gynecologic cancer patients is paramount. Further research focusing on optimizing care in CALD populations should be considered.

Purpose/Objective(s) To report the degree to which post-graduate trainees in radiation oncology perceive their education has been impacted by COVID-19. Materials/Methods A cross-sectional online survey was administered in June 2020 to trainee members of Canadian Association of Radiation Oncology (CARO). The 82-item survey was adapted from a similar survey administered during SARS and included the Stanford Acute Stress Reaction and Ways of Coping Questionnaires. The survey was developed using best practices including expert review and cognitive pre-testing. Frequency statistics are reported. Results Thirty-four trainees (10 fellows, 24 residents) responded. Nearly half of participants indicated that the overall impact of COVID-19 on training was negative/very negative (n = 15; 46%) or neutral (n = 15; 46%) with a small number indicating a positive/very positive (n = 3; 9%). Majority of trainees agreed/strongly agreed with the following statements: “I had difficulty concentrating on tasks because of concerns about COVID-19” (n = 17; 52%), “I had fears about contracting COVID-19” (n = 17; 52%), “I had fears of family/loved ones contracting COVID-19” (n = 29; 88%), “I felt socially isolated from friends and family because of COVID-19” (n = 23; 70%), “I felt safe from COVID-19 in the hospital during my clinical duties“ (n = 15; 46%), and “I was concerned that my personal safety was at risk if/when I was redeployed from my planned clinical duties” (n = 20; 61%). The changes that had a negative/very negative impact on learning included “the impact of limited patient contact” (n = 19; 58%), “the impact of virtual patient contact” (n = 11; 33%), and “limitations to travel and networking” (n = 31; 91%). Most reported reduced teaching from staff (n = 22; 66%). Two-thirds of trainees (n = 22, 67%) reported severe (> 50%) reduction in ambulatory clinical activities, 16 (49%) reported a moderate (< 50%) reduction in new patient consultations, while virtual follow-ups (n = 25: 76%) and in-patient clinical care activities (n = 12; 36%) increased. Nearly half of respondents reported no impact on contouring (n = 16; 49%), on-treatment management (n = 17; 52%) and tumor boards (n = 14; 42%) with the majority of other respondents reporting a decrease in these activities. Electives were cancelled in province (n = 10/20; 50%), out-of-province (n = 16/20; 80%) and internationally (n = 15/18; 83%). Conclusion Significant changes to radiation oncology training were wrought by the COVID-19 pandemic and roughly half of trainees perceive that these changes had a negative impact on their training. Safety concerns for self and family were significant and strategies to mitigate these concerns should be a priority.