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Purpose: Most medical students have limited exposure to radiation oncology (RO) before deciding which specialty to choose for residency. This may limit the number and diversity of RO applicants. The purpose of this study was to determine students’ views on a combined pathway program of RO with internal medicine (IM), as well as other related medical specialties, as a potential means of overcoming barriers to interest in RO and the early decision point to solo training in a highly specialized field. Methods and Materials: In July to August 2022, all 299 United States student and postgraduate year 1 members of the American Society for Radiation Oncology were sent an electronic survey assessing their views on advantages and disadvantages of a combined IM/RO training pathway, and interest in several options of combined pathway programs. Results: Eighty participants completed the survey (response rate 27%). Thirty-four (43%) were very or extremely interested in IM/RO residency (median Likert-type rating 3, IQR 2-4). The most important potential advantages of an IM/RO pathway included greater flexibility in employment options (n = 51, 64%), enhanced general medical knowledge to facilitate ambitions in other career pathways (n = 46, 58%), improved patient care (n = 43, 54%), and having a pathway for combined hematologic/oncology and RO board certification (n = 46, 58%). In comparison to IM/RO, participants were significantly more interested in a combined RO and hematology/oncology program (median Likert-type rating 5, IQR 5-5, P = .005). Among the subgroup of 26 survey participants who believed it less likely they would apply for RO residency, 18 (69%) thought an IM/RO pathway would increase their interest in RO (median Likert-type rating 4, IQR 3-5). Interest in IM/RO did not differ by gender, race, or ethnicity. Conclusions: Combined training pathways involving RO were viewed positively by survey respondents, and may be particularly appealing to those less committed to a career in RO. Further research will help guide recommendations for the creation of these programs.

Abstract Background Medical school acceptance rates in the United States (US) have been lower for applicants who identify as Underrepresented-in-Medicine (UiM) compared to non-UiM applicants. The gap between UiM and no-UiM groups is narrowing in recent years. Less well-studied are associations of acceptance decisions with family income and parental education. This study’s purpose is to evaluate the relationships between medical school acceptance and family income, parental education status, racial/ethnic background, Grade Point Average (GPA), Medical College Admission Test (MCAT) score, and participation in extracurricular activities. Methods This is a cross-sectional study of first-time US medical school applicants between 2017 and 2020. Acceptance rates for first-time applicants were calculated for first-generation (FG), low-income (LI), and UiM applicants. Associations of these attributes with MCAT scores, science GPAs, and seven categories of extracurricular activities were evaluated. Regression analyses estimated associations between acceptance to medical school with all variables with and without interaction terms (FG*URM, LI*URM, FG*LI). Results The overall acceptance rate for first-time applicants from 2017–2020 was 45.3%. The acceptance rates among FG, LI and UiM applicants were 37.9%, 39.6% and 44.2%, respectively. In univariable logistic regression analyses, acceptance was negatively associated with being FG (OR: 0.68, CI: 0.67–0.70), LI (OR: 0.70, CI: 0.69–0.72), and UiM (OR: 0.95, CI: 0.93–0.97). In multivariable regression, acceptance was most strongly associated with science GPA (OR: 7.15, CI: 6.78–7.54 for the highest quintile) and UiM (OR: 5.56, CI: 5.48–5.93) status and MCAT score (OR: 1.19, CI: 1.18–1.19), FG (OR: 1.14, CI: 1.10–1.18), and most extracurricular activities. Including interaction terms revealed a negative association between acceptance and LI (OR:0.90, CI: 0.87–0.94) and FG was no longer significant (OR:1.10, CI:0.96–1.08). Conclusions Collectively these results suggest medical school admissions committees may be relying on holistic admission practices. While MCAT and GPA scores continue to predict acceptance, individuals from racially and ethnically UiM backgrounds have favorable odds of acceptance when controlling for MCAT and GPA. However, these positive associations were not seen for low-income and first-generation applicants. Additional preparation for college and the MCAT for these latter groups may help further diversify the medical profession.

Abstract Background Hospitals account for approximately 6% of United States’ gross domestic product. We examined the association between hospital competition and outcomes in elderly with localized prostate cancer (PCa). We also assessed if race moderated this association. Methods Retrospective study using Surveillance, Epidemiology, and End Results (SEER) – Medicare database. Cohort included fee-for-service, African American and white men aged ≥ 66, diagnosed with localized PCa between 1998 and 2011 and their claims between 1997 and 2016. We used Hirschman-Herfindahl index (HHI) to measure of hospital competition. Outcomes were emergency room (ER) visits, hospitalizations, Medicare expenditure and mortality assessed in acute survivorship phase (two years post-PCa diagnosis), and long-term mortality. We used Generalized Linear Models for analyzing expenditure, Poisson models for ER visits and hospitalizations, and Cox models for mortality. We used propensity score to minimize bias. Results Among 253,176 patients, percent change in incident rate of ER visit was 17% higher for one unit increase in HHI (IRR: 1.17, 95% CI: 1.15–1.19). Incident rate of ER was 24% higher for whites and 48% higher for African Americans. For one unit increase in HHI, hazard of short-term all-cause mortality was 7% higher for whites and 11% lower for African Americans. The hazard of long-term all-cause mortality was 10% higher for whites and 13% higher for African Americans. Conclusions Lower hospital competition was associated with impaired outcomes of localized PCa care. Magnitude of impairment was higher for African Americans, compared to whites. Future research will explore process through which competition affects outcomes and racial disparity.

Purpose: Although both intensity-modulated radiation therapy (IMRT) and proton beam therapy (PBT) offer effective long-term disease control for localized prostate cancer (PCa), there are limited data directly comparing the 2 modalities. Methods: The data from 334 patients treated with conventionally fractionated (79.2 GyRBE in 44 fractions) PBT or IMRT were retrospectively analyzed. Propensity score matching was used to balance factors associated with biochemical failure-free survival (BFFS). Age, race, and comorbidities (not BFFS associates) remained imbalanced after matching. Univariable and covariate-adjusted multivariable (MVA) Cox regression models were used to determine if modality affected BFFS. Results: Of 334 patients, 176 (52.7%) were included in the matched cohort with exact matching to National Comprehensive Cancer Network (NCCN) risk group. With a median follow-up time of 9.0 years (interquartile range [IQR]: 7.8-10.2 years), long-term BFFS was similar between the IMRT and PBT matched arms with 8-year estimates of 85% (95% CI: 76%-91%) and 91% (95% CI: 82%-96%, P = .39), respectively. On MVA, modality was not significantly associated with BFFS in both the unmatched (hazard ratio [HR] = 0.75, 95% CI: 0.35-1.63, P = .47) and matched (HR = 0.87, 95% CI: 0.33-2.33, P = .78) cohorts. Prostate cancer–specific survival (PCSS) and overall survival (OS) were also similar (P > .05). However, in an unmatched analysis, the PBT arm had significantly fewer incidences of secondary cancers within the irradiated field (0.6%, 95% CI: 0.0%-3.1% versus 4.5%, 95% CI: 1.8%-9.0%, P = .028). Conclusions: Both PBT and IMRT offer excellent long-term disease control for PCa, with no significant differences between the 2 modalities in BFFS, PCSS, and OS in matched patients. In the unmatched cohort, fewer incidences of secondary malignancy were noted in the PBT group; however, owing to overall low incidence of secondary cancer and imbalanced patient characteristics between the 2 groups, these data are strictly hypothesis generating and require further investigation.

Abstract Background Continuity of care is an important element of advanced prostate cancer care due to the availability of multiple treatment options, and associated toxicity. However, the association between continuity of care and outcomes across different racial groups remains unclear. Objective To assess the association of provider continuity of care with outcomes among Medicare fee‐for‐service beneficiaries with advanced prostate cancer and its variation by race. Design Retrospective cohort study using Surveillance, Epidemiology, and End Results (SEER)‐Medicare data. Subjects African American and white Medicare beneficiaries aged 66 or older, and diagnosed with advanced prostate cancer between 2000 and 2011. At least 5 years of follow‐up data for the cohort was used. Measures Short‐term outcomes were emergency room (ER) visits, hospitalizations, and cost during acute survivorship phase (2‐year post‐diagnosis), and mortality (all‐cause and prostate cancer‐specific) during the follow‐up period. We calculated continuity of care using Continuity of Care Index (COCI) and Usual Provider Care Index (UPCI), for all visits, oncology visits, and primary care visits in acute survivorship phase. We used Poisson models for ER visits and hospitalizations, and log‐link GLM for cost. Cox model and Fine‐Gray competing risk models were used for survival analysis, weighted by propensity score. We performed similar analysis for continuity of care in the 2‐year period following acute survivorship phase. Results One unit increase in COCI was associated with reduction in short‐term ER visits (incidence rate ratio [IRR] = 0.65, 95% confidence interval [CI] 0.64, 0.67), hospitalizations (IRR = 0.65, 95% CI 0.64, 0.67), and cost (0.64, 95% CI 0.61, 0.66) and lower hazard of long‐term mortality. Magnitude of these associations differed between African American and white patients. We observed comparable results for continuity of care in the follow‐up period. Conclusions Continuity of care was associated with improved outcomes. The benefits of higher continuity of care were greater for African Americans, compared to white patients. Advanced prostate cancer survivorship care must integrate appropriate strategies to promote continuity of care.

Abstract Biorepositories enable precision oncology research by sharing clinically annotated genomic data, but it remains unknown whether these data registries reflect the true distribution of cancers in racial and ethnic minorities. Our analysis of Project Genomics Evidence Neoplasia Information Exchange (GENIE), a real-world cancer data registry designed to accelerate precision oncology discovery, indicates that minorities do not have sufficient representation, which may impact the validity of studies directly comparing mutational profiles between racial/ethnic groups and limit generalizability of biomarker discoveries to all populations.

Abstract Background The optimal upfront treatment modality for patients with nonmetastatic Gleason Score 9 and 10 prostate cancer (GS 9–10 PCa) is unknown. Methods We conducted a retrospective cohort study of patients in the Veterans Health Administration (VHA) with GS 9–10 PCa treated with radical prostatectomy (RP) or external beam radiation therapy with androgen deprivation therapy (EBRT+ADT) from 1/2000 to 12/2010. Outcomes included overall survival (OS), distant metastasis‐free survival (DMFS), and salvage/adjuvant therapy‐free survival (SAFS), as assessed by Kaplan–Meier analysis. Results We identified 1220 veterans with GS 9–10 PCa; 335 were treated with RP, and 885 were treated with EBRT+ADT. With a median follow‐up of 9.9 years, propensity score‐matched analyses demonstrated that RP had superior 10‐year OS (70.8% [RP] vs. 61.2% [EBRT+ADT], p

Inter- and intra-fractional prostate motion can deteriorate the dose distribution in extremely hypofractionated intensity-modulated proton therapy. We used verification CTs and prostate motion data calculated from 1024 intra-fractional prostate motion records to develop a voxel-wise based 4-dimensional method, which had a time resolution of 1 s, to assess the dose impact of prostate motion. An example of 100 fractional simulations revealed that motion had minimal impact on planning dose, the accumulated dose in 95 % of the scenarios fulfilled the clinical goals for target coverage (D95 > 37.5 Gy). This method can serve as a complementary measure in clinical setting to guarantee plan quality.

Fatigue is a common symptom associated with cancer treatments. Brain mechanisms underlying cancer-related fatigue (CRF) and its progression following therapy are poorly understood. Previous studies have suggested a role of the default mode network (DMN) in fatigue. In this study we used arterial spin labeling (ASL) perfusion functional magnetic resonance imaging (fMRI) and compared resting cerebral blood flow (CBF) differences in the posterior cingulate cortex (PCC), a core hub of the DMN, between 16 patients treated with radiation therapy (RAT) for prostate (9 males) or breast (7 females) cancer and 18 healthy controls (HC). Resting CBF in patients was also measured immediately after the performance of a fatiguing 20-min psychomotor vigilance task (PVT). Twelve of 16 cancer patients were further followed between 3 and 7 months after completion of the RAT (post-RAT). Patients reported elevated fatigue on RAT in comparison to post-RAT, but no change in sleepiness, suggesting that the underlying neural mechanisms of CRF progression are distinct from those regulating sleep drive progression. Compared to HC, patients showed significantly increased resting CBF in the PCC and the elevated PCC CBF persisted during the follow up visit. Post-PVT, but not pre-PVT, resting CBF changes in the PCC correlated with fatigue changes after therapy in patients with CRF, suggesting that PCC CBF following a fatiguing cognitive task may be a biomarker for CRF recovery.

Purpose: Long-term data regarding the disease control outcomes of proton beam therapy (PBT) for patients with favorable risk intact prostate cancer (PC) are limited. Herein, we report our institution's long-term disease control outcomes in PC patients with clinically localized disease who received PBT as primary treatment. Methods: One hundred sixty-six favorable risk PC patients who received definitive PBT to the prostate gland at our institution from 2010 to 2012 were retrospectively assessed. The outcomes studied were biochemical failure-free survival (BFFS), biochemical failure, local failure, regional failure, distant failure, PC-specific survival, and overall survival. Patterns of failure were also analyzed. Multivariate Cox proportional hazards modeling was used to estimate independent predictors of BFFS. Results: The median length of follow-up was 8.3 years (range, 1.2–10.5 years). The majority of patients had low-risk disease (58%, n = 96), with a median age of 64 years at the onset of treatment. Of 166 treated men, 13 (7.8%), 8 (4.8%), 2 (1.2%) patient(s) experienced biochemical failure, local failure, regional failure, respectively. Regional failure was seen in an obturator lymph node in 1 patient and the external iliac lymph nodes in the other. None of the patients experienced distant failure. There were 5 (3.0%) deaths, none of which were due to PC. The 5- and 8-year BFFS rate were 97% and 92%, respectively. None of the clinical disease characteristics or treatment-related factors assessed were associated with BFFS on multivariate Cox proportional hazards modeling (all P >.05). Conclusion: Disease control rates reported in our assessment of PBT were similar to those reported in previous clinically localized intact PC analyses, which used intensity-modulated radiotherapy, three-dimensional conformal radiotherapy, or radical prostatectomy as definitive therapy. In addition, BFFS rates were similar, if not improved, to previous PBT studies.

Abstract Objective To assess the association between Genomic Classifier (GC)‐risk group and post‐radical prostatectomy treatment in clinical practice. Methods Two prospective observational cohorts of men with prostate cancer (PCa) who underwent RP in two referral centers and had GC testing post‐prostatectomy between 2013 and 2018 were included. The primary endpoint of the study was to assess the association between GC‐risk group and time to secondary therapy. Univariable (UVA) and multivariable (MVA) Cox proportional hazards models were constructed to assess the association between GC‐risk group and time to receipt of secondary therapy after RP, where secondary therapy is defined as receiving either RT or ADT after RP. Results A total of 398 patients are included in the analysis. Patients with high‐GC risk were more likely to receive any secondary therapy (OR: 6.84) compared to patients with low/intermediate‐GC risk. The proportion of high‐GC risk patients receiving RT at 2 years post‐RP was 31.5%, compared to only 6.3% among the low/intermediate‐GC risk patients. Conclusion This study demonstrates that physicians in routine practice used GC to identify high risk patients who might benefit the most from secondary treatment. As such, GC score was independent predictor of receipt of secondary treatment.

Abstract Background Health disparities in prostate cancer (PC) are thought to reflect the complex interplay of socioeconomics, environment and biology. The potential impact of beliefs and perceptions about PC among Black and Latino populations on clinical disparities are not well understood. This qualitative study was conducted to assess current prevalent and pervasive stigma, beliefs and perceptions regarding PC among Blacks and Latinos living in a large metropolitan area, thereby identifying potentially modifiable barriers to care. Methods Qualitative data were collected through four separate focus groups of self-identified Black and Latino adult men and women living in Philadelphia to better understand their perceptions of PC diagnosis, screening and treatment. Each focus group was single-sex and conducted by racial/ethnic group in order to assess possible differences in beliefs about PC based on gender and racial/ethnic affiliation. Audio recordings were transcribed verbatim by trained research assistants and qualitative data analysis was conducted using modified grounded theory. Results There were a total of 34 participants: 19 Hispanics/Latinos and 15 Blacks, with equal numbers of men and women (n=17). Median age was 57 years (range: 18 to 85 years). Dominant themes that emerged with respect to PC diagnosis included the stigma surrounding this condition and the perceived role of an “unhealthy lifestyle” and certain sexual behaviors as risk factors for PC development. While the majority of participants acknowledged the importance of PC screening and early detection, discussion centered around the barriers to both the interest in seeking medical care and the likelihood of securing it. These barriers included misunderstanding of PC etiology, distrust of the medical profession, and financial/access limitations. Men expressed substantial confusion about PC screening guidelines. In the Black female group, the role of faith and religion in the course of disease was a major theme. Both Black and Latina females discussed the role of fear and avoidance around PC screening and treatment, as well as the prevalence of misinformation about PC in their familial and social communities. Conclusion Black and Latino focus groups revealed the existence of cultural beliefs, misunderstandings and fears pertaining to PC which could influence health-related behaviors. Some themes were common across groups; others suggested racial and gender predilections. Future targeted efforts focused on directly addressing prevalent misperceptions among underserved communities in urban settings could help to improve health literacy and equity in PC outcomes in these populations.

Proton therapy is a promising but controversial treatment in the management of prostate cancer. Despite its dosimetric advantages when compared with photon radiation therapy, its increased cost to patients and insurers has raised questions regarding its value. Multiple prospective and retrospective studies have been published documenting the efficacy and safety of proton therapy for patients with localized prostate cancer and for patients requiring adjuvant or salvage pelvic radiation after surgery. The Particle Therapy Co-Operative Group (PTCOG) Genitourinary Subcommittee intends to address current proton therapy indications, advantages, disadvantages, and cost effectiveness. We will also discuss the current landscape of clinical trials. This consensus report can be used to guide clinical practice and research directions.

Background: While psychological difficulties, such as depression, among prostate cancer patients are known, their longitudinal burden remains understudied. We assessed the burden of depression across low-, intermediate- and high-risk prostate cancer groups, and the association between regret and long-term depression. Methods: Secondary analysis of data from a multi-centered randomized controlled study among localized prostate cancer patients was carried out. Assessments were performed at baseline, and at 3-, 6-, 12- and 24-month follow-up. Depression was assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. A CES-D score ≥ 16 indicates high depression. Regret was measured using the regret scale of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). The proportion of patients with high depression was compared over time, for each risk category. Logistic regression was used to assess the association between regret, and long-term depression after adjusting for age, race, insurance, smoking status, marital status, income, education, employment, treatment, number of people in the household and study site. Results: The study had 743 localized prostate cancer patients. Median depression scores at 6, 12 and 24 months were significantly larger than the baseline median score, overall and for the three prostate cancer risk groups. The proportion of participants with high depression increased over time for all risk groups. Higher regret at 24-month follow-up was significantly associated with high depression at 24-month follow-up, after adjusting for covariates. Conclusions: A substantial proportion of localized prostate cancer patients continued to experience long-term depression. Patient-centered survivorship care strategies can help reduce depression and regret, and improve outcomes in prostate cancer care.

ABSTRACT: Purpose: The radiation oncology workforce in the United States is comparatively less diverse than the U.S. population and U.S. medical school graduates. Workforce diversity correlates with higher quality care and outcomes. The purpose of this study was to determine whether student members of the American Society for Radiation Oncology (ASTRO) are any more diverse than resident members-in-training using the recently established medical student membership category. Methods and Materials: Self-reported sex, race and Hispanic ethnicity, medical school, and degree(s) earned for all medical students (n = 268) and members-in-training (n = 713) were collected from the ASTRO membership database. International members were excluded. The χ2 test was used to assess for differences between subgroups. Results: Compared with members-in-training, student members were more likely to be female (40.0% vs 31.5%, P = .032), black or African American (10.7% vs 4.8%, P = .009), candidates for or holders of a DO rather than MD degree (5.2% vs 1.5%, P = .002), and from a U.S. medical school that is not affiliated with a radiation oncology residency program (30.5% vs 20.9%, P = .001). There was no significant difference in self-reported Hispanic ethnicity (7.3% vs 5.4%, P = .356). There were no indigenous members in either category assessed. Conclusions: Medical student members of ASTRO are more diverse in terms of black race, female sex, and osteopathic training, though not in terms of Hispanic ethnicity or nonmultiracial indigenous background, than the members-in-training. Longitudinal engagement with these students and assessment of the factors leading to specialty retention versus attrition may increase diversity, equity, and inclusion in radiation oncology.

Abstract Background The significance of perineural invasion (PNI) in prostate cancer (PC) is unclear. A recent report of patients with pT2N0R0 PC found that PNI at prostatectomy was independently associated with higher Gleason score and more diffuse prostatic disease. We aimed to test our hypothesis that PNI on prostate biopsy in pT2N0R0 patients is associated with increased Gleason score upgrading at prostatectomy. Methods We identified 2892 patients status post prostatectomy with pT2N0R0 PC from three institutions, diagnosed between 1 January 2008 and 31 December 2014. Multivariable logistic regression (MVA) was used to evaluate the association between prostate biopsy PNI status and surgical Gleason upgrading, while controlling for potential confounders. Results Of the 2892 patients identified, 14% had PNI on biopsy, of whom 21% had surgical Gleason upgrading, while 28% without PNI on biopsy had such upgrading (P 4 ng/mL (OR 1.26, P = .02). Conclusions In post‐prostatectomy patients with favorable‐risk PC, PNI on prostate biopsy was not associated with surgical Gleason score upgrading. This may be due to the association of PNI with more diffuse disease, leading to increased biopsy tumor yield and grading accuracy. These findings suggest that in this setting, biopsy PNI alone should not be a concern for more aggressive disease requiring pathologic confirmation or intervention. This may help guide treatment decision‐making for men debating active surveillance, radiation, and surgery.

Despite the fact that a large portion of medical students pursue training in a cancer-related discipline, oncology is emphasized to a disproportionately lesser extent than are other disciplines in medical school. Medical students have wide gaps in their oncology-specific knowledge, and undergraduate medical education fails to address the multidisciplinary nature of oncology. To address these shortcomings and improve medical students’ understanding of the multidisciplinary nature of oncology, we have instituted a clinical oncology elective for medical students: an optional, 2-day session held after classes and promoted by student interest groups. Day 1 comprised a series of short faculty lectures beginning with the concepts of and rationale for staging, an approach to breaking bad news, guideline-based management, and multidisciplinary tumor board discussion. Three multidisciplinary tumor boards were simulated on the second day, run by attending surgeons, medical oncologists, and radiation oncologists with expertise in the cancer of interest, using real patient examples. Ultimately, the clinical oncology elective shows medical students how the oncology care team works together to care for cancer patients.

Coronavirus disease 2019 (COVID-19) affected medical student clerkships and education around the country. A virtual medical student clerkship was created to integrate didactic education with disease specific lectures for medical students, contouring, and hands on learning with telehealth. Twelve medical students in their 3rd and 4th year were enrolled in this 2 week elective from April 27, 2020 to June 5, 2020. There was significant improvement of overall knowledge about the field of radiation oncology from pre elective to post elective (P < .001). Feedback included enjoying direct exposure to contouring, telehealth, and time with residents. Overall this 2 week rotation was successful in integrating radiation oncology virtually for medical students. This is now being expanded to multiple institutions as an educational resource and future rotations for medical students.

Purpose: Our purpose was to assess the terminology used to describe the different oncologic subspecialties at academic institutions in the United States and determine whether the use of the term “oncologist” to describe a medical oncologist (MO) may affect the multidisciplinary care of patients with cancer. Methods and Materials: An electronic survey was sent to chairs and program directors at all 94 academic radiation oncology departments in the United States. Questions assessed the terminology used to describe the oncologic subspecialties in their hospital’s electronic medical record system, their views on how that terminology may affect referral patterns, and the perception of radiation oncologists’ (ROs) role in patient care. Results: Responses were received from 40 institutions (response rate, 42.6%). Fifteen percent of hospital electronic medical record systems used the term “oncology” instead of “medical oncology” (51%) or “hematology/oncology” (28%). Describing MOs simply as “oncologists” was thought to more likely affect patient views of MOs as the primary decision maker in their cancer care (mean Likert-type rating, 3.43) than it would affect the probability of up-front multidisciplinary referrals (mean Likert-type rating, 2.69). Patient perceptions of ROs as equal partners in care were thought to be less associated with the terminology used to describe MOs (mean Likert-type rating, 3.15) than the behavior of ROs in patient care (mean Likert-type rating, 4.65; P < .001), the attitude of MOs toward ROs (mean Likert-type rating, 4.59; P < .001), and the involvement of ROs in the initial new patient visits rather than a downstream referral (mean Likert-type rating, 3.95; P < .001). Conclusions: The terminology used to describe MOs was thought to affect patient and provider perceptions of RO, but less so than other patient-provider interaction factors.

Purpose: Residency training environments can differ significantly; therefore, resident satisfaction may vary widely among programs. Here, we sought to examine several variables in program satisfaction through a survey of radiation oncology (RO) trainees in the United States. Methods and materials: An anonymous, institutional review board-approved, internet-based survey was developed and distributed to U.S. residents in RO in September 2016. This email-based survey assessed program-specific factors with regard to workload, work-life balance, and education as well as resident-specific factors such as marital status and postgraduate year. Binomial multivariable regression assessed the correlations between these factors and the endpoint of resident-reported likelihood of selecting an alternative RO residency program if given the choice again. Results: A total of 215 residents completed the required survey sections, representing 29.3% of U.S. RO residents. When asked whether residency allowed for an adequate balance between work and personal life, the majority of residents (75.6%) agreed or strongly agreed, but a minority (9.3%) did not feel that residency allowed for sufficient time for personal life. The majority of residents (69.7%) indicated that they would choose the same residency program again, but 12.2% would have made a different choice. Almost three-fourths of residents (73.0%) felt that faculty and staff cared about the educational success of residents, but 9.27% did not. Binomial multivariable regression revealed that senior residents (odds ratio: 6.70; 95% confidence interval, 2.20-22.4) were more likely to desire a different residency program. In contrast, residents who reported constructive feedback use by the residency program (odds ratio:0.22; 95% confidence interval, 0.06-0.91) were more satisfied with their program choice. Conclusions: Most RO residents reported satisfaction with their choice of residency program, but seniors had higher rates of dissatisfaction. Possible interventions to improve professional satisfaction include incorporating constructive resident feedback to enhance the program. The potential impact of job market pressures on seniors should be further explored.

Purpose: To present the most updated American College of Radiology (ACR) Appropriateness Criteria formed by an expert panel on the appropriate delivery of external beam radiation to manage stage T1 and T2 prostate cancer (in the definitive setting and post-prostatectomy) and to provide clinical variants with expert recommendations based on accompanying Appropriateness Criteria for target volumes and treatment planning. Methods and materials: The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a panel of multidisciplinary experts. The guideline development and revision process includes an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In instances in which evidence is lacking or equivocal, expert opinion may supplement available evidence to recommend imaging or treatment. Results: The panel summarizes the most recent and relevant literature on the topic, including organ motion and localization methods, image guidance, and delivery techniques (eg, 3-dimensional conformal intensity modulation). The panel presents 7 clinical variants, including (1) a standard case and cases with (2) a distended rectum, (3) a large-volume prostate, (4) bilateral hip implants, (5) inflammatory bowel disease, (6) prior prostatectomy, and (7) a pannus extending into the radiation field. Each case outlines the appropriate techniques for simulation, treatment planning, image guidance, dose, and fractionation. Numerical rating and commentary is given for each treatment approach in each variant. Conclusions: External beam radiation is a key component of the curative management of T1 and T2 prostate cancer. By combining the most recent medical literature, these Appropriateness Criteria can aid clinicians in determining the appropriate treatment delivery and personalized approaches for individual patients.

Purpose: Despite increasing use, proton therapy (PT) remains a relatively limited resource. The purpose of this study was to assess clinical and demographic differences in PT use for prostate cancer compared to intensity modulated radiation therapy (IMRT) at a single institution. Methods and materials: All patients with low- and intermediate-risk prostate cancer (N = 633) who underwent definitive radiation therapy between 2010 and 2015 were divided into PT (n = 508) and IMRT (n = 125) comparison groups and compared using χ2 and independent sample t tests. Univariable and multivariable logistic regression analyses were conducted to assess the associations between PT use and demographic, clinical, and treatment characteristics. Results: The PT and IMRT cohorts varied by age, race, poverty, distance, treatment year, and treating physician. Patients who underwent IMRT were more likely to be older (mean age, 66 vs. 68 years), black (51% vs. 75%), and living in poverty or close to the facility (mean distance between residence and facility, 90 vs. 21 miles; P < .05). Prostate-specific antigen, prostate volume, and International Index of Erectile Function were significantly higher in the IMRT cohort (P < .05), but insurance type, risk group, tumor stage, Gleason score, and patient-reported urinary and bowel scores did not differ significantly (P > .05). Patients who underwent PT were more likely to receive hypofractionated therapy and less likely to receive androgen deprivation therapy (P < .01). On multivariable analysis, black (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.15-0.57) and other race (OR, 0.42; 95% CI, 0.20-0.90); distance (OR, 1.14; 95% CI, 1.06-1.24); treatment years 2011 (OR, 4.87; 95% CI, 2.23-10.6), 2012 (OR, 8.27; 95% CI, 3.43-19.9), and 2014 (OR, 4.44; 95% CI, 1.94-10.2) relative to 2010; and a single treating physician (OR, 0.38; 95% CI, 0.18-0.81) relative to the reference physician with the highest rate of use were associated with PT use, whereas clinical factors such as prostate-specific antigen, prostate volume, International Index of Erectile Function, and androgen deprivation therapy were not. Conclusion: Sociodemographic disparities exist in PT use for prostate cancer at an urban academic institution. Further investigation of potential barriers to access is warranted to ensure equitable distribution across all demographic groups.

Purpose: There is growing evidence supporting incorporating multiparametric (mp) magnetic resonance imaging (MRI) scans into risk stratification, active surveillance, and treatment paradigms for prostate cancer. The purpose of our study was to determine whether demographic disparities exist in staging MRI utilization for prostate cancer patients. Methods and materials: An institutional database of 705 nonmetastatic prostate cancer patients treated with radiation therapy from 2005 through 2013 was used to identify patients undergoing versus not undergoing pretreatment diagnostic prostate mpMRI. Uni- and multivariable logistic regression evaluated the relationship of clinical and demographic characteristics with MRI utilization. Results: All demographic variables assessed, except the other race category, were significantly associated with MRI utilization (all P < .05), including age (odds ratio [OR], 0.92), black race (OR, 0.51), poverty (OR, 0.53), closer distance to radiation facility (OR, 1.79), and nonprivate primary insurance (OR, 0.57) on univariable analysis, while clinical stage T3 (OR, 3.37) was the only clinical characteristic. On multivariable analysis stratified by D'Amico risk group, age remained significant across all risk groups, whereas the black versus white racial (OR, 0.21; 95% confidence interval, 0.08-0.55) and nonprivate versus private insurance type (OR, 0.37; 95% confidence interval, 0.16-0.86) disparities persisted in the low-risk group. Clinical stage T3 remained associated in the high-risk group. For race specifically, the percentages of whites, blacks, and others undergoing MRI in the overall cohort and by risk group were, respectively: overall, 80% (343/427), 68% (156/231), and 85% (40/47); low risk, 86%, 56%, and 63%; intermediate risk, 79%, 72%, and 95%; and high risk, 72%, 72%, and 100%. Conclusions: In this urban, academic center cohort, older patients across all risk groups and black or nonprivate insurance patients in the low risk group were less likely to undergo staging prostate MRI scans. Further research should investigate these differences to ensure equitable utilization across all demographic groups considering the burden of prostate cancer disparities.