Selective omission of level V nodal coverage for patients with oropharyngeal cancer: Clinical validation of intensity-modulated radiotherapy experience and dosimetric significance.

BACKGROUND: We sought to validate the consensus recommendation and assess dosimetric significance of selective omission of nodal level V from intensity-modulated radiotherapy (IMRT) clinical target volume (CTV) for oropharyngeal cancer. METHODS: IMRT plans and clinical outcomes for 112 patients with oropharyngeal cancer (nodal classification N0-N2b) were analyzed for coverage of ipsilateral and contralateral nodal level V. Additionally, new IMRT plans were generated in 6 randomly selected patients to assess its dosimetric impact. RESULTS: With median follow-up of 3.4 years, there were no failures identified in nodal level V with or without nodal level V omission. Upon dosimetric evaluation, significant reduction in integral dose, V10 Gy , V20 Gy , V30 Gy , V40 Gy , and V50 Gy was observed by excluding unilateral and bilateral level V from the CTV. CONCLUSION: We clinically validate the consensus recommendation for selective omission of level V nodal coverage in IMRT planning of patients with oropharyngeal cancer and demonstrate significant dosimetric advantages.

Academic portfolio in the digital era: organizing and maintaining a portfolio using reference managers.

The academic portfolio has become an integral part of the promotions process. Creating and maintaining an academic portfolio in paper-based or web-based formats can be a cumbersome and time-consuming task. In this article, we describe an alternative way to efficiently organize an academic portfolio using a reference manager software, and discuss some of the afforded advantages. The reference manager software Papers (Mekentosj, Amsterdam, The Netherlands) was used to create an academic portfolio. The article outlines the key steps in creating and maintaining a digital academic portfolio. Using reference manager software (Papers), we created an academic portfolio that allows the user to digitally organize clinical, teaching, and research accomplishments in an indexed library enabling efficient updating, rapid retrieval, and easy sharing. To our knowledge, this is the first digital portfolio of its kind.

Exploring implications of Medicaid participation and wait times for colorectal screening on early detection efforts in Connecticut--a secret-shopper survey.

BACKGROUND: Routine colorectal screening, decreases in incidence, and advances in treatment have lowered colorectal cancer mortality rates over the past three decades. Nevertheless, it remains the second most common cause of cancer death amongst men and women combined in U.S. Most cases of colon cancer are diagnosed at a late stage leading to poor survival outcomes for patients. After extensive research of publically available data, it would appear that the state of Connecticut does not have available state-wide data on patient wait times for routine colonoscopy screening. Furthermore, there are no publicly available, or Connecticut-specific, reports on Medicaid participation rates for colorectal screening amongst gastroenterologists (GI) in Connecticut. In 2012, the American Cancer Society report on Colorectal Cancer Screening Rates confirmed barriers to health-care access and disparities in health outcomes and survival rates for colon cancer patients based on race, ethnicity, and low socioeconomic status. Given this information, one could conjecture that low Medicaid participation rates among GIs could potentially have a more severe impact on health-care access and outcomes for underserved populations. At present, funding and human resources are being employed across the state of Connecticut to address bottlenecks in colorectal cancer screening. More specifically, patient navigation and outreach programs are emerging and expanding to address the gaps in services for hard-to-reach populations and the medically underserved. Low Medicaid participation rates and increased wait times for colonoscopy screening may impair the efficacy of colorectal cancer patient navigation and outreach efforts and potentially funding for future interventions. In this study, we report the results of our secret-shopper telephone survey comprising of 93 group and independent gastroenterologist (GI) practices in different counties of Connecticut. METHODS: Reviewing online resources and yellow pages, researchers compiled a county-specific list of GI practices throughout Connecticut and conducted a secret-shopper survey by telephone. A standard script and set of questions was formulated and used for each telephone call to GI practices. Data was analyzed in context of statistics available to the public at large from the U.S. Census Bureau. RESULTS: Overall, 46% of all 93 practices and 62% of individual GIs from all 93 practices state-wide reported Medicaid participation. About 35% of surveyed practices were independent practices; 41% of these reported Medicaid participation. About 65% of surveyed practices were group practices; 49% of these reported Medicaid participation. Approximately, 85% of all practices are in Fairfield, Hartford, orNew Haven counties. Of all three counties, New Haven reported the highest Medicaid participation rate by practices; 62% of all practices in New Haven reported participation. Fairfield reported the lowest Medicaid participation rate by practices; 29% of all practices in Fairfield reported participation. When Medicaid participation rates were calculated for total number of gastroenterologists from all practices in a given county (as opposed to participation rates by number of practices), Medicaid participation rates were 80% and 44% for New Haven and Fairfield, respectively. Of all practices in Hartford, only 50% reported Medicaid participation, whereas 67% of the total number of gastroenterologists (as opposed to practices) reported Medicaid participation. According to a recent national survey, 47% of gastroenterologists reported stopping accepting new Medicaid patients. Overall minimum and maximum wait times were reported to be the highest for Hartford, but wait times were long even for smaller counties, reflecting a possible imbalance in supply and demand or inefficiency in allocating the available resources. CONCLUSIONS: Only a limited number of gastroenterology practices in Connecticut accept Medicaid patients, notably in selected counties, but in all counties, and this may add to access barriers. It is yet unclear whether these disparities are significant enough to create a supply-demand imbalance and thus, have a significantly negative impact on health outcomes for the underserved. Nevertheless, with the high unemployment rates and impending implementation of mandated state-wide health-care reform as outlined in the Affordable Care Act, the Medicaid population in the state of Connecticut will increase, increasing future demand for services. In addition, based on the survey findings, longer wait times for colonoscopy screening are reported for the many of GI practices in Connecticut for Medicaid-insured as well as non-Medicaid patients. Longer wait times may have an impact on patient compliance, especially for the underserved populations that are hard to reach and ensure follow-up, contributing to potential delayed diagnosis. A Medicaid-associated disparity in this area will serve to exacerbate the problem for the underserved compared to those relatively well served. Those currently not seeking screening are at even higher risk of contributing to the higher mortality rate, and we need to find out how best to ensure that we can more uniformly apply screening and have the capacity to do so.

Successful treatment of an angiosarcoma of the nose with radiation therapy.

Angiosarcoma is a rare, aggressive malignancy of endothelial cells lining blood vessels. It poses therapeutic challenges since there is no standard established treatment. It is typically treated with resection and wide-field postoperative radiation therapy. Chemotherapy and radiation therapy have also been reported as initial therapies. Regardless of the treatment rendered, the risk of local regional failure and distant relapse remains high for this disease. We present the case of a patient who developed a well-differentiated angiosarcoma of the nose with bilateral malar extension. No commonly associated risk factors such as lymphedema, prior radiotherapy or chronic venous ulceration were present. Given her age, pre-existing renal condition and preference not to receive chemotherapy, systemic therapy was not utilized. Surgery was also refused by the patient due to the projected cosmetic deficit. The patient was ultimately treated with definitive radiotherapy, utilizing electrons to the central face, differential thickness bolus, an intraoral stent, eye shields, an aquaplast mask for immobilization and a wax-coated lead shield over the face in order to limit penumbra of the radiation beam. Right and left anterior 6-MV photons were used to tangentially treat the bilateral malar region in order to extend the field edges. At the time of this report, the patient remains disease free at nearly 2.0 years after radiotherapy. To the best of our knowledge, this represents only the second case in the literature reporting radiotherapy as a single modality treatment that resulted in complete remission of an angiosarcoma of the face.