Technology and clinician-learner interaction: how clinicians expect introduction of a new electronic health record to affect educational practice.

INTRODUCTION: Electronic health records (EHRs) are increasingly common platforms used in medical settings to capture and store patient information, but their implementation can have unintended consequences. One particular risk is damaging clinician-learner-interactions, but very little has been published about how EHR implementation affects educational practice. Given the importance of stakeholder engagement in change management, this research sought to explore how EHR implementation is anticipated to affect clinician-learner interactions, educational priorities and outcomes. METHODS: Semi-structured interviews were conducted with a group of practicing oncologists who work in outpatient clinics while also providing education to medical student and resident trainees. Data regarding perceived impact on the teaching dynamic between clinicians and learners were collected prior to implementation of an EHR and analyzed thematically. RESULTS: Physician educators expected EHR implementation to negatively influence their engagement in teaching and the learning they themselves normally gain through teaching interactions. Additionally, EHR implementation was expected to influence learners by changing what is taught and the students' role in clinical care and the educational dynamic. Potential benefits included harnessing learners' technological aptitude, modeling adaptive behaviour, and creating new ways for students to be involved in patient care. CONCLUSION: Anticipating the concerns clinicians have about EHR implementation offers both potential to manage change to minimize disruptions caused by implementation and a foundation from which to assess actual educational impacts.

Locally Advanced Malignant Myoepithelioma of the Parotid Gland Treated With Radiotherapy: A Case Study and Review of the BC Cancer Agency Experience.

OBJECTIVES: Malignant myoepithelioma of salivary glands is a rare neoplasm; most arise in the parotid gland and minor salivary glands of the palate. Surgery has been the mainstay of treatment. METHODS: This is case report of a patient treated with primary radical radiotherapy and retrospective review of institutional experience. RESULTS: An 87-year-old man with locoregionally advanced malignant myoepithelioma of the parotid gland received radiotherapy alone with complete clinical response and sustained 39 months of posttreatment. Between 1981 and 2012, 15 cases of malignant myoepithelioma of the parotid were seen. Thirteen patients received surgical excision and adjuvant radiotherapy. At a median follow-up of 47 months, 12 patients were alive without recurrence, 2 died without recurrence, and 1 died with metastatic myoepithelioma. CONCLUSIONS: Durable locoregional disease control and disease-free-survival was achieved in the majority of patients. The case reported suggests radiation therapy may be an effective treatment option for inoperable cases.

LINAC radiosurgery for cerebral arteriovenous malformations: a single centre prospective analysis and review of the literature.

Stereotactic radiosurgery (SRS) is a well established, minimally invasive treatment option for patients diagnosed with cerebral arteriovenous malformations (AVM). We present the experience in linear accelerator-based SRS for cerebral AVM treated over 14 years. We prospectively followed 67 patients with 69 AVM treated with SRS from 1994 to 2008, inclusive. The mean patient age was 37 years (range 7-69) with 36 women and 31 men. The median AVM size, as defined by maximal diameter, was 2.5 cm (range 0.5-4.6 cm) and the median marginal dose was 18 Gy in one fraction. The crude angiographic obliteration rate was 55% with a 3 and 5 year actuarial rate of 39% and 65%, respectively. Median time to obliteration was 4.2 years. Higher treatment dose (p<0.0001) and smaller maximal AVM diameter (p=0.002) were associated with an increased obliteration rate. There were no deaths from treatment. Post-treatment neurological complications occurred in 10 patients (15%) including hemorrhage in two. Twelve patients (18%) required a second SRS procedure. Larger AVM diameter was associated with increased odds of requiring re-treatment (p=0.02). Radiosurgery for intracerebral AVM is a non-invasive therapeutic option with low morbidity and a reasonable likelihood of nidus obliteration. Treatment dose and AVM diameter are the main determinants of obliteration.

Evaluating adjacent organ radiation doses from postoperative intracavitary vaginal vault brachytherapy for endometrial cancer.

PURPOSE: To document doses received by critical organs during adjuvant high-dose-rate (HDR) vaginal vault brachytherapy. METHODS AND MATERIALS: Patients treated with HDR vaginal vault radiation between January 1, 2009, and January 31, 2012, who had a CT simulation with the treatment cylinder in situ were included. The CT scans were retrospectively reviewed and the rectum, sigmoid, small bowel, and bladder were contoured. Standardized plans treating the upper 4 cm of the vaginal vault were used to deliver a total of 21 Gy (Gy) at 0.5 cm from the apex of the vaginal vault in three fractions. RESULTS: There were 41 patients. Median age was 62 years. The median vaginal cylinder diameter was 3 cm. The mean 2cc dose to the rectum, sigmoid, small bowel, and bladder were 5.7, 4.7, 4.0, and 5.6 Gy, respectively. Bladder volume ranged from 67-797cc. Assuming minimal interfraction organ variation, the equivalent dose in 2 Gy/fraction was extrapolated from data and may be near or beyond organ tolerance for rectum, sigmoid, and small bowel in some cases. Spearman correlation found that increased bladder volume was not associated with adjacent organs at risk dose but may be associated with a trend (p=0.06) toward increased bladder dose (R=0.30). CONCLUSIONS: This study describes the dose received by adjacent critical structures during vaginal vault HDR brachytherapy. This is important information for documentation in the rare setting of treatment-related toxicity or recurrence. Bladder volume was not associated with dose to adjacent organs.

Treatment and outcomes of primary breast lymphoma.

PURPOSE: To evaluate treatment and outcomes in a population-based cohort of patients diagnosed with primary breast lymphoma. METHODS AND MATERIALS: Prognostic factors, management, and outcomes (local control, lymphoma-specific survival, and overall survival) were analyzed for all patients diagnosed with limited-stage, primary breast non-Hodgkin lymphoma (n = 50) diagnosed in British Columbia between 1981 and 2009. RESULTS: The median follow-up was 3.5 years; 64% presented with a breast mass. Histologic subtypes were indolent (n = 16 [32%]) or aggressive (n = 34 [68%]). Of those with indolent lymphoma, 81% had stage I, and 19% had stage II disease; 13% received no initial treatment; 75% received radiotherapy (RT) alone. One (6%) patient received surgical resection alone, and 1 (6%) patient received surgical resection in addition to RT. Of those with aggressive lymphoma, 62% had stage I and 38% had stage II disease; 3% received no initial treatment; 6%, RT alone; 38%, chemotherapy only; 41%, chemotherapy and RT; 9%, surgical resection alone; and 3%, surgical resection in addition to chemotherapy and RT. In patients with indolent and aggressive disease, 5-year local control estimates were 92% and 96%, lymphoma-specific survivals were 91% and 71%, and overall survivals were 75% and 54%, respectively. On univariate analysis, stage (I vs. II) (P = .006) and RT use (P = .032) were statistically significant predictors of improved overall survival in patients with indolent breast lymphoma. Combined chemoradiation was associated with a trend for improved overall survival (P = .061) in patients with aggressive disease. There were 4 cases of central nervous system relapse, all occurred in subjects with aggressive primary breast lymphoma. CONCLUSIONS: Patients with indolent breast lymphoma were most frequently treated with RT alone and achieved high rates of local control and survival. Patients with aggressive histology most often treated with chemotherapy, alone or combined with RT, had excellent local control but lower survival compared with indolent disease. Improved systemic therapies are needed to improve outcomes for patients with aggressive breast lymphoma.

Assessing the risk of inadvertent radiation exposure of pregnant patients during radiation therapy planning and treatment in British Columbia.

PURPOSE: To explore health care professionals' perceptions of, and experience with, the risk of inadvertent radiation exposure to pregnant patients in radiation therapy (RT) departments. METHODS AND MATERIALS: The survey was distributed to 342 health care professionals working in RT departments in British Columbia (BC), including radiation therapists, medical physicists, radiation oncologists, and radiation oncology residents. RESULTS: There were 119 responses, 65% of who were radiation therapists. Respondents' mean duration of experience was 13.9 years (range, 1-25), over which time the BC Cancer Agency has delivered at least one course of RT to an estimated 16,000 women under the age of 50. Of the responses, 11.6% indicated that they had ever, in their training or career, encountered a situation where RT was inadvertently given to a pregnant patient. Upon reviewing anonymous comments, at least 7 discrete incidents were described. Fifty-two percent of radiation oncologists never, or only occasionally, remembered to discuss the risk of RT in pregnancy; 53% did not believe there were signs posted in their cancer center warning patients or reminding staff of this risk. Furthermore, 61% did not know if there was any patient education material designed for this purpose. Establishment of a checklist to screen for potentially fertile females prior to RT was felt to be a useful intervention by 49% of respondents. CONCLUSIONS: There is a risk of RT exposure to pregnant patients. Procedures and policies to prevent inadvertent irradiation of pregnant patients appear to be inadequate in BC. Provincial policies should be introduced to help reduce the risk of inadvertent RT of pregnant patients.