Association Between Geographic Access to Cancer Care and Receipt of Radiation Therapy for Rectal Cancer.

PURPOSE: Trimodality therapy (chemoradiation and surgery) is the standard of care for stage II/III rectal cancer but nearly one third of patients do not receive radiation therapy (RT). We examined the relationship between the density of radiation oncologists and the travel distance to receipt of RT. METHODS AND MATERIALS: A retrospective study based on the National Cancer Data Base identified 26,845 patients aged 18 to 80 years with stage II/III rectal cancer diagnosed from 2007 to 2010. Radiation oncologists were identified through the Physician Compare dataset. Generalized estimating equations clustering by hospital service area was used to examine the association between geographic access and receipt of RT, controlling for patient sociodemographic and clinical characteristics. RESULTS: Of the 26,845 patients, 70% received RT within 180 days of diagnosis or within 90 days of surgery. Compared with a travel distance of <12.5 miles, patients diagnosed at a reporting facility who traveled ≥50 miles had a decreased likelihood of receipt of RT (50-249 miles, adjusted odds ratio 0.75, P<.001; ≥250 miles, adjusted odds ratio 0.46; P=.002), all else being equal. The density level of radiation oncologists was not significantly associated with the receipt of RT. Patients who were female, nonwhite, and aged ≥50 years and had comorbidities were less likely to receive RT (P<.05). Patients who were uninsured but self-paid for their medical services, initially diagnosed elsewhere but treated at a reporting facility, and resided in Midwest had an increased the likelihood of receipt of RT (P<.05). CONCLUSIONS: An increased travel burden was associated with a decreased likelihood of receiving RT for patients with stage II/III rectal cancer, all else being equal; however, radiation oncologist density was not. Further research of geographic access and establishing transportation assistance programs or lodging services for patients with an unmet need might help decrease geographic barriers and improve the quality of rectal cancer care.

Association Between Geographic Access to Cancer Care, Insurance, and Receipt of Chemotherapy: Geographic Distribution of Oncologists and Travel Distance.

PURPOSE: Geographic access to care may be associated with receipt of chemotherapy but has not been fully examined. This study sought to evaluate the association between density of oncologists and travel distance and receipt of adjuvant chemotherapy for colon cancer within 90 days of colectomy. PATIENTS AND METHODS: Patients in the National Cancer Data Base with stage III colon cancer, diagnosed between 2007 and 2010, and age 18 to 80 years were selected. Generalized estimating equation clustering by hospital service area was conducted to examine the association between geographic access and receipt of oncology services, controlling for patient sociodemographic and clinical characteristics. RESULTS: Of 34,694 patients in the study cohort, 75.7% received adjuvant chemotherapy within 90 days of colectomy. Compared with travel distance less than 12.5 miles, patients who traveled 50 to 249 miles (odds ratio [OR], 0.87; P=.009) or ≥250 miles (OR, 0.36; P<.001) had decreased likelihood of receiving adjuvant chemotherapy. Density level of oncologists was not statistically associated with receipt of adjuvant chemotherapy (low v high density: OR, 0.98; P=.77). When stratifying analyses by insurance status, non-privately insured patients who resided in areas with low density of oncologists were less likely to receive adjuvant chemotherapy (OR, 0.85; P=.03). CONCLUSION: Increased travel burden was associated with a decreased likelihood of receiving adjuvant chemotherapy, regardless of insurance status. Patients with nonprivate insurance who resided in low-density oncologist areas were less likely to receive adjuvant chemotherapy. If these findings are validated prospectively, interventions to decrease geographic barriers may improve the timeliness and quality of colon cancer treatment.

An assessment of the current US radiation oncology workforce: methodology and global results of the American Society for Radiation Oncology 2012 Workforce Study.

PURPOSE: To determine the characteristics, needs, and concerns of the current radiation oncology workforce, evaluate best practices and opportunities for improving quality and safety, and assess what we can predict about the future workforce. METHODS AND MATERIALS: An online survey was distributed to 35,204 respondents from all segments of the radiation oncology workforce, including radiation oncologists, residents, medical dosimetrists, radiation therapists, medical physicists, nurse practitioners, nurses, physician assistants, and practice managers/administrators. The survey was disseminated by the American Society for Radiation Oncology (ASTRO) together with specialty societies representing other workforce segments. An overview of the methods and global results is presented in this paper. RESULTS: A total of 6765 completed surveys were received, a response rate of 19%, and the final analysis included 5257 respondents. Three-quarters of the radiation oncologists, residents, and physicists who responded were male, in contrast to the other segments in which two-thirds or more were female. The majority of respondents (58%) indicated they were hospital-based, whereas 40% practiced in a free-standing/satellite clinic and 2% in another setting. Among the practices represented in the survey, 21.5% were academic, 25.2% were hospital, and 53.3% were private. A perceived oversupply of professionals relative to demand was reported by the physicist, dosimetrist, and radiation therapist segments. An undersupply was perceived by physician's assistants, nurse practitioners, and nurses. The supply of radiation oncologists and residents was considered balanced. CONCLUSIONS: This survey was unique as it attempted to comprehensively assess the radiation oncology workforce by directly surveying each segment. The results suggest there is potential to improve the diversity of the workforce and optimize the supply of the workforce segments. The survey also provides a benchmark for future studies, as many changes in the healthcare field exert pressure on the workforce.

American Society for Radiation Oncology (ASTRO) 2012 Workforce Study: the radiation oncologists' and residents' perspectives.

PURPOSE: The American Society for Radiation Oncology (ASTRO) conducted the 2012 Radiation Oncology Workforce Survey to obtain an up-to-date picture of the workforce, assess its needs and concerns, and identify quality and safety improvement opportunities. The results pertaining to radiation oncologists (ROs) and residents (RORs) are presented here. METHODS: The ASTRO Workforce Subcommittee, in collaboration with allied radiation oncology professional societies, conducted a survey study in early 2012. An online survey questionnaire was sent to all segments of the radiation oncology workforce. Respondents who were actively working were included in the analysis. This manuscript describes the data for ROs and RORs. RESULTS: A total of 3618 ROs and 568 RORs were surveyed. The response rate for both groups was 29%, with 1047 RO and 165 ROR responses. Among ROs, the 2 most common racial groups were white (80%) and Asian (15%), and the male-to-female ratio was 2.85 (74% male). The median age of ROs was 51. ROs averaged 253.4 new patient consults in a year and 22.9 on-treatment patients. More than 86% of ROs reported being satisfied or very satisfied overall with their career. Close to half of ROs reported having burnout feelings. There was a trend toward more frequent burnout feelings with increasing numbers of new patient consults. ROs' top concerns were related to documentation, reimbursement, and patients' health insurance coverage. Ninety-five percent of ROs felt confident when implementing new technology. Fifty-one percent of ROs thought that the supply of ROs was balanced with demand, and 33% perceived an oversupply. CONCLUSIONS: This study provides a current snapshot of the 2012 radiation oncology physician workforce. There was a predominance of whites and men. Job satisfaction level was high. However a substantial fraction of ROs reported burnout feelings. Perceptions about supply and demand balance were mixed. ROs top concerns reflect areas of attention for the healthcare sector as a whole.

Dosimetric perturbation from cloth and paper gowns for total skin electron irradiation.

Traditionally, total skin electron patients remove all clothing for treatment. It is generally assumed that this is best for the treatment of superficial skin lesions out of concern clothing may significantly perturb dose. We investigate the dosimetric effect of patient gowns and determine the necessity of treating patients naked. Using GAFCHROMIC EBT2 film, dose to a cylindrical phantom was measured with cloth, paper, and tri-layer cloth gowns, compared to no covering. A 6 MeV electron beam with spoiler accessory was used at ~ 4 meters source-to-skin distance. The gantry was angled at 248° and 292°. The phantom was rotated at -60°, 0°, and 60° relative to the beam's central axis, simulating the Stanford technique. This was also repeated for films sandwiched between the phantom's discs. Using a Markus chamber, the effect of air gaps of 0 to 5 cm in cloth and paper gowns was measured. The water equivalent attenuation of the gowns was determined through transmission studies. Compared to no covering, films placed on the phantom surface revealed an average increase of 0.8% in dose for cloth, 1.8% for tri-layered cloth, and 0.7% for paper. Films sandwiched within the phantom showed only slight shift of the percent depth-dose curves. Markus chamber readings revealed 1.4% for tri-layered cloth, and < 0.2% for single layer cloth or paper. Air gaps appeared to have a minimal effect. Transmission measurements found that one layer of cloth is equal to 0.2mm of solid water. Cloth and paper gowns appear to slightly increase the dose to the skin, but will not introduce any significant dose perturbation (<1%). Gowns having folds and extra layers will have a small additional perturbation (<2%). To minimize perturbation, one should smooth out any folds or remove any pockets that form extra layers on the gown.

FDG PET imaging in the staging and management of gastric cancer.

Gastric cancer is a leading cause of cancer death worldwide. Complete resection offers the only chance for permanent control, and accurate staging and evaluation of treatment response are crucial for appropriate management. Positron Emission Tomography (PET) is increasingly used to complement anatomic imaging in cancer management. PET use in gastric cancer has been limited by 1) some gastric histologies are not PET avid, 2) spatial resolution limits the ability to distinguish between primary tumor and compartment I or II lymph nodes, and 3) the lack of a unified criteria in how to interpret PET for management decisions. New criteria have been proposed establishing response metrics in the utilization of PET. More study is needed to support these criteria in routine practice and establish the place of PET in the staging and management of gastric cancer.

Positron emission tomography as predictor of rectal cancer response during or following neoadjuvant chemoradiation.

Positron emission tomography (PET) shows great promise as a tool to evaluate the effectiveness of rectal cancer neoadjuvant therapy as it has demonstrated high predictive value in several studies. Creating a standardized method of using PET has the potential to reduce ineffective treatments. However, relevant studies have been heterogenous in approach, making any unified standard difficult to establish. PET related parameters used to assess treatment response include magnitude and change of standard uptake value, total lesion glycolysis, and visual response. Finding the best evaluation interval and parameters to use for interpreting PET results in the neo-adjuvant treatment of rectal cancer needs additional study.

Positron Emission Tomography's Utility in Esophageal Cancer Management.

Esophageal cancer is rising in incidence and has a poor prognosis. Positron Emission Tomography (PET) is increasingly being investigated as a tool to more discriminately manage these patients. Several studies have indicated benefits in the use of PET for staging and assessment of treatment response while others have provided contradicting results. There are many possible factors that might contribute to these results, including variability in the manner of PET administration and interpretation, timing, and study design. PET acquired after chemoradiation or chemotherapy may give important prognostic information that can guide additional management decisions. Studies have had substantial variability in the timing and manner of assessing PET for this purpose, and additional study is needed.

Positron emission tomography's changing significance in the treatment of esophageal cancer.

Incidence of esophageal cancer has been rising, and Positron Emission Tomography (PET) is one tool that has shown utility and promise as a tool for staging, treatment response, and prognosis. PET delivery has evolved over time and is now frequently registered with a CT scan at the time of acquisition. However, resolution and confounders such as post-treatment radiation changes may limit clinical utility. PET has been shown to be helpful in staging, especially in evaluating for distant metastases. PET acquired after chemoradiation may give important prognostic information that can guide additional treatment decisions. Studies have had substantial variability in recommendations for the timing and manner of using PET for this purpose, and additional study is needed.

Posttreatment FDG-PET uptake in the supraglottic and glottic larynx correlates with decreased quality of life after chemoradiotherapy.

PURPOSE: Inflammation and increased metabolic activity associated with oxidative stress in irradiated normal tissues may contribute to both complications following radiotherapy and increased glucose uptake as detected by posttherapy fluorodeoxyglucose (FDG)-PET imaging. We sought to determine whether increased glucose uptake in normal tissues after chemoradiotherapy is associated with increased toxicity. METHODS AND MATERIALS: Consecutive patients with locoregionally advanced head and neck cancers treated with intensity-modulated radiation therapy and free of recurrence at 1 year were studied. FDG-PET imaging was obtained at 3 and 12 months posttreatment. Standardized uptake value (SUV) levels were determined at various head and neck regions. Functional outcome was measured using a quality of life questionnaire and weight loss and type of diet tolerated 1 year after therapy. A one-tailed Pearson correlation test was used to examine associations between SUV levels and functional outcome measures. RESULTS: Standardized uptake value levels in the supraglottic and glottic larynx from FDG-PET imaging obtained 12 months posttreatment were inversely associated with quality of life measures and were correlated with a more restricted diet 1 year after therapy. SUV levels at 3 months after therapy did not correlate with functional outcome. Increases in SUV levels in normal tissues between 3 and 12 months were commonly found in the absence of recurrence. CONCLUSION: Altered metabolism in irradiated tissues persists 1 year after therapy. FDG-PET scans may be used to assess normal tissue damage following chemoradiotherapy. These data support investigating hypermetabolic conditions associated with either inflammation, oxidative stress, or both, as causal agents for radiation-induced normal tissue damage.