Smoking Cessation at a Safety-Net Hospital: A Radiation Oncology Resident-Led Quality Improvement Initiative.

PURPOSE: Continued smoking among patients with cancer has been associated with increased toxicities, resistance to treatment, and recurrence. This resident-led quality improvement study attempted to increase smoking cessation by providing free smoking cessation medications in the radiation oncology clinic. METHODS AND MATERIALS: Twenty currently smoking patients with nonmetastatic cancer were prospectively enrolled. First line treatment was protocol-standardized combined nicotine replacement therapy (patches and lozenges). Therapy was initiated before radiation therapy and given for 12 weeks. Patient self-reported tobacco use was assessed at midtreatment, end of 12-week treatment, 3-month follow-up, 6-month follow-up, and 12-month follow-up. RESULTS: Within the initial cohort of 20 patients, average years smoked was 36.3 years (median = 37.5). In addition, 85% had attempted to quit previously. Among patients initially enrolled, 3 did not initiate radiation therapy, and 4 were removed from the study by midtreatment due to noncompliance. Midway through treatment, patients had cut self-reported cigarette use to 31% of baseline. However, 75% or more of patients had smoked within the last week at all timepoints assessed. With further follow-up, the number of cigarettes smoked daily continued to rise, reaching 61% of baseline by the 12-month follow-up. CONCLUSIONS: Patients reduced cigarette consumption, but all patients eventually resumed smoking during the 12-month follow-up. Although it is unfortunate that this study did not result in long-term smoking cessation, the results demonstrate the difficulties faced in helping patients with cancer quit, particularly patients seen at a safety-net hospital. Future efforts could be directed at intensified smoking cessation programs, likely incorporating a more standardized counseling component.

Impact of radiotherapy duration on overall survival in squamous cell carcinoma of the anus.

BACKGROUND: Prolongation of radiotherapy (RT) in the treatment of numerous types of cancer has been shown to reduce overall survival (OS). Treatment delays are common in squamous cell carcinoma of the anus (SCCA) due to the toxicity of definitive chemoradiation (CRT). The effect of these delays on outcomes has not been well evaluated. This study investigated the effects of RT prolongation on OS in patients receiving CRT for SCCA. METHODS: The National Cancer Database was queried for adult patients diagnosed with SCCA and treated with CRT from 2004-2014. Cox proportional hazard regression models examined the effect of duration of RT, measured as fractions delivered per week, on OS. Negative binomial regression assessed the effects of demographic and prognostic factors on the duration of RT. RESULTS: A total of 8,948 patients were included in the analysis of factors impacting treatment duration, and 6,429 patients in the OS analysis. Multivariable analysis (MVA) showed female gender, non-private insurance, treatment at a low or intermediate volume facility, Charlson/Deyo score ≥2, and advanced disease were associated with longer RT duration. Treatment with IMRT, with single agent chemotherapy, at an academic center, and in later years were associated with shorter RT duration. A decrease in fractions delivered per week was independently associated with reduced OS with a cutoff of 4.72 fractions per week (about 2 missed fractions over a 30 fraction treatment) delineating the largest differences in OS. CONCLUSIONS: Efforts should be made to avoid RT interruptions of any length in SCCA patients and to compensate for treatment breaks to reduce the total duration of RT.

Socioeconomic Factors Associated With Burnout Among Oncology Trainees.

PURPOSE: Burnout in the medical workforce leads to early retirement, absenteeism, career changes, financial losses for medical institutions, and adverse outcomes for patients. Recent literature has explored burnout in different specialties of medicine. This article examines burnout among medical oncology trainees and identifies factors associated with burnout and professional dissatisfaction, including socioeconomic factors. METHODS: US medical oncology programs were sent a survey that included the Maslach Burnout Index-Human Services Survey as well as demographic, socioeconomic, and program-specific questions tailored to medical oncology fellowship. Primary binary end points included burnout, satisfaction with being a physician, and satisfaction with being a medical oncologist. Binomial logistic models determined associations between various characteristics and end points. RESULTS: Overall, 261 US fellows completed the survey. Seventy percent of international medical graduates reported no educational debt, whereas only 36% of US graduates reported no educational debt. Eighty-two percent of survey respondents reported their mother had at least a bachelor's degree, and 87% of respondents reported their father had at least a bachelor's degree. At least 27% of respondents had symptoms of burnout. Factors inversely associated with burnout on multivariable analysis included having a mother who graduated college (odds ratio [OR], 0.27), reporting an adequate perceived balance between work and personal life (OR, 0.22), feeling that faculty care about educational success (OR, 0.16), and being in the final year of training (OR, 0.45). Having debt ≥ $150,000 (OR, 2.14) was directly associated with burnout. CONCLUSION: Symptoms of burnout are common among medical oncology fellows and are associated with educational debt and socioeconomic factors.

Disparities in adherence to head and neck cancer follow-up guidelines.

OBJECTIVES: In this study, we aim to determine the frequency of adherence to National Comprehensive Cancer Network follow-up guidelines in a population of head and neck cancer patients who received curative treatment. We will also assess the impact of race, ethnicity, socioeconomic status, and treatment setting on utilization of follow-up care. METHODS: This study included patients with biopsy-proven, nonmetastatic oropharyngeal or laryngeal cancer treated with radiotherapy between January 1, 2014, and June 30, 2016, at a safety-net hospital or adjacent private academic hospital. Components of follow-up care analyzed included an appointment with a surgeon or radiation oncologist within 3 months and posttreatment imaging of the primary site within 6 months. Univariable and multivariable analyses were conducted using a logistic regression model to estimate odds ratios and corresponding 95% confidence intervals. RESULTS: Two hundred and thirty-four patients were included in this study. Of those, 88.8% received posttreatment imaging of the primary site within 6 months; 88.5% attended a follow-up appointment with a radiation oncologist within 3 months; and 71.1% of patients attended a follow-up appointment with a surgeon within 3 months. On multivariable analysis, private academic hospital treatment versus safety-net hospital treatment was associated with increased utilization of both surgical and radiation oncology follow-up. Non-Hispanic black (NHB) patients, Hispanic patients, and those with a low socioeconomic status were also less likely to receive follow-up. CONCLUSION: Safety-net hospital treatment, socioeconomic status, Hispanic ethnicity, and NHB race were associated with decreased follow-up service utilization. Quality improvement initiatives are needed to reduce these disparities. LEVEL OF EVIDENCE: 2b Laryngoscope, 129:2303-2308, 2019.

Resident satisfaction with radiation oncology training.

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.

Limb-sparing surgery plus radiotherapy results in superior survival: an analysis of patients with high-grade, extremity soft-tissue sarcoma from the NCDB and SEER.

Small randomized trials have not shown an overall survival (OS) difference among local treatment modalities for patients with extremity soft-tissue sarcomas (E-STS) but were underpowered for OS. We examine the impact of local treatment modalities on OS and sarcoma mortality (SM) using two national registries. The National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) Program were analyzed separately to identify patients with stage II-III, high-grade E-STS diagnosed between 2004 and 2013 and treated with (1) amputation alone, (2) limb-sparing surgery (LSS) alone, (3) preoperative radiation therapy (RT) and LSS, or (4) LSS and postoperative RT. Multivariable analyses (MVAs) and 1:1 matched pair analyses (MPAs) examined treatment impacts on OS (both databases) and SM (SEER only). From the NCDB and SEER, 7828 and 2937 patients were included. On MVAs, amputation was associated with inferior OS and SM. Relative to LSS alone, both preoperative RT and LSS (HR, 0.70; 95% CI: 0.62-0.78) and LSS and postoperative RT (HR, 0.69; 95% CI: 0.63-0.75) improved OS in NCDB analyses with confirmation by SEER. Estimated median survivals from MPA utilizing NCDB data were 7.2 years with LSS alone (95% CI: 6.5-8.9 years) vs 9.8 years (95% CI: 9.0-11.2 years) with LSS and postoperative RT. A MPA comparing preoperative RT and LSS to LSS alone found median survivals of 8.9 years (95% CI: 7.9-not estimable) and 6.6 years (95% CI: 5.4-7.8 years). Optimal high-grade E-STS management includes LSS with preoperative or postoperative RT as evidenced by superior OS and SM.

Assessment of Oropharyngeal and Laryngeal Cancer Treatment Delay in a Private and Safety Net Hospital System.

Objective To examine the impact of treatment setting and demographic factors on oropharyngeal and laryngeal cancer time to treatment initiation (TTI). Study Design Retrospective case series. Setting Safety net hospital and adjacent private academic hospital. Subjects and Methods Demographic, staging, and treatment details were retrospectively collected for 239 patients treated from January 1, 2014, to June 30, 2016. TTI was defined as days between diagnostic biopsy and initiation of curative treatment (defined as first day of radiotherapy [RT], surgery, or chemotherapy). Results On multivariable analysis, safety net hospital treatment (vs private academic hospital treatment), initial diagnosis at outside hospital, and oropharyngeal cancer (vs laryngeal cancer) were all associated with increased TTI. Surgical treatment, severe comorbidity, and both N1 and N2 status were associated with decreased TTI. Conclusion Safety net hospital treatment was associated with increased TTI. No differences in TTI were found when language spoken and socioeconomic status were examined in the overall cohort.

Delays in definitive cervical cancer treatment: An analysis of disparities and overall survival impact.

OBJECTIVE: Delays in time to treatment initiation (TTI) with definitive radiation therapy (RT) or chemotherapy and RT (CRT) for cervical cancer could lead to poorer outcomes. This study investigates disparities in TTI and the impact of TTI on overall survival (OS). METHODS: Adult women with non-metastatic cervical squamous cell carcinoma diagnosed between 2004 and 2014, treated with definitive RT or CRT, and reported to the National Cancer Database were included. TTI was defined as days from diagnosis to start of RT or CRT. The impact of TTI on OS in patients treated with concurrent CRT which included brachytherapy was then assessed. RESULTS: Overall, 14,924 patients were included (84.7% CRT, 15.3% RT). TTI was significantly longer for Non-Hispanic Black (NHB) (RR, 1.14; 95% CI, 1.11 to 1.18) and Hispanic women (RR, 1.19; 95% CI, 1.15 to 1.24) compared to Non-Hispanic White (NHW) women. Expected TTI (eTTI) for NHW, NHB, and Hispanic women were 38.1, 45.2, and 49.4days. eTTI rose from 36.2days in 2004 to 44.3days by 2014. Intensity-modulated radiation therapy (IMRT) was associated with increased eTTI of 46.5days versus 40.0days for non-IMRT. Longer TTI was not associated with inferior OS in patients treated with concurrent CRT. CONCLUSIONS: Delays in starting RT/CRT for cervical cancer increased from 2004 to 2014. Delays disproportionately affect NHB and Hispanic women. However, increased TTI was not associated with increased mortality for women receiving CRT. Further study of TTI's impact on other endpoints is warranted to determine if TTI represents an important quality indicator.

Demographic disparities in delay of definitive chemoradiation for anal squamous cell carcinoma: a nationwide analysis.

BACKGROUND: Prolonged time to treatment initiation (TTI) for patients with curable anal cancer may reduce tumor control. This study investigated demographic disparities in TTI for patients receiving definitive chemoradiation (CRT) for anal squamous cell carcinoma (A-SCC). METHODS: Adult patients with A-SCC diagnosed from 2004 to 2014 and treated with definitive CRT were identified in the National Cancer Database (NCDB). TTI was defined as days from diagnosis to start of CRT. A negative binomial regression model estimated predicted TTI (pTTI) values. Cox proportional hazards model evaluated the impact of TTI on overall survival (OS). RESULTS: Overall, 12,546 patients were included with 9% Non-Hispanic Black patients and 4% Hispanic patients. Multivariable analysis (MVA) showed that pTTI varied significantly by race/ethnicity with Non-Hispanic Black patients having a pTTI of 50 vs. 38 days for Non-Hispanic White patients [relative risk (RR), 1.21; 95% confidence interval (CI), 1.17-1.25]. For Hispanic patients, pTTI was 48 days, significantly longer than that of Non-Hispanic White patients (RR, 1.19; 95% CI, 1.14-1.24). Gender, insurance status, education level, urban category, distance to reporting facility, treatment facility type, intensity-modulated radiation therapy (IMRT)/proton use, T/N classification, and comorbidity status were all also associated with significant variation in TTI. TTI was not independently associated with changes in OS on MVA [hazard ratio (HR), 0.999; 95% CI, 0.997-1.002]. CONCLUSIONS: Non-Hispanic Black and Hispanic patients have longer delays in starting definitive CRT for A-SCC. While TTI was not associated with OS, future analyses should explore the impact of TTI on local control, metastases, and patient-reported outcomes.

Multi-institutional Evaluation of Elective Nodal Irradiation and/or Androgen Deprivation Therapy with Postprostatectomy Salvage Radiotherapy for Prostate Cancer.

BACKGROUND: Outcomes with postprostatectomy salvage radiation therapy (SRT) are not ideal. Little evidence exists regarding potential benefits of adding whole pelvic radiation therapy (WPRT) alone or in combination with androgen deprivation therapy (ADT). OBJECTIVE: To explore whether WPRT and/or ADT added to prostate bed radiation therapy (PBRT) improves freedom from biochemical failure (FFBF) or distant metastases (DM). DESIGN, SETTING, AND PARTICIPANTS: A database was compiled from 10 academic institutions of patients with postprostatectomy prostate-specific antigen (PSA) >0.01 ng/ml; pT1-4, Nx/0, cM0; and Gleason score (GS) ≥7 treated between 1987 and 2013. Median follow-up was 51 mo. INTERVENTIONS: WPRT and/or ADT in addition to PBRT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES: FFBF and DM were calculated using cumulative incidence estimation. Multivariable analysis (MVA) utilized cumulative incidence regression. RESULTS AND LIMITATION: Median pre-SRT PSA was 0.5 ng/ml for 1861 patients. Median follow-up for patients not experiencing biochemical failure (BF) was 55 mo. MVA showed increased BF for PBRT versus WPRT (hazard ratio [HR] 1.82, p<0.001) and no ADT versus ADT (HR 1.70, p<0.001). WPRT was associated with a 5-yr FFBF of 62% versus 49% (p<0.001) for PBRT. ADT use was associated with improved 5-yr FFBF (55% vs 50%, p=0.012). No significant differences in DM cumulative incidence were found. CONCLUSIONS: For patients with GS ≥7 receiving SRT, clinicians should weigh FFBF benefits of WPRT and ADT against toxicities. Future studies should explore the impact of WPRT on quality of life, clinical progression, and overall survival. PATIENT SUMMARY: We evaluated patients with prostate cancer treated with radiation after surgery to remove the prostate. Both radiation to the pelvic lymph nodes and suppression of testosterone lowered the chance of increasing prostate-specific antigen (a marker for cancer returning).

Nutrition and Swallowing Therapy in Head and Neck Cancer: Utilization of Care and Preventative Efficacy.

PURPOSE: To examine the impact of ethnicity, Spanish language preference, socioeconomic status, and treatment setting on utilization of supportive services before radiotherapy (RT) among head and neck cancer patients and to determine whether a lack of these services is associated with an increased rate of adverse events. METHODS AND MATERIALS: Demographic, staging, and treatment details were retrospectively collected for patients treated at a safety-net hospital (n = 56) or adjacent private academic hospital (n = 183) from January 1, 2014, to June 30, 2016. Supportive care services evaluated were limited to speech/swallowing therapy and nutrition therapy. Adverse events and performance measures examined included weight loss during RT, gastric tube placement, emergency department visits, hospital admissions, and missed RT days. RESULTS: On multivariable analysis, patients receiving treatment at the safety-net hospital were less likely to receive speech/swallowing services. Receiving speech/swallowing therapy before treatment was associated with less weight loss during treatment, and in conjunction with nutrition therapy, was associated with fewer missed RT days. CONCLUSION: Safety-net hospital treatment was associated with a lack of utilization of pre-RT speech/swallowing therapy which in turn was associated with increased weight loss. Interventions aimed at improving utilization of these services would improve treatment tolerance and patient outcomes.

Burnout Evaluation of Radiation Residents Nationwide: Results of a Survey of United States Residents.

PURPOSE: To assess rates of burnout among US radiation oncology residents and evaluate program/resident factors associated with burnout. METHODS AND MATERIALS: A nationwide survey was distributed to residents in all US radiation oncology programs. The survey included the Maslach Burnout Index-Human Services Survey (MBI-HSS) as well as demographic and program-specific questions tailored to radiation oncology residents. Primary endpoints included rates of emotional exhaustion, depersonalization, and personal accomplishment from MBI-HSS subscale scores. Binomial logistic models determined associations between various residency/resident characteristics and high burnout levels. RESULTS: Overall, 232 of 733 residents (31.2%) responded, with 205 of 733 (27.9%) completing the MBI-HSS. High levels of emotional exhaustion and depersonalization were reported in 28.3% and 17.1%, respectively; 33.1% experienced a high burnout level on at least 1 of these 2 MBI-HSS subscales. Low rates of personal accomplishment occurred in 12% of residents. Twelve residents (5.9%) reported feeling "at the end of my rope" on a weekly basis or more. On multivariable analysis there was a statistically significant inverse association between perceived adequacy of work-life balance (odds ratio 0.37; 95% confidence interval 0.17-0.83) and burnout. CONCLUSIONS: Approximately one-third of radiation oncology residents have high levels of burnout symptoms, consistent with previous oncology literature, but lower levels than those among physicians and residents of other specialties. Particularly concerning was that more than 1 in 20 felt "at the end of my rope" on a weekly basis or more. Targeted interventions to identify symptoms of burnout among radiation oncology residents may help to prevent the negative downstream consequences of this syndrome.

Re-irradiation for salvage of prostate cancer failures after primary radiotherapy.

PURPOSE: To review the literature on use of radiation as a salvage option after local-only failure following initial treatment with radiation. METHODS: PubMed was searched from inception to June 2012 using terms designed to include relevant articles on salvage radiation as a treatment for local-only failures after radiation. RESULTS: Eighteen separate studies were found which demonstrated widely different patient populations, treatment methods, follow-up periods, and reporting. Only one phase II prospective study was found with no randomized controlled trials. Biochemical disease-free survival (bDFS) at four to 5 years ranged from 20 to 75%. Patient selection may have influenced these varying rates since some studies with lower bDFS had higher risk populations. Factors associated with improved bDFS included post-treatment prostate-specific antigen (PSA) nadir of <0.5 ng/mL, pre-salvage PSA <6, Gleason score ≤7, and PSA doubling time (PSADT) >10 months. Overall survival ranged from 54 to 94%, and disease-specific survival ranged from 74 to 100%. The crude rate of grade 3-4 genitourinary toxicities among all studies was 13% (range 0-47%), and the crude rate of grade 3-4 gastrointestinal toxicities was 5% (range 0-20%). Incontinence rates were low among reviewed studies at 4% (range 0-29%). CONCLUSIONS: Brachytherapy represents a reasonable salvage option for patients with local recurrence after initial radiotherapy for prostate cancer. However, rates of toxicities, as in other salvage treatments, can be fairly high, and the likelihood of death from prostate recurrence variable. Prospective studies are needed to better define the efficacy and toxicity of this treatment modality.

Synchronous bilateral inverted papilloma of the temporal bone: Case report and review of the literature.

BACKGROUND: Temporal bone inverted papilloma (IP) is an extremely rare tumor. Its etiology is unknown and represents a source of debate. Only 2 previous cases of bilateral temporal bone IP have been reported. A case report and review of the literature via PubMed database search are presented. MATHODS AND RESULTS: A 52-year-old African-American man who initially underwent medial maxillectomy for right-sided nasal IP returned with bilateral temporal bone IP 7 months later without evidence of extension through the Eustachian tubes. Despite multiple resections and adjuvant radiation, the tumor transformed into squamous cell carcinoma and progressed to involve the intracranial dura, temporal lobe, and cervical dura. CONCLUSIONS: Multiple origins may exist for temporal IP: direct extension, iatrogenic seeding, or development from ectopic Schneiderian epithelium. Temporal bone IP appears to represent a much more aggressive tumor than its nasal counterpart, necessitating aggressive early surgical intervention to decrease recurrence and transformation risk.

Disparity in hospice utilization by African American patients with cancer.

Patients with cancer represent the largest group of hospice users, making this population critically important in hospice research studies. Despite the potential benefits of hospice, many studies have noted lower levels of utilization among African Americans. The goal of this literature review was to determine whether this disparity exists within this population of patients with cancer. The largest studies focusing on multiple cancers found lower hospice use among African American patients with cancer. Disparities also existed after entry into hospice. Age, gender, geographic location, preference for aggressive care, and knowledge of hospice influenced hospice use by these patients. Since African American patients with cancer evidently use hospice at a lower rate, future studies should explore potential barriers to participation by this patient population and methods to remove these obstacles.