Abstract Purpose Many health professions education programs involve people with lived experience as expert speakers. Such presentations may help learners better understand the realities of living with chronic illness or experiencing an acute health problem. However, lectures from only one or a small number of people may not adequately illustrate the perspectives and experiences of a diverse patient cohort. Additionally, logistical constraints such as public health restrictions or travel barriers may impede in-person presentations, particularly among people who have more restrictions on their time. Health professions education programs may benefit from understanding the potential effects of online patient-led presentations with a diverse set of speakers. We aimed to explore whether patient-led online learning modules about diabetes care would influence learners’ responses to clinical scenarios and to collect learners’ feedback about the modules. Method This within-subjects randomized experiment involved 26 third-year medical students at Université Laval in Quebec, Canada. Participation in the experiment was an optional component within a required course. Prior to the intervention, participating learners responded to three clinical scenarios randomly selected from a set of six such scenarios. Each participant responded to the other three scenarios after the intervention. The intervention consisted of patient-led online learning modules incorporating segments of narratives from 21 patient partners (11 racialized or Indigenous) describing why and how clinicians could provide patient-centered care. Working with clinical teachers and psychometric experts, we developed a scoring grid based on the biopsychosocial model and set 0.6 as a passing score. Independent evaluators, blinded to whether each response was collected before or after the intervention, then scored learners’ responses to scenarios using the grid. We used Fisher’s Exact test to compare proportions of passing scores before and after the intervention. Results Learners’ overall percentage of passing scores prior to the intervention was 66%. Following the intervention, the percentage of passing scores was 76% (p = 0.002). Overall, learners expressed appreciation and other positive feedback regarding the patient-led online learning modules. Discussion Findings from this experiment suggest that learners can learn to provide better patient-centered care by watching patient-led online learning modules created in collaboration with a diversity of patient partners.

Purpose: Uncontrolled studies suggest that the addition of high-dose-rate intraluminal brachytherapy (HDRIB) to external beam radiation therapy (EBRT) may improve palliation for patients with advanced non-small cell lung cancer (NSCLC). The purpose of this study was to evaluate the potential clinical benefit of adding HDRIB to EBRT in a multicenter randomized trial. Methods and Materials: Patients with symptomatic stage III or IV NSCLC with endobronchial disease were randomized to EBRT (20 Gy in 5 daily fractions over 1 week or 30 Gy in 10 daily fractions over 2 weeks) or the same EBRT plus HDRIB (14 Gy in 2 fractions separated by 1 week). The primary outcome was the proportion of patients who achieved symptomatic improvement in patient-reported overall lung cancer symptoms on the Lung Cancer Symptom Scale (LCSS) at 6 weeks after randomization. Secondary outcomes included improvement in individual symptoms, symptom-progression-free survival, overall survival, and toxicity. The planned sample size was 250 patients based on detection of symptomatic improvement from 40% to 60% with a 2-sided a of .05 and 80% power.Results: A total of 134 patients were randomized over 4.5 years: 67 to each arm. The study closed early owing to slow accrual. The mean age was 69.8 years, and 67% of patients had metastatic disease. At 6 weeks, 19 patients (28.4%) in the EBRT arm and 20 patients (29.9%) in the EBRT plus HDRIB arm experienced an improvement in lung cancer symptoms (P = .84). When limited to patients who completed the LCSS, percentages were 40.4% versus 47.6%, respectively (P = .49). Between group dif-ferences in mean change scores (0.3-0.5 standard deviations) in favor of EBRT plus HDRIB were observed for overall symp-toms, but only hemoptysis was significantly improved (P = .03). No significant differences were observed in progression-free or overall survival. Grade 3/4 toxicities were similar between groups. Conclusions: Small to moderate improvements were seen in symptom relief with the combined therapy, but they did not reach statistical significance. Further research is necessary before recommending HDRIB in addition to EBRT for palliation of lung cancer symptoms. & COPY; 2023 Elsevier Inc. All rights reserved.

To evaluate whether patient-led video modules affect health profession students’ responses to clinical scenarios.

Uncontrolled studies suggest that the addition of HDRILB to EBR may improve palliation for patients with metastatic or locally advanced NSCLC. The purpose of this study was to evaluate the addition of HDRILB to EBR in a multicenter randomized trial. Patients with symptomatic stage 3 or 4 NSCLC with endobronchial disease from 8 centers who are not candidates for radical chemo radiation were randomized to EBR (20 Gy in 5 daily fractions or 30 Gy in 10 daily fractions) or EBR plus HDRILB (14 Gy in 2 fractions over two weeks). The primary outcome was the proportion of patients who achieved symptomatic improvement in patient-reported lung cancer symptoms defined as a 10 point improvement (on a 100 point scale) for overall lung cancer symptoms on the Lung Cancer Symptom Scale (LCSS) at 6 weeks following randomization. Secondary outcomes included improvement in individual lung cancer symptoms and the LCSS summary score, symptom progression free and overall survival. Patients were assessed at 6 week intervals following randomization up to 18 weeks and then every 8 weeks. For the primary analysis treatment arms were compared using an exact conditional test stratified on pre-treatment LCSS score (<50, >50), prior chemotherapy (yes or no) and center. Change in LCSS scores from baseline were compared on a general linear model. Time to event outcomes were estimated using the Kaplan-Meier method and compared using the Cox regression test. The planned sample size was 250 patients based on detection of symptomatic improvement from 40 to 60% with a two-sided α of 0.05 and 80% power. Between October 2011 and April 2016, 134 patients were randomized: 67 to each arm. The study was closed early due to low accrual. The mean age was 69.8 years, 57% were male, 87% had ECOG score < or = 2 and 67% had metastatic disease. Seven patients in the EBR arm and 6 patients in the EBR+HDRILB arm had grade 3 acute (<6 weeks) radiation toxicity (commonly fatigue); 1 patient in the EBR arm had grade 4 late (>6 weeks) toxicity (febrile neutropenia) and 3 patients in the EBR+HDRILB arm had grade 3 late radiation toxicity (2 cases of bronchitis and 1 case of pneumonitis). At six weeks 19 patients (28.4%) in the EBR arm and 20 patients (29.9%) in the EBR+HDRILB arm experienced a 10 point improvement in lung cancer symptoms (P = 0.84). Small between group differences in mean change scores (0.2-0.3 standard deviations) in favor of EBR+HDRILB were observed for overall symptoms, individual symptoms and the LCSS summary score but they were not statistically significant. No significant differences between groups were observed in progression free [HR = 0.68; 95% CI = 0.34, 1.35; P = 0.27) or overall survival [HR = 1.06; 95% CI = 0.73, 1.55; P = 0.77). EBR plus HDRILB was well tolerated. Small improvements were seen in symptom relief with the combined therapy, but they did not reach statistical significance. Further research is necessary before recommending HDRILB in addition to EBR for palliation of lung cancer symptoms.

Purpose: To present a new automated patient classification method based on relative gamma analysis and hidden Markov models (HMM) to identify patients undergoing important anatomical changes during radiation therapy. Methods: Daily EPID images of every treatment field were acquired for 52 patients treated for lung cancer. In addition, CBCT were acquired on a regular basis. Gamma analysis was performed relative to the first fraction given that no significant anatomical change was observed on the CBCT of the first fraction compared to the planning CT. Several parameters were extracted from the gamma analysis (e.g., average gamma value, standard deviation, percent above 1). These parameters formed patient‐specific time series. Data from the first 24 patients were used as a training set for the HMM. The trained HMM was then applied to the remaining 28 patients and compared to manual clinical evaluation and fixed thresholds. Results: A three‐category system was used for patient classification ranging from minor deviations (category 1) to severe deviations (category 3) from the treatment plan. Patient classified using the HMM lead to the same result as the classification made by a human expert 83% of the time. The HMM overestimate the category 10% of the time and underestimate 7% of the time. Both methods never disagree by more than one category. In addition, the information provided by the HMM is richer than the simple threshold‐based approach. HMM provides information on the likelihood that a patient will improve or deteriorate as well as the expected time the patient will remain in that state. Conclusion: We showed a method to classify patients during the course of radiotherapy based on relative changes in EPID images and a hidden Markov model. Information obtained through this automated classification can complement the clinical information collected during treatment and help identify patients in need of a plan adaptation.

Background: There is little evidence to guide the management of early limited-stage small cell lung cancer (LS-SCLC). We examined outcome of early LS-SCLC patients treated within a contemporary trial. Methods: This is an exploratory analysis of early (TNM stage I-II) LS-SCLC patients included in the CONVERT trial. This is a randomized phase III trial that compared twice-daily (45 Gray (Gy) in 30 twice-daily fractions over 3 weeks) and once-daily (66 Gy in 33 daily fractions over 6.5 weeks) radiotherapy starting on day 22 of chemotherapy cycle 1 in good performance score (PS) patients. Chemotherapy consisted of 4-6 cycles of cisplatin and etoposide. Prophylactic cranial irradiation (PCI) was offered if indicated. Radiotherapy was delivered using three-dimensional conformal or intensity modulated technique. Results: Between 2008 and 2013, 547 patients were recruited to this trial. Five hundred and thirteen patients were eligible for this analysis and 87 (17%) had early disease. Staging flurodeoxyglucose positron emission tomography (FDG-PET) use (68% versus 55.4%, p = 0.05) and baseline PS (PS0 57.5% versus 43.2%, p = 0.04) were different between early and non-early LS-SCLC patients, respectively. Early patients achieved longer overall survival (median 50 versus 25 months, p = 0.001) and time to local (median 40 versus 17 months, p = 0.0017) and metastatic progression (median 49 versus 16 months, p = 0.0004) compared to non-early patients, irrespective of treatment arm. In early patients, there was no significant overall survival difference between treatment arms, p = 0.31. Radiotherapy compliance was significantly higher in early patients (p = 0.004) and these patients were less likely to experience grade ≥3 acute oesophagitis, compared to non-early patients (11% versus 21%, p < 0.005). Conclusions: Early LS-SCLC patients achieve good long-term survival with minimal acute side-effects following chemo-radiotherapy and PCI. This study guides practice and provides a benchmark for future studies comparing a surgical to a non-surgical approach in this patient cohort. Clinical trial identification: ISRCTN91927162, NCT00433563 Legal entity responsible for the study: MAHSC-CTU, The Christie NHS Foundation Trust, Manchester, UK Funding: Cancer Research UK Disclosure: All authors have declared no conflicts of interest.

Hyperbaric oxygen therapy has been reported to be effective in the treatment of delayed soft tissue radiation injuries. HBOT stimulates angiogenesis, improves tissue oxygenation, stimulates stem cell activity, and decreases fibrosis. However, few follow-up data are available. This study assesses follow-up outcomes at one clinical center for patients with radiation cystitis receiving HBOT. Patients with radiation cystitis receiving HBOT at our facility between January 2006 and December 2014 were included. HBOT involved patients breathing nearly 100% oxygen for 90 minutes in a hyperbaric chamber pressurized to 2.4 atmospheres absolute (ATA). Data recorded included patient characteristics, type of cancer, dose of radiotherapy (RT) received, time between RT and diagnosis of cystitis, time between diagnosis of cystitis and HBOT, and the number of HBOT sessions completed. Hyperbaric physicians evaluated patients' symptoms before, during, and upon completion of HBOT. After HBOT, radio-oncologists and urologists conducted follow-up evaluations. Treatment was considered effective if symptoms were resolved or improved. Unimproved or worsening symptoms were classified as failure of treatment. A bivariate analysis was made for the number of exposures and the effectiveness of HBOT. Data are presented as mean±SD with range or percentage as appropriate. Significance was accepted at P<0.05. Thirty-five patients (67±10 [29-84] years of age at start of HBOT) received 43±9 (29-60) hyperbaric treatments. The majority of patients had hematuria as the principal symptom (n=34; 97%), were male (n=30; 86%), non-smoking (n=32; 91%), and had prostate cancer (n=30; 86%). The radiation dose received was 67±17 (33-120) Gy (EQD2). Post-HBOT follow-up ran for 29±21 (1-60) months. The time between RT and diagnosis was 42±39 (1-146) months. The time between diagnosis of cystitis and HBOT was 21±50 (0-298) months. Twenty-three patients had tried pentosan polysulfate, 18 electrofulguration, and 8 needed transfusions. There was no difference in symptom resolution if patients had 40 or 50 HBO exposures. At 6 months, 91% (n=32) had improved or resolved symptoms. Overall, treatment was effective in 71% (n=25) of cases. Conversely, 29% (n=10) of patients had a failure of treatment, four at ≤3 months of follow-up, and 6 at 22±9 (12-36) months. Six patients with failure of treatment returned to their pre-HBOT condition, and 4 had worsening symptoms. Seven patients (20%) with failure of treatment needed surgery post-HBOT: 5 had cystectomy, 1 cystoprostatectomy, and 1 pelvic exenteration. HBOT was effective in the majority of patients with radiation cystitis as evidenced through a mean 2.5-year follow-up period. Patients that needed surgical management presented an early failure to HBOT. Studies with longer follow-up periods are still required.

Background &aims: Radical radiation therapy is commonly used for treatment of pelvic cancer. Up to 80% of patients receiving radiotherapy will develop acute radiation induced diarrhea. The primary aim of this randomized double blind controlled trial is to evaluate the effect of the probiotic Bifilact on moderate and severe treatment-induced diarrhea during pelvic radiation.Methods: Patients with pelvic cancers were treated between 2006 and 2010 at L'Heitel-Dieu de Quebec, University Health Center. Some patients had surgery before pelvic radiotherapy and some received chemotherapy. A total of 246 Patients were randomized between a placebo and either of two regiments of double strain Bifilact probiotics (Lactobacillus acidophilus LAC-361 and Bifidobacterium longum BB536): a standard dose twice a day (1.3 billion CFU) or a high dose three times a day (10 billion CFU). Patients were trained to record their digestive symptoms daily with a standardized scale and they met a registered dietician and radiation oncologist every week during treatment. The main analysis compared time to first appearance of grade >= 2-3-4 diarrhea using Kaplan-Meier curves as measured by proportion of patients without moderate and severe diarrhea.Results: 229 patients were analyzed. The difference between the groups for overall grade 2-3-4 diarrhea was not statistically significant (p = 0.13). However at 60 days, the proportion of patients without moderate and severe diarrhea in the standard dose group (35%) was more than twice as high as that of the placebo group (17%) with a hazard ratio of 0.69 (p = 0.04). In patients who had surgery, the standard probiotics dose group had a better proportion of patients without very severe diarrhea than the placebo group, respectively 97% and 74% (p = 0.03). In all groups, the average number of bowel movements per day during treatment was less than 3 soft stools (p = 0.80) and the median abdominal pain less than 1 based on the National Cancer Institute scale (p = 0.23).Conclusion: Standard dose of Bifilact may reduce radiation induced grade 2-3-4 diarrhea at the end of the treatment of patients with pelvic cancer. In patients operated on before RI, a standard dose of probiotics may reduce radiation induced grade 4 diarrhea. Nutritional interventions by a registered dietician seemed to reduce global digestive symptoms. (C) 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

The initial discovery of mesothelioma can be traced back to 1767 when Dr. Joseph Lieutaud, an anatomy pathologist in France, first identified a tumour in the chest wall of a young boy [1]. Mesothelioma is a rare, aggressive form of cancer that develops from transformed cells originating in the mesothelium, which is the protective lining covering many of the body's internal organs. Mesothelioma arises in the pleura but also occurs in the peritoneum, the tunica vaginalis, and the pericardium [2]. Mesothelioma tends to have a local progression. While disseminated disease has sometimes been reported in a very late stage of the disease [3– 7], patients usually die from local progression.

Lung cancer is one of the leading causes of cancer in the population. The aging population is a reality. More and more, in oncology, we are facing challenges about management of cancer in this important population. In this chapter, we will review data on lung cancer and aging. We will explore how to evaluate this particular population to offer them the best treatment possible, bearing in mind that some adjustment may be necessary compared to younger population.

Purpose: To implement and evaluate a functional mean dose‐based objective in a well‐established IMRT system, using lung perfusion images and direct machine parameter optimization (DMPO). Methods: Nineteen patients underwent SPECT perfusion imaging prior to treatment. In this retrospective study, plans were generated using Pinnacleˈ DMPO (Philips Healthcare, Andover, MA) with the aim of minimizing either the mean lung dose (MLD) or the lung functional mean dose (FMD). A seven equidistant beam configuration was used in all plans. Two levels of dose were prescribed: 50 Gy to the PTV1 (clinical target volume with margins) and 66 Gy to the PTV2 (gross tumor volume with margins). The MLD or FMD objective was decreased by steps of 1 Gy until dose to target volumes or organs at risk was deemed unacceptable. Plans were compared in terms of dose‐volume and dose‐function parameters. Statistical significance was assessed with a Wilcoxon matched pairs test. Results: While keeping PTV coverage similar (volumes receiving 93% of the prescribed dose were all over 98%), differences in MLD between both types of plans for a given patient ranged from –1.0 to +1.5 Gy (p = 0.2050), while FMD decreased significantly with a range of –2.1 to 0.0 Gy (p = 0.0003). The net improvement (FMD difference − MLD difference) ranged between −2.2 and 0.0 Gy. Dose to other organs at risk were similar and below widely‐ accepted tolerances. Conclusions: The use of SPECT perfusion images in conjunction with DMPO allowed a significant decrease of FMD while keeping dose to other structures at an acceptable level. Functionality‐aware dose redistribution could prove useful for dose escalation to improve tumor control with similar or lower lung complication probabilities. The approach can also be easily ported to arc therapy treatment planning using SmartArc.This work is supported by the Natural Sciences and Engineering Research Council of Canada and by a research agreement with Philips Healthcare.

PURPOSE:To implement SPECT-based optimization in an anatomy-based aperture inverse planning system for the functional avoidance of lung in thoracic irradiation.MATERIAL AND METHODS:SPECT information has been introduced as a voxel-by-voxel modulation of lung importance factors proportionally to the local perfusion count. Fifteen cases of lung cancer have been retrospectively analyzed by generating angle-optimized non-coplanar plans, comparing a purely anatomical approach and our functional approach. Planning target volume coverage and lung sparing have been compared. Statistical significance was assessed by a Wilcoxon matched pairs test.RESULTS:For similar target coverage, perfusion-weighted volume receiving 10 Gy was reduced by a median of 2.2% (p=0.022) and mean perfusion-weighted lung dose, by a median of 0.9 Gy (p=0.001). A separate analysis of patients with localized or non-uniform hypoperfusion could not show which would benefit more from SPECT-based treatment planning. Redirection of dose sometimes created overdosage regions in the target volume. Plans consisted of a similar number of segments and monitor units.CONCLUSIONS:Angle optimization and SPECT-based modulation of importance factors allowed for functional avoidance of the lung while preserving target coverage. The technique could be also applied to implement PET-based modulation inside the target volume, leading to a safer dose escalation.

Purpose: Determine decision thresholds for replanning lung tumor patients and verify the relation between volume variations and thresholds. Method and Materials:We used a relative gamma analysis approach with an EPID portal dose‐based imaging on Varian Clinac iX. After testing our preliminary thresholds against a weekly CBCT with the first patient, we followed 24 patients with lung tumor. Typically patient received 60 Gy in 30 fractions. When threshold were reached, a CBCT was done to evaluate the quality of the planning. If the target moves outside planning margin or OAR doses increased, a replanning procedure started. Only 3 patients were planned with IMRT. A target volume study, final CBCT volume over initial CT volume, was made for 17 patients to check if there is a relation between thresholds and volume variation. The effect of chemotherapy is also verified. Results: The thresholds were evaluated with the first patient using a weekly CBCT. A good correlation of 0.98 was found between %>1 and the average gamma. The thresholds of 15% and 0.60 were confirmed for %>1 and average gamma respectively. 8 patients exceeded the thresholds but only 3 were replanned due to target outside margins. 2 other patients became palliatve one. For the target volume study, 6 patients who has exceeded thresholds the mean Vf/Vi has 0.45 ± 19 and 0.80 ± 0.38 for the other 11 patients. In those 11 patients, if we remove 4 patients with a diffuse tumor, the mean Vf/Vi becomes 0.85 ± 0.08. Chemotherapy does not have an effect on this study or the relative gamma analysis. Conclusion: The utility of gamma analysis from dose EPID images was demonstrated for patients having lung tumor treatments. With this technique, CBCT scan has to be done only when EPID gamma analysis indicates significant dosimetric change.

BACKGROUND AND PURPOSE:To assess the effectiveness of prophylactic irradiation of intervention track (PIT) to prevent tumor seeding in patients with malignant pleural mesothelioma.MATERIALS AND METHODS:A retrospective review was conducted of 171 patients with a histological diagnosis of pleural mesothelioma with some undergoing prophylactic irradiation of intervention sites.RESULTS:Forty-eight patients (28%) received PIT. A majority of patients were followed until death. Thoracoscopy (88%) was the procedure most often performed. Thirty-three percent of patients received chemotherapy. The median dose of PIT was 21 Gy in 3 fractions with electrons or 6 MV photons. The local progression free survival (LPFS) at the intervention site was significantly higher in the PIT group and was not influenced by chemotherapy. At 6 months, LPFS for the intervention sites was 91% with PIT and 74% without PIT (p=0.002). During the follow-up, 6 patients (13%) in the PIT group had tumor invasion of the subcutaneous tissue compared to 40 patients (33%) in the group without PIT (p=0.008).CONCLUSIONS:This study suggests that PIT in mesothelioma reduces the incidence of procedure tract metastasis. Finally, chemotherapy does not seem to have an influence on the incidence of tract metastasis.