BackgroundIn the wake of the COVID-19 pandemic and with increasing non-clinical demands on physician time and effort, the health care community is experiencing disproportionate rates of burnout. Oncologists, specifically, frequently endure challenging situations of caring for terminally ill patients who require emotional support along with intricate medical care. In response, various well-being initiatives for physicians have emerged, predominantly focusing on education or wellness opportunities. However, most these programs are institution-based and not accessible to the physician community as a whole. The effect of physical exercise, particularly team-based activity, on physician well-being and burnout has been postulated but not rigorously studied. We therefore seek to formally investigate whether team-based exercise programs can facilitate collective well-being by enabling physicians to address burnout collectively rather than individually.MethodsThis prospective study will involve the two-month voluntary team-based multi-sport competition, ACRO Race to the Summit, which will track total exercise minutes logged across various forms of physical activities during the racing period of January 1st, 2023- February 28th, 2023. A pre/post survey design will be used to investigate the potential impact of such collective activity on radiation oncology physician well-being. Included in both surveys, a set of 25 multiple-choice questions based on the validated Stanford Medicine well-being survey and the IPAQ (International Physical Activity Questionnaire) will focus on physical activity level and psychological and emotional well-being in the work place. The post-race survey will include additional questions meant to evaluate participants' perceived impact of the competition on these categories.ResultsPrimary endpoints will assess change in pre- and post-survey metrics related to level of physical activity, and psychological and emotional well-being at work. Secondary endpoints will examine perceived value of team-based exercise in cultivating well-being.DiscussionWe anticipate that the results from this survey may inform commentary on the role of collective, inclusive exercise as a tool to combat physician burnout. Moreover, the study may provide insight into existing trends in physical activity, and psychological and emotional well-being in the radiation oncology community. Formation of and investment in non-institution, non-work related teams may prove to be a unique means of addressing burnout by strengthening a sense of community within the field as a whole. In the wake of the COVID-19 pandemic and with increasing non-clinical demands on physician time and effort, the health care community is experiencing disproportionate rates of burnout. Oncologists, specifically, frequently endure challenging situations of caring for terminally ill patients who require emotional support along with intricate medical care. In response, various well-being initiatives for physicians have emerged, predominantly focusing on education or wellness opportunities. However, most these programs are institution-based and not accessible to the physician community as a whole. The effect of physical exercise, particularly team-based activity, on physician well-being and burnout has been postulated but not rigorously studied. We therefore seek to formally investigate whether team-based exercise programs can facilitate collective well-being by enabling physicians to address burnout collectively rather than individually. This prospective study will involve the two-month voluntary team-based multi-sport competition, ACRO Race to the Summit, which will track total exercise minutes logged across various forms of physical activities during the racing period of January 1st, 2023- February 28th, 2023. A pre/post survey design will be used to investigate the potential impact of such collective activity on radiation oncology physician well-being. Included in both surveys, a set of 25 multiple-choice questions based on the validated Stanford Medicine well-being survey and the IPAQ (International Physical Activity Questionnaire) will focus on physical activity level and psychological and emotional well-being in the work place. The post-race survey will include additional questions meant to evaluate participants' perceived impact of the competition on these categories. Primary endpoints will assess change in pre- and post-survey metrics related to level of physical activity, and psychological and emotional well-being at work. Secondary endpoints will examine perceived value of team-based exercise in cultivating well-being. We anticipate that the results from this survey may inform commentary on the role of collective, inclusive exercise as a tool to combat physician burnout. Moreover, the study may provide insight into existing trends in physical activity, and psychological and emotional well-being in the radiation oncology community. Formation of and investment in non-institution, non-work related teams may prove to be a unique means of addressing burnout by strengthening a sense of community within the field as a whole. Disclosure: Schutz: None LaVigne: None Everett: None Lally: None Jaboin: None

Background Most travel grant opportunities available to radiation oncology trainees are for research, with selection criteria focused on the scientific merit of an abstract submitted by the applicant. Despite increasing interest in trainees serving as educators, there are few opportunities to encourage scientific meeting participation for those interested in education. In 2022, the American College of Radiation Oncology (ACRO) launched a novel industry-supported travel grant for the ACRO Annual Meeting for trainees who successfully contributed new cases to the free online contouring reference eContour.org. Methods Applications for the grant were solicited via email, social media, the ACRO and eContour websites, and word of mouth. Applicants were required to complete a form with details for their proposed case for eContour, including disease site, stage, and literature that would be used to guide contouring recommendations. Selection criteria included the novelty of the proposed case, the strength of the available evidence base, case feasibility, and credentials of the identified mentor. Each aspect of this rubric was rated on a 1-5 scale by two reviewers independently to generate preliminary scores. Final rankings were then determined by consensus of the entire review committee. Recipients were awarded $500 for travel expenses supported by an industry partner and complimentary registration courtesy of ACRO ($100 value). Recipients were instructed to upload their educational cases to eContour where they were peer-reviewed prior to publication. Results A total of 24 submissions were received from 16 institutions in the United States and Canada. Applicants primarily learned about the award via word of mouth from colleagues/mentors (n=6, 25%), twitter (n=5, 21%), email (n=5, 21%), and a banner on the eContour website (n=4, 17%). The median training level of submitters was PGY-3 (range MS-4 to PGY-5). Disease sites with multiple case proposals included gynecologic cancer (n=7, including 5 vulvar cancer), CNS/pediatrics (n=4), lymphoma (n=2) and prostate (n=2). 10 grants were awarded, resulting in successful initial submission of 10 new cases. Four cases were finalized and uploaded to the eContour website coinciding with the ACRO interactive contouring session on March 10, 2022. The remaining cases are in final stages of quality assurance prior to publication. Almost all recipients (n=9, 90%) were able to attend the ACRO annual meeting. Discussion Education-focused travel grants are feasible and generated significant interest from a diverse cohort of radiation oncology trainees. Recipients successfully generated novel educational content and attended a national radiation oncology meeting. Most travel grant opportunities available to radiation oncology trainees are for research, with selection criteria focused on the scientific merit of an abstract submitted by the applicant. Despite increasing interest in trainees serving as educators, there are few opportunities to encourage scientific meeting participation for those interested in education. In 2022, the American College of Radiation Oncology (ACRO) launched a novel industry-supported travel grant for the ACRO Annual Meeting for trainees who successfully contributed new cases to the free online contouring reference eContour.org. Applications for the grant were solicited via email, social media, the ACRO and eContour websites, and word of mouth. Applicants were required to complete a form with details for their proposed case for eContour, including disease site, stage, and literature that would be used to guide contouring recommendations. Selection criteria included the novelty of the proposed case, the strength of the available evidence base, case feasibility, and credentials of the identified mentor. Each aspect of this rubric was rated on a 1-5 scale by two reviewers independently to generate preliminary scores. Final rankings were then determined by consensus of the entire review committee. Recipients were awarded $500 for travel expenses supported by an industry partner and complimentary registration courtesy of ACRO ($100 value). Recipients were instructed to upload their educational cases to eContour where they were peer-reviewed prior to publication. A total of 24 submissions were received from 16 institutions in the United States and Canada. Applicants primarily learned about the award via word of mouth from colleagues/mentors (n=6, 25%), twitter (n=5, 21%), email (n=5, 21%), and a banner on the eContour website (n=4, 17%). The median training level of submitters was PGY-3 (range MS-4 to PGY-5). Disease sites with multiple case proposals included gynecologic cancer (n=7, including 5 vulvar cancer), CNS/pediatrics (n=4), lymphoma (n=2) and prostate (n=2). 10 grants were awarded, resulting in successful initial submission of 10 new cases. Four cases were finalized and uploaded to the eContour website coinciding with the ACRO interactive contouring session on March 10, 2022. The remaining cases are in final stages of quality assurance prior to publication. Almost all recipients (n=9, 90%) were able to attend the ACRO annual meeting. Education-focused travel grants are feasible and generated significant interest from a diverse cohort of radiation oncology trainees. Recipients successfully generated novel educational content and attended a national radiation oncology meeting.

Background Resident and medical student attendance at national conferences can be associated with significant personal financial toxicity for travel expenses. As a result, attendance at conferences favors large academic programs who have sizeable research-based programs with associated travel support. Individuals from smaller programs whose departments lack adequate funding, as well as medical students, are forced to pay out of pocket expenses to attend. To help address this deficit, the American College of Radiation Oncology (ACRO) secured sponsorship from an industry partner to award ten trainees a financial travel grant via a need-based method to enable attendance at the 2022 ACRO annual meeting. Methods The ten $500 travel grants supported by the industry sponsor were advertised on the ACRO website, via email, and on social media. ACRO also contributed complimentary registration, thus the total award was $600. ACRO members in good standing with lack of departmental financial support to attend were eligible. Submission included a letter of support, copy of CV, a personal statement, and acceptance of the grant required confirmation of attending the conference in-person. Of the 10 grants, 7 were designated for residents and 3 for medical students. Need-based selection criteria was based on departmental funding, size of residency, distance from the conference, and was determined by a non-biased panel of individuals. Results: There were 26 total applications submitted for the 10 travel grants offered. Of those, 20 were current residents and 6 were current medical students. Of the resident submissions, 5% PGY-5, 40% PGY-4, 25% PGY-3, 30% PGY-2. Of the medical students, 33% MS4, 17% MS2, 50% MS1. Applications were received from 16 different states in the USA, and 3 different countries including the United States, Canada, and India. When asked about how they heard about the award, 8 responded from twitter, 5 from ACRO website, 5 from mentors, 5 from email, and 3 from colleagues. 75 residents registered and attended the ACRO 2022 conference compared to 59 for the 2020 conference. The number of medical students registered also increased from 2 in 2020 to 14 in 2022. Discussion By utilizing industry sponsored funds for monetary travel grants, we were able to further diversify the attendance at the ACRO 2022 annual meeting through supporting international residents, smaller programs, and medical students via our need-based selection method. There remains utility in travel awards to offer the future of our field an equal opportunity of attending these highly valuable conferences. Resident and medical student attendance at national conferences can be associated with significant personal financial toxicity for travel expenses. As a result, attendance at conferences favors large academic programs who have sizeable research-based programs with associated travel support. Individuals from smaller programs whose departments lack adequate funding, as well as medical students, are forced to pay out of pocket expenses to attend. To help address this deficit, the American College of Radiation Oncology (ACRO) secured sponsorship from an industry partner to award ten trainees a financial travel grant via a need-based method to enable attendance at the 2022 ACRO annual meeting. The ten $500 travel grants supported by the industry sponsor were advertised on the ACRO website, via email, and on social media. ACRO also contributed complimentary registration, thus the total award was $600. ACRO members in good standing with lack of departmental financial support to attend were eligible. Submission included a letter of support, copy of CV, a personal statement, and acceptance of the grant required confirmation of attending the conference in-person. Of the 10 grants, 7 were designated for residents and 3 for medical students. Need-based selection criteria was based on departmental funding, size of residency, distance from the conference, and was determined by a non-biased panel of individuals. Results: There were 26 total applications submitted for the 10 travel grants offered. Of those, 20 were current residents and 6 were current medical students. Of the resident submissions, 5% PGY-5, 40% PGY-4, 25% PGY-3, 30% PGY-2. Of the medical students, 33% MS4, 17% MS2, 50% MS1. Applications were received from 16 different states in the USA, and 3 different countries including the United States, Canada, and India. When asked about how they heard about the award, 8 responded from twitter, 5 from ACRO website, 5 from mentors, 5 from email, and 3 from colleagues. 75 residents registered and attended the ACRO 2022 conference compared to 59 for the 2020 conference. The number of medical students registered also increased from 2 in 2020 to 14 in 2022. By utilizing industry sponsored funds for monetary travel grants, we were able to further diversify the attendance at the ACRO 2022 annual meeting through supporting international residents, smaller programs, and medical students via our need-based selection method. There remains utility in travel awards to offer the future of our field an equal opportunity of attending these highly valuable conferences.

Purpose The purpose of this study was to assess the treatment planning feasibility of volumetrically modulated arc therapy total body irradiation (VMAT TBI) using a simultaneous integrated marrow and body approach (SIMBa). We also aimed to compare SIMBa TBI with the more conventional VMAT TBI approach using the entire body as the target. The goal of using an integrated approach like SIMBa is to balance the known clinical benefit of TBI with the toxicity decrease of Total Marrow Irradiation (TMI) using two prescription volumes. In anticipation of a clinical trial to investigate a novel conditioning regimen that uses SIMBa, our institution retrospectively analyzed the dosimetric differences between 20 clinical VMAT TBI which were re-planned using SIMBa. Methods Twenty patients who previously received conventional VMAT TBI at our institution with a dose of 12 Gy in six fractions were re-planned using SIMBa with a planning aim of delivering a uniform dose of 12 Gy to at least 90% of the PTV_BodyEval. The planning aims of SIMBa were to deliver a uniform dose of 12 Gy to at least 90% of the PTV_Marrow and 8 Gy to at least 90% of the PTV_TotalBody while limiting the mean lung dose to less than 8 Gy. The plans were normalized so that 100% of the PTV_Marrow received at least 90% of the dose with the PTV_TotalBody optimized to stay as close to 100% at 90% as possible. Results All 20 patient plans achieved 12 Gy/8 Gy to at least 90% of the PTV_Marrow and PTV_TotalBody, respectively, with max doses of <16 Gy (130%). As compared with the delivered TBI, the following reductions in mean dose were notable: small bowel 21.3±4.2%, lung 16.3±7.9%, heart 25.3±8.6%, and kidney 16.4±6.2%. Coverage of the sanctuary sites was maintained despite a significant reduction to sensitive organs at risk (OARs). Conclusion This study supports that VMAT TBI treatment planning with SIMBa is feasible. In this sample, SIMBa provided dosimetrically similar doses to marrow and sanctuary site doses as TBI while achieving lower doses to OARs. A clinical trial is needed to investigate the clinical implications of VMAT TBI with SIMBa.

Purpose: Brain metastases are a common sequelae of breast cancer. Survival varies widely based on diagnosis-specific prognostic factors (PF). We previously published a prognostic index (Graded Prognostic Assessment [GPA]) for patients with breast cancer with brain metastases (BCBM), based on cohort A (1985-2007, n = 642), then updated it, reporting the effect of tumor subtype in cohort B (1993-2010, n = 400). The purpose of this study is to update the Breast GPA with a larger contemporary cohort (C) and compare treatment and survival across the 3 cohorts. Methods and Materials: A multi-institutional (19), multinational (3), retrospective database of 2473 patients with breast cancer with newly diagnosed brain metastases (BCBM) diagnosed from January 1, 2006, to December 31, 2017, was created and compared with prior cohorts. Associations of PF and treatment with survival were analyzed. Kaplan-Meier survival estimates were compared with log-rank tests. PF were weighted and the Breast GPA was updated such that a GPA of 0 and 4.0 correlate with the worst and best prognoses, respectively. Results: Median survival (MS) for cohorts A, B, and C improved over time (from 11, to 14 to 16 months, respectively; P < .01), despite the subtype distribution becoming less favorable. PF significant for survival were tumor subtype, Karnofsky Performance Status, age, number of BCBMs, and extracranial metastases (all P <.01). MS for GPA 0 to 1.0, 1.5-2.0, 2.5-3.0, and 3.5-4.0 was 6, 13, 24, and 36 months, respectively. Between cohorts B and C, the proportion of human epidermal receptor 2 thorn subtype decreased from 31% to 18% (P <.01) and MS in this subtype increased from 18 to 25 months (P <.01). Conclusions: MS has improved modestly but varies widely by diagnosis-specific PF. New PF are identified and incorporated into an updated Breast GPA (free online calculator available at brainmetgpa.com). The Breast GPA facilitates clinical decision making and will be useful for stratification of future clinical trials. Furthermore, these data suggest human epidermal receptor 2-targeted therapies improve clinical outcomes in some patients with BCBM. (C) 2020 Elsevier Inc. All rights reserved.

Background. Breast cancer treatment is based on estrogen receptors (ERs), progesterone receptors (PRs), and human epidermal growth factor receptor 2 (HER2). At the time of metastasis, receptor status can be discordant from that at initial diagnosis.The purpose of this study was to determine the incidence of discordance and its effect on survival and subsequent treatment in patients with breast cancer brain metastases (BCBM). Methods. A retrospective database of 316 patients who underwent craniotomy for BCBM between 2006 and 2017 was created. Discordance was considered present if the ER, PR, or HER2 status differed between the primary tumor and the BCBM. Results. The overall receptor discordance rate was 132/316 (42%), and the subtype discordance rate was 100/316 (32%). Hormone receptors (HR, either ER or PR) were gained in 40/160 (25%) patients with HR-negative primary tumors. HER2 was gained in 22/173 (13%) patients with HER2-negative primary tumors. Subsequent treatment was not adjusted for most patients who gained receptors-nonetheless, median survival (MS) improved but did not reach statistical significance (HR, 17-28 mo, P= 0.12; HER2, 15-19 mo, P= 0.39). MS for patients who lost receptors was worse (HR, 27-18 mo, P= 0.02; HER2, 30-18 mo, P= 0.08). Conclusions. Receptor discordance between primary tumor and BCBM is common, adversely affects survival if receptors are lost, and represents a missed opportunity for use of effective treatments if receptors are gained. Receptor analysis of BCBM is indicated when clinically appropriate. Treatment should be adjusted accordingly.

Purpose: Recently, the Coalition for Physician Accountability Work Group on Medical Students in the Class of 2021 recommended limiting visiting medical student rotations, conducting virtual residency interviews, and delaying the standard application timeline owing to the ongoing coronavirus disease 2019 (COVID-19) pandemic. These changes create both challenges and opportunities for medical students and radiation oncology residency programs. We conducted a comprehensive needs assessment to prepare for a virtual recruitment season, including a focus group of senior medical students seeking careers in oncology. Methods and Materials: A single 1.5-hour focus group was conducted with 10 third- and fourth-year medical students using Zoom videoconferencing software. Participants shared opinions relating to visibility of residency programs, virtual clerkship experiences, expectations for program websites, and remote interviews. The focus group recording was transcribed and analyzed independently by 3 authors. Participants’ statements were abstracted into themes via inductive content analysis. Results: Inductive content analysis of the focus group transcript identified several potential challenges surrounding virtual recruitment, including learning the culture of a program and/or city, obtaining accurate information about training programs, and uncertainty surrounding the best way to present themselves during a virtual interview season. In the present environment, the focus group participants anticipate relying more on departmental websites and telecommunications because in-person interactions will be limited. In addition, students perceived that the educational yield of a virtual clerkship would be low, particularly if an in-person rotation had already been completed at another institution. Conclusions: With the COVID-19 crisis limiting visiting student rotations and programs transitioning to hosting remote interviews, we recommend programs focus resources toward portraying the culture of their program and city, accurately depicting program information, and offering virtual electives or virtual interaction to increase applicant exposure to residency program culture.

PURPOSEConventional wisdom has rendered patients with brain metastases ineligible for clinical trials for fear that poor survival could mask the benefit of otherwise promising treatments. Our group previously published the diagnosis-specific Graded Prognostic Assessment (GPA). Updates with larger contemporary cohorts using molecular markers and newly identified prognostic factors have been published. The purposes of this work are to present all the updated indices in a single report to guide treatment choice, stratify research, and define an eligibility quotient to expand eligibility.METHODSA multi-institutional database of 6,984 patients with newly diagnosed brain metastases underwent multivariable analyses of prognostic factors and treatments associated with survival for each primary site. Significant factors were used to define the updated GPA. GPAs of 4.0 and 0.0 correlate with the best and worst prognoses, respectively.RESULTSSignificant prognostic factors varied by diagnosis and new prognostic factors were identified. Those factors were incorporated into the updated GPA with robust separation (P < .01) between subgroups. Survival has improved, but varies widely by GPA for patients with non-small-cell lung, breast, melanoma, GI, and renal cancer with brain metastases from 7-47 months, 3-36 months, 5-34 months, 3-17 months, and 4-35 months, respectively.CONCLUSIONMedian survival varies widely and our ability to estimate survival for patients with brain metastases has improved. The updated GPA (available free at brainmetgpa.com) provides an accurate tool with which to estimate survival, individualize treatment, and stratify clinical trials. Instead of excluding patients with brain metastases, enrollment should be encouraged and those trials should be stratified by the GPA to ensure those trials make appropriate comparisons. Furthermore, we recommend the expansion of eligibility to allow for the enrollment of patients with previously treated brain metastases who have a 50% or greater probability of an additional year of survival (eligibility quotient > 0.50).

Background: Brain radiotherapy is used in the management of melanoma brain metastases (MBM) and can result in radionecrosis. Anti-PD-1 is active in the brain and may increase the risk of radionecrosis when combined with radiotherapy. We studied the incidence, associated factors and management of radionecrosis in longer-term survivors with MBM treated with this combination. Methods: Patients with MBM treated with radiotherapy and anti-PD-1 who survived > 1 year were identified to determine radionecrosis incidence (Cohort A, n = 135). Cohort A plus additional radionecrosis cases were examined for factors associated with radionecrosis and management (Cohort B, n = 148). Results: From Cohort A, 17% developed radionecrosis, with a cumulative incidence at 2 years of 18%. Using Cohort B, multivariable analysis confirmed an association between radionecrosis and elevated lactate dehydrogenase (p = 0.0496) and prior treatment with ipilimumab (p = 0.0319). Radionecrosis was diagnosed based on MRI (100%), symptoms (69%) and pathology (56%). Treatment included corticosteroids, bevacizumab and neurosurgery. Conclusions: Radionecrosis is a significant toxicity in longer-term melanoma survivors with MBM treated with anti-PD-1 and radiotherapy. Identification of those at risk of radionecrosis who may avoid radiotherapy is required.

1079 Background: Brain metastases (BM) are a common and fatal complication of breast cancer but survival varies widely based on various prognostic factors (PF). Hence, patient counseling and therapeutic decisions should be individualized. We previously published a prognostic index (Breast GPA) based on cohort A (1985-2007, n = 642), updated it with tumor subtype in cohort B (1993-2010, n = 400) and are now updating it with a larger contemporary cohort (C). Methods: A multi-institutional (19) multi-national (3) retrospective database of 2473 breast cancer patients with BM diagnosed from 1/1/2006-12/31/2017 was created and compared to our prior cohorts. Demographic, clinical, molecular factors, tumor subtype and treatment were correlated with survival. Kaplan-Meier survival estimates were calculated and compared with log-rank tests. Results: The median survival (MS) for cohorts A, B and C improved over time [12, 14 and 16 mo, respectively ( < 0.01)] despite the subtype distribution becoming less favorable: Luminal B (ER/PR/HER2+) decreased from 26% to 21%; HER2 (HER2+/ER/PR-) decreased from 31% to 17%, Luminal A (ER/PR+/HER2-) increased from 20% to 31%; Basal (ER/PR/HER2-) was unchanged at 24%.MS by subtype improved from 21 to 27 mo in Luminal B, 18 to 25 mo in HER2, 10 to 14 mo in Luminal A and 6 to 9 mo in Basal tumors. The number of BM was 1 in 35%, ≤4 in 67% and > 10 in 18%. PF significant for survival were tumor subtype, age, KPS, number of BM and extracranial metastases (ECM) (all < 0.01). Surprisingly, Hispanic women (7%) showed improved survival (p < 0.01). BRCA1 was mutated in 57/533 (11%) and those patients showed a trend (0.16) toward improved survival. Treatment patterns have changed: the use of whole brain radiation therapy decreased from 71% to 67% to 47% in cohorts A, B and C, respectively. Conclusions: Despite the shift to less favorable tumor subtypes, MS has improvedbut varies widely by diagnosis-specific PF. Compared to prior cohorts, number of BM and ECM were identified as new PF. Ethnic, genetic and treatment differences between the eras are apparent. The updated Breast GPA, based on these data, and the correlation between BRCA1 and tumor subtype will be presented.

Contemporary recommendations for postmastectomy radiation have undergone a shift in thinking away from simple stage based recommendations (one size fits all) to a system that considers both tumor biology and host factors. While surgical staging has traditionally dictated indications for postmastectomy radiation therapy (PMRT), our current understanding of tumor biology, host, immunoprofiles, and tumor microenvironment may direct a more personalized approach to radiation. Understanding the interaction of these variables may permit individualization of adjuvant therapy aimed at appropriate escalation and deescalation, including recommendations for PMRT. This article summarizes the current data regarding tumor and host molecular biomarkers in vitro and in vivo that support the individualization of PMRT and discusses open questions that may alter the future of breast cancer treatment.

Abstract Purpose/Objective(s): ASTRO Choosing Wisely campaign recommends no more than annual mammography after breast conservation therapy (BCT). HER2+ disease portends increased risk of locoregional recurrence in comparison to Luminal A disease. Our previous institutional practice included surveillance imaging every 6 months for the first 2-3 years after BCT. The purpose of this study is to evaluate surveillance imaging intervals as a means of detecting early locoregional recurrence at one institution. Materials/Methods: Women with HER2+ locoregionally confined invasive breast cancer treated with lumpectomy and radiation as part of breast conservation therapy at one institution were retrospectively identified after IRB approval. Patient demographics, treatment, surveillance, and outcomes data were captured. BRCA+ patients or those without available surveillance follow-up at our institution were excluded. Surveillance period started after the last fraction of radiation was completed. Results: In 86 women treated from 2008-2016, median age at diagnosis was 57, and 69% were Caucasian. Most patients were treated for Stage I-II invasive ductal carcinoma. All but one were treated with chemotherapy, with similar distribution between adjuvant and neoadjuvant regimens. Receptor status was as follows: ER+ 66%, PR+ 59%, ER+/PR+/HER2+ in 58%, ER-/PR-/HER2+ in 33%. Mammography +/- ultrasound was utilized, with infrequent use of magnetic resonance imaging. Median time from end of radiation to first surveillance imaging was 4 months. All women had 1 post-BCT imaging, with 2nd, 3rd, and 4th available in 91%, 85%, 73% respectively. Interval frequency between first 4 images was 6 months. No patients had expired at the time of analysis. Recurrence were identified in 2 women: 1 identified clinically after negative mammography, and 1 identified on mammography at 27 months. Conclusion: While overall events are small, discordant biannual mammography did not identify locoregional recurrences in this biologically higher risk group in the first two years post-treatment. This data supports current guideline recommendations limiting surveillance breast imaging in patients undergoing breast conservation to an annual frequency. Citation Format: Everett A, Wallace AS, De Los Santos JF, Rocgue GB, Parker CS, Keene KS. Choosing wisely: Radiographic surveillance after breast conservation therapy in HER2+ breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-01-02.

Throughout various eras of breast cancer therapy, postmastectomy radiation therapy (PMRT) has played an important role in the treatment of locally advanced breast cancer. PMRT decreases locoregional recurrence and may improve overall survival in patients with tumors over 5 cm or positive lymph nodes. As novel cancer therapies improve survival in breast cancer, the role of radiation therapy is evolving. Individualized recommendations for PMRT dependent on pathologic response after neoadjuvant systemic therapy are under investigation. This article summarizes the role of PMRT during breast cancer therapy and discusses open questions that may change the landscape of future breast cancer treatment.

259 Background: Increasing patient volume and treatment complexity in the field of radiation oncology has resulted in increased number of errors possibly affecting patient safety. Effective methods of mitigating these errors include automation, computerization, simplification, and standardization. To improve quality of care and patient safety, our institution established consensus standardized treatment guidelines for each cancer site. However, physician orders for computed tomography (CT) simulation for radiation treatment planning continued to have extreme variability, with error rates of 31%. Therefore, a team was assembled to devise standardized orders to reduce error, improve patient safety, and improve quality of care in the CT simulation order process. Methods: For this study, we investigated 3 commonly treated sites at our institution: breast (14%), prostate (7%), and brain metastases treated with radiosurgery (14%). A standardized template CT simulation order was defined for each disease site using the consensus treatment guidelines. These orders were integrated into the electronic medical record (EMR) on March 5, 2018. To evaluate the efficacy of the intervention, CT simulation order data were queried for the two-month period before and after implementation of standardized template orders. Orders with variation from the treatment guidelines were counted to calculate error rates with and without standardized simulation orders. Results: In the two-months prior to implementation of the standardized order templates, 48 of 151 (31%) CT simulation orders for the three selected sites had variation from the consensus standardized orders. After implementation of the EMR standardized template, 17 of 129 simulation orders (13%) in the three selected sites had variations from the standard during this two-month period. Standardization of CT simulation orders using an EMR template reduced error rates from 31% to 13% (18% absolute reduction; 42% relative reduction). Conclusions: Simplification and standardization of CT simulation orders decreased error rates by 42%, thereby improving clinic efficiency and appropriate patient treatment.

Talimogene laherparepvec (TVEC) is the first oncolytic viral immunotherapy approved by the FDA, for advanced melanoma consisting of genetically modified herpes simplex type 1 virus which selectively replicates causing tumor lysis, expressing granulocyte macrophage-colony stimulating factor (GM-CSF) and activating dendritic cells. Intratumoral injection of TVEC produces objective response in 41% of stage IIB-IV M1a melanoma. However, clinical response assessment can be problematic due to immune-related inflammation at established tumor sites. Herein, we report 5 cases of granulomatous dermatitis developing at sites of TVEC injection associated with pathologic complete response in 4 of 5 patients. Over 5 months, TVEC injections were administrated in a median of 20 tumors per patient for 9 median doses prior to biopsy of persistent, indurated nodules. Granulomatous dermatitis with melanophages and melanin pigment incontinence was observed in all samples without evidence of melanoma cells in 4 patients. The fifth patient was rendered melanoma-free by resection of the 1 nodule out of 4 with persistent tumor. Repetitive administration of TVEC or other oncolytic viral immunotherapies mimicking unresolved infection can produce granulomatous inflammation confounding assessment of the degree of tumor response and need for additional TVEC therapy. Tumor biopsies are encouraged after 4 to 6 months of TVEC administration to differentiate melanoma from granulomatous inflammation. Patients with confirmed granulomatous dermatitis replace continued with remained in remission after treatment discontinuation. Inflammatory nodules typically regress spontaneously.

9513 Background: Melanoma brain metastases confer poor prognosis, with various treatments used including RT and PD1. While RT and PD1 may have a synergistic effect to improve efficacy, RN may complicate RT, and whether PD1 potentiates this is unknown. We examined the incidence and features of RN and other neurotoxicities in melanoma pts treated with PD1 and whole brain radiotherapy (WBRT) or stereotactic radiosurgery (SRS). Methods: Pts treated with PD1 who received WBRT/SRS during or within 1 year (y) of PD1 who survived > 1y were examined for short and long term neurotoxicity. 2 cohorts were included: (A) consecutive pts fulfilling eligibility criteria from 8 melanoma centers, (B) additional cases of RN from 3 centers. Pt demographics, disease features, treatment details, neurotoxicity, and outcome data were collected. Results: Cohort A included 118 pts, with median follow-up of 24.3 months (mo). Median age was 56yo, 51% had mutant BRAF, 41% elevated LDH and 65% were ECOG 1-2 at PD1 start. 58% had prior ipilimumab and 43% prior MAPK inhibitors. 85% were treated with pembrolizumab, 10% nivolumab and 5% combination ipilimumab/nivolumab. Most pts (82, 69%) had SRS, 22 (19%) had WBRT alone and 14 pts (12%) had both. Median PFS was 24mo and OS was 45.8mo. 21 pts (18%) developed RN, (14/82) 17% after SRS, (2/22) 9% after WBRT and (5/14) 36% after both. With 13 further cases from cohort B (total 34), all had radiological signs on MRI, 78% had neurological symptoms and 56% had pathological confirmation of RN. Median time to symptom onset and to first radiological sign was 9.8mo and 10.8mo, respectively. 52% were treated with steroids and 30% had bevacizumab, with clinical improvement in 64% and 100%, respectively. Updated analysis including clinical variables associated with RN development will be presented, including RT dose and schedule. Conclusions: RN is a significant toxicity in melanoma pts with brain metastases treated with RT and PD1, particularly in long term survivors. Further research to identify those at risk of RN, those who do not require RT, and studies exploring RT and PD1 schedules are required.

Health is not defined by the absence of disease or suffering, but by response to a series of life events that can markedly alter the quality and quantity of life. Patients with cancer experience significant but dynamic physical, psychosocial, and financial challenges. With the increasing number of patients with early stage cancers transitioning to survivorship, there is a critical need to address health promotion and overall well-being. For those with advanced cancer, discussion about prognosis and early integration of palliative care can have a profound impact on the quality of life. Effective communication between healthcare providers and patients is important in aligning treatment recommendations with patient goals and preferences throughout cancer therapy. This review provides a dynamic definition of health and proposes actionable guidelines for health promotion at any point along the cancer continuum: survivorship after early cancer or when goals of care transition to improve quality at the end of life.