Purpose: Endobronchial electromagnetic transponder beacons (EMT) provide real-time, precise positional data of moving lung tumors. We report results of a phase 1/2, prospective, single-arm cohort study evaluating the treatment planning effects of EMT-guided SABR for moving lung tumors. Methods and Materials: Eligible patients were adults, Eastern Cooperative Oncology Group 0 to 2, with T1-T2N0 non-small cell lung cancer or pulmonary metastasis ≤4 cm with motion amplitude ≥5 mm. Three EMTs were endobronchially implanted using navigational bronchoscopy. Four-dimensional free-breathing computed tomography simulation scans were obtained, and end-exhalation phases were used to define the gating window internal target volume. A 3-mm expansion of gating window internal target volume defined the planning target volume (PTV). EMT-guided, respiratory-gated (RG) SABR was delivered (54 Gy/3 fractions or 48 Gy/4 fractions) using volumetric modulated arc therapy. For each RG-SABR plan, a 10-phase image-guided SABR plan was generated for dosimetric comparison. PTV/organ-at-risk (OAR) metrics were tabulated and analyzed using the Wilcoxon signed-rank pair test. Treatment outcomes were evaluated using RECIST (Response Evaluation Criteria in Solid Tumours; version 1.1). Results: Of 41 patients screened, 17 were enrolled and 2 withdrew from the study. Median age was 73 years, with 7 women. Sixty percent had T1/T2 non-small cell lung cancer and 40% had M1 disease. Median tumor diameter was 1.9 cm with 73% of targets located peripherally. Mean respiratory tumor motion was 1.25 cm (range, 0.53-4.04 cm). Thirteen tumors were treated with EMT-guided SABR and 47% of patients received 48 Gy in 4 fractions while 53% received 54 Gy in 3 fractions. RG-SABR yielded an average PTV reduction of 46.9% (P < .005). Lung V5, V10, V20, and mean lung dose had mean relative reductions of 11.3%, 20.3%, 31.1%, and 20.3%, respectively (P < .005). Dose to OARs was significantly reduced (P < .05) except for spinal cord. At 6 months, mean radiographic tumor volume reduction was 53.5% (P < .005). Conclusions: EMT-guided RG-SABR significantly reduced PTVs of moving lung tumors compared with image-guided SABR. EMT-guided RG-SABR should be considered for tumors with large respiratory motion amplitudes or those located in close proximity to OARs.

BackgroundDuring coronavirus disease 2019 (COVID-19)-related operating room closures, some multidisciplinary thoracic oncology teams adopted a paradigm of stereotactic ablative radiotherapy (SABR) as a bridge to surgery, an approach called SABR-BRIDGE. This study presents the preliminary surgical and pathological results. MethodsEligible participants from four institutions (three in Canada and one in the United States) had early-stage presumed or biopsy-proven lung malignancy that would normally be surgically resected. SABR was delivered using standard institutional guidelines, with surgery >3 months following SABR with standardized pathologic assessment. Pathological complete response (pCR) was defined as absence of viable cancer. Major pathologic response (MPR) was defined as <= 10% viable tissue. ResultsSeventy-two patients underwent SABR. Most common SABR regimens were 34 Gy/1 (29%, n = 21), 48 Gy/3-4 (26%, n = 19), and 50/55 Gy/5 (22%, n = 16). SABR was well-tolerated, with one grade 5 toxicity (death 10 days after SABR with COVID-19) and five grade 2-3 toxicities. Following SABR, 26 patients underwent resection thus far (13 pending surgery). Median time-to-surgery was 4.5 months post-SABR (range, 2-17.5 months). Surgery was reported as being more difficult because of SABR in 38% (n = 10) of cases. Thirteen patients (50%) had pCR and 19 (73%) had MPR. Rates of pCR trended higher in patients operated on at earlier time points (75% if within 3 months, 50% if 3-6 months, and 33% if >= 6 months; p = .069). In the exploratory best-case scenario analysis, pCR rate does not exceed 82%. ConclusionsThe SABR-BRIDGE approach allowed for delivery of treatment during a period of operating room closure and was well-tolerated. Even in the best-case scenario, pCR rate does not exceed 82%.

Background: Radiation therapy (RT) is an established palliative treatment for bone metastases; however, little is known about post-radiation survival and factors which impact it. The aim of this study was to assess a population-based sample of metastatic prostate cancer patients receiving palliative radiation therapy to bone metastases and contemporary palliative systemic therapy and identify factors that impact long-term survival. Materials/methods: This retrospective, population-based, cohort study assessed all prostate cancer patients receiving palliative RT for bone metastases at a Canadian provincial Cancer program during a contemporary time period. Baseline patient, disease, and treatment characteristics were extracted from the provincial medical physics databases and the electronic medical record. Post-RT Survival intervals were defined as the time interval from the first fraction of palliative RT to death from any cause or date of the last known follow-up. The median survival of the cohort was used to dichotomize the cohort into short- and long-term survivors following RT. Univariable and multivariable hazard regression analyses were performed to identify variables associated with post-RT survival. Results: From 1 January 2018 until 31 December 2019, 545 palliative RT courses for bone metastases were delivered to n = 274 metastatic prostate cancer patients with a median age of 76 yrs (Interquartile range (IQR) 39–83) and a median follow-up of 10.6 months (range 0.2 to 47.9). The median survival of the cohort was 10.6 months (IQR 3.5–25 months). The ECOG performance status of the whole cohort was ≤2 in n = 200 (73%) and 3–4 in n = 67 (24.5%). The most commonly treated sites of bone metastasis were the pelvis and lower extremities n = 130 (47.4%), skull and spine n = 114 (41.6%), and chest and upper extremities n = 30 (10.9%). Most patients had CHAARTED high volume disease n = 239 (87.2%). On multivariable hazard regression analysis, an ECOG performance status of 3–4 (p = 0.02), CHAARTED high volume disease burden (p = 0.023), and non-receipt of systemic therapy (p = 0.006) were significantly associated with worse post-RT survival. Conclusion: Amongst metastatic prostate cancer patients treated with palliative radiotherapy to bone metastases and modern palliative systemic therapies, ECOG performance status, CHAARTED metastatic disease burden, and type of first-line palliative systemic therapy were significantly associated with post-RT survival durations.

PURPOSE:The number of Canadians diagnosed with cancer, and subsequent demand for radiation therapy, are expected to increase over time. This study aimed to update our needs-based workforce planning model to ensure appropriate staffing levels in the future. METHODS AND MATERIALS:The supply of radiation oncologists, by age group, sex, and full-time equivalent status, was projected from 2020 to 2040 using a recursive-aging, input-output model developed with seeding parameters derived from national sources. The demand for radiation oncologists until 2040 was estimated using referral patterns for radiation therapy and consultation workload metrics applied to projected annual cancer incident cases to calculate required full-time equivalent positions. Baseline model parameters were also applied to the 2005-2019 workforce and incident case data to evaluate preprojection supply and demand trends. RESULTS:Preprojection trends for 2005 to 2019 revealed accelerated staffing growth that transitioned from a workforce shortage to a surplus state in 2014 followed by substantial growth slowdown in 2016. The model predicts a transient surplus of radiation oncologists until 2026 followed by a projected deficit in subsequent years. Sensitivity analyses using the plausible range for each parameter continued to favor an undersupply, suggesting a trainee shortage unable to meet workforce expansion needs. Considering possible future declining trends in radiotherapy utilization and workload, calculations to inform corrective efforts in resident numbers resulted in 25 entry positions per year, up from 21 per year currently. Geographic distribution of trainees, relative to workforce and cancer incidence distributions, could be improved with more residency positions in Canadian regions outside Ontario. CONCLUSIONS:Demand for radiation therapy and radiation oncologists in Canada are expected to grow more quickly than future expansion in staffing levels. Our workforce planning model provides evidence for more trainee requirements to inform stakeholders of possible corrective actions to training programs and recruitment. Further research is needed to explore additional strategies to expand capacity and high-quality delivery of radiation therapy to meet the foreseeable increase in Canadian patients with cancer.

CARO 2022 (pCR). Secondary outcomes included presence of any treatment response and incidence of radiation-associated toxicity.Outcomes were analysed with univariable logistic regressions and stepwise multivariable logistic regressions.Descriptive statistics were used to characterize the sample population.Results: Ninety-seven patients met inclusion criteria.The median Charlson Comorbidity Index was 5.The median clinical T-and N-stage were 3 and 1, respectively.37.5% of patients had threatened circumferential resection margins, and the median tumour distance from the anal verge was 6cm.Patients received a radiation dose of 25 Gy in five fractions.11% of patients received short-course radiation as part of total neoadjuvant therapy (TNT), and were excluded from further analysis.44% of patients were using statins during neoadjuvant therapy.9.2% of patients had pCR and 29% had no treatment response on pathology.43% of patients had radiation-associated toxicity, with 6.3% of patients having toxicity of Grade 3 or more.Statin use was not associated with increased pCR (OR 1.63, p=0.51), however it was associated with a significantly lower incidence of no pathologic response (OR 0.31, 95%CI 0.10-0.93,p=0.04).On stepwise multivariable logistic regression, statin use (OR 0.20, 95%CI 0.04-0.94,p=0.04) and male gender (OR 0.19, 95%CI 0.04-0.77,p=0.02) were associated with decreased incidence of no pathologic response.Incidence of radiation-associated toxicity was unchanged with statin use (OR 0.83, p=0.66). Conclusions:Statin use during neoadjuvant short-course radiation for rectal cancer did not increase pCR, but was associated with pathologic treatment response.Further prospective study evaluating the use of statins in conjunction with neoadjuvant short-course radiation is warranted.

OBJECTIVES:Androgen deprivation therapy (ADT) is the standard of care for men with nonmetastatic hormone-sensitive prostate cancer (nmHSPC) after treatment failure. Although intermittent ADT (iADT) is noninferior to continuous ADT for prostate cancer outcomes, with superior quality of life and cost-to-benefit ratio, little is known regarding its real-world utilization. The authors aimed to determine the utilization of iADT in a Canadian Provincial Cancer Program for relapsed nmHSPC and identified risk factors associated with the nonreceipt of iADT.MATERIALS AND METHODS:This retrospective population-based cohort study used linked administrative databases to identify all patients with relapsed nmHSPC from 2012 to 2016 and quantified ADT prescription history. Patients were defined as iADT eligible if prostate-specific antigen (PSA) was <4 ng/mL and trending downwards on ≥2 sequential PSAs after ≥6 months of ADT. Univariable and multivariable logistic regression analyses were performed to determine factors associated with nonreceipt of iADT.RESULTS:A total of 601 men with relapsed, nmHSPC were included with a median age at relapse of 73 (range, 46 to 96), pre-ADT PSA of 12.2 ng/mL, and a median pre-ADT PSA doubling time of 7.8 months. 80.9% of the cohort were eligible to receive iADT and 74.4% were treated with iADT. On multivariable analysis, patients originally treated with surgery (odds ratio [OR], 0.19; 95% confidence interval [CI], 0.08-0.46) or having a Gleason Score ≥8 (OR, 0.30; 95% CI, 0.12-0.78) had decreased odds of receipt of iADT. Patients with longer PSA doubling times were more likely to receive iADT (OR, 2.71; 95% CI, 1.17-6.31).CONCLUSIONS:The utilization of iADT was relatively common for men in Manitoba during the study period, however, the uptake of iADT can be improved among identified subgroups.

We are in the midst of an unprecedented crisis worldwide. Since the first reports in China on December 31, 2019, coronavirus disease 2019 (COVID-19) infections have spread extensively across the globe. As of April 4, 2020, >1,100,000 cases and >60,000 deaths have been reported worldwide.1World Health OrganizationCoronavirus disease (COVID-19) pandemic.https://www.who.int/emergencies/diseases/novel-coronavirus-2019Google Scholar These numbers continue to increase exponentially and the health care system is strained to the maximum. Immunocompromised and elderly individuals are susceptible to COVID-19 with a higher risk of mortality.2Guan W.J. Ni Z.Y. Hu Y. et al.Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382: 1708-1720Crossref PubMed Scopus (19386) Google Scholar Data show an aggressive course of COVID19 and >3 times a higher risk of death in patients with cancer.3Liang W. Guan W. Chen R. et al.Cancer patients in SARS-CoV-2 infection: A nationwide analysis in China.Lancet Oncol. 2020; 21: 335-337Abstract Full Text Full Text PDF PubMed Scopus (3137) Google Scholar The health care system is under enormous pressure to deal with this constantly changing and ever-evolving crisis. Several countries and provinces are reallocating resources and prioritizing available options in this emergency. Radiation oncology is an integral part of cancer care and expected to face significant challenges in the coming weeks as COVID-19 continues to impact our lives.4Filippi A.R. Russi E. Magrini S.M. Corvò R. Letter from Italy: First practical indications for radiation therapy departments during COVID-19 outbreak [Epub ahead of print].Int J Radiat Oncol Biol Phys. 2020; (Accessed April 4, 2020)https://doi.org/10.1016/j.ijrobp.2020.03.007Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar, 5Rivera A.O.N. Thomas E. Miller R. Knoll M.A. The impact of COVID-19 on radiation oncology clinics and cancer patients in the U.S..Adv Radiat Oncol. 2020; 5: 538-543Abstract Full Text Full Text PDF Scopus (50) Google Scholar, 6Krengli M. Ferrara E. Mastroleo F. Brambilla M. Ricardi U. Running a radiation oncology department at the time of coronavirus: An Italian experience.Adv Radiat Oncol. 2020; 5: 527-530Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Classic radiation oncology is based on the 4 classic R's: repair, reassortment, repopulation, and reoxygenation. During the COVID-19 pandemic and global emergency, we suggested a radiation oncology model based on 4 new R's to mitigate the impact of the current pandemic on patients and cancer centers.7Rathod S. Dubey A. Bashir B. et al.Bracing for impact with new 4R's in the COVID-19 pandemic- a provincial thoracic radiation oncology consensus [Epub ahead of print].Radiother Oncol. 2020; (Accessed April 4, 2020)https://doi.org/10.1016/j.radonc.2020.03.045Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar The new 4R's are remote/virtual care (ie, reduce in-person consultation/follow up/treatment visits), ration radiation (ie, offer radiation wisely and avoid radiation therapy with minimal benefit), rational deferring of radiation (as appropriate), and reduce fractions/hypofractionated radiation (where applicable). Significant emphasis is placed on minimizing in-person visits for patients, and several Canadian provinces have adopted remote/virtual care as a standard model during the current emergency.8Canadian Medical AssociationVirtual care in Canada.https://www.cma.ca/sites/default/files/pdf/News/Virtual_Care_discussionpaper_v2EN.pdfGoogle Scholar Remote/virtual care helps minimize patient visits to the hospital and thus the risk of infection. Radiation oncologists should wisely ration radiation and avoid radiation in cases where there is minimal or questionable benefit. Favorable ductal carcinoma in situ9McCormick B. Winter K. Hudis C. et al.RTOG 9804: A prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation.J Clin Oncol. 2015; 33: 709-715Crossref PubMed Scopus (301) Google Scholar (ie, mammographically detected, <2.5 cm in size, low-intermediate grade, and adequate resection margins), favorable low-grade invasive breast carcinoma10Hughes K.S. Schnaper L.A. Bellon J.R. et al.Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: Long-term follow-up of CALGB 9343.J Clin Oncol. 2013; 31: 2382-2387Crossref PubMed Scopus (870) Google Scholar (age ≥70 years, primary ≤3 cm with negative resection margins, estrogen receptor positive, node negative, and eligible to receive hormone therapy), and low-volume favorable intermediate-risk prostate carcinoma11Mohler J.L. Antonarakis E.S. Armstrong A.J. et al.Prostate cancer, version 2.2019, NCCN clinical practice guidelines in oncology.J Natl Compr Canc Netw. 2019; 17: 479-505Crossref PubMed Scopus (856) Google Scholar may be appropriate for active surveillance. There are several potential scenarios where avoiding radiation should be strongly considered. We should also diligently assess options of rational deferring of radiation as appropriate based on the clinical scenario. Ductal carcinoma in situ and invasive breast carcinoma could be safely delayed up to 12 weeks.12Shurell E. Olcese C. Patil S. McCormick B. Zee K.J.V. Pilewskie M.L. Delay in radiotherapy is associated with an increased risk of disease recurrence in women with ductal carcinoma in situ: Risk of IBTR With RT Delay in DCIS.Cancer. 2017; 124: 46-54Crossref PubMed Scopus (37) Google Scholar, 13Olivotto I.A. Lesperance M.L. Truong P.T. et al.Intervals longer than 20 weeks from breast-conserving surgery to radiation therapy are associated with inferior outcome for women with early-stage breast cancer who are not receiving chemotherapy.J Clin Oncol. 2008; 27: 16-23Crossref PubMed Scopus (82) Google Scholar, 14Karlsson P. Cole B.F. Colleoni M. et al.Timing of radiotherapy and outcome in patients receiving adjuvant endocrine therapy.Int J Radiat Oncol Biology Phys. 2010; 80: 398-402Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Favorable intermediate-risk prostate cancer and unfavorable intermediate-risk prostate cancer could defer radiation for 3 to 4 months or longer. Androgen deprivation therapy could be used as a temporizing measure for radiation deferral in appropriate cases, such as unfavorable intermediate-risk and high-risk prostate cancer.15Pisansky T.M. Hunt D. Gomella L.G. et al.Duration of androgen suppression before radiotherapy for localized prostate cancer: Radiation therapy oncology group randomized clinical trial 9910.J Clin Oncol. 2015; 33: 332-339Crossref PubMed Scopus (102) Google Scholar,16Zaorsky N. Yu J. McBride S. et al.Prostate cancer radiotherapy recommendations in response to COVID-19.Adv Radiat Oncol. 2020; 5: 659-665Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar In these unusual times, the use of reduced fractions/hypofractionation regimens is strongly recommended. Before COVID-19, the use of hypofractionated radiation was highly variable across the world for various reasons despite supportive data. There are enough data to practice this regimen safely for common cancer sites, such as as the prostate, breast, rectum, lung, and even palliative situations.7Rathod S. Dubey A. Bashir B. et al.Bracing for impact with new 4R's in the COVID-19 pandemic- a provincial thoracic radiation oncology consensus [Epub ahead of print].Radiother Oncol. 2020; (Accessed April 4, 2020)https://doi.org/10.1016/j.radonc.2020.03.045Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar,17Dearnaley D. Syndikus I. Mossop H. et al.Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: 5-year outcomes of the randomised, noninferiority, phase 3 CHHiP trial.Lancet Oncol. 2016; 17: 1047-1060Abstract Full Text Full Text PDF PubMed Scopus (825) Google Scholar, 18Widmark A. Gunnlaugsson A. Beckman L. et al.Ultra-hypofractionated versus conventionally fractionated radiotherapy for prostate cancer: 5-year outcomes of the HYPO-RTPC randomised, non-inferiority, phase 3 trial.Lancet. 2019; 394: 385-395Abstract Full Text Full Text PDF PubMed Scopus (425) Google Scholar, 19Brunt A. Wheatley D. Yarnold J. et al.Acute skin toxicity associated with a 1-week schedule of whole breast radiotherapy compared with a standard 3-week regimen delivered in the UK FAST-Forward Trial.Radiother Oncol. 2016; 120: 114-118Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar, 20Whelan T.J. Julian J.A. Berrang T.S. et al.External beam accelerated partial breast irradiation versus whole breast irradiation after breast conserving surgery in women with ductal carcinoma in situ and node-negative breast cancer (RAPID): A randomised controlled trial.Lancet. 2019; 394: 2165-2172Abstract Full Text Full Text PDF PubMed Scopus (231) Google Scholar, 21Vicini F.A. Cecchini R.S. White J.R. et al.Long-term primary results of accelerated partial breast irradiation after breast-conserving surgery for early-stage breast cancer: a randomised, phase 3, equivalence trial.Lancet. 2019; 394: 2155-2164Abstract Full Text Full Text PDF PubMed Scopus (267) Google Scholar, 22Rathod S.J.B. Fidarova E. et al.Quality of life outcomes in a phase 3 randomized trial of optimization of treatment of advanced non–small cell lung cancer using radiation therapy and chemotherapy: IAEA multicentric randomized phase 3 study (NCT00864331).Int J Radiat Oncol Biol Phys. 2017; 99: S103Abstract Full Text Full Text PDF PubMed Google Scholar The use of hypofractionated and ultra-hypofractionated radiation could save potentially 10 to 20 visits and thus lower the risk of infection and even mitigate the risk of treatment breaks and allow for radiation facilities with reduced manpower. With the expected resource and manpower constraints, this model is gaining popularity.23Al-Rashdan A. Roumeliotis M. Quirk S. et al.Adapting radiotherapy treatments for breast cancer patients during the COVID-19 pandemic: Hypofractionation and accelerated partial breast irradiation to address World Health Organization recommendations.Adv Radiat Oncol. 2020; 5: 575-576Abstract Full Text Full Text PDF Scopus (32) Google Scholar A clinical scenario where boost radiation adds minimal benefits to the outcomes is also another potential opportunity to reduce the number of fractions.24Moran M.S. Zhao Y. Ma S. et al.Association of radiotherapy boost for ductal carcinoma in situ with local control after whole-breast radiotherapy.JAMA Oncol. 2017; 3: 1060Crossref PubMed Scopus (60) Google Scholar,25Bartelink H. Maingon P. Poortmans P. et al.Whole-breast irradiation with or without a boost for patients treated with breast-conserving surgery for early breast cancer: 20-year follow-up of a randomised phase 3 trial.Lancet Oncol. 2015; 16: 47-56Abstract Full Text Full Text PDF PubMed Scopus (468) Google Scholar Judicious resource allocation is paramount and hypofractionation regimens serve a vital purpose. We used this model and proposed thoracic cancer-specific provincial consensus.7Rathod S. Dubey A. Bashir B. et al.Bracing for impact with new 4R's in the COVID-19 pandemic- a provincial thoracic radiation oncology consensus [Epub ahead of print].Radiother Oncol. 2020; (Accessed April 4, 2020)https://doi.org/10.1016/j.radonc.2020.03.045Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Prostate and breast cancer-specific radiation guidelines were recently proposed.16Zaorsky N. Yu J. McBride S. et al.Prostate cancer radiotherapy recommendations in response to COVID-19.Adv Radiat Oncol. 2020; 5: 659-665Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar,23Al-Rashdan A. Roumeliotis M. Quirk S. et al.Adapting radiotherapy treatments for breast cancer patients during the COVID-19 pandemic: Hypofractionation and accelerated partial breast irradiation to address World Health Organization recommendations.Adv Radiat Oncol. 2020; 5: 575-576Abstract Full Text Full Text PDF Scopus (32) Google Scholar The new 4Rs-based model framework could help several other disease site group designs and use site-specific policies. The framework would also help the global radiation oncology community use constrained resources efficiently, function and fight better, and ultimately flatten the curve of the COVID-19 pandemic. May we all emerge victoriously.

PURPOSE:Although level 1 evidence supports the use of single-fraction radiation therapy (SFRT) compared with multiple-fraction radiation therapy (MFRT) for the palliative management of bone metastases, SFRT is underused. In early 2017, the Canadian Partnership Against Cancer and CancerCare Manitoba undertook a comprehensive knowledge translation campaign in Manitoba, Canada featuring educational outreach visits, local consensus meetings, and audit and feedback interventions to encourage greater use of SFRT. This study assessed the impact of this campaign on SFRT use and identified variables associated with MFRT usage.METHODS AND MATERIALS:This retrospective, population-based cohort study identified all patients treated with palliative radiation therapy for bone metastases in Manitoba, Canada, from January 1, 2017, to December 31, 2017, using the provincial radiation therapy database. Baseline characteristics were extracted and tabulated by fractionation schedule. The proportion of patients treated with SFRT in 2017 (postintervention) was compared with the 2016 (preintervention) levels. Univariable and multivariable logistic regression analyses were performed to identify risk factors associated with MFRT use.RESULTS:In 2017, 927 patients received palliative radiation therapy for bone metastasis, of which 548 (59.1%) received SFRT, a 21.1% absolute increase in SFRT use compared with 2016 levels (38.0%). With use of multivariable analysis, variables associated with receipt of MFRT included: complicated bone metastasis, soft tissue extension, hematological primary malignancy, and treatment at a subsidiary center.CONCLUSION:The comprehensive knowledge translation campaign carried out in Manitoba resulted in a significant increase in SFRT use for bone metastases. Continued audit/feedback strategies are recommended to further reinforce knowledge translation efforts supporting SFRT use in the future.

As COVID-19 pandemic continues to explode, cancer centers worldwide are trying to adapt and are struggling with this constantly changing scenario. Intending to ensure patient safety and deliver quality care, we sought consensus on the preferred thoracic radiation regimen in a Canadian province with 4 new R's of COVID era.

Extensive stage small cell lung cancer (ES-SCLC) carries a poor prognosis, and the thoracic progression is common. Consolidation radiation to thoracic disease (cRT) could improve progression-free survival (PFS) and overall survival (OS). We conducted an electronic search of PubMed and Embase with no language, year or publication status restrictions and evaluated randomised controlled trials (RCTs) addressing the role of cRT in ES-SCLC. Preferred Reporting of Systematic Reviews and Meta-Analyses guidelines for systematic review and Cochrane methodology for meta-analysis were followed. Effect estimates (hazard ratios [HRs] and confidence intervals [CIs]) and risk ratios were extracted, with a fixed/randomeffects model created to estimate treatment effects. I2 statistics and heterogeneity statistics were performed. Comprehensive and systematic search identified 1107 records, after removal of duplicate records screened 922 records, assessed 31 full-text articles for eligibility and 3 RCTs with a total of 690 patients were included. Pooled analysis showed cRT significant improved PFS (p < 0.0001) with HR 0.72 (95% CI: 0.61-0.83, I2-0%). In addition, cRT significantly (p < 0.001) reduced the risk of thoracic progression as the first site of progression with a relative risk of 0.52 (95% CI: 0.44-0.61, I2-0%). OS analysis showed no significant (p = 0.36) benefit with HR of 0.88 (95% CI 0.66-1.18, I2-52%) with cRT. Pooled meta-analysis of 3 randomised controlled studies shows consolidation thoracic radiotherapy (RT) offers significant improvement in PFS and reduction in thoracic failures. Further research on subclassification of ES-SCLC (limited vs extensive metastasis), optimise strategy for RT integration (sequential vs concurrent) and optimal RT dose is needed to identify the subset of ES-SCLC likely to have significant OS benefit. (C) 2019 Elsevier Ltd. All rights reserved.

Objective: To confirm the long-term excess risk of SLC due to radiotherapy for various stages of breast cancers. Materials and Methods:Patients from the SEER registry diagnosed for breast cancer between 1988 and 2012 were accrued in the study.Extracted variables included the date of breast cancer diagnosis, cancer stage, patient's age, radiotherapy delivery, survival, status at study cut-off, and date of lung cancer.Kaplan Meyer statistics was used to calculate the SLC free survival and log-rank test to compare survival with or without RT for each cancer stage.Results: A total of 641,000 cases were identified, with 325,852 patients (51%) treated with radiotherapy.There was 11,416 DCIS (2%), 325,646 Stage I (51%), 224,748 Stage II (35%), and 79,190 Stage III (12%).Early stages had a longer median survival and a significant excess of SLC risk when treated with RT compared to higher stages.For DCIS the 28 years SLC risk was 8% with RT and 4% without RT (p=0.002).This corresponds to a predicted excess of mortality of 3.2%. Conclusions:Early stage breast cancers have an excess of long term SLC after RT, which is not significant for advanced stages.APBI reduces the lung exposure to radiation and may reduce this risk.

With the obvious benefit from low dose computed tomography to reduce the lung cancer-specific mortality, lung cancer screening is on the rise. With the implementation of the screening programs, diagnosis of early stage lung cancer is expected to increase, and small cell lung cancer (SCLC) would account for 10% of screen-detected lung cancer. Apart from Concurrent chemoradiation (CRT), the present guidelines virtually do not support other options for radiation (RT). There is a paucity of data addressing the role of Stereotactic Body Radiation Therapy (SBRT) in SCLC and we conducted the current systematic review on this topic. We systematically searched literature using the electronic databases PubMed and Embase with no language, year or publication status restrictions. After removal of duplicate records, 3469 screened, 3446 excluded with reasons, 23 full-text articles were assessed for eligibility, and 7 studies (8 reports) were included. Unsuitability for surgery or refusal for surgery was the most common reason for the use of SBRT in early stage SCLC in the included studies. Variable patterns of SBRT-chemotherapy (CT) sequencing including concurrent, pre-CT and post-CT and radiation doses were noted. Within the reported studies overall survival (OS) at 1 year, 2 year and 3 year varied from 63% to 87%, 37% to 72%, and 35% to 72%, respectively. Distant metastasis was the most common pattern of failure ranging from 38% to 53%. There was no increase in the reported grade III toxicity. SBRT could be a potential option in stage I SCLC with comparable outcomes with no added toxicity. Acknowledging the limitations and absence of high-quality data, presently cautious interpretation is warranted and further studies are needed to establish the role of SBRT in SCLC.

Background Primary tracheal cancers (PTCs) are rare and current evidence-based understanding is limited to retrospective reports and national databases. We present single institutional study of a historical cohort of PTC from Canadian provincial cancer registry database. Materials and Methods: After institutional research ethics board approval, all PTC patients diagnosed from 1980 to 2014 were identified through the Canadian provincial cancer registry. Demographic and tumor related factors were evaluated using descriptive statistics. Survival rates were estimated using the Kaplan-Meier method and cox hazard regression analyses were performed to identify predictors of disease-free survival (DFS) and overall survival (OS). Results: A total of 30 patients were included in the study. At presentation, 10 patients (33%) had only local disease, 14 patients (47%) had locoregional disease and the remaining 4 patients (13%) had distant metastasis. The majority of patients underwent primary radiation treatment. The overall survival rate was 30% at 2 years and 16% at 5 years. Patients receiving radical-intent therapy had better 2-year DFS and OS compared to patients managed with palliative radiotherapy and best supportive care (46%, 17% and 0%) (p=<0.001) and (50%, 23% and 0%) (p=<0.001), respectively. Radiotherapy resulted in a better 2-year OS and DFS (32% versus 14%) (p=<0.03) and (32% versus 0%) (p=<0.001), respectively. Conclusion: PTC is an uncommon neoplasm making the study of the disease technically and logistically challenging. Radical radiotherapy alone is curative option in inoperable PTC. Intent of treatment and radiotherapy were associated with superior survival outcomes.

BACKGROUND:We compared the performance of 7th and 8th edition of the Union for International Cancer Control (UICC) / American Joint Committee on Cancer (AJCC) TNM staging for non-small cell lung cancer (NSCLC) in non-metastatic (stage I-III) North American cohort undergoing primary radiation treatment. METHODS:Newly diagnosed NSCLC between (Jan 2011 - Dec 2014) were screened through a Canadian Provincial Cancer Registry. Clinico-radiologically and pathologically confirmed non-metastatic NSCLC undergoing primary radiation treatment were included. Kaplan-Meier methods, Cox proportional hazard regression and Akaike information criterion (AIC) were applied to evaluate discriminatory ability and prognostic performance of 7th and 8th edition of staging systems. RESULTS:In this cohort of 295 patients, 8th edition stages IA3, IB, IIA, IIB, IIIA, IIIB, and IIIC showed progressive increase in the hazard ratio compared to best stage IA2 (8th edition IA3 vs IA2: HR 1.72; IB vs IA2: HR 2.04; IIA vs IA2: HR 2.66; IIB vs IA2: HR 2.91; IIIA vs IA2: HR 3.38; IIIB vs IA2: HR 3.62 and IIIC vs IA2: HR 8.22). In a multivariate model, 8th edition stage grouping had smaller AIC of 2342.08 compared to 7th edition 2349.55, confirming better performance. International Association for the Study of Lung Cancer (IASLC) map based nodal categorization N1, N2 and N3, showed good survival and hazard discrimination over stage N0 (1.39, 1.48 and 2.16 respectively). CONCLUSION:In an independent cohort of non-metastatic NSCLC undergoing primary radiation treatment, improved performance of 8th edition UICC/AJCC staging system over 7th edition was observed.

PURPOSE:To report findings from an in vivo dosimetry program implemented for all stereotactic body radiation therapy patients over a 31-month period and discuss the value and challenges of utilizing in vivo electronic portal imaging device (EPID) dosimetry clinically. METHODS AND MATERIALS:From December 2013 to July 2016, 117 stereotactic body radiation therapy-volumetric modulated arc therapy patients (100 lung, 15 spine, and 2 liver) underwent 602 EPID-based in vivo dose verification events. A developed model-based dose reconstruction algorithm calculates the 3-dimensional dose distribution to the patient by back-projecting the primary fluence measured by the EPID during treatment. The EPID frame-averaging was optimized in June 2015. For each treatment, a 3%/3-mm γ comparison between our EPID-derived dose and the Eclipse AcurosXB-predicted dose to the planning target volume (PTV) and the ≥20% isodose volume were performed. Alert levels were defined as γ pass rates <85% (lung and liver) and <80% (spine). Investigations were carried out for all fractions exceeding the alert level and were classified as follows: EPID-related, algorithmic, patient setup, anatomic change, or unknown/unidentified errors. RESULTS:The percentages of fractions exceeding the alert levels were 22.6% for lung before frame-average optimization and 8.0% for lung, 20.0% for spine, and 10.0% for liver after frame-average optimization. Overall, mean (± standard deviation) planning target volume γ pass rates were 90.7% ± 9.2%, 87.0% ± 9.3%, and 91.2% ± 3.4% for the lung, spine, and liver patients, respectively. CONCLUSIONS:Results from the clinical implementation of our model-based in vivo dose verification method using on-treatment EPID images is reported. The method is demonstrated to be valuable for routine clinical use for verifying delivered dose as well as for detecting errors.