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

Among 333 patients with Stage III non-small cell lung cancer who completed concurrent chemoradiotherapy (cCRT), 69% received consolidation immune checkpoint inhibitors (ICIs), meaning 31% did not. Common reasons for ICI nonreceipt included progressive disease, comorbidity/intercurrent illness, cCRT toxicity, and EGFR/ALK alteration. Median survival was 16 months in the no-ICI group vs 34.4 months in the ICI group. Objectives: We sought to determine the proportion of patients with stage III non-small cell lung cancer (NSCLC) who initiate consolidation durvalumab or other immune checkpoint inhibitors (ICIs) after concurrent chemoradiotherapy (cCRT), as well as reasons for nonreceipt and prognostic implications. Materials and Methods: We retrospectively identified consecutive patients with unresectable stage III NSCLC treated with definitive cCRT between October 2017 and December 2021 within a large US academic health system. Patients either received consolidation ICIs (ICI group) or did not (no-ICI group). Baseline characteristics and overall survival (OS) of the groups were assessed. Factors predictive of ICI nonreceipt were evaluated using logistic regression. Results: Of 333 patients who completed cCRT, 229 (69%) initiated consolidation ICIs; 104 (31%) did not. Reasons for ICI nonreceipt included progressive disease post-cCRT (N = 31, 9%), comorbidity or intercurrent illness (N = 25, 8%), cCRT toxicity (N = 23, 7%; 19/23 pneumonitis), and EGFR/ALK alteration (N = 14, 4%). The no-ICI group had worse performance status and a higher rate of baseline pulmonary comorbidity. Larger planning target volume was associated with post-cCRT progressive disease, and higher lung radiation dose with cCRT toxicity. Median OS was 16 months in the no-ICI group and 34.4 months in the ICI group. In the no-ICI group, OS was superior among those with EGFR/ALK alterations (median 44.5 months) and worst among those with progressive disease (median 5.9 months, P < 0.001). Conclusion: 31% of patients who completed cCRT for stage III NSCLC did not receive consolidation ICIs. Survival amongst these patients is poor, especially for those with progressive disease post-cCRT.

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.

8523 Background: The PACIFIC trial demonstrated a 10% improvement in 5-year survival with the addition of consolidation durvalumab versus placebo after chemoradiation (CRT) in good performance status patients (pts) with stage III non-small cell lung cancer (NSCLC). However, not all patients who complete CRT go on to receive consolidation durvalumab. We sought to describe real-world use of consolidation durvalumab or other immune checkpoint inhibitors (ICI) in this setting within a single academic health system. Methods: We retrospectively identified pts with unresectable stage III NSCLC treated with definitive CRT between October 2017 and October 2020 within the University of Pennsylvania Health System, including two urban hospitals and two satellite centers. Pts either received consolidation ICI (ICI group) or did not (no ICI group). Baseline characteristics of the groups were compared with the Chi-squared, Fisher exact, or Wilcoxon rank-sum test as appropriate. Overall survival (OS), measured from the last day of CRT, was compared using the Kaplan-Meier method and log-rank test. Results: Of the 148 consecutively treated pts who completed CRT, 108 (73%) received consolidation ICI; 40 (27%) did not. Within the ICI group, 42% completed 1 year (yr) of treatment. Within the no ICI group, reasons for non-receipt included disease progression (n = 14, 35%), CRT toxicity (n = 7, 18%), comorbidity or decline unrelated to CRT (n = 7, 18%), provider choice (n = 6, 15%) due to EGFR mutation (n = 5) or atypical histology (n = 1), pt refusal (n = 3, 8%), and death without progression (n = 3, 8%). The ICI group had better performance status (ECOG 0/1/2, 46%/49%/5% ICI vs 25%/48%/28% no ICI, p < 0.001) lower Charlson Comorbidity Index (median, 5 [IQR 4-6] ICI vs 6 [IQR 5-8] no ICI, p = 0.02), and lower rates of active autoimmune disease or immunosuppression (5% ICI vs 15% no ICI, p = 0.03). There were no differences between groups in age (median, 68 yrs [IQR 63-73] ICI vs 71 yrs [IQR 65-73] no ICI, p = 0.25), sex (female, 60% ICI vs 50% no ICI, p = 0.27), race (Black, 19% ICI vs 20% no ICI, p = 0.82), stage (IIIA/B/C, 42%/48%/11% ICI vs 40%/50%/10% no ICI, p = 0.96), and PD-L1 expression ( < 1%/1-50%/ > 50%/unknown, 36%/25%/29%/10% ICI vs 40%/25%/28%/8% no ICI, p = 0.97). 1- and 2-yr OS were 83% and 61% in the ICI group versus 52% and 34% in the no ICI group, respectively (p < 0.001). Within the no ICI group, OS was worse among those with versus those without disease progression (PD) post-CRT (1-yr OS 24% vs 74%, p = 0.03). Conclusions: In this retrospective study within a large academic health system, we found that over one-quarter of pts who completed chemoradiation for stage III NSCLC did not receive consolidation ICI, most commonly due to disease progression, CRT toxicity, or comorbidity. Survival amongst these pts is particularly poor, especially for those who experience PD shortly after CRT.

Background The impact of the COVID-19 pandemic on the lives of radiation oncologists, from the attending to trainee level, has been multifactorial. One such notable shift has been the limitation of colleague interactions to Zoom-type calls for over two years. Moreover, work-related stress has significantly risen largely due to additional and increasingly complex patient management secondary to COVID-related precautions. As part of the run-up to the ACRO 2022 Annual Meeting, we initiated a friendly competition utilizing a social media-based cycling platform to promote physician well-being as part of #TOURdeACRO. The goal was to support both formation of new connections and strengthening of existing ones between colleagues. Methods Team members were solicited via email, social media, the ACRO websites, and word of mouth. #TOURdeACRO occurred between 1/1/2022 and 2/28/2022. Team members competed based on the number of miles they completed using a social media-based cycling platform. Participants were asked to post their rides on social media platforms so that other Team Members could view the rides and offer positive encouragement. Interval updates were given to encourage friendly competition and reinforce continued investment of teammates in one another's progress. At the Annual meeting, all Team Members were given an official ACRO Racing Jersey to strengthen the unified team culture. Results A total of 7 female and 5 male team members participated, including3 resident physicians and 9 attending physicians. Female riders were significantly more productive than male riders, as evident by total combined mileage. The overall winner was determined on the last day of the #TOURdeACRO. The top three productive team members produced 1066 miles, 834 miles, and 787 miles over the two months. Eight riders reported significant increases in weekly and monthly mileage over their baseline in preceding months. Discussion A social media-based cycling platform was useful and effective in creating and fostering a team culture for a demographically diverse group of radiation oncology physicians. Moving forward, additional riders will be recruited and other social media-based platforms that involve exercise (other than cycling) will be explored to further strengthen this inclusive team environment to enhance physician well-being. The impact of the COVID-19 pandemic on the lives of radiation oncologists, from the attending to trainee level, has been multifactorial. One such notable shift has been the limitation of colleague interactions to Zoom-type calls for over two years. Moreover, work-related stress has significantly risen largely due to additional and increasingly complex patient management secondary to COVID-related precautions. As part of the run-up to the ACRO 2022 Annual Meeting, we initiated a friendly competition utilizing a social media-based cycling platform to promote physician well-being as part of #TOURdeACRO. The goal was to support both formation of new connections and strengthening of existing ones between colleagues. Team members were solicited via email, social media, the ACRO websites, and word of mouth. #TOURdeACRO occurred between 1/1/2022 and 2/28/2022. Team members competed based on the number of miles they completed using a social media-based cycling platform. Participants were asked to post their rides on social media platforms so that other Team Members could view the rides and offer positive encouragement. Interval updates were given to encourage friendly competition and reinforce continued investment of teammates in one another's progress. At the Annual meeting, all Team Members were given an official ACRO Racing Jersey to strengthen the unified team culture. A total of 7 female and 5 male team members participated, including3 resident physicians and 9 attending physicians. Female riders were significantly more productive than male riders, as evident by total combined mileage. The overall winner was determined on the last day of the #TOURdeACRO. The top three productive team members produced 1066 miles, 834 miles, and 787 miles over the two months. Eight riders reported significant increases in weekly and monthly mileage over their baseline in preceding months. A social media-based cycling platform was useful and effective in creating and fostering a team culture for a demographically diverse group of radiation oncology physicians. Moving forward, additional riders will be recruited and other social media-based platforms that involve exercise (other than cycling) will be explored to further strengthen this inclusive team environment to enhance physician well-being.

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.

An 88-year-old woman with a history of left-sided breast cancer, treated with lumpectomy and adjuvant whole-breast radiotherapy (RT), presented with abdominal pain and constipation for several days, for which chest and abdominal plain-film imaging was obtained and demonstrated a bowel obstruction. Incidentally, her chest radiograph revealed a new 8-cm, oblong upper thoracic mass. A computed tomography (CT) scan of the chest revealed a large, lobulated, anterior mediastinal mass measuring up to 10 cm, with a central heart-shaped calcification (Fig. 1).

Purpose: Recent data indicate consolidative radiation therapy improves progression-free survival (PFS) for patients with oligometastatic non-small cell lung cancer (NSCLC). Data on long-term outcomes are limited. Methods and Materials: This prospective, multicenter, single-arm, phase 2 trial was initiated in 2010 and enrolled patients with oligometastatic NSCLC. Oligometastatic disease was defined as a maximum of 5 metastatic lesions for all disease sites, including no more than 3 active extracranial metastatic lesions. Limited mediastinal lymph node involvement was allowed. Patients achieving a partial response or stable disease after 3 to 6 cycles of platinum-based chemotherapy were treated with CRT to the primary and metastatic sites of disease, followed by observation alone. The primary endpoint was PFS, with secondary endpoints of local control, overall survival (OS), and safety. Results: Twenty-nine patients were enrolled between October 2010 and October 2015, and 27 were eligible for consolidative radiation therapy. The study was closed early because of slow accrual but met its primary endpoint for success, which was PFS >6 months (P < .0001). The median PFS (95% confidence interval) was 11.2 months (7.6-15.9 months), and the median OS was 28.4 months (14.5-45.8 months). Survival outcomes were not significantly different for patients with brain metastases (P = .87 for PFS; P = .12 for OS) or lymph node involvement (P = .74 for PFS; P = .86 for OS). Conclusions: For patients with oligometastatic NSCLC, chemotherapy followed by consolidative radiation therapy without maintenance chemotherapy was associated with encouraging long-term outcomes. (C) 2018 Elsevier Inc. All rights reserved.

Clinical questions arise frequently at the point of care, and approximately half of these questions go unanswered, representing an opportunity to improve quality of care. Radiation oncologists perform the unique task of contour delineation, which has been linked to decreased survival and increased toxicity when performed inaccurately. Little is known about how radiation oncologists approach contouring-related questions in clinical practice.

The optimal treatment paradigm for patients with oligometastatic non-small cell lung cancer (NSCLC) remains controversial. While primary systemic therapy is essential to maintain disease control, the role for subsequent local therapy is less well-defined. This prospective, multi-institutional phase II study was conducted to evaluate the potential survival benefit of radiotherapy to the chest and/or sites of oligometastatic disease after first-line chemotherapy. Twenty-six patients with metastatic NSCLC and ≤5 total lesions underwent a median 4 (range 3-6) cycles of first-line chemotherapy. Patients with partial response or stable disease by RECIST criteria were eligible. This was followed by radiotherapy to the primary tumor (if not previously treated) and/or up to 3 additional extracranial sites. No maintenance chemotherapy was administered. Eleven patients (42%) had brain metastases previously treated with surgery or stereotactic radiosurgery with or without whole brain radiotherapy followed by confirmation of intracranial disease control prior to registration. Radiotherapy techniques included stereotactic body radiotherapy (SBRT) or conventionally fractionated radiotherapy to the primary (median 60 Gy, range 50-70.2 Gy) and/or metastatic sites (median 50 Gy, range 27-60). The trial was closed early due to slow accrual; herein we report the results of patients enrolled prior to study closure. Progression-free survival (PFS) and overall survival (OS) were evaluated using Kaplan-Meier method. Mean age was 65 years (range 42-83). Primary histology was adenocarcinoma in 16 (62%) and squamous cell carcinoma in 6 (23%). The median number of lesions treated was 2 (range 1-4), including the primary site (89%), non-primary lung (27%), bone (15%), adrenal (12%), spine/paraspinal (12%), liver (8%), and other (12%). Median progression-free survival was 11 months (95% CI 7.4-15.9) and 5-year PFS was 29%. Of the 21 (81%) patients that experienced disease progression, the site of progression was identified in 18. Site of initial failure was distant in 9 (35%) patients, intracranial in 6 (23%), both local and distant in 2 (8%) and local alone in 1 (4%). Seven (27%) patients were alive at last follow-up. Median overall survival was 22.2 months (95% CI 13.3-45.8) and 5-year OS was 29%. In this prospective, phase II study, patients receiving consolidative/ablative radiotherapy after first-line chemotherapy for oligometastatic NSCLC demonstrated favorable disease-free and overall survival outcomes. Further prospective study evaluating more aggressive local therapies to carefully selected patients is warranted.

PURPOSE:This guideline presents evidence-based recommendations for stereotactic body radiation therapy (SBRT) in challenging clinical scenarios in early-stage non-small cell lung cancer (NSCLC). METHODS AND MATERIALS:The American Society for Radiation Oncology convened a task force to perform a systematic literature review on 4 key questions addressing: (1) application of SBRT to operable patients; (2) appropriate use of SBRT in tumors that are centrally located, large, multifocal, or unbiopsied; (3) individual tailoring of SBRT in "high-risk" clinical scenarios; and (4) SBRT as salvage therapy after recurrence. Guideline recommendations were created using a predefined consensus-building methodology supported by American Society for Radiation Oncology-approved tools for grading evidence quality and recommendation strength. RESULTS:Although few randomized trials have been completed for SBRT, strong consensus recommendations based on extensive, consistent publications were generated for several questions, including recommendations for fractionation for central tumors and surgery versus SBRT in standard-risk medically operable patients with early-stage NSCLC. Lower quality evidence led to conditional recommendations on use of SBRT for tumors >5 cm, patients with prior pneumonectomy, T3 tumors with chest wall invasion, synchronous multiple primary lung cancer, and as a salvage therapy after prior radiation therapy. These areas of moderate- and low-quality evidence highlight the importance of clinical trial enrollment as well as the role of prospective data registries. CONCLUSIONS:SBRT has an important role to play in treating early-stage NSCLC, particularly for medically inoperable patients with limited other treatment options. Shared decision-making with patients should be performed in all cases to ensure the patient understands the risks related to SBRT, the side effects, and the alternative treatments available.

9047 Background: Unselected patients with stage 4 lung cancer who receive front line platinum based chemotherapy and maintenance chemotherapy have demonstrated a PFS less than 6 months with very few patients alive at 5 years. Patients with a small number of metastatic lesions may have a different biology, and aggressive local treatment of oligometastases is an active area of investigation. Methods: Patients were required to have stable disease or response after 3-6 cycles of platinum based chemotherapy and PS 0-2. Oligometastatic disease was defined as a maximum number of 5 metastatic lesions for all disease sites including no more than 3 active extracranial metastatic lesions. Limited mediastinal lymph node involvement was allowed. Results: 29 patients were enrolled between 10/2010 and 10/2015. 3 patients were excluded from analysis due to concerns regarding eligibility/treatment response. Despite closing early due to slow accrual, the study met its primary endpoint for success which was PFS greater than 6 months. The median PFS (95% CI) was 11.0 months (7.4-15.9 months) and the median OS was 22.2 months (13.3-45.7 months). The 1-year, 3-year, and 5-year OS were 73%, 35%, and 29%. Conclusions: Patients with oligometastatic NSCLC who received platinum based chemotherapy followed by oligometastatic consolidative radiation without maintenance chemotherapy demonstrated prolonged disease control and overall survival. Clinical trial information: nct01185639.

Patients with locally advanced non-small cell lung cancer (NSCLC) represent a heterogeneous portion of the population, often with multiple comorbidities and barriers to healthcare. We sought to analyze trends with regards to race, sex, and rural/urban locales that could influence factors affecting the care such as differences in chemotherapy regimens, total doses of radiation, and overall outcomes. We retrospectively reviewed patients with stage IIb-IIIb NSCLC treated from 2001-2014, recording basic patient characteristics, rural or urban patients, chemotherapy regimens, total radiation dose, dose fractionation, and outcome data with regards to local control (LC), locoregional control (LRC), distant failure (DF), overall survival (OS), and progression free survival (PFS). Utilizing a univariate analysis, we associated sex, urban vs rural, and race to different chemotherapy regimens, total radiation dose, and outcome measures including OS, LC, LRC, DF, and PFS. Fisher's Exact Test was used to test categorical associations; proportional hazards regression was used to test for survival differences. Nonparametric tests were used to test for dose differences. Two hundred and sixty one patients were identified for review with a median follow up of 62.1 months (95% CI 50.2-81.7). Thirty-five percent of the patients were women, 20% were minorities, and 75% of patients lived in rural locales. ECOG performance status was similar between sexes, races, and rural/urban locales. With regards to chemotherapy regimens, women were less likely to receive carboplatin or Paclitaxel compared to men (carboplatin P=0.051), (Paclitaxel P = 0.0024) and there was a trend that African Americans were less likely to receive carboplatin than whites (P=0.08). This association with race was not observed with Paclitaxel (P=0.12). There were no differences observed for carboplatin use between patients from rural/urban locales. Significant associations between cisplatin, pemetrexed, gemcitabine, or docetaxel did not exist with race, sex, or rural vs urban patient locale. Women and rural locale patients were more likely to receive a lower radiation dose (sex P = 0.016, rural P = 0.023); this difference did not differ by race. OS, LC, DF, PFS was not influenced by sex, urban/rural locale, or race. An association between female sex and inferior LRC was observed (P=0.046) but this did not extend to African Americans or rural patients. This study suggests that sex, race, and patient locale may influence treatment delivery for patients with stage IIb-IIIB NSCLC. Despite this difference in chemotherapy choice with radiation therapy, no difference was noted in outcomes suggesting equivalence of clinical care across this mixed population. This study is limited in its retrospective nature and does not account for comorbidities within each cohort, it suggests basic demographic differences between groups receive different treatment modalities.

Background and Purpose: High rates of spontaneous rib fractures are associated with thoracic stereotactic body radiation therapy (SBRT). These fractures likely originate within the cortical bone and relate to the cortical thickness (Ct.Th). We report the development and application of a novel Ct.Th and radiation dose mapping technique to assess early site-specific changes of cortical bone in ribs.Materials and methods: Rib Ct.Th maps were constructed from pre-SBRT and 3 month post-SBRT CT scans for 28 patients treated for peripheral lung lesions. The Ct.Th at approximately 50,000 homologous points within the entire rib cage was determined pre- and post-SBRT. Each rib was then divided into 30 homologous regions. The mean dose and thinning were determined per section.Results: Regions of ribs that received >= 10 Gy exhibited significant thinning of cortical bone (p = 0.001). The mean Ct.Th percent difference (95% CI) in regions receiving 10-20 Gy, 20-30 Gy, 30-40 Gy, and >= 40 Gy were -7% (-4%,-11%), 14% (-18%,-11%), 15% (-19%,-11%), and 18% (-22%,-15%) respectively. Regions receiving >20 Gy experienced significantly more thinning than regions receiving lower doses.Conclusions: Substantial early cortical bone thinning was observed post-SBRT in regions of ribs that received >= 10 Gy. The rapid thinning of ribs may predispose ribs to fracture after SBRT. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Successive clinical trials have demonstrated that concurrent chemotherapy and radiation therapy (CMT) is superior to both sequential therapy and radiation therapy alone. However, many of these studies were done with older agents. Studies in patients with Stage IV disease have shown the advantage of "histology-based" chemotherapy; this concept is a current standard combination with radiation therapy in patients with locally advanced disease. We hypothesize that patients who receive "histology-based" chemotherapy will have improved outcomes. We retrospectively reviewed patients (N=261) with stage IIb-IIIb NSCLC treated from 2001 to 2014 definitive radiation therapy +/- chemotherapy. We defined "histology-based" chemotherapy as the time period when pemetrexed was specifically used to treat patients with adenocarcinoma histology. We abstracted basic patient characteristics, chemotherapy regimens, total radiation dose, dose fractionation, and outcome data with regards to local control (LC), loco-regional control (LRC), distant failure (DF), overall survival (OS), and progression free survival (PFS). Fisher's Exact Test was used to test categorical associations. For survival analysis, univariate analysis was performed via Kaplan-Meier and proportional hazards regression was used to test for multivariate differences in the outcomes. The mean age for the cohort was 64+/-10 years. The median radiation dose was 66 Gy. 75% of the patients were ECOG 0-1 and 36% were female. The ratio of adenocarcinoma/squamous cell carcinoma/other was 31%/43%/26%. For overall survival, the use of carboplatin was associated with increased survival (HR=1.63; 1.20-2.21). Sex, histology, and year of diagnosis were prognostic for both LC and LRC. In the patients who received chemotherapy (N=239), the use of pemetrexed resulted in 1 year and 3 year local recurrence free survival of 100%, and 84%. For patients receiving chemotherapy other than pemetrexed, the 1 year and 3 year local recurrence free survival were 78.1% and 56%. This analysis suggests that use of histology based chemotherapy may be associated with improved local control. We did not identify any improvement in survival. However, this study is limited by its retrospective nature and limited numbers.

Radiation oncology faculty members have diverse backgrounds and include clinicians, medical physicists, and non-clinical scientists. Given the assorted individuals, success/productivity can be assessed in a variety of methods. We sought to investigate the relationship between academic output, grant funding, and clinical trials in radiation oncology by evaluating a series of academic metrics with respect to productivity. We reviewed 45 academic institutions in the United States and recorded the demographic information for clinical, medical physics, and radiation biology faculty appointed to each radiation oncology department. Academic productivity metrics included publications, citations, citations over the last 3 years, and the Hirsch Index (H-Index) as defined by SCOPUS. Successful funding included both National Institutes of Health (NIH) and non-NIH funding. Clinical trial participation was defined by www.clinicaltrials.gov and included both overall principal investigator status as well and local principal investigator status. National Cancer Institute (NCI) status (NCI Comprehensive Cancer Centers, NCI Cancer Centers, or non-NCI Centers) was used to stratify the cohort. Comparisons were evaluated by Chi-Square testing for statistical significance. In total, 1057 faculty members (73.6% male, 27.4% female) at 45 academic institutions were evaluated. This represented 741, 180, 136 faculty members from NCI Comprehensive Cancer Centers, NCI Cancer Centers, and Non-NCI Centers, respectively. The median number of publications, total citations, and citations in the last 3 years, and H-Index for the entire cohort was 37.5, 677.5, 213, and 13, respectively. The academic productivity metrics did not have statistical difference between NCI Comprehensive Cancer Center and NCI Cancer Centers, but were both were statistically greater than non-NCI Centers. Faculty members with NIH funding had a higher citation rate and a higher H-index than those with non-NIH while maintaining a similar publication rate. Individuals without funding had decreased levels of all academic productivity metrics. Individuals with large NIH grant (R01/P01/U01) funding had the lowest rate of clinical trial leadership compared to those with non-R01/P01/U01funding (16.7% vs. 42.1%, p<0.01). NCI Cancer Center status did not impact clinical trial leadership rates. NCI designated cancer centers were associated with greater academic productivity by faculty members. Clinical trial leader leadership was equal with the NCI designations.

Thoracic stereotactic body radiation therapy (SBRT) leads to an increased incidence of spontaneous rib fractures often occurring early after treatment. The etiology of radiation induced rib fracture (RIRF) is unclear, but likely results from bone damage and deterioration. Spontaneous fractures are believed to initiate within cortical bone; cortical thickness (C.Th) is a major determinant of the bone strength. Unfortunately, thin laminar structures comprising the bone cortex of ribs are poorly visualized on clinical CT images due to limited spatial resolution. The objective of this study was to assess early radiation effects on the C.Th of ribs after SBRT using a novel C.Th mapping technique capable of resolving thickness differences >30 μm. Rib cortical thickness maps were constructed from pretreatment and follow-up CT scans acquired 4 months after SBRT for 40 patients treated for primary and metastatic lung malignancies. Patients were treated with several dose fractionation schedules: 50 Gy × 10 fractions (fr) (n = 5), 50 Gy × 5 fr (n = 13), 45 Gy × 3 fr (n = 5), and 54 Gy × 3 fr (n = 7). Post-treatment scans were registered to corresponding pretreatment scans using rigid body transformation. Regions of interest (ROI) along the length of each rib were defined in 10 Gy increments (0 – 50 Gy) and clustered into the following groupings for analysis based on absorbed dose: 0–10 Gy; 20–30 Gy; 30–40 Gy; and >40 Gy. Regions receiving dose on the internal and external surface were analyzed independently, and irradiated regions with volumes <0.5 cm3 were excluded. The mean C.Th within each ROI was determined pre-SBRT and post-SBRT, and the percent difference was calculated. Data were compared using Kruskal-Wallace ANOVA to identify main effects of dose on C.Th, with Dunn's post-hoc analysis for between group differences. Exposure to radiation at doses >20 Gy resulted in significant thinning of cortical bone at the both the internal (P = .029) and external (P = .008) rib surfaces. While no significant cortical thinning was observed at either the internal (+0.5%) or external (-2.9%) surfaces in ribs absorbing 0–10 Gy; significant thinning occurred at, i] the internal surface at locations absorbing 20–30 Gy (-12.7%; P = .013), 30–40 Gy (-12.3%; P = .017); and marginally lower at 40+ Gy (-9.5%; P = 0.08); and ii] the external surface at ROIs absorbing 20–30 Gy (-12.0%; P = .004), 30–40 Gy (-15.4%, P = .003), and 40+ Gy (-9.6%, P = .024). This substantial thinning of cortical bone at both external and internal surfaces could greatly increase the risk of spontaneous fracture. Stereotactic body radiation therapy induced rapid thinning of the cortical bone throughout ribs that absorb >20 Gy. The thinning of cortical bone in irradiated regions of the rib likely contributes to the occurrence of RIRF in patients treated with SBRT.

Purpose/Objective(s)Pelvic insufficiency fractures (PIF) occur in 15-45% of patients following radiation therapy. Studies have demonstrated regions of cortical bone thinning by 30% at common fracture sites in the pelvis. New image processing techniques facilitate the accurate detection of cortical thickness (CTh) using standard CT scans. Acute changes occurring within 1-2 months of treatment have not been assessed. The objective of this study was to evaluate acute changes of CTh in the proximal femur following external beam radiation therapy (EBRT).Materials/MethodsFemoral head CTh maps were constructed from a control scan (1-3 months prior to radiation), the CT simulation scan, and the CT scan performed within 1-2 months following treatment in patients treated for pelvic malignancies. The CTh values from the control scan and simulation scan were compared to establish baseline pretreatment values. Using the radiation treatment plans, dose regions were created in 10 Gy increments ranging from 0 Gy to 60 Gy. Regions of interest (ROI) were defined as the intersection of the dose regions and femoral head. The pretreatment scans were registered to the posttreatment scan using rigid body transformation, and analogous ROIs were identified. A similar process was performed to obtain the ROI for the control subjects. The mean CTh within each ROI was determined posttreatment and compared to the baseline thickness using a repeated measures ANCOVA model that included patient age, gender, chemotherapy treatment, and radiation exposure as main effects.ResultsFifty-one femoral heads were analyzed from 27 patients (15 female). Median patient age was 54 years (range 30 to 87). Radiation treatment techniques included VMAT, 3-field, and 4-field arrangements. Treatments were performed primarily using 6 or 10 MV photons. Dose to the femoral head ranged from 0-59.2 Gy. Median date to follow-up scans was 15 days (range 0 to 52) from the last radiation treatment. The effect of radiation exposure on CTh was significant (P=.050). Significant cortical bone thinning versus control was observed in all ROIs that absorbed >20 Gy, with a mean loss of 15.4% (P=.006), 14.1% (P=.017), and 14.4% (P=.011) in the 20-30 Gy, 30-40 Gy, and > 40 Gy ROIs, respectively. Conversely, the overall effect of age, gender, and use of chemotherapy were not significant.ConclusionThe significant reduction of femoral head CTh of up to 15% seen in patients receiving EBRT in the acute setting presents a possible mechanism for radiation induced fracture. This suggests CTh may be a potential marker for radiation induced PIF. Early CTh loss appears to be primarily affected by radiation exposure. Further research is needed evaluating the correlation between CTh and incidence of fracture. Purpose/Objective(s)Pelvic insufficiency fractures (PIF) occur in 15-45% of patients following radiation therapy. Studies have demonstrated regions of cortical bone thinning by 30% at common fracture sites in the pelvis. New image processing techniques facilitate the accurate detection of cortical thickness (CTh) using standard CT scans. Acute changes occurring within 1-2 months of treatment have not been assessed. The objective of this study was to evaluate acute changes of CTh in the proximal femur following external beam radiation therapy (EBRT). Pelvic insufficiency fractures (PIF) occur in 15-45% of patients following radiation therapy. Studies have demonstrated regions of cortical bone thinning by 30% at common fracture sites in the pelvis. New image processing techniques facilitate the accurate detection of cortical thickness (CTh) using standard CT scans. Acute changes occurring within 1-2 months of treatment have not been assessed. The objective of this study was to evaluate acute changes of CTh in the proximal femur following external beam radiation therapy (EBRT). Materials/MethodsFemoral head CTh maps were constructed from a control scan (1-3 months prior to radiation), the CT simulation scan, and the CT scan performed within 1-2 months following treatment in patients treated for pelvic malignancies. The CTh values from the control scan and simulation scan were compared to establish baseline pretreatment values. Using the radiation treatment plans, dose regions were created in 10 Gy increments ranging from 0 Gy to 60 Gy. Regions of interest (ROI) were defined as the intersection of the dose regions and femoral head. The pretreatment scans were registered to the posttreatment scan using rigid body transformation, and analogous ROIs were identified. A similar process was performed to obtain the ROI for the control subjects. The mean CTh within each ROI was determined posttreatment and compared to the baseline thickness using a repeated measures ANCOVA model that included patient age, gender, chemotherapy treatment, and radiation exposure as main effects. Femoral head CTh maps were constructed from a control scan (1-3 months prior to radiation), the CT simulation scan, and the CT scan performed within 1-2 months following treatment in patients treated for pelvic malignancies. The CTh values from the control scan and simulation scan were compared to establish baseline pretreatment values. Using the radiation treatment plans, dose regions were created in 10 Gy increments ranging from 0 Gy to 60 Gy. Regions of interest (ROI) were defined as the intersection of the dose regions and femoral head. The pretreatment scans were registered to the posttreatment scan using rigid body transformation, and analogous ROIs were identified. A similar process was performed to obtain the ROI for the control subjects. The mean CTh within each ROI was determined posttreatment and compared to the baseline thickness using a repeated measures ANCOVA model that included patient age, gender, chemotherapy treatment, and radiation exposure as main effects. ResultsFifty-one femoral heads were analyzed from 27 patients (15 female). Median patient age was 54 years (range 30 to 87). Radiation treatment techniques included VMAT, 3-field, and 4-field arrangements. Treatments were performed primarily using 6 or 10 MV photons. Dose to the femoral head ranged from 0-59.2 Gy. Median date to follow-up scans was 15 days (range 0 to 52) from the last radiation treatment. The effect of radiation exposure on CTh was significant (P=.050). Significant cortical bone thinning versus control was observed in all ROIs that absorbed >20 Gy, with a mean loss of 15.4% (P=.006), 14.1% (P=.017), and 14.4% (P=.011) in the 20-30 Gy, 30-40 Gy, and > 40 Gy ROIs, respectively. Conversely, the overall effect of age, gender, and use of chemotherapy were not significant. Fifty-one femoral heads were analyzed from 27 patients (15 female). Median patient age was 54 years (range 30 to 87). Radiation treatment techniques included VMAT, 3-field, and 4-field arrangements. Treatments were performed primarily using 6 or 10 MV photons. Dose to the femoral head ranged from 0-59.2 Gy. Median date to follow-up scans was 15 days (range 0 to 52) from the last radiation treatment. The effect of radiation exposure on CTh was significant (P=.050). Significant cortical bone thinning versus control was observed in all ROIs that absorbed >20 Gy, with a mean loss of 15.4% (P=.006), 14.1% (P=.017), and 14.4% (P=.011) in the 20-30 Gy, 30-40 Gy, and > 40 Gy ROIs, respectively. Conversely, the overall effect of age, gender, and use of chemotherapy were not significant. ConclusionThe significant reduction of femoral head CTh of up to 15% seen in patients receiving EBRT in the acute setting presents a possible mechanism for radiation induced fracture. This suggests CTh may be a potential marker for radiation induced PIF. Early CTh loss appears to be primarily affected by radiation exposure. Further research is needed evaluating the correlation between CTh and incidence of fracture. The significant reduction of femoral head CTh of up to 15% seen in patients receiving EBRT in the acute setting presents a possible mechanism for radiation induced fracture. This suggests CTh may be a potential marker for radiation induced PIF. Early CTh loss appears to be primarily affected by radiation exposure. Further research is needed evaluating the correlation between CTh and incidence of fracture.