388 Background: Patient Reported Outcomes (PROs) can help guide patient-provider discussions and generate high alert values (HAVs) that prompt clinical response. We analyzed PRO use among Gynecologic Radiation Oncology (GYN RO) patients to identify predictors of HAVs and provider response. Methods: We retrospectively analyzed PRO responses among GYN RO patients seen at our institution from 2022-2024. Patients received PRO-CTCAE surveys 72 hours prior to each consult, follow up (F/U), and on-treatment visit (OTV). HAVs (prespecified high severity/frequency PRO responses) sent alerts to the care team via Epic. Demographic (age, race, marital status), clinical (cancer type, metastatic disease [mets], comorbidities, ECOG performance status [PS]), and treatment (radiation [RT], chemotherapy [chemo]) data were collected. Multivariable logistic regression models (MVA) were used to identify variables associated with 1) patients reporting at least 1 HAV and 2) documented provider response to HAVs within 7 days. Results: Among 369 patients completing at least 1 survey, the median age was 63 (IQR 52-70). Most common cancer types included uterine (50%) and cervix (31%). Only 34% had mets. Within this cohort, 45% generated at least 1 HAV. Common HAVs included pain (42%), vaginal bleeding (27%), anxiety (10%), and urinary symptoms (7%). On MVA, higher ECOG PS (score 2: OR 2.78, p<0.01; score 3: OR 4.12, p=0.02; score 4: OR 23.61, p<0.01; ref score 0) and diagnoses of depression (OR 2.27, p<0.01), chronic pain (OR 3.24, p<0.01), neuropathy/neuralgia (OR 1.64, p=0.04), and sleep disorders (OR 1.92, p=0.01) were associated with higher HAV risk. Compared to consult visits, OTVs were less likely to generate HAVs (OR 0.40, p<0.01). HAV risk did not differ with age, race, marital status, cancer type, mets, concurrent chemo, RT modality/fraction, or other comorbidities. Providers responded to pain, vaginal bleeding, and urinary HAVs 94%, 79% and 60% of the time, while response rates for anxiety HAVs were 33%. On MVA, provider response was more likely for patients with higher Charlson Comorbidity Index (CCI) scores and non-uterine cancers (Table). Provider response was less likely prior to F/U visits or for non-pain related HAVs. Provider response did not differ with age, race, marital status, ECOG PS, concurrent chemo, or RT modality/fraction. Conclusions: 45% of patients completing PROs generated HAVs. Providers frequently documented interventions for pain and bleeding related HAVs, but infrequently intervened for mental health-related HAVs. This may indicate room for improvement in how psychosocial care is integrated into oncology care. Significant variables Provider response (%) OR p-value Visit type Consult 79 Ref F/U 62 0.20 0.001 HAV type Pain 94 Ref Vaginal Bleeding 79 0.10 <0.001 Anxiety 33 0.02 <0.001 Urinary Symptoms 60 0.08 <0.001 Other 57 0.09 <0.001 Uterine cancer Yes ( Ref = no) 70 0.45 0.047 CCI 1.32 <0.001

381 Background: Patient reported outcomes (PROs) can help guide patient-provider discussions and generate high alert values (HAVs) that prompt clinical response. We analyzed PRO outcomes among Thoracic Radiation Oncology (TRO) patients to identify predictors of HAVs and provider response. Methods: We retrospectively analyzed PRO responses among TRO patients seen at our institution from 2021-2024. Patients received surveys comprised of 13 symptom items from the PRO-CTCAE Measurement System, 72 hours prior to each consult, follow up, and weekly on-treatment visit (OTV). HAVs (prespecified high severity/frequency PRO responses) sent alerts to the care team via Epic Inbasket. Demographic (age, gender, race/ethnicity, marital status) and clinical (cancer type, metastatic disease [mets], smoking status, alcohol use, psychiatric diagnoses/treatment) data were collected. Multivariable logistic regression models (MVA) were used to identify variables associated with 1) patients reporting a HAV and 2) documented provider response to HAVs within 7 days. Results: Among 2973 patients who completed at least one survey, 52% were male with median age 68 (IQR 61-75). Most common cancer types included lung (64%) and esophagus (13%). Within this cohort, 40% of patients generated at least one HAV. Common HAVs included pain (49%), dyspnea (17%), anxiety (14%), and sadness (9%). Younger age (OR 1.02/yr, p<0.01 ), former or current heavy smoking (OR 1.29, p<0.01; OR 1.70, p<0.01; ref never smoker), divorced/separated/widowed status (OR 1.32, p=<0.01; ref married/significant other), psychiatric diagnosis or treatment (OR 1.39, p=0.01; OR 1.79, p<0.01), mesothelioma/trachea/thymus primary (OR 1.94, p<0.01; ref lung), and bone mets (OR 2.03, p<0.01) were associated with greater reporting of HAVs. Patients with lung mets were less likely to generate HAVs (OR 0.72, p=0.02). Providers responded to pain HAVs 79% of the time, while response rates for anxiety and depression HAVs were <25%. On MVA, providers were more likely to respond to HAVs reported prior to OTVs and for patients with bone mets (Table). In comparison to alerts related to pain, providers were less likely to respond to HAVs for dyspnea, anxiety, sadness, or palpitations. Both HAV risk and provider response did not differ by gender, race/ethnicity, or presence of other types of mets. Conclusions: 40% of patients completing PROs generated HAVs. Providers frequently acknowledged and documented interventions for pain-related HAVs, but infrequently documented interventions for mental health-related HAVs. This may indicate room for improvement in how psychosocial care is integrated into oncology care. Significant Variables Provider response (%) OR p-value Visit type Consult 54 Ref OTV 68 1.63 0.010 HAV type Pain 79 Ref Dyspnea 69 0.69 0.046 Anxiety 21 0.08 <0.001 Sadness 14 0.04 <0.001 Palpitations 7 0.02 <0.001 Bone mets No 57 Ref Yes 74 1.58 0.021

419 Background: Adolescents and young adults (AYAs), defined as patients (pts) aged 15–39, experience unique physical and psychosocial side effects from cancer treatment as compared to older adults. Discrepancies between physician- and pt-reported toxicities may lead to underrecognition and undertreatment of adverse events (AEs) during radiation therapy (RT). Implementing physician- and pt-reported outcome surveys may improve AE detection and symptom management in AYAs. Herein, we describe preliminary pt characteristics and survey response rates from our automated, electronic, low burden, low resource prospective study assessing physician- vs. pt-reported outcomes. Methods: AYAs receiving RT between March 2024–April 2025 were screened for participation. Exclusion criteria included inability to independently complete PROs and RT dose < 10 Gy. AEs were assessed using Patient Reported Outcome-Common Terminology Criteria for Adverse Events (PRO-CTCAE; pt) and CTCAE (physician) tools. Surveys were delivered electronically via email or text message, with four fully automated electronic reminders sent out to patients per survey and one sent to physicians. The primary endpoint was agreement between physician- and pt-reported AEs across five domains (nausea, vomiting, radiation dermatitis, tumor pain, fatigue, anxiety, and depression) at the final weekly RT visit. Secondary endpoints included agreement at earlier visits and association of AE disagreement with co-variates, including sociodemographic, clinical, and treatment-related factors. Results: Of 101 consented pts, 68% were female; median age was 31 years (range 17–39). Most pts were Caucasian (73%), followed by Hispanic/Latino (25%), Asian (14%), or Black (12%). The most prevalent cancer types included breast (31%), sarcoma (20%), central nervous system (16%), and hematologic (10%). Patient clinical stages were stage I (13%), II (21%), III (31%), and IV (36%). Most pts received curative-intent RT (90%), with a median dose of 50 Gy (range: 12–70) in a median number of 22.5 fractions (range: 1–44); 70% received concurrent chemotherapy. Of 101 pts initiating RT, 73% of pts and 65% of physicians completed baseline PRO-CTCAE and CTCAE surveys, respectively. Response rates across the 6 weekly RT appointments ranged from 64–79% and 56–76% for patients and physicians, respectively (see Table). Conclusions: PRO and physician electronic reporting offers a low-resource, low-burden, and feasible approach for capturing AEs in real time, with potential to improve symptom management in AYAs receiving RT. Weekly #1n=98 Weekly #2n=84 Weekly #3n=79 Weekly #4n=63 Weekly #5n=45 Weekly #6n=27 Patient 75(76.5%) 62(73.8%) 62(78.5%) 47(74.6%) 29(64.4%) 18(66.7%) Physician 74(75.5%) 55(65.5%) 60(75.9%) 36(57.1%) 25(55.6%) 16(59.3%)

PURPOSE:Brachytherapy-induced prostate edema (PE) can result in altered target dose coverage in prostate cancer patients treated with low-dose-rate (LDR) brachytherapy. While visualization of PE on CT is limited, PE is evident on magnetic resonance imaging (MRI) day 0 (D0) postimplant assessment, a critical step in the MRI-assisted radiosurgery (MARS) framework that improves LDR brachytherapy quality assurance. This study investigated PE in patients treated with MARS to analyze the effect on postimplant dosimetry and further optimize the treatment-planning process. MATERIALS AND METHODS:We identified 317 patients with low-risk to intermediate-risk prostate cancer treated with cesium-131, iodine-125, or palladium-103 MARS definitive monotherapy from 2016 to 2021. Postimplant dosimetry was performed using MRI on D0. Simple linear regression with Pearson correlation analysis and ordinary ANOVA were used for analysis. RESULTS:The median D0 prostate volume was 29% higher (IQR, 16%-42%) compared with preimplant measurement, with no significant differences in PE magnitude by isotope (p = 0.33) or number of needles implanted (p = 0.70). PE magnitude decreased with increasing preplan prostate size (p < 0.001). Greater PE was associated with decreased D0 prostate V100 (p < 0.001), V150 (p < 0.001), and D90 (p < 0.001), but was not associated with V200 (p = 0.06), and >98% implants achieved D90/prescription dose >90%. Greater PE was associated with decreased rectum V100 (p = 0.02). CONCLUSIONS:MRI on D0 confirmed PE after LDR brachytherapy. PE was not significantly different between isotopes, supporting the use of the same preplan target-volume margins among isotopes. Greater PE was associated with decreased prostate V100, V150, and D90, without significant impact on overall implant quality.

BackgroundSelect patients with relapsed/refractory aggressive B cell lymphoma may benefit from bridging radiation (bRT) prior to anti-CD19-directed chimeric antigen receptor T cell therapy (CAR-T). Here, we examined patient and treatment factors associated with outcomes and patterns of failure after bRT and CAR-T.MethodsWe retrospectively reviewed adults with diffuse large B-cell lymphoma (DLBCL) who received bRT prior to axicabtagene ciloleucel, tisagenlecleucel, or lisocabtagene maraleucel between 11/2017-4/2023. Clinical/treatment characteristics, response, and toxicity were extracted. Survival was modeled using Kaplan-Meier or Cox regression models for events distributed over time, or binary logistic regression for disease response. Fisher’s Exact Test or Mann-Whitney U methods were used.ResultsOf 51 patients, 25.5% had bulky disease and 64.7% had Stage III/IV disease at the time of RT. Comprehensive bRT alone to all disease sites was delivered to 51% of patients, and 29.4% were additionally bridged with systemic therapy. Median follow-up was 10.3 months (95% CI: 7.7-16.4). Overall response rate (ORR) was 82.4% at 30 days post-CAR-T infusion. Median overall survival (OS) was 22.1 months (6.6-not reached) and the median progression-free survival (PFS) was 7.4 months (5.5-30). OS/PFS were 80% (66-99)/78% (64-87) at 1-year, and 59% (44-71)/54% (40-67) at 2-years, respectively. Comprehensive RT to all sites of disease correlated with improved PFS and OS, p ≤ 0.04. Additionally, ECOG ≥2 and Stage III/IV disease predicted poor OS (p ≤ 0.02). Disease bulk, IPI ≥3, and non-GCB histology were poor predictors for disease-specific survival (DSS), p<0.05. The latter two, as well as bRT dose of ≤30 Gy predicted worse PFS (p<0.05). Among patients with advanced stage disease, comprehensive bRT to all sites of disease (n=10) was not associated with improved OS and PFS compared to focal bRT (n=23), p>0.17. No difference was seen in bridging RT vs. chemoRT. Twenty-six patients developed relapse (50.9%), of which 46% was in-field. Risk of in-field relapse correlated with bulky disease (OR=7, 95% CI: 1.2-41, p=0.03) and lack of response at 30 day post-CAR-T evaluation (OR=16.8, 95% CI: 1.6-176, p=0.02), but not with bRT dose (p=0.27).ConclusionbRT and CART is a good treatment strategy for select patients with aggressive B cell lymphoma. Comprehensive bRT including all sites of disease is associated with improved outcomes.

BackgroundDiffuse large B-cell lymphoma (DLBCL) involving the gastrointestinal (GI) organs is rare, and real-world outcomes after combined modality therapy (CMT) with systemic therapy (ST) and radiotherapy (RT) are not well-characterized, particularly in the contemporary era. We characterized outcomes in a large cohort of GI-DLBCL patients treated with ST alone or CMT.MethodsPatients with GI-DLBCL treated at a single institution were retrospectively reviewed. Kaplan-Meier and Cox regression models estimated survival. Multivariable analyses were conducted using the Cox proportional hazards model.ResultsOf 204 patients, gastric involvement was most common (63%). Most presented with early-stage disease (61%). All patients received ST and 65 patients (32%) received RT, 88% as part of first-line CMT. Median dose was 36 Gy (IQR 30.6–39.6) in 18 fractions (IQR 17–22). Median follow-up was 46 months. Five-year overall survival (OS) and progression-free survival (PFS) was 88% and 84%, respectively; complete response (CR) rate was 82%. Improved OS associated with low IPI (p=0.001), fewer chemotherapy lines (p<0.001), early stage (p<0.006), and CR (p<0.001). Survival did not differ by RT receipt (p>0.25). Only early stage and CR correlated with improved OS on multivariable analysis. Stomach-directed RT vs. RT to other sites correlated with improved PFS and OS (p<0.04). Patients with early stage DLBCL treated with CMT in the post-rituximab era had equivalent OS vs. ST alone, even with fewer chemotherapy cycles (p<0.02; median of 4 with RT vs. 6 cycles without). Fifty patients had bulky disease (≥7.5 cm), of whom 18 (36%) had early stage disease. Among patients with bulky disease, 5 (10%) developed relapse at the initial site of disease bulk. Four of the 5 patients did not receive consolidative radiation. Among these 4 patients, 3 relapsed only in their initial site of bulky disease. Of 191 patients with luminal GI-DLBCL, n=4 (2.1%) developed perforation; only one received RT. Acute Grade 3 toxicities were reported in 41.2% of patients, and 12 (5.8%) patients had late Grade 3 toxicities, 99% attributed to chemotherapy.ConclusionGI-DLBCL patients have favorable outcomes after CMT with minimal late toxicity. CMT may be offered with abridged systemic regimens with equivalent outcomes. Stomach directed-RT may mitigate relapse risk associated with incomplete disease response or bulky disease.

INTRODUCTION:We aimed to assess contouring-related practices among US radiation oncologists and explore how access to and use of resources and quality improvement strategies vary based on individual- and organization-level factors.METHODS:We conducted a mixed methods study with a sequential explanatory design. Surveys were emailed to a random 10% sample of practicing US radiation oncologists. Participating physicians were invited to a semi-structured interview. Kruskal-Wallis and Wilcoxon rank-sum tests and a multivariable regression model were used to evaluate associations. Interview data were coded using thematic content analysis.RESULTS:Survey overall response rate was 24%, and subsequent completion rate was 97%. Contouring-related questions arise in ≥50% of clinical cases among 73% of respondents. Resources accessed first include published atlases (75%) followed by consulting another radiation oncologist (60%). Generalists access consensus guidelines more often than disease-site specialists (P = 0.04), while eContour.org is more often used by generalists (OR 4.3, 95% CI 1.2-14.8) and younger physicians (OR 1.33 for each 5-year increase, 95% CI 1.08-1.67). Common physician-reported barriers to optimizing contour quality are time constraints (58%) and lack of access to disease-site specialists (21%). Forty percent (40%, n = 14) of physicians without access to disease-site specialists indicated it could facilitate the adoption of new treatments. Almost all (97%) respondents have formal peer review, but only 43% have contour-specific review, which is more common in academic centres (P = 0.02).CONCLUSION:Potential opportunities to improve radiation contour quality include improved access to disease-site specialists and contour-specific peer review. Physician time must be considered when designing new strategies.

Purpose Patient experience scores are increasingly important in measuring quality of care and determining reimbursement from payers, including the Hospital Value-Based Purchasing Program and the Radiation Oncology Model. However, the role of bias in patient experience scores in oncology is unknown, raising the possibility that such payment structures may inadvertently perpetuate bias in reimbursement. Therefore, the authors characterized patient-, physician-, and practice-level predictors of patient experience scores in patients undergoing radiation therapy. Methods The authors retrospectively reviewed patient experience surveys for radiation oncology patients treated at two large multisite academic cancer centers. The outcome was responses on four survey questions. Covariates included self-reported patient demographics, physician characteristics, practice setting characteristics, and wait-time rating linked to each survey. Multivariable ordinal regression models were fitted to identify predictors of receiving a higher score on each of the survey questions. Results In total, 2,868 patients completed surveys and were included in the analysis. Patient experience scores were generally high, with >90% of respondents answering 5 of 5 on the four survey items. Physician gender was not associated with any measured patient experience outcomes (P > 0.40 for all). Independent predictors of higher score included a wait-time experience classified as “good” compared with “not good” (q < .001 for all). Conclusions Oncology practices aiming to improve patient experience scores may wish to focus their attention on improving wait times for patients. Although a difference in patient experience scores on the basis of physician gender was not observed, such bias is likely to be complex, and further research is needed to characterize its effects.

Purpose:: Guidelines for early-stage breast cancer allow for radiation therapy (RT) omission after breast conserving surgery among older women, though high utilization of RT persists. This study explored surgeon referral and the effect of a productivity-based bonus metric for radiation oncologists in an academic institution with centralized quality assurance review. Methods and materials:: We evaluated patients ≥70 years of age treated with breast conserving surgery for estrogen receptor (ER)+ pT1N0 breast cancer at a single tertiary cancer network between 2015 and 2018. The primary outcomes were radiation oncology referral and RT receipt. Covariables included patient and physician characteristics and treatment decisions before versus after productivity metric implementation. Univariable generalized linear effects models explored associations between these outcomes and covariables. Results:: Of 703 patients included, 483 (69%) were referred to radiation oncology and 273 (39%) received RT (among those referred, 57% received RT). No difference in RT receipt pre- versus post-productivity metric implementation was observed (P = .57). RT receipt was associated with younger patient age (70-74 years; odds ratio [OR], 2.66; 95% confidence interval [CI], 1.54-4.57) and higher grade (grade 3; OR, 7.75; 95% CI, 3.33-18.07). Initial referral was associated with younger age (70-74; OR, 5.64; 95% CI, 3.37-0.45) and higher performance status (Karnofsky performance status ≥90; OR, 5.34; 95% CI, 2.63-10.83). Conclusions:: Nonreferral to radiation oncology accounted for half of RT omission but was based on age and Karnofsky performance status, in accordance with guidelines. Lack of radiation oncologist practice change in response to misaligned financial incentives is reassuring, potentially reflecting incentive design and/or centralized quality assurance review. Multi-institutional studies are needed to confirm these findings.

BACKGROUND AND PURPOSE:Artificial intelligence advances have stimulated a new generation of autosegmentation, however clinical evaluations of these algorithms are lacking. This study assesses the clinical utility of deep learning-based autosegmentation for MR-based prostate radiotherapy planning. MATERIALS AND METHODS:Data was collected prospectively for patients undergoing prostate-only radiation at our institution from June to December 2019. Geometric indices (volumetric Dice-Sørensen Coefficient, VDSC; surface Dice-Sørensen Coefficient, SDSC; added path length, APL) compared automated to final contours. Physicians reported contouring time and rated autocontours on 3-point protocol deviation scales. Descriptive statistics and univariable analyses evaluated relationships between the aforementioned metrics. RESULTS:Among 173 patients, 85% received SBRT. The CTV was available for 167 (97%) with median VDSC, SDSC, and APL for CTV (prostate and SV) 0.89 (IQR 0.83-0.95), 0.91 (IQR 0.75-0.96), and 1801 mm (IQR 1140-2703), respectively. Physicians completed surveys for 43/55 patients (RR 78%). 33% of autocontours (14/43) required major "clinically significant" edits. Physicians spent a median of 28 min contouring (IQR 20-30), representing a 12-minute (30%) time savings compared to historic controls (median 40, IQR 25-68, n = 21, p < 0.01). Geometric indices correlated weakly with contouring time, and had no relationship with quality scores. CONCLUSION:Deep learning-based autosegmentation was implemented successfully and improved efficiency. Major "clinically significant" edits are uncommon and do not correlate with geometric indices. APL was supported as a clinically meaningful quantitative metric. Efforts are needed to educate and generate consensus among physicians, and develop mechanisms to flag cases for quality assurance.

Purpose: We aimed to develop and study the implementation of a remote system for toxicity assessment and management of acute side effects of breast radiation using electronic patient-reported outcomes (ePROs). Methods and Materials: A response-adapted Patient-Reported Outcomes Common Terminology Criteria for Adverse Events -based assessment for breast radiation toxicity was administered weekly during and for 8 weeks after radiation from June 2019 to July 2020. The care team received alerts when "severe" symptoms were reported by patients, who were then contacted. Treatment, clinic, and sociodemographic characteristics were abstracted from patient records. A subsample of patients and care team members was qualitatively interviewed at follow-up. Results: Overall, 5787 assessments were sent to 678 patients, of whom 489 (72%) completed 2607 assessments (45%). Moderate or greater toxicity was reported by 419 responders (86%; 95% CI, 82%-89%). Clinician alerts for severe toxicity were generated for 264 assessments among 139 unique patients, of which 83% occurred posttreatment. The proportion of surveys that prompted an alert was significantly higher after treatment (219 [13%]) than during treatment (45 [5%]) (P < .001). Survey completion rates in the posttreatment period were higher among patients undergoing partial breast irradiation than postmastectomy radiation (incidence rate ratio, 0.70; 95% CI, 0.60-0.81) (P < .001) despite these patients experiencing less severe toxicity. Interviews (15) found that patients had a positive experience with ePROs, although many thought the primary purpose was for research rather than symptom management. Conclusions: With the majority of toxicity occurring after breast radiation has ended, remote symptom monitoring with ePROs appears to fill a gap in clinical practice, particularly for patients undergoing shorter courses of radiation. It is important to properly onboard patients and explain that the purpose of ePROs is to aid clinical care. Further research is needed to determine whether the costs associated with ePROs can be offset by reducing routine clinic visits and whether this approach is acceptable and appropriate. (C) 2021 Elsevier Inc. All rights reserved.

Purpose Guidelines for early-stage breast cancer allow for radiotherapy (RT) omission following breast conserving surgery (BCS) among older women, though high utilization of RT persists. This study explores surgeon referral and the effect of a productivity-based bonus metric for radiation oncologists in an academic institution with centralized quality assurance (QA) review. Methods We evaluated patients ≥ 70 years of age treated with BCS for ER + pT1N0 breast cancer at a single institution between 2015–2018. The primary outcomes were radiation oncology referral and RT receipt. Covariables included patient and physician characteristics, and treatment decisions before versus after productivity metric implementation. Univariable generalized linear effects models explored associations between these outcomes and covariables. Results Of 703 patients included, 483 (69%) were referred to radiation oncology and 273 (39%) received RT (among those referred, 57% received RT). No difference in RT receipt pre- versus post- productivity metric implementation was observed (p = 0.57). RT receipt was associated with younger patient age (70–74 years, OR 2.66, 95% CI 1.54–4.57) and higher grade (grade 3, OR 7.75, 95% CI 3.33–18.07). Initial referral was associated with younger age (70–74, OR 5.64, 95% CI 3.37–0.45) and higher performance status (KPS ≥90, OR 5.34, 95% CI 2.63–10.83). Conclusion Non-referral to radiation oncology accounted for half of RT omission, but was based on age and KPS, in accordance with guidelines. Lack of radiation oncologist practice change in response to misaligned financial incentives is reassuring, potentially reflecting centralized QA review. Multi-institutional studies are needed to confirm these findings.

BACKGROUND:The COVID-19 pandemic has transformed cancer care with the rapid expansion of telemedicine, but given the limited use of telemedicine in oncology, concerns have been raised about the quality of care being delivered. We assessed the patient experience with telemedicine in routine radiation oncology practice to determine satisfaction, quality of care, and opportunities for optimization.PATIENTS AND METHODS:Patients seen within a multistate comprehensive cancer center for prepandemic office visits and intrapandemic telemedicine visits in December 2019 through June 2020 who completed patient experience questionnaires were evaluated. Patient satisfaction between office and telemedicine consultations were compared, patient visit-type preferences were assessed, and factors associated with an office visit preference were determined.RESULTS:In total, 1,077 patients were assessed (office visit, n=726; telemedicine, n=351). The telemedicine-consult survey response rate was 40%. No significant differences were seen in satisfaction scores between office and telemedicine consultations, including the appointment experience versus expectation, quality of physician's explanation, and level of physician concern and friendliness. Among telemedicine survey respondents, 45% and 34% preferred telemedicine and office visits, respectively, and 21% had no preference for their visit type. Most respondents found their confidence in their physician (90%), understanding of the treatment plan (88%), and confidence in their treatment (87%) to be better or no different than with an office visit. Patients with better performance status and who were married/partnered were more likely to prefer in-person office visit consultations (odds ratio [OR], 1.04 [95% CI, 1.00-1.08]; P=.047, and 2.41 [95% CI, 1.14-5.47]; P=.009, respectively). Patients with telephone-only encounters were more likely to report better treatment plan understanding with an office visit (OR, 2.25; 95% CI, 1.00-4.77; P=.04).CONCLUSIONS:This study is the first to assess telemedicine in routine radiation oncology practice, and found high patient satisfaction and confidence in their care. Optimization of telemedicine in oncology should be a priority, specifically access to audiovisual capabilities that can improve patient-oncologist communication.

249 Background: The objective of this study was to assess contouring-related quality improvement practices employed by radiation oncologists in the United States (US) and to identify individual and organizational factors associated with use. Methods: We conducted a mixed methods study with a sequential explanatory design. A survey was developed with domains assessing individual and organizational demographic characteristics, clinical decision support strategies, and quality assurance and improvement processes. Study invitations were sent to a random 10% sample of practicing US radiation oncologists. After survey completion, physicians were invited to participate in a 30-minute audio-recorded semi-structured interview. Kruskal-Wallis and Wilcoxon rank-sum tests were used to evaluate associations between participant characteristics and survey responses. Interview data were coded using thematic content analysis. Results: The web-based survey response rate was 24% (115/482), and we completed 15 interviews. 72% of survey respondents report that contouring-related questions arise in at least half of cases in routine patient care, and the resources they access first are cooperative group guidelines and contouring atlases (e.g. RTOG/NRG) (75%) followed by consulting another radiation oncologist (60%). The most frequent barriers to optimizing quality of contours and treatment plans are time constraints (58%) and lack of access to disease site specialists (22%). About half (54%) of respondents do not have access to on-site disease site specialists. A majority of survey respondents (75%) believe having access to disease site specialists to review image-based radiation treatment-related questions would be helpful, and 40% indicated it could facilitate adoption of new radiation treatments. Seven interviewees mentioned engaging with out-of-network sub-specialists by phone, text or email. Five interviewees without access to sub-specialists mentioned a formalized system for consultation could be helpful. While almost all (97%) respondents report having a formal process for peer review, only 44% have contour-specific peer review. Academic centers/university setting and higher number of colleagues are factors associated with increased access to contour-specific peer review (p = 0.02 and p = 0.001). Clinical pathway use was reported by 18% of survey respondents, and interviews revealed concerns related to physician autonomy (i.e. ability to individualize treatment recommendations). Conclusions: This study identifies two potential opportunities to improve the radiation treatment quality from the physician’s perspective– improved access to disease site specialists and contour-specific peer review. Research is needed to test the acceptability and effectiveness of these strategies. Time and resource constraints must be considered when designing quality improvement efforts.

Purpose: Telemedicine was rapidly implemented for initial consultations and radiation treatment planning in the wake of the coronavirus disease 2019 (COVID-19) pandemic. In this study, we explore utilization of and physician perspectives on this approach in an attempt to identify patient populations that may benefit most from virtual care. Methods and Materials: This is a mixed-methods study with a convergent design. Approximately 6 to 8 weeks after implementation of telemedicine, all radiation oncologists in a single academic radiation oncology department were invited to participate in either semistructured interviews with embedded survey questions or a concurrently administered survey only. Rapid qualitative analysis was used to identify common themes, and quantitative data was assessed using descriptive statistics and univariable analyses. Results: At the apex of the pandemic, 92% of radiation oncology visits were conducted via telemedicine. In total, 51 of 61 radiation oncologists participated in the study (response rate 84%). Most (71%) reported no difference in ability to treat cancer appropriately via telemedicine, which was more common among specialized physicians (P Z .01) but not those with higher visit volume or years of experience. Over half (55%) perceived no difference or even improvement in overall visit quality with telemedicine. Virtual visits were deemed acceptable for a median of 70% to 96% of patients, which varied by disease site. Need for physical examination, and availability of an acceptable proxy, factored into telemedicine acceptability. Most (88%) found telemedicine better than expected, but opinions were split on how telemedicine would affect physician burnout. Almost all (96%) foresaw a role for telemedicine beyond the pandemic and would opt for a median of 50% (interquartile range 20%-66%) of visits conducted via telemedicine. Conclusions: Among radiation oncologists in an academic setting, telemedicine was perceived to be highly appropriate and acceptable for most patients. Future studies should focus on identifying the 5% to 30% of patients whose care may be optimized with in-person visits, and if there is alignment with patient preferences. (C) 2020 Elsevier Inc. All rights reserved.