Faculty Bibliography

Purpose/Objective(s): The LGBTQ community is an understudied and medically underserved population who experience increased cancer risk and worse cancer outcomes. Negative provider interactions, including discrimination and lack of knowledge regarding LGBTQ-specific health issues are cited by patients as barriers to care, including in radiation oncology (RO). Notably, little is known regarding LGBTQ knowledge and attitudes among RO residents (ROR) or LGBTQ-specific training in RO residency training programs. Thus, we sought to assess the extent of current LGBTQ-specific training in U.S. RO residency programs. Materials/Methods: Two published surveys of LGBTQ-education in residency were adapted to RO. The first assessed LGBTQ education from the perspective of program directors (PD) and associate PDs (APD), while the second survey was to RORs. The surveys were sent to all ACGME-accredited U.S. RO residency PD, APD, and program coordinators (PC), with the ROR survey being disseminated by the respective PCs. Each survey consisted of subsections of attitudes and knowledge in the care of LGBTQ patients, RO program characteristics, program inclusion of LGBTQ-specific education, and individual demographics.
Result(s): There were 69 responses (29 PD, APD and 40 ROR). The majority of respondents (PD, APD/ROR) identified as white (79%/58%), non-Hispanic (76%/72%), male (55%/55%), and heterosexual (86%/78%). The majority of PD, APDs did not receive LGBTQ education in medical school (60%) or residency training (96%), while the majority of residents (68%) did receive LGBTQ training in medical school; yet, both groups felt this training was insufficient to care for LGBTQ patients during residency (76%/68%). Overall, respondents felt comfortable treating LGB (90%/85%) and T (79%/62.5%) patients. However, the majority did not feel confident in their knowledge for LGB (52%/62.5%) or T (79%/85%) health needs. The majority of respondents' programs have never had a didactic session on LGBTQ health (78%/80%) resulting in 61%/61% of respondents feeling their program inadequately prepares residents to work confidently with LGBTQ patients. However, the majority felt their program is receptive to incorporating LGBTQ health content into their curriculum (75%/75%) and expressed a personal interest in such education (97%/80%). Additional data will be available by time of conference.
Conclusion(s): We found an increase of LGTBQ education in medical schools between PD, APD and ROR, suggestive of a recent improvement in LGBTQ content; yet most residency programs still lacked any LGBTQ-specific education. While the majority felt comfortable treating LGBTQ patients, they simultaneously lacked confidence in knowledge regarding LGBTQ health needs; yet, possessed desire for additional education and belief that such trainings should require. Conclusion is that residencies need to do a better job incorporating LGBTQ health content into their curricula, which is supported by interest from ROR and program leadership.
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PURPOSE/OBJECTIVE:Verification of patient position through pretreatment setup imaging is crucial in modern radiation therapy. As treatment complexity increases and technology evolves, physicist-physician collaboration becomes imperative for safe and successful radiation delivery. Despite the importance of both, residency programs lack formal interprofessional education (IPE) activities or structured training for image verification. Here we show the impact of an interprofessional image verification workshop for residents in a multi-institutional setting. METHODS:The workshop included a lecture by the attending physicist and physician, and hands-on image registration practice by learners (medical physics residents, MP; and radiation oncology residents, RO). All participants filled out pre- and postactivity surveys and rated their comfort from 1 to 10 in (A) selecting what type of imaging to order for a given case and (B) independently assessing the setup quality based on imaging. A paired 1-tailed t test (α = 0.05) was used to evaluate significance; Spearman rank correlation coefficient was used to assess correlation of ratings and RO postgraduate year (PGY). Surveys had free-response questions about IPE and image verification activities in residency. RESULTS: = 1.2 ± 1.6, P = .016). RO confidence scores moderately correlated with PGY. Survey responses indicated that image verification training is mostly unstructured, with extent of exposure varying by program and attending; most with little-to-no training. Time constraints were identified as the main barrier. IPE was noted as a useful way to incorporate different perspectives into the process. CONCLUSIONS:Formal image verification training increases resident comfort with setup imaging review and provides opportunities for interprofessional collaboration in radiation oncology residency programs.

PURPOSE/OBJECTIVE(S): NRG/RTOG 0848 is a two-step randomized trial to evaluate the benefit of the addition of concurrent fluoropyrimidine and radiotherapy (RT) following adjuvant gemcitabine-based chemotherapy (2nd step) for patients with resected pancreatic head adenocarcinoma. Real-time quality assurance (QA) was performed for each patient who underwent RT. QA findings were reviewed, frequencies & reasons for resubmissions are reported. MATERIALS/METHODS: Patients were treated using either a 3D-conformal RT (3DCRT) or intensity-modulated RT (IMRT) technique. In addition to a web-based contouring atlas, the protocol outlined step-by-step instructions for generating the clinical treatment volume (CTV) through the creation of specific regions of interest. The planning target volume (PTV) was established by expanding the CTV by 0.5 cm in all directions. Treatment planning data, including pre-operative imaging, surgical and pathology reports, simulation images with isodose lines, structure set, and dose volume histograms were submitted for review. One of two radiation oncology study chairs independently reviewed each plan. Plans with unacceptable deviations were returned for revision and then resubmitted for review until approved. Treatment started after final approval of the RT plan.
RESULT(S): Of the 354 patients who underwent second randomization, 180 were randomized to the RT arm. Of these, 160 received RT and were included in the QA analysis. Most patients (86%) were treated using IMRT. Resubmissions were more common for patients planned with 3D-CRT (43%) than with IMRT (31%). In total, at least one resubmission of the treatment plan was required for 33% of patients (see Table 1). Among patients requiring resubmission, the majority only needed to be resubmitted once (87%). The most common reasons for resubmission were unacceptable deviations with respect to the pre-operative gross target volume (GTV, 61%) and the pancreatojejunostomy (48%), leading to unacceptable deviations of the contours of the CTV and PTV (70% for each). Most patients requiring a resubmission had 5-9 unacceptable deviations (46%). Unacceptable deviations were similar for the few treatment plans that needed to be resubmitted more than once.
CONCLUSION(S): One third of patients required resubmission to meet protocol compliance criteria, demonstrating the continued need for expending resources on pretreatment QA for adjuvant pancreas cancer trials. Rigorous QA is of critical importance for clinical trials involving RT to ensure that the true impact of RT can be assessed. Moreover, RT QA serves as an educational process by training radiation oncologists on best practices.
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PROBLEM/OBJECTIVE:Physician-scientists are individuals trained in both clinical practice and scientific research. Often, the goal of physician-scientist training is to address pressing questions in biomedical research. The established pathways to formally train such individuals are, mainly, MD-PhD programs and physician-scientist track residencies. Although graduates of these pathways are well equipped to be physician-scientists, numerous factors, including funding and length of training, discourage application to such programs and impede success rates. APPROACH/METHODS:To address some of the pressing challenges in training and retaining burgeoning physician-scientists, New York University Grossman School of Medicine formed the Accelerated MD-PhD-Residency Pathway in 2016. This pathway builds on the previously established accelerated three-year MD pathway to residency at the same institution. The Accelerated MD-PhD-Residency Pathway conditionally accepts MD-PhD trainees to a residency position at the same institution through the National Resident Matching Program. OUTCOMES/RESULTS:Since its inception, 2 students have joined the Accelerated MD-PhD-Residency Pathway, which provides protected research time in their chosen residency. The pathway reduces the time to earn an MD and PhD by one year and reduces the MD training phase to three years, reducing the cost and lowering socioeconomic barriers. Remaining at the same institution for residency allows for the growth of strong research collaborations and mentoring opportunities, which foster success. NEXT STEPS/UNASSIGNED:The authors and institutional leaders plan to increase the number of trainees that are accepted into the Accelerated MD-PhD-Residency Pathway and track the success of these students through residency and into practice to determine if the pathway is meeting its goal of increasing the number of practicing physician-scientists. The authors hope this model can serve as an example to leaders at other institutions who may wish to adopt this pathway for the training of their MD-PhD students.

Background: Malnutrition incidence in cancer approaches 85%, disproportionately burdening those with lung, GI, and advanced stage cancers. Malnourished patients have impaired chemotherapy response, shorter survival, longer hospital stays, and decreased QoL. Home delivered meals are nutritional interventions that improve patient well- being, nutrition, and lower healthcare costs in the elderly but have not been studied as an intervention in cancer patients. HDMTM are nutritionist prescribed home delivered meals tailored to patient's symptoms, co-morbidities, and health needs. Preliminary data in 211 cancer patients showed with HDMTM 87% ate more than half of meals, 91% lived more independently, 89% ate more nutritiously, and 70% had less fatigue. HDMTM may be a strategy to reduce financial toxicity and healthcare utilization and improve QoL in cancer patients, but no primary data exists evaluating its efficacy.
Method(s): We sought to develop the first RCT evaluating patientcentered QoL improvement from nutritional intervention with HDMTM in those with metastatic lung and non-colorectal GI cancer. We established a partnership with God's Love We Deliver, a 501c3 non-profit specializing in HDMTM.
Result(s): We developed a protocol for a single-institution RCT of standard of care (SoC) versus SoC and HDMTM in metastatic lung and non-colorectal GI cancer patients with primary aim comparing QoL between arms at 12 weeks using the FACT-G questionnaire. Sample size is 180. Secondary aims assess HDMTM's impact on nutritional status, weight, mood, survival, food security, financial toxicity, healthcare utilization, and cost effectiveness. Eligible patients tolerate oral alimentation, have PS 0-3, and newly diagnosed (< 6 weeks) metastatic cancer. All patients have pre-randomization nutritional evaluation by an oncologic dietician.
Conclusion(s):We present the first PRMC reviewed and IRB approved RCT evaluating the efficacy of HDMTM in metastatic cancer patients with primary endpoint of patient reported QoL. Investigating HDMTM expands our knowledge of nutrition as an effective arm of palliative oncology

BACKGROUND:In patients with rectal cancer who achieve clinical complete response after neoadjuvant chemoradiotherapy, watch and wait is a novel management strategy with potential to avoid major surgery. Study-level meta-analyses have reported wide variation in the proportion of patients with local regrowth. We did an individual participant data meta-analysis to investigate factors affecting occurrence of local regrowth. METHODS:We updated search results of a recent systematic review by searching MEDLINE and Embase from Jan 1, 2016, to May 5, 2017, and used expert knowledge to identify published studies reporting on local regrowth in patients with rectal cancer managed by watch and wait after clinical complete response to neoadjuvant chemoradiotherapy. We restricted studies to those that defined clinical complete response using criteria equivalent to São Paulo benchmarks (ie, absence of residual ulceration, stenosis, or mass within the rectum on clinical and endoscopic examination). The primary outcome was 2-year cumulative incidence of local regrowth, estimated with a two-stage random-effects individual participant data meta-analysis. We assessed the effects of clinical and treatment factors using Cox frailty models, expressed as hazard ratios (HRs). From these models, we derived percentage differences in mean θ as an approximation of the effect of measured covariates on between-centre heterogeneity. This study is registered with PROSPERO, number CRD42017070934. FINDINGS/RESULTS:=0·0330). We estimated that measured factors contributed 4·8-45·3% of observed between-centre heterogeneity. INTERPRETATION/CONCLUSIONS:In patients with rectal cancer and clinical complete response after chemoradiotherapy managed by watch and wait, we found some evidence that increasing cT stage predicts for local regrowth. These data will inform clinician-patient decision making in this setting. Research is needed to determine other predictors of a sustained clinical complete response. FUNDING/BACKGROUND:None.