Faculty Bibliography

PURPOSE/OBJECTIVE:Recognition of disparities for vulnerable populations in the field of oncology is increasing, but little attention has been paid to deaf patients. At least a million Americans are culturally deaf and use American Sign Language. Poor linguistic and cultural competency among physicians is a barrier to care delivery for these patients, placing them at risk for treatment disparities. To better educate oncology practitioners, including radiation oncologists, regarding the unique needs of this cohort, we performed an evidence-based literature review of culturally competent care for deaf patients to improve patient care and delivery. METHODS AND MATERIALS/METHODS:PubMed was systematically reviewed for publications reporting on deaf patients for articles regarding (1) survivorship, patterns of failure, or toxicity in treating malignancies or (2) cultural and linguistic barriers to delivery of oncological care. Publications were excluded if deafness was a side effect of treatment or barriers and outcomes were reported on nonmalignant conditions. RESULTS:Barriers to care were poor health literacy, accessibility to providers or resources in preferred language (ie, American Sign Language), and limited cultural and linguistic proficiency of providers. Deaf patients may have a delay in cancer diagnosis, but no articles reported on treatment outcomes for malignancies in deaf patients. Currently, no oncology-specific guidelines exist on care delivery for deaf patients with cancer. We propose the need for a care model that provides guidelines on creating effective and total communication accessibility for deaf patients and improves cultural and linguistic competency among providers. Guidance should be provided on implementation of resources and training for oncology practitioners and how their respective institutions and staff can help create inclusive care environments. CONCLUSIONS:Clinical outcomes of deaf patients with cancer remain poorly characterized, highlighting the need for a care model to promote provision of linguistically and culturally competent oncological care for deaf patients.

Some deaf men who use American Sign Language (ASL) experience barriers in patient-physician communication which may leave them at disparity for shared decision making compared to hearing men. Transparent communication accessibility is needed between deaf male ASL users and their physicians to maximize the benefit to risk ratio of using the prostate-specific antigen (PSA) as a screening tool for early detection. The objective is to compare shared decision-making outcomes between deaf and hearing males who are (1) age-eligible for PSA screening and (2) younger than 45 years old with a family history of cancer. An accessible health survey including questions about PSA test, PCC, modes of communication, and cancer history was administered in ASL to a nationwide sample of deaf adults from February 2017 to April 2018. Two subsamples were created: (1) 45- to 69-year-old men who were age-eligible for PSA testing and (2) 18- to 44-year-old men with a family history of cancer. Age-eligible and younger deaf men with a family history of cancer are at disparity for shared decision making compared to their hearing peers. Regardless of age and PSA testing status, deaf men felt significantly less engaged in shared decision making with their health care providers compared to hearing men. Participation in shared decision making requires not only accessible communication but also cultural competency in working with deaf patients. This is critical in the shared decision-making era in maximizing the benefit of prostate cancer screening in deaf male patient population.

BACKGROUND:Brachytherapy (BT) is a vital component of the curative treatment of locally advanced cervical cancer. The American Brachytherapy Society has published guidelines for high dose rate (HDR) BT with recommended dose limits. However, recent reports suggest lower doses may be needed to avoid toxicity. The purpose of this study is to investigate incidence and predictive factors influencing gastrointestinal (GI) and genitourinary (GU) toxicity following HDR intracavitary brachytherapy for locally advanced cervical cancer. METHODS:We retrospectively evaluated a cohort of patients with locally advanced cervical cancer who received CT-based HDR BT. Cumulative doses were calculated using the linear-quadratic model. Statistical analyses were used to investigate clinical and dosimetric predictors of GI and GU toxicity following HDR brachytherapy according to CTCAE v4.0 grading criteria. RESULTS: ≥ 65 Gy and seven patients had a sigmoid D2cc ≥ 65 Gy. Amongst clinically meaningful factors for development of adverse events (i.e. diabetes, smoking status, ovoid size, and treatment duration), there were no statistically significant prognostic factors identified. CONCLUSIONS:Severe adverse events are observed even with adherence to current ABS guidelines. In the era of recent multi-institutional study results, our data also supports more stringent dosimetric goals. We suggest cumulative D2cc dose limits of: less than 80 Gy for the bladder and less than 65 Gy for the rectum and sigmoid.

PURPOSE:To evaluate the delivery costs, using time-driven activity-based costing, and reimbursement for definitive radiation therapy for locally advanced cervical cancer. METHODS AND MATERIALS:Process maps were created to represent each step of the radiation treatment process and included personnel, equipment, and consumable supplies used to deliver care. Personnel were interviewed to estimate time involved to deliver care. Salary data, equipment purchasing information, and facilities costs were also obtained. We defined the capacity cost rate (CCR) for each resource and then calculated the total cost of patient care according to CCR and time for each resource. Costs were compared with 2016 Medicare reimbursement and relative value units (RVUs). RESULTS:The total cost of radiation therapy for cervical cancer was $12,861.68, with personnel costs constituting 49.8%. Brachytherapy cost $8610.68 (66.9% of total) and consumed 423 minutes of attending radiation oncologist time (80.0% of total). External beam radiation therapy cost $4055.01 (31.5% of total). Personnel costs were higher for brachytherapy than for the sum of simulation and external beam radiation therapy delivery ($4798.73 vs $1404.72). A full radiation therapy course provides radiation oncologists 149.77 RVUs with intensity modulated radiation therapy or 135.90 RVUs with 3-dimensional conformal radiation therapy, with total reimbursement of $23,321.71 and $16,071.90, respectively. Attending time per RVU is approximately 4-fold higher for brachytherapy (5.68 minutes) than 3-dimensional conformal radiation therapy (1.63 minutes) or intensity modulated radiation therapy (1.32 minutes). CONCLUSIONS:Time-driven activity-based costing was used to calculate the total cost of definitive radiation therapy for cervical cancer, revealing that brachytherapy delivery and personnel resources constituted the majority of costs. However, current reimbursement policy does not reflect the increased attending physician effort and delivery costs of brachytherapy. We hypothesize that the significant discrepancy between treatment costs and physician effort versus reimbursement may be a potential driver of reported national trends toward poor compliance with brachytherapy, and we suggest re-evaluation of payment policies to incentivize quality care.

While stereotactic radiosurgery (SRS) has been shown effective in the management of brain metastases, small brain metastases (≤10 mm) can pose unique challenges. Our aim was to investigate the efficacy of SRS in the treatment of small brain metastases, as well as elucidate clinically relevant factors impacting local failure (LF). We utilized a large, single-institution cohort to perform a retrospective analysis of patients with brain metastases up to 1 cm in maximal dimension. Clinical and radiosurgical parameters were investigated for an association with LF and compared using a competing risk model to calculate cumulative incidence functions, with death and whole brain radiotherapy serving as competing risks. 1596 small brain metastases treated with SRS among 424 patients were included. Among these tumors, 33 developed LF during the follow-up period (2.4% at 12 months following SRS). Competing risk analysis demonstrated that LF was dependent on tumor size (0.7% if ≤2 mm and 3.0% if 2-10 mm at 12 months, p = 0.016). Other factors associated with increasing risk of LF were the decreasing margin dose, increasing maximal tumor diameter, volume, and radioresistant tumors (each p < 0.01). 22 tumors (0.78%) developed radiographic radiation necrosis following SRS, and this incidence did not differ by tumor size (≤2 mm and 2-10 mm, p = 0.200). This large analysis confirms that SRS remains an effective modality in treatment of small brain metastases. In light of the excellent local control and relatively low risk of toxicity, patients with small brain metastases who otherwise have a reasonable expected survival should be considered for radiosurgical management.