Faculty Bibliography

Purpose/UNASSIGNED:While Ir-192 remains the mainstay isotope for gynecologic high-dose-rate (HDR) brachytherapy in the U.S., Co-60 is used abroad. Co-60 has a longer half-life than Ir-192, which may lead to long-term cost savings; however, its higher energy requires greater shielding. This study analyzes Co-60 acceptability based on a one-time expense of additional shielding and reports the financial experience of Co-60 in Peru's National Cancer Institute, which uses both isotopes. Material and methods/UNASSIGNED:A nationwide survey was undertaken assessing physician knowledge of Co-60 and willingness-to-pay (WTP) for additional shielding, assuming a source more cost-effective than Ir-192 was available. With 440 respondents, 280 clinicians were decision-makers and provided WTPs, with results previously reported. After completing a shielding report, we estimated costs for shielding expansion, noting acceptability to decision makers' WTP. Using activity-based costing, we note the Peruvian fiscal experience. Results/UNASSIGNED:Shielding estimates ranged from $173,000 to $418,000. The percentage of respondents accepting high-density modular or lead shielding (for union and non-union settings) were 17.5%, 11.4%, 3.9%, and 3.2%, respectively. Shielding acceptance was associated with greater number of radiation oncologists in a respondent's department but not time in practice or the American Brachytherapy Society membership. Peru's experience noted cost savings with Co-60 of $52,400 annually. Conclusions/UNASSIGNED:By comparing the cost of additional shielding for a sample institution's HDR suite with radiation oncologists' WTP, this multi-institutional collaboration noted < 20% of clinicians would accept additional shielding. Despite low acceptability in the US, Co-60 demonstrates cost-favorability in Peru and may similarly in other locations.

PURPOSE/OBJECTIVE:Hypofractionated whole-breast radiation therapy (RT) has proved to be equivalent to conventionally fractionated RT in multiple randomized trials. There is controversy regarding its use in younger women because of their underrepresentation in trials and the concern for late toxicity. We evaluated disease control and cosmetic outcomes in patients aged <50 years treated with hypofractionated RT in 4 prospective single-institutional trials. METHODS AND MATERIALS/METHODS:From 2003 to 2015, 1313 patients were enrolled in 4 prospective protocols investigating the use of adjuvant hypofractionated RT after breast-conserving surgery with a daily or weekly concomitant boost. We identified the records of 348 patients aged <50 years at consultation for this analysis. Overall survival, disease-free survival, and local recurrence-free survival were estimated using the Kaplan-Meier method by study and across studies using meta-analytic methods. The late effects of RT, clinician-rated cosmesis, and patient-rated cosmesis were also evaluated. RESULTS:With a median follow-up period of 66.9 months, the overall survival rate was 99.6%, the disease-free survival rate was 96.3%, and the local recurrence-free survival rate was 97.7% at 3 years. Clinician-rated cosmesis (n = 242) was excellent or good in 93.4% of cases and fair or poor in 6.6%. Patient-rated cosmesis (n = 259) was excellent or good in 86.1% and fair or poor in 13.9%. When patients rated themselves differently than their physicians, patients more often rated themselves poorly compared with their physicians (P = .0044, Cochran-Mantel-Haenszel test). CONCLUSIONS:At a median follow-up of 5 years, an analysis of patients aged <50 years demonstrated that hypofractionated RT was safe and effective, with good to excellent cosmesis as assessed by both clinicians and patients.

Purpose: While Ir-192 remains the American mainstay isotope for gynecologic high dose rate (HDR) brachytherapy, Co-60 is an isotope that has been used abroad but has yet to impact the U.S. market. Co-60 has an advantage of a longer half-life than Ir-192 which may lead to long-term cost-savings; however, its higher energy requires greater shielding than does Ir-192. To assess clinicians' acceptability for this one-time shielding cost, a survey of U.S. radiation oncologists was conducted, and we previously reported their willingness-to-pay (WTP). The purpose of this study is to analyze what percentage of physicians would accept the onetime expense of additional shielding based on cost estimates from an internal shielding report and vendor price quotes for a single sample institution. Materials and Methods: A nationwide survey was undertaken to assess physician knowledge of Co-60 and their WTP a one-time expense for additional shielding, assuming a source more cost-effective than Ir-192 were available. With 440 respondents, 280 clinicians were decisionmakers who provided WTP answers, and the results were previously reported. Subsequently, we conducted shielding analysis of an HDR suite in a single sample institution to obtain the tenth-value layers (TVLs) necessary to maintain adequate shielding. Partnering with an external vendor of both lead and ultra-high density modular shielding, we calculated the costs necessary for design, shielding, shipping, and installation for both union and non-union settings, and compared these costs to decision makers' WTP. Results: For the single institution sample suite to appropriately shield for Co-60, 1.11 TVLs, 2.46 TVLs, and 1.15 TVLs would have to be added, respectively, to the walls, door, ceiling & floor to achieve the same current level of shielding. Cost estimates of adding shielding using proprietary ultra-high density modular shielding were $173.5K and $211K for non-union and union setting, respectively. Costs for lead shielding instead were $376.5K and $418K, respectively. The percentage of all 280 respondents who would accept these cost estimates for ultrahigh density modular shielding (union and non-union) or lead shielding (union and non-union) were 17.5%, 11.4%, 3.9%, and 3.2%, respectively. Of the 122 self-described decision-makers who were ABS members, the percentage of these who would accept these cost estimates for ultra-high density modular shielding (union and non-union) or lead shielding (union and non-union) were 18%, 9%, 2.4%, and 1.6%, respectively. of the 227 self-described decision-makers who were more than 5 years postresidency completion, the percentage of these who would accept these cost estimates for ultra-high density modular shielding (union and nonunion) or lead shielding (union and non-union) were 18.5%, 12.8%, 4.4%, and 3.5%, respectively. Conclusions: By comparing the cost of additional shielding for a sample institution's HDR suite with radiation oncologists' WTP, this multiinstitutional collaboration noted that less than 20% of clinicians would accept the most favorable financial situation of ultra-high density modular shielding with non-union labor. Percentage of cost-acceptability did not vary in subgroup analysis by ABS membership or years of experience. This analysis is limited by looking at the TVL requirements of only a single sample institution and cost estimates from a single vendor. However, knowing that the sole vendor of Co-60 afterloaders for gynecological cancer brachytherapy treatment has left the American market, we gain information by looking at the cost of shielding with reference to clinician WTP