October, 2014

Crème de la Crumbs

By Michael J. Katin, MD

It was a true test of patience to get from the day of receiving the abstracts from the 56th Annual Meeting of the American Society of Radiation Oncology until the day it was legally permissible to discuss them. The specification was that sharing with outside sources (the internet?) was forbidden until the material was actually presented, or released as an ASTRO NEWS BRIEFING, whichever came first. I diligently followed C-SPAN, CNN, TMZ, and other reputable sources, but did not see any announcements of ASTRO NEWS BRIEFINGs , but I assume that now that we are well past September 17 I am not violating any laws.

The delay was unfortunate, considering that the abstracts contained a treasure trove of material for the advancement of medical and social sciences, and it may be well until mid-2015, if we are still around by then, before all this material can be assimilated, by which time the abstracts for the 57th Annual Meeting will arrive and, again, be embargoed. Little mystery as to why cancer hasn't yet been cured.

In fact, curing cancer is made even that much more difficult by the fact that the abstracts cannot easily be navigated. The two most impactful submissions were brought to the front of the line to be identified as worthy to be plenary presentations, and another eight were designated as reports of significant clinical trials. Once past these ten, all bets are off. The remaining 2,350 (2,354 minus 4 withdrawn) oral scientific session presentations, digital poster discussion abstracts, and poster viewing abstracts are listed under rather broad categories, over which, granted, only a person with advanced OCD would make an issue.

Before going further, credit should be given to the 427 (plus one chairperson) reviewers who sorted through all of these, I'm certain that being an ASTRO reviewer is its own reward and is done in addition to clinical and research responsibilities, but it might not have been asking too much to have had these items sorted out in a more accessible fashion. For example, looking through to find any information on Hurthle cell carcinoma is a challenge (abstract 2857 is listed under "Head and Neck Cancer" along with 206 other entries). On the other hand, it is possible to search by author (from Mehmet Ufuk Abacioglu to Zachary Zumsteg), which is great if you happen to identify that a certain author has exceptional experience in dealing with Hurthle cell carcinoma. If you already knew that, you probably could have just texted him or her already or just sent the patient there to be treated. In fact, an abstract on Hurthle cell carcinoma might also have been found under the category of" Radiation and Cancer Physics" (396 items), "Radiation and Cancer Biology" (205 items), or even "Patient-Reported Outcomes " (48) or "Palliative Care" (44). Are you trying to find out nuances of prone positioning for patients treated with tomotherapy for breast cancer? Don't look for this under "Breast Cancer" (190 items), but abstract 3576 by Winky Wing Ki Fung et al. is under "Radiation and Cancer Physics." So is the work by Bernard Jones, et al., on adaptive motion mapping in patients with pancreas cancer treated with SBRT (abstract 3595), while it could well be under "Gastrointestinal Cancer" (229 items) or even "Patient Safety" (54 items)? In fact, how does one determine which items go under "Patient Safety" when everything we do is supposed to be directed toward patient safety? Presumably, selecting these categories is done at a very high level.

The important thing, of course, is to get one's name into print, and that is accomplished nicely in both indices and, presumably, will continue to be the organizational pattern for ASTRO abstracts as it has been for the past years. Fortunately, some of us are resolute enough to dig out the gems of this year's crop, to mix a metaphor. Please note capitalizations are repeated as in the ASTRO Proceedings and we are not responsible for inconsistencies.

CATEGORY 1: Wholly Matrimony

2928: "Demographic Disparities in Time From Prostate Cancer Diagnosis to Definitive Treatment in Patients at a Diverse Academic Medical Center." Shorter time to treatment in married patients. Spouse told him to keep medical appointments.

2933: " Impact of Breast Cancer Patient Demographics and Treatment Type on Time from Diagnosis to Adjuvant Treatment at a Diverse Academic Medical Center." Marital status had no impact on time to adjuvant treatment. Didn't pay attention to getting spouse to her medical appointments.

2939: "Effect of Patient Demographics and Radiation Timing on PSA Reduction in Patients Treated With Definitive Radiation Therapy for Prostate Cancer." Marital status had no impact on greater average absolute PSA drop, but having a primary language of Haitian-Creole did!

Special Notation: All three abstracts from the same (roughly) group of authors from the same diverse academic medical center. Good effort at getting CVs pumped up. Also, probably less hazardous to use Haitian-Creole as your primary language rather than get married, for more than one reason.

CATEGORY 2: Oh, Canada!

2936: "A National Analysis of Gender and Ethnocultural Diversity Within the Canadian Radiation Oncology Physician Workforce." 72.5% male, 60% white, 1% black, 0% of Aboriginal Identity.

2997: "Evaluation he Impact of a Canadian Anatomy and Radiology Contouring (ARC) Boot Camp for Radiation Oncology Residents." As long as they're male and white, anyway.

3347: " A National System for Incident Reporting in Radiation Therapy: Development of a Taxonomy and Severity Classification." Set up among ten major Canadian cancer centers. Taxonomy without representation?

CATEGORY 3: Lightning Strikes Twice

2767: "Is Radiographic Extracapsular Extension Prognostic in Human Papillomavirus-Related Oropharyngeal Cancers?" It's good to be HPV+ at the Icahn School of Medicine, New York, New York.

2905: " HPV Status May Alter the Significance of Extranodal Extension as a Negative Prognostic Factor in Postoperative Squamous Cell Carcinoma of the Head and Neck." It's also good to be HPV+ at the University of Louisville, Louisville, Kentucky. Great minds thinking alike 738.3 miles apart.

CATEGORY 4: A Little Knowledge...

3000: "Caught In the Web: The Quality of Online Resources for Cancer Patients." Out of 500 websites evaluated, only 46% were updated in the past four years. For the top 100 websites dealing with ovarian cancer, 30% were considered accurate.

2993: "A National Assessment of Medical Student Knowledge in Radiation Oncology and Comparison to Primary Care and Radiation Oncology Attending Physicians." Don't worry about educating just patients: 42% of first-year medical students, 49% of fourth-year medical students, and 31% of primary care physicians thought patients emit radiation after receiving external beam therapy.

CATEGORY 5: Who would have thought?

2858 "Thyroid V50 Predicts Hypothyroidism in head and Neck Cancer Patients Treated with IMRT." Truly unexpected.

2895 "Unplanned Hospitalizations Greater Than 5 Days Predict for Worse Outcomes After Radiation Therapy for Head and Neck Cancer." Don't let your head and neck patients go to the hospital if you want them to do well.

2925 "Referral Patterns for Pediatric Proton Therapy in Florida." Children who lack commercial insurance are less likely to be referred. Shocking.

2891 " Skin Cancer of the Head and Neck: A 21-Year Single-Institution Experience." Amazingly, metastatic disease was a statistically significant predictor of mortality, and Merkel Cell Carcinomas did worse than other types. Extra-credit for taking 21 years to finish this presentation.

CATEGORY 6: Leap of Faith

2907: "Disease Outcomes in Human Immunodeficiency Virus-Positive Patients Treated With Primary or Adjuvant Radiation Therapy for Head and Neck Cancer " Out of 24 patients, three were tested for HPV positivity and two were positive. They tested twelve-and-a-half per cent!! Their conclusion: results suggest HIV+ patients carry a positive prognostic factor, such as high rates of HPV positivity. Could be true. Maybe do it again for real and get another publication.

2977: " Preoperative Short Course Radiation for Locally Advanced Rectal Cancer: A National Opinion Survey". 4,356 "deliverable e-mails" were sent to the membership of ASTRO, with 514 responding. Twelve per cent!!!! We'll write the paper anyway.

CATEGORY 7: Leading a Horse to Water

2941: "The Impact of New EMR Adoption on the Number of Radiology Exams Ordered in a Busy Radiation Oncology Clinic". Possibly the most apocryphal presentation. A RAND corporation study in 2005 estimated EMR adoption could save $80.9 billion per year in healthcare overall, including $3.6 billion with radiology savings. In fact, there were significantly more radiology exams ordered within 30 days after consultation after EMR had been adopted in 2013, although the overall numbers for 2012 and 2013 were similar. So much for balancing the budget.

CATEGORY 8: Publish or perish

3850: "The Credentialing Process for the NSABP B-51/RTOG 1304 Phase 3 Randomized Clinical Trial." This is a submitted work literally consisting of the credentialing process for a protocol! Presumably the table of contents will be submitted as a separate poster.

3339: " A Model for Pre-emptive Maintenance of Medical Linear Accelerators: Predictive Maintenance." These authors have submitted their maintenance program for linear accelerators. Probably the instruction manual for operating the vault door will be their next entry, followed by another abstract with directions for office evacuation in case of fire.

2966: ""Choosing Wisely"; the American Society for Radiation Oncology's Top 5 List." Hmmm, wasn't this already out in multiple versions? Why not make a poster out of it, too, then?

2942: " Analysis of Clinical Trials in Radiation Oncology: A Systematic Characterization of the clinicaltrials.gov Database." How many of the 160,091 clinical trials had to do with radiation therapy? 4.7% of all registered trials. Not a big surprise but enough to keep us in our place.

With this limited review, it is now obvious how ASTRO can wind up with two plenary session presentations, eight clinical trials, 348 oral scientific session reports, 144 digital poster discussion abstracts, and 1,862 (minus 4 withdrawn) poster viewing abstracts, divided among 19 topics, and with 218 having a first author whose name beings with the letter "S."

Hey, wait, I think I just produced an abstract!!!! Who else wants his or her name on it????