Suzanne Evans - Independent Researcher (original) (raw)
Papers by Suzanne Evans
The American Association of Physicists in Medicine (AAPM) is a nonprofit profes-sional society wh... more The American Association of Physicists in Medicine (AAPM) is a nonprofit profes-sional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States. The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the qual-ity of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner. Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been sub-jected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effecti...
Unusual complications after MammoSite brachytherapy: out‐of‐field rib fracture and Mondor's disease
Precision Radiation Oncology, 2021
Recent reports have documented in‐field rib fractures as a rare complication of accelerated parti... more Recent reports have documented in‐field rib fractures as a rare complication of accelerated partial breast irradiation. Here, we report a case of an out‐of‐field rib fracture, with a maximum point dose of <50% of the prescribed dose, and Mondor's disease in a 61‐year‐old woman after MammoSite brachytherapy. This is the first case in the literature in which rib fractures occurred out‐of‐field, without trauma or risk factors. It also highlights a rare clinical entity, Mondor's disease, of which its recognition is important for radiation oncologists given its potential for tumor recurrence.
Appreciation of 2018 peer reviewers for Practical Radiation Oncology
Practical Radiation Oncology, 2019
A Systems Approach Using Big Data to Improve Safety and Quality in Radiation Oncology
International journal of radiation oncology, biology, physics, Jul 1, 2016
Cost-effectiveness assessment of lumpectomy cavity boost in elderly women with early stage estrogen receptor positive breast cancer receiving adjuvant radiotherapy
Radiotherapy and Oncology, 2016
Breast radiotherapy (RT) for elderly women with estrogen receptor positive early stage breast can... more Breast radiotherapy (RT) for elderly women with estrogen receptor positive early stage breast cancer (ER+ESBC) improves local recurrence (LR) rates without benefitting overall survival. Breast boost is a common practice, although the absolute benefit decreases with age. Consequently, an analysis of its cost-effectiveness in the elderly ESBC populations is warranted. A Markov model was used to compare cost-effectiveness of RT with or without a boost in elderly ER+ESBC patients. The ten-year probability of LR with boost was derived from the CALGB 9343 trial and adjusted by the hazard ratio for LR from boost radiotherapy trial data, yielding the LR rate without boost. Remaining parameters were estimated using published data. Boost RT was associated with an increase in mean cost ($7139 vs 6193)andeffectiveness(5.66vs5.64qualityadjustedlifeyears;QALYs)relativetonoboost.Theincrementalcost−effectivenessratio(ICER)forboostwas6193) and effectiveness (5.66 vs 5.64 quality adjusted life years; QALYs) relative to no boost. The incremental cost-effectiveness ratio (ICER) for boost was 6193)andeffectiveness(5.66vs5.64qualityadjustedlifeyears;QALYs)relativetonoboost.Theincrementalcost−effectivenessratio(ICER)forboostwas55,903 per QALY. On one-way sensitivity analysis, boost remained cost-effective if the hazard ratio of LR with boost was &amp;amp;amp;amp;amp;amp;amp;lt;0.67. Boost RT for ER+ESBC patients was cost-effective over a wide range of assumptions and inputs over commonly accepted willingness-to pay-thresholds, but particularly in women at higher risk for LR.
Association of 21-gene recurrence score assay and adjuvant chemotherapy use in the medicare population, 2008-2011
Journal of geriatric oncology, Jan 17, 2015
The 21-gene recurrence score (RS) assay helps guide adjuvant chemotherapy use for patients with b... more The 21-gene recurrence score (RS) assay helps guide adjuvant chemotherapy use for patients with breast cancer, and is predicted to reduce overall chemotherapy use. Little is known about recent patterns of testing in the Medicare program and the impact of testing on chemotherapy use as a function of patient age. We conducted a national claims-based study of Medicare beneficiaries age ≥66years. We assessed trends in assay use (using multivariable regression), adjuvant chemotherapy use, and associated expenditures, for all patients and for two age strata: age 66-74years and 75-94years. Geographic variations in assay adoption and regional-level correlation between assay and chemotherapy use were measured. We identified 132,222 women who underwent breast surgery from 2008-2011. Assay use increased from 9.0% to 17.2% from 2008-2011 (p<.001), but chemotherapy use remained stable at 12.5% (p=.49). In younger patients, assay use increased from 14.3% to 23.7% (p<.001), while chemotherap...
Influence of a 21-Gene Recurrence Score Assay on Chemotherapy Delivery in Breast Cancer
Clinical breast cancer, Jan 21, 2015
We performed an analysis to determine the relative contribution of the Oncotype DX (ODX) recurren... more We performed an analysis to determine the relative contribution of the Oncotype DX (ODX) recurrence score (RS) results in adjuvant therapy delivery compared with traditional pathologic factors. We performed a retrospective review of women with stage I-IIIA breast cancer treated at the Yale Comprehensive Cancer Center from 2006 to 2012 with available ODX results. We constructed separate logistic models with the clinicopathologic factors alone and also integrating RS and compared these models using the likelihood ratio test and c-statistic to determine whether integration of the RS will result in better prediction of chemotherapy (CTx) delivery. We identified 431 women with a median age of 58 years. The RS was low (< 18), intermediate (18-30), and high (> 30) in 56%, 37%, and 7%, respectively. CTx was delivered to 30% of the patients. Age, differentiation, lymphovascular invasion, and progesterone receptor (PR) positivity < 50% were associated with CTx delivery in multivariab...
Physician participation in incident learning
Journal of oncology practice / American Society of Clinical Oncology, 2014
International Journal of Radiation Oncology*Biology*Physics, 2006
The aim of this study was to select patients with heart anatomy that is specifically unfavorable ... more The aim of this study was to select patients with heart anatomy that is specifically unfavorable for tangential irradiation in whole-breast radiotherapy (WBRT), to be used as an experimental cohort to compare cardiac dosimetric and radiobiological parameters of three-dimensional conformal external beam accelerated partial breast irradiation (3D-CRT APBI) to WBRT with techniques as defined by the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-39/Radiation Therapy Oncology Group (RTOG) 0413 clinical trial. Methods and Materials: A dosimetric modeling study that compared WBRT and 3D-CRT APBI was performed on CT planning data from 8 patients with left-sided breast cancer. Highly unfavorable cardiac anatomy was defined by the measured contact of the myocardium with the anterior chest wall in the axial and para-sagittal planes. Treatment plans of WBRT and 3D-CRT APBI were generated for each patient in accordance with NSABP B-39/RTOG 0413 protocol. Dose-volume relationships of the heart, including the V 5 min (minimum dose delivered to 5% of the cardiac volume), biological effective dose (BED) of the V 5 min, and normal tissue complication probability (NTCP) were analyzed and compared. Results: Despite expected anatomic variation, significantly large differences were found favoring 3D-CRT APBI in cumulative dose-volume histograms (p < 0.01), dose to the entire heart (mean difference 3.85 Gy, p < 0.01), NTCP (median difference, 1.00 Gy; p < 0.01), V 5 min (mean difference, 24.53 Gy; p < 0.01), and proportional reduction in radiobiological effect on the V 5 min (85%, p < 0.01). Conclusions: Use of 3D-CRT APBI can demonstrate improved sparing of the heart in select patients with highly unfavorable cardiac anatomy for WBRT, and may result in reduced risk of cardiac morbidity and mortality.
International Journal of Radiation Oncology*Biology*Physics, 2012
Results of an online survey regarding error disclosure practices are reported. Results are simila... more Results of an online survey regarding error disclosure practices are reported. Results are similar to those of Gallagher's Archives of Internal Medicine survey of internal medicine doctors and surgeons, but this study compared the survey responses of radiation oncologists to vignettebased questions. The study examined error disclosure practices currently taking place and how these compared with ideal disclosure behaviors. Purpose: To analyze error disclosure attitudes of radiation oncologists and to correlate error disclosure beliefs with survey-assessed disclosure behavior. Methods and Materials: With institutional review board exemption, an anonymous online survey was devised. An email invitation was sent to radiation oncologists (American Society for Radiation Oncology [ASTRO] gold medal winners, program directors and chair persons of academic institutions, and former ASTRO lecturers) and residents. A disclosure score was calculated based on the number or full, partial, or no disclosure responses chosen to the vignette-based questions, and correlation was attempted with attitudes toward error disclosure. Results: The survey received 176 responses: 94.8% of respondents considered themselves more likely to disclose in the setting of a serious medical error; 72.7% of respondents did not feel it mattered who was responsible for the error in deciding to disclose, and 3.9% felt more likely to disclose if someone else was responsible; 38.0% of respondents felt that disclosure increased the likelihood of a lawsuit, and 32.4% felt disclosure decreased the likelihood of lawsuit; 71.6% of respondents felt near misses should not be disclosed; 51.7% thought that minor errors should not be disclosed; 64.7% viewed disclosure as an opportunity for forgiveness from the patient; and 44.6% considered the patient's level of confidence in them to be a factor in disclosure. For a scenario that could be considerable, a non-harmful error, 78.9% of respondents would not contact the family. Respondents with high disclosure scores were more likely to feel that disclosure was an opportunity for forgiveness (PZ.003) and to have never seen major medical errors (PZ.004). Conclusions: The surveyed radiation oncologists chose to respond with full disclosure at a high rate, although ideal disclosure practices were not uniformly adhered to beyond the initial decision to disclose the occurrence of the error.
Medical Error Disclosure Attitudes Among Radiation Oncologists
International Journal of Radiation Oncology*Biology*Physics, 2011
International Journal of Clinical Oncology, 2013
In this issue of the journal, Kusko et al. (6) present the results of breast conservation therapy... more In this issue of the journal, Kusko et al. (6) present the results of breast conservation therapy for ductal carcinoma in situ. These results add to the increasing body of liter
Brachytherapy, 2006
Purpose: To investigate the incidence of, and possible factors associated with, seroma formation ... more Purpose: To investigate the incidence of, and possible factors associated with, seroma formation after intraoperative placement of the MammoSite catheter for accelerated partial breast irradiation. Methods and Materials: This study evaluated 38 patients who had undergone intraoperative MammoSite catheter placement at lumpectomy or reexcision followed by accelerated partial breast irradiation with 34 Gy in 10 fractions. Data were collected regarding dosimetric parameters, including the volume of tissue enclosed by the 100%, 150%, and 200% isodose shells, dose homogeneity index, and maximal dose at the surface of the applicator. Clinical and treatment-related factors were analyzed, including patient age, patient weight, history of diabetes and smoking, use of reexcision, interval between surgery and radiotherapy, total duration of catheter placement, total excised specimen volume, and presence or absence of postprocedural infection. Seroma was verified by clinical examination, mammography, and/or ultrasonography. Persistent seroma was defined as seroma that was clinically detectable >6 months after radiotherapy completion. Results: After a median follow-up of 17 months, the overall rate of any detectable seroma was 76.3%. Persistent seroma (>6 months) occurred in 26 (68.4%) of 38 patients, of whom 46% experienced at least modest discomfort at some point during follow-up. Of these symptomatic patients, 3 required biopsy or complete cavity excision, revealing squamous metaplasia, foreign body giant cell reaction, fibroblasts, and active collagen deposition. Of the analyzed dosimetric, clinical, and treatment-related variables, only body weight correlated positively with the risk of seroma formation (p ؍ 0.04). Postprocedural infection correlated significantly (p ؍ 0.05) with a reduced risk of seroma formation. Seroma was associated with a suboptimal cosmetic outcome, because excellent scores were achieved in 61.5% of women with seroma compared with 83% without seroma. Conclusion: Intraoperative placement of the MammoSite catheter for accelerated partial breast irradiation is associated with a high rate of clinically detectable seroma that adversely affects the cosmetic outcome. The seroma risk was positively associated with body weight and negatively associated with postprocedural infection.
“Unnecessary” Postmastectomy Radiation Therapy—Reply
Archives of Surgery, 2011
... AUTHOR INFORMATION. Correspondence: Dr Evans, Department of Therapeutic Radiology, Smilow Can... more ... AUTHOR INFORMATION. Correspondence: Dr Evans, Department of Therapeutic Radiology, Smilow Cancer Hospital at YaleNew Haven, South Frontage Rd and Park St, Lower Level, New Haven, CT 06510 (suzanne.evans{at}yale.edu). Financial Disclosure: None reported. ...
The Number of Lymph Nodes Dissected in Breast Cancer Patients Influences the Accuracy of Prognosis
Annals of Surgical Oncology, 2013
Recent trials have suggested that axillary node dissection may not be warranted in some breast ca... more Recent trials have suggested that axillary node dissection may not be warranted in some breast cancer patients with one to two positive nodes. Given that lymph node ratio (LNR; number of positive lymph nodes divided by the total examined) has been shown to be a significant prognostic factor, we sought to determine whether the number of nodes removed in this low risk population predicted survival. The National Cancer Database is a comprehensive clinical surveillance resource capturing 70% of newly diagnosed malignancies in the United States; 309,216 breast cancer patients diagnosed between 1998 and 2005, with tumors ≤5 cm and one to two positive nodes, formed the cohort of interest. Median age at diagnosis was 57 (range 18-90) years. Median tumor size was 2 (range 0.1-5) cm; 215,382 patients (69.7%) had one positive node, and 93,834 (30.3%) had two. The median number of lymph nodes examined was 11 (range 1-84). Patients were categorized into low (≤0.2), medium (0.21-0.65), or high (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;0.65) LNR groups, with 228,822 (74%), 55,797 (18%), and 24,597 (8%) patients in each of these categories, respectively. Median follow-up was 54.1 months. Median overall survival (OS) for low, intermediate, and high LNR was 66.1, 61.1, and 56.5 months, respectively (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). In a Cox model controlling for clinicopathologic and therapy covariates, LNR category remained a significant predictor of OS (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). LNR is an independent predictor of OS in a low-risk population with one to two positive nodes and tumors ≤5 cm. Therefore, the number of lymph nodes excised may influence prognostic stratification.
Severe Acute Toxicity From Whole Breast Radiotherapy in the Setting of Collagen Vascular Disease
American Journal of Clinical Oncology, 2006
Page 1. UNUSUAL MANIFESTATION OF MALIGNANCY Severe Acute Toxicity From Whole Breast Radiotherapy ... more Page 1. UNUSUAL MANIFESTATION OF MALIGNANCY Severe Acute Toxicity From Whole Breast Radiotherapy in the Setting of Collagen Vascular Disease Sophy Hernandez, BA, Suzanne B. Evans, MD, MPH, and David E. Wazer, MD ...
Toxicity of Three-Dimensional Conformal Radiotherapy for Accelerated Partial Breast Irradiation
International Journal of Radiation Oncology*Biology*Physics, 2009
To assess the incidence and severity of late normal tissue toxicity using three-dimensional confo... more To assess the incidence and severity of late normal tissue toxicity using three-dimensional conformal radiotherapy to deliver accelerated partial breast irradiation. A total of 60 patients were treated with three-dimensional conformal radiotherapy for accelerated partial breast irradiation. Treatment planning and delivery were in strict accordance with the technique and specified dose-volume constraints of the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 protocol. Late toxicity was evaluated according to the Radiation Therapy Oncology Group grading schema. The cosmetic outcome was scored using the Harvard criteria. Univariate logistic regression analysis was performed to evaluate the correlation of dosimetric variables with outcome. At a median follow-up of 15 months, moderate-to-severe late toxicity developed in 10% of patients. The most pronounced late toxicity was subcutaneous fibrosis: 25% Grade 2-4 and 8.3% Grade 3-4. The modified planning tumor volume/whole breast volume ratio, ratio of the volume of breast tissue receiving 5%, 20%, 50%, and 80% of the prescription dose to the whole breast volume, and maximal dose within the breast correlated with the development of fibrosis (p = .10, p = .03, p = .04, p = .06, p = .09, and p = .046, respectively). The overall cosmetic outcome was good to excellent in 81.7%, fair in 11.7%, and poor in 6.7%. The presence of subcutaneous fibrosis, modified planning tumor volume/whole breast volume ratio, ratio of the volume of breast tissue receiving 5% and 20% of the prescription dose to the whole breast volume, and pathologic specimen volume correlated with the risk of a fair/poor cosmetic outcome (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001, p = .02, p = .05, p = .04, p = .01, respectively). The three-dimensional conformal radiotherapy technique for accelerated partial breast irradiation as specified in the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 protocol resulted in a remarkably high rate of moderate-to-severe late normal tissue effects, despite the relatively brief follow-up period. The toxic events correlated clearly with several dose-volume parameters.
Journal of Applied Clinical Medical Physics
Purpose: Previous studies suggest that within radiation oncology, medical physicists (MP) experie... more Purpose: Previous studies suggest that within radiation oncology, medical physicists (MP) experience high workloads. Little is known about how MPs use social support (SS) in times of stress. Methods: In collaboration with the Workgroup on Prevention of Medical Error, the American Association of Physicists in Medicine administered this Human Investigation Committee (HIC) approved email survey to 8566 members. Respondents were considered likely to seek SS if they answered (probably/definitely would) and unlikely to seek support if they answered (probably/definitely would not). Logistic regression was applied to determine associations between demographic factors and willingness to seek support as well as perception of barriers. Results: One thousand two hundred and ninety-seven members (15.1%) accessed and gave consent for the survey. One thousand and one (11.7%) respondents answered all relevant questions. Respondents were predominantly male (69.1%), MP in radiation oncology (81.8%), private practice (51.6%), with practice duration> 10 yr (60.2%). MPs were likely to seek SS for personal physical illness (78.63%), involvement in a medical error (73.94%) or adverse patient outcome (75.17%). MPs sought SS in the setting of personal fatigue (33.2%) or burnout (44.3%). Barriers to seeking SS were lack of time (80.3%), and uncertainty about whom to access (70.7%). MPs responded that they would be most likely to seek support from an equally experienced medical physicist colleague (81.0%). Most MPs (67.0%) identified as having experienced stressors, with serious family illness (35.2%), or burnout (32.8%) being most common. Factors associated with MPs unwillingness to seek SS for medical error included> 20 yr in practice (vs still in training-OR 0.30, P = 0.015), and male gender (OR 0.60, P = 0.003). Male gender was associated with the lowest willingness to seek support (OR 2.10, P = 0.0001), but also with fewer perceived barriers (OR 1.60, P = 0.0075). Conclusion: Willingness to seek SS is demonstrated, and MPs want colleagues to provide support. Given these results, peer support could be considered among MPs.
Quality at the American Society for Radiation Oncology Annual Meeting: Gender Balance Among Invited Speakers and Associations with Panel Success
International Journal of Radiation Oncology*Biology*Physics
PURPOSE The American Society for Radiation Oncology (ASTRO) annual meeting is the most prominent ... more PURPOSE The American Society for Radiation Oncology (ASTRO) annual meeting is the most prominent international conference in radiation oncology. It represents one of the greatest time efforts for ASTRO volunteers, and the quality of the annual meeting is a high priority. Measures of diversity have been linked with quality of academic efforts. We conducted a study of gender diversity of the ASTRO invited speakers, focusing on speaker and panel characteristics, and associations of these characteristics with measures of audience satisfaction. METHODS AND MATERIALS We created a database of all invited speakers (n = 1499 cumulative speaking positions, n = 725 individual speakers) and panels (n = 381) in the ASTRO annual meetings from 2012 to 2016. Speaker characteristics were acquired using publically available online search tools (including Scopus for citation metrics). SAS software was used for statistical analysis. RESULTS Of the 725 individual speakers, 27% were women. Men had higher median Hirsch index (H-index) (27 vs 20, P < .001), M-index (1.36 vs 1.11, P < .001), earlier first publication (1994 vs 1997), professorship (57% vs 40%, P < .001), chair status (25% vs 14%, P < .001) and fellow designations/distinctions (ie, FASTRO/FACR/FAAPM) (12% vs 9.5%, P < .17). Median panel gender distribution was 25% female, and greatest female representation was in breast, gynecology, and pediatrics. On multivariable analysis, panel characteristics associated with individual measures of audience satisfaction included single discipline presentations (metric: overall evaluation score), panels not proposed or endorsed by committee (metric: room count), higher H-index (metric: room count) and M-index (metric: request for session repeat), and panels with gender composition >50% female (metric: request for session repeat). Female conveners were associated with greater panel gender diversity. CONCLUSION Given observations that women constitute a minority of invited speakers and that greater female representation correlates with a key panel success metric, efforts to ensure greater diversity of those included in AM speaking invitations merit serious attention.
Medical physics, 2018
Incident learning is a key component for maintaining safety and quality in healthcare. Its use is... more Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems (ILS) in radiation oncology, with over 40 publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root cause analysis, and national and international ILS for shared learning. Core principles of patient safety in the context of ILS are discussed, including the systems view of error, culture of safety, and contributing factors such as cognitive bias. Finally, the topics of medical error disclosure and second victim syndrome are discussed. In spite of the rapid progress and under...
The American Association of Physicists in Medicine (AAPM) is a nonprofit profes-sional society wh... more The American Association of Physicists in Medicine (AAPM) is a nonprofit profes-sional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States. The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the qual-ity of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner. Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been sub-jected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effecti...
Unusual complications after MammoSite brachytherapy: out‐of‐field rib fracture and Mondor's disease
Precision Radiation Oncology, 2021
Recent reports have documented in‐field rib fractures as a rare complication of accelerated parti... more Recent reports have documented in‐field rib fractures as a rare complication of accelerated partial breast irradiation. Here, we report a case of an out‐of‐field rib fracture, with a maximum point dose of <50% of the prescribed dose, and Mondor's disease in a 61‐year‐old woman after MammoSite brachytherapy. This is the first case in the literature in which rib fractures occurred out‐of‐field, without trauma or risk factors. It also highlights a rare clinical entity, Mondor's disease, of which its recognition is important for radiation oncologists given its potential for tumor recurrence.
Appreciation of 2018 peer reviewers for Practical Radiation Oncology
Practical Radiation Oncology, 2019
A Systems Approach Using Big Data to Improve Safety and Quality in Radiation Oncology
International journal of radiation oncology, biology, physics, Jul 1, 2016
Cost-effectiveness assessment of lumpectomy cavity boost in elderly women with early stage estrogen receptor positive breast cancer receiving adjuvant radiotherapy
Radiotherapy and Oncology, 2016
Breast radiotherapy (RT) for elderly women with estrogen receptor positive early stage breast can... more Breast radiotherapy (RT) for elderly women with estrogen receptor positive early stage breast cancer (ER+ESBC) improves local recurrence (LR) rates without benefitting overall survival. Breast boost is a common practice, although the absolute benefit decreases with age. Consequently, an analysis of its cost-effectiveness in the elderly ESBC populations is warranted. A Markov model was used to compare cost-effectiveness of RT with or without a boost in elderly ER+ESBC patients. The ten-year probability of LR with boost was derived from the CALGB 9343 trial and adjusted by the hazard ratio for LR from boost radiotherapy trial data, yielding the LR rate without boost. Remaining parameters were estimated using published data. Boost RT was associated with an increase in mean cost ($7139 vs 6193)andeffectiveness(5.66vs5.64qualityadjustedlifeyears;QALYs)relativetonoboost.Theincrementalcost−effectivenessratio(ICER)forboostwas6193) and effectiveness (5.66 vs 5.64 quality adjusted life years; QALYs) relative to no boost. The incremental cost-effectiveness ratio (ICER) for boost was 6193)andeffectiveness(5.66vs5.64qualityadjustedlifeyears;QALYs)relativetonoboost.Theincrementalcost−effectivenessratio(ICER)forboostwas55,903 per QALY. On one-way sensitivity analysis, boost remained cost-effective if the hazard ratio of LR with boost was &amp;amp;amp;amp;amp;amp;amp;lt;0.67. Boost RT for ER+ESBC patients was cost-effective over a wide range of assumptions and inputs over commonly accepted willingness-to pay-thresholds, but particularly in women at higher risk for LR.
Association of 21-gene recurrence score assay and adjuvant chemotherapy use in the medicare population, 2008-2011
Journal of geriatric oncology, Jan 17, 2015
The 21-gene recurrence score (RS) assay helps guide adjuvant chemotherapy use for patients with b... more The 21-gene recurrence score (RS) assay helps guide adjuvant chemotherapy use for patients with breast cancer, and is predicted to reduce overall chemotherapy use. Little is known about recent patterns of testing in the Medicare program and the impact of testing on chemotherapy use as a function of patient age. We conducted a national claims-based study of Medicare beneficiaries age ≥66years. We assessed trends in assay use (using multivariable regression), adjuvant chemotherapy use, and associated expenditures, for all patients and for two age strata: age 66-74years and 75-94years. Geographic variations in assay adoption and regional-level correlation between assay and chemotherapy use were measured. We identified 132,222 women who underwent breast surgery from 2008-2011. Assay use increased from 9.0% to 17.2% from 2008-2011 (p<.001), but chemotherapy use remained stable at 12.5% (p=.49). In younger patients, assay use increased from 14.3% to 23.7% (p<.001), while chemotherap...
Influence of a 21-Gene Recurrence Score Assay on Chemotherapy Delivery in Breast Cancer
Clinical breast cancer, Jan 21, 2015
We performed an analysis to determine the relative contribution of the Oncotype DX (ODX) recurren... more We performed an analysis to determine the relative contribution of the Oncotype DX (ODX) recurrence score (RS) results in adjuvant therapy delivery compared with traditional pathologic factors. We performed a retrospective review of women with stage I-IIIA breast cancer treated at the Yale Comprehensive Cancer Center from 2006 to 2012 with available ODX results. We constructed separate logistic models with the clinicopathologic factors alone and also integrating RS and compared these models using the likelihood ratio test and c-statistic to determine whether integration of the RS will result in better prediction of chemotherapy (CTx) delivery. We identified 431 women with a median age of 58 years. The RS was low (< 18), intermediate (18-30), and high (> 30) in 56%, 37%, and 7%, respectively. CTx was delivered to 30% of the patients. Age, differentiation, lymphovascular invasion, and progesterone receptor (PR) positivity < 50% were associated with CTx delivery in multivariab...
Physician participation in incident learning
Journal of oncology practice / American Society of Clinical Oncology, 2014
International Journal of Radiation Oncology*Biology*Physics, 2006
The aim of this study was to select patients with heart anatomy that is specifically unfavorable ... more The aim of this study was to select patients with heart anatomy that is specifically unfavorable for tangential irradiation in whole-breast radiotherapy (WBRT), to be used as an experimental cohort to compare cardiac dosimetric and radiobiological parameters of three-dimensional conformal external beam accelerated partial breast irradiation (3D-CRT APBI) to WBRT with techniques as defined by the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-39/Radiation Therapy Oncology Group (RTOG) 0413 clinical trial. Methods and Materials: A dosimetric modeling study that compared WBRT and 3D-CRT APBI was performed on CT planning data from 8 patients with left-sided breast cancer. Highly unfavorable cardiac anatomy was defined by the measured contact of the myocardium with the anterior chest wall in the axial and para-sagittal planes. Treatment plans of WBRT and 3D-CRT APBI were generated for each patient in accordance with NSABP B-39/RTOG 0413 protocol. Dose-volume relationships of the heart, including the V 5 min (minimum dose delivered to 5% of the cardiac volume), biological effective dose (BED) of the V 5 min, and normal tissue complication probability (NTCP) were analyzed and compared. Results: Despite expected anatomic variation, significantly large differences were found favoring 3D-CRT APBI in cumulative dose-volume histograms (p < 0.01), dose to the entire heart (mean difference 3.85 Gy, p < 0.01), NTCP (median difference, 1.00 Gy; p < 0.01), V 5 min (mean difference, 24.53 Gy; p < 0.01), and proportional reduction in radiobiological effect on the V 5 min (85%, p < 0.01). Conclusions: Use of 3D-CRT APBI can demonstrate improved sparing of the heart in select patients with highly unfavorable cardiac anatomy for WBRT, and may result in reduced risk of cardiac morbidity and mortality.
International Journal of Radiation Oncology*Biology*Physics, 2012
Results of an online survey regarding error disclosure practices are reported. Results are simila... more Results of an online survey regarding error disclosure practices are reported. Results are similar to those of Gallagher's Archives of Internal Medicine survey of internal medicine doctors and surgeons, but this study compared the survey responses of radiation oncologists to vignettebased questions. The study examined error disclosure practices currently taking place and how these compared with ideal disclosure behaviors. Purpose: To analyze error disclosure attitudes of radiation oncologists and to correlate error disclosure beliefs with survey-assessed disclosure behavior. Methods and Materials: With institutional review board exemption, an anonymous online survey was devised. An email invitation was sent to radiation oncologists (American Society for Radiation Oncology [ASTRO] gold medal winners, program directors and chair persons of academic institutions, and former ASTRO lecturers) and residents. A disclosure score was calculated based on the number or full, partial, or no disclosure responses chosen to the vignette-based questions, and correlation was attempted with attitudes toward error disclosure. Results: The survey received 176 responses: 94.8% of respondents considered themselves more likely to disclose in the setting of a serious medical error; 72.7% of respondents did not feel it mattered who was responsible for the error in deciding to disclose, and 3.9% felt more likely to disclose if someone else was responsible; 38.0% of respondents felt that disclosure increased the likelihood of a lawsuit, and 32.4% felt disclosure decreased the likelihood of lawsuit; 71.6% of respondents felt near misses should not be disclosed; 51.7% thought that minor errors should not be disclosed; 64.7% viewed disclosure as an opportunity for forgiveness from the patient; and 44.6% considered the patient's level of confidence in them to be a factor in disclosure. For a scenario that could be considerable, a non-harmful error, 78.9% of respondents would not contact the family. Respondents with high disclosure scores were more likely to feel that disclosure was an opportunity for forgiveness (PZ.003) and to have never seen major medical errors (PZ.004). Conclusions: The surveyed radiation oncologists chose to respond with full disclosure at a high rate, although ideal disclosure practices were not uniformly adhered to beyond the initial decision to disclose the occurrence of the error.
Medical Error Disclosure Attitudes Among Radiation Oncologists
International Journal of Radiation Oncology*Biology*Physics, 2011
International Journal of Clinical Oncology, 2013
In this issue of the journal, Kusko et al. (6) present the results of breast conservation therapy... more In this issue of the journal, Kusko et al. (6) present the results of breast conservation therapy for ductal carcinoma in situ. These results add to the increasing body of liter
Brachytherapy, 2006
Purpose: To investigate the incidence of, and possible factors associated with, seroma formation ... more Purpose: To investigate the incidence of, and possible factors associated with, seroma formation after intraoperative placement of the MammoSite catheter for accelerated partial breast irradiation. Methods and Materials: This study evaluated 38 patients who had undergone intraoperative MammoSite catheter placement at lumpectomy or reexcision followed by accelerated partial breast irradiation with 34 Gy in 10 fractions. Data were collected regarding dosimetric parameters, including the volume of tissue enclosed by the 100%, 150%, and 200% isodose shells, dose homogeneity index, and maximal dose at the surface of the applicator. Clinical and treatment-related factors were analyzed, including patient age, patient weight, history of diabetes and smoking, use of reexcision, interval between surgery and radiotherapy, total duration of catheter placement, total excised specimen volume, and presence or absence of postprocedural infection. Seroma was verified by clinical examination, mammography, and/or ultrasonography. Persistent seroma was defined as seroma that was clinically detectable >6 months after radiotherapy completion. Results: After a median follow-up of 17 months, the overall rate of any detectable seroma was 76.3%. Persistent seroma (>6 months) occurred in 26 (68.4%) of 38 patients, of whom 46% experienced at least modest discomfort at some point during follow-up. Of these symptomatic patients, 3 required biopsy or complete cavity excision, revealing squamous metaplasia, foreign body giant cell reaction, fibroblasts, and active collagen deposition. Of the analyzed dosimetric, clinical, and treatment-related variables, only body weight correlated positively with the risk of seroma formation (p ؍ 0.04). Postprocedural infection correlated significantly (p ؍ 0.05) with a reduced risk of seroma formation. Seroma was associated with a suboptimal cosmetic outcome, because excellent scores were achieved in 61.5% of women with seroma compared with 83% without seroma. Conclusion: Intraoperative placement of the MammoSite catheter for accelerated partial breast irradiation is associated with a high rate of clinically detectable seroma that adversely affects the cosmetic outcome. The seroma risk was positively associated with body weight and negatively associated with postprocedural infection.
“Unnecessary” Postmastectomy Radiation Therapy—Reply
Archives of Surgery, 2011
... AUTHOR INFORMATION. Correspondence: Dr Evans, Department of Therapeutic Radiology, Smilow Can... more ... AUTHOR INFORMATION. Correspondence: Dr Evans, Department of Therapeutic Radiology, Smilow Cancer Hospital at YaleNew Haven, South Frontage Rd and Park St, Lower Level, New Haven, CT 06510 (suzanne.evans{at}yale.edu). Financial Disclosure: None reported. ...
The Number of Lymph Nodes Dissected in Breast Cancer Patients Influences the Accuracy of Prognosis
Annals of Surgical Oncology, 2013
Recent trials have suggested that axillary node dissection may not be warranted in some breast ca... more Recent trials have suggested that axillary node dissection may not be warranted in some breast cancer patients with one to two positive nodes. Given that lymph node ratio (LNR; number of positive lymph nodes divided by the total examined) has been shown to be a significant prognostic factor, we sought to determine whether the number of nodes removed in this low risk population predicted survival. The National Cancer Database is a comprehensive clinical surveillance resource capturing 70% of newly diagnosed malignancies in the United States; 309,216 breast cancer patients diagnosed between 1998 and 2005, with tumors ≤5 cm and one to two positive nodes, formed the cohort of interest. Median age at diagnosis was 57 (range 18-90) years. Median tumor size was 2 (range 0.1-5) cm; 215,382 patients (69.7%) had one positive node, and 93,834 (30.3%) had two. The median number of lymph nodes examined was 11 (range 1-84). Patients were categorized into low (≤0.2), medium (0.21-0.65), or high (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;0.65) LNR groups, with 228,822 (74%), 55,797 (18%), and 24,597 (8%) patients in each of these categories, respectively. Median follow-up was 54.1 months. Median overall survival (OS) for low, intermediate, and high LNR was 66.1, 61.1, and 56.5 months, respectively (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). In a Cox model controlling for clinicopathologic and therapy covariates, LNR category remained a significant predictor of OS (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). LNR is an independent predictor of OS in a low-risk population with one to two positive nodes and tumors ≤5 cm. Therefore, the number of lymph nodes excised may influence prognostic stratification.
Severe Acute Toxicity From Whole Breast Radiotherapy in the Setting of Collagen Vascular Disease
American Journal of Clinical Oncology, 2006
Page 1. UNUSUAL MANIFESTATION OF MALIGNANCY Severe Acute Toxicity From Whole Breast Radiotherapy ... more Page 1. UNUSUAL MANIFESTATION OF MALIGNANCY Severe Acute Toxicity From Whole Breast Radiotherapy in the Setting of Collagen Vascular Disease Sophy Hernandez, BA, Suzanne B. Evans, MD, MPH, and David E. Wazer, MD ...
Toxicity of Three-Dimensional Conformal Radiotherapy for Accelerated Partial Breast Irradiation
International Journal of Radiation Oncology*Biology*Physics, 2009
To assess the incidence and severity of late normal tissue toxicity using three-dimensional confo... more To assess the incidence and severity of late normal tissue toxicity using three-dimensional conformal radiotherapy to deliver accelerated partial breast irradiation. A total of 60 patients were treated with three-dimensional conformal radiotherapy for accelerated partial breast irradiation. Treatment planning and delivery were in strict accordance with the technique and specified dose-volume constraints of the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 protocol. Late toxicity was evaluated according to the Radiation Therapy Oncology Group grading schema. The cosmetic outcome was scored using the Harvard criteria. Univariate logistic regression analysis was performed to evaluate the correlation of dosimetric variables with outcome. At a median follow-up of 15 months, moderate-to-severe late toxicity developed in 10% of patients. The most pronounced late toxicity was subcutaneous fibrosis: 25% Grade 2-4 and 8.3% Grade 3-4. The modified planning tumor volume/whole breast volume ratio, ratio of the volume of breast tissue receiving 5%, 20%, 50%, and 80% of the prescription dose to the whole breast volume, and maximal dose within the breast correlated with the development of fibrosis (p = .10, p = .03, p = .04, p = .06, p = .09, and p = .046, respectively). The overall cosmetic outcome was good to excellent in 81.7%, fair in 11.7%, and poor in 6.7%. The presence of subcutaneous fibrosis, modified planning tumor volume/whole breast volume ratio, ratio of the volume of breast tissue receiving 5% and 20% of the prescription dose to the whole breast volume, and pathologic specimen volume correlated with the risk of a fair/poor cosmetic outcome (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001, p = .02, p = .05, p = .04, p = .01, respectively). The three-dimensional conformal radiotherapy technique for accelerated partial breast irradiation as specified in the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 protocol resulted in a remarkably high rate of moderate-to-severe late normal tissue effects, despite the relatively brief follow-up period. The toxic events correlated clearly with several dose-volume parameters.
Journal of Applied Clinical Medical Physics
Purpose: Previous studies suggest that within radiation oncology, medical physicists (MP) experie... more Purpose: Previous studies suggest that within radiation oncology, medical physicists (MP) experience high workloads. Little is known about how MPs use social support (SS) in times of stress. Methods: In collaboration with the Workgroup on Prevention of Medical Error, the American Association of Physicists in Medicine administered this Human Investigation Committee (HIC) approved email survey to 8566 members. Respondents were considered likely to seek SS if they answered (probably/definitely would) and unlikely to seek support if they answered (probably/definitely would not). Logistic regression was applied to determine associations between demographic factors and willingness to seek support as well as perception of barriers. Results: One thousand two hundred and ninety-seven members (15.1%) accessed and gave consent for the survey. One thousand and one (11.7%) respondents answered all relevant questions. Respondents were predominantly male (69.1%), MP in radiation oncology (81.8%), private practice (51.6%), with practice duration> 10 yr (60.2%). MPs were likely to seek SS for personal physical illness (78.63%), involvement in a medical error (73.94%) or adverse patient outcome (75.17%). MPs sought SS in the setting of personal fatigue (33.2%) or burnout (44.3%). Barriers to seeking SS were lack of time (80.3%), and uncertainty about whom to access (70.7%). MPs responded that they would be most likely to seek support from an equally experienced medical physicist colleague (81.0%). Most MPs (67.0%) identified as having experienced stressors, with serious family illness (35.2%), or burnout (32.8%) being most common. Factors associated with MPs unwillingness to seek SS for medical error included> 20 yr in practice (vs still in training-OR 0.30, P = 0.015), and male gender (OR 0.60, P = 0.003). Male gender was associated with the lowest willingness to seek support (OR 2.10, P = 0.0001), but also with fewer perceived barriers (OR 1.60, P = 0.0075). Conclusion: Willingness to seek SS is demonstrated, and MPs want colleagues to provide support. Given these results, peer support could be considered among MPs.
Quality at the American Society for Radiation Oncology Annual Meeting: Gender Balance Among Invited Speakers and Associations with Panel Success
International Journal of Radiation Oncology*Biology*Physics
PURPOSE The American Society for Radiation Oncology (ASTRO) annual meeting is the most prominent ... more PURPOSE The American Society for Radiation Oncology (ASTRO) annual meeting is the most prominent international conference in radiation oncology. It represents one of the greatest time efforts for ASTRO volunteers, and the quality of the annual meeting is a high priority. Measures of diversity have been linked with quality of academic efforts. We conducted a study of gender diversity of the ASTRO invited speakers, focusing on speaker and panel characteristics, and associations of these characteristics with measures of audience satisfaction. METHODS AND MATERIALS We created a database of all invited speakers (n = 1499 cumulative speaking positions, n = 725 individual speakers) and panels (n = 381) in the ASTRO annual meetings from 2012 to 2016. Speaker characteristics were acquired using publically available online search tools (including Scopus for citation metrics). SAS software was used for statistical analysis. RESULTS Of the 725 individual speakers, 27% were women. Men had higher median Hirsch index (H-index) (27 vs 20, P < .001), M-index (1.36 vs 1.11, P < .001), earlier first publication (1994 vs 1997), professorship (57% vs 40%, P < .001), chair status (25% vs 14%, P < .001) and fellow designations/distinctions (ie, FASTRO/FACR/FAAPM) (12% vs 9.5%, P < .17). Median panel gender distribution was 25% female, and greatest female representation was in breast, gynecology, and pediatrics. On multivariable analysis, panel characteristics associated with individual measures of audience satisfaction included single discipline presentations (metric: overall evaluation score), panels not proposed or endorsed by committee (metric: room count), higher H-index (metric: room count) and M-index (metric: request for session repeat), and panels with gender composition >50% female (metric: request for session repeat). Female conveners were associated with greater panel gender diversity. CONCLUSION Given observations that women constitute a minority of invited speakers and that greater female representation correlates with a key panel success metric, efforts to ensure greater diversity of those included in AM speaking invitations merit serious attention.
Medical physics, 2018
Incident learning is a key component for maintaining safety and quality in healthcare. Its use is... more Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems (ILS) in radiation oncology, with over 40 publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root cause analysis, and national and international ILS for shared learning. Core principles of patient safety in the context of ILS are discussed, including the systems view of error, culture of safety, and contributing factors such as cognitive bias. Finally, the topics of medical error disclosure and second victim syndrome are discussed. In spite of the rapid progress and under...