Session Content Resources

This session will provide a global overview of breast radiotherapy indications, approaches and techniques, informed by the latest clinical trials and relevant research. By the completion of the session, attendees should be able to identify which patients are suitable for omission of radiation therapy for early stage breast cancer, what kinds of genomic tests have been explored for risk stratification, and what techniques and dose/fractionation schemes demonstrate appropriate efficacy and toxicity profiles for definitive breast radiotherapy.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Appropriately identify patients suitable for omission of adjuvant radiation therapy in early-stage breast cancer.
• Utilize hypofractionation techniques, when applicable, in early-stage breast cancer.
• Understand the relative value and limitations of genomic signatures in risk stratification for breast radiotherapy.

References

• Kunkler, IH, et al. Breast-Conserving Surgery with or without Irradiation in Early Breast Cancer. NEJM 2023. 388:585-594.
• ​Murray Brunt, A, et al. Hypofractionated breast radiotherapy for 1 week versus 3 weeks (FAST-Forward): 5-year efficacy and late normal tissue effect results from a multicentre, non-inferiority, randomized, phase 3 trial. Lancet 2020. 395:10237:1613-1626.
• EBCTCG , Radiotherapy to regional nodes in early breast cancer: an individual patient data meta-analysis of 14324 women in 16 trials. Lancet 2023. 402: 10416:1991-2003.\

Potential Challenges/Barriers to Change

• Lack of knowledge/expertise
• Implications to physician/departmental compensation
• Lack of resources

This session will focus on recent and emerging research in radiation oncology for patients with brain and spine tumors. Special emphasis will be placed on radiosurgery dose/fractionation selection, IDH inhibition in glioma and glioma contouring/targeting. Future directions for brain tumor research will also be discussed, including several ongoing clinical trials.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Understand reasonable approaches to selecting dose and fractionation in stereotactic radiosurgery for brain tumors.
• Appropriately critique the recent evidence in support of IDH inhibitors in patients with glioma.
• Appropriately select eligible patients with brain metastases for stereotactic radiosurgery.

References

• https://pubmed.ncbi.nlm.nih.gov/37889444/ 
• https://pubmed.ncbi.nlm.nih.gov/37889441/ 
• https://pubmed.ncbi.nlm.nih.gov/37652602/ 

Potential Challenges/Barriers to Change

• Stereotactic radiosurgery workflow at their institution
• Stereotactic radiosurgery platforms at their institution
• Access to IDH-inhibitor therapy

There have been many advances and evolutions in the treatment of primary and metastatic CNS tumors. There are different treatment planning and contouring guidelines for CNS tumors. Without a clear and consolidated understanding of best practices, this could affect quality of care.

This will be a focused econtouring session on primary and secondary brain tumors, including the planning/treatment of CSI for leptomeningeal disease, brain SRS for intact and post operative brain metastases, and the treatment of glioma with a brief discussion and application of different MRI sequences.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Treatment planning for CSI
• Contouring and planning of intact and resected brain metastases
• MRI-specific contouring for gliomas

References

• Yang JT, Wijetunga NA, Pentsova E, et al. Randomized Phase II Trial of Proton Craniospinal Irradiation Versus Photon Involved-Field Radiotherapy for Patients With Solid Tumor Leptomeningeal Metastasis. J Clin Oncol. 2022 Nov 20;40(33):3858-3867. 
• Kruser TJ, Bosch WR, Badiyan SN, et al. NRG brain tumor specialists consensus guidelines for glioblastoma contouring. J Neurooncol. 2019 May;143(1):157-166. 
• Susko M, Yu Y, Ma L, et al. Preoperative Dural Contact and Recurrence Risk After Surgical Cavity Stereotactic Radiosurgery for Brain Metastases: New Evidence in Support of Consensus Guidelines. Adv Radiat Oncol. 2019 Mar 14;4(3):458-465. 

Potential Challenges/Barriers to Change

• Lack of MRI resources
• Expertise of implementation
• Insurance reimbursement for advanced techniques

This session will include an introduction covering common head and neck cancer subtypes. Basics of head and neck anatomy will be reviewed. Subsequently, we will transition to a case-based approach that will demonstrate target volume design for common head and neck tumor types.

Program Objectives

Upon completion of this live activity, attendees should be able to do the following:

• Understand patterns of spread based on primary tumor location and develop appropriate CTVs to target potential microscopic disease.
• Translate pathological findings into adjuvant target volumes in post-operative cases.
• Develop dose painting strategies for common cases of head and neck cancer.

References

• Perineural Invasion and Perineural Tumor Spread in Head and Neck Cancer Bakst, Richard L. et al. International Journal of Radiation Oncology, Biology, Physics, Volume 103, Issue 5, 1109-1124
• Head and Neck Cancer International Group (HNCIG) Consensus Guidelines for the Delivery of Postoperative Radiation Therapy in Complex Cutaneous Squamous Cell Carcinoma of the Head and Neck (cSCCHN) Porceddu, Sandro V. et al. International Journal of Radiation Oncology, Biology, Physics, Volume 107, Issue 4, 641-651.
• A contouring guide for head and neck cancers with perineural invasion. Ko C et al. PRO 014 Nov-Dec;4(6):e247-58.

Potential Challenges/Barriers to Change

• Lack of working knowledge of head and neck anatomy
• Lack of close collaboration with head and neck radiologists, pathologists and surgeons who can assist understanding regions at risk

Sarcomas are rare tumors. There are numerous ongoing advances in radiation therapy dosing and delivery for soft tissue sarcoma. Many physicians do not routinely see these tumors in practice because of their rarity. Failure to stay informed of current expert thinking on dosing and contouring leads to lower quality of care for patients with this rare malignancy.

This session will review indications for RT for STS in adults. We will review dosing and contouring rationale for STS in adults. We will review toxicity management and expectations for radiotherapeutic management for STS in adults.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Understand the contouring principles for soft tissue sarcoma in adults.
• Understand dosing principles for pre-operative and post-operative RT for STS in adults.
• Understand basic indications for RT for STS in adults.

References

• Radiation Therapy for Treatment of Soft Tissue Sarcoma in Adults: Executive Summary of an ASTRO Clinical Practice Guideline. Salerno KE, Alektiar KM, Baldini EH, et al. Pract Radiat Oncol. 2021 Sep-Oct;11(5):339-351. 
• Radiotherapy for management of extremity soft tissue sarcomas: why, when, and where? Haas RL, Delaney TF, O'Sullivan B, et al. Int J Radiat Oncol Biol Phys. 2012 Nov 1;84(3):572-80. 

Potential Challenges/Barriers to Change

• Sarcomas are rare, so practitioners do not see them routinely enough to maintain expertise.
• Long-term data regarding hypofractionation are lacking, so review of what is known is critical.
• Patients may have access difficulties getting to a sarcoma referral center.

It is difficult to know when to strongly advocate for radiation therapy in many GI malignancies. This talk will provide an overview of that topic to help practicing radiation oncologists gain clarity around the benefits of RT in specific GI malignancies as supported by current prospective trials.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Describe recent updates for upper and lower GI cancers.
• Articulate the role of radiation therapy in pancreatic cancer.
• Clearly understand the use of radiation therapy and applications of recent data for patients with rectal cancer.

References

1. Alliance Pancreatic Cancer Trial, 021501 PMID: 35834226

2. Prospect Trial, NEJM, PMID 37272534

3. Long-Term Results of the Dutch Randomized PREOPANC Trial PMID: 35084987

Potential Challenges/Barriers to Change

• New clinical trial data is confusing with regard to the role of radiation therapy in GI cancers.
• Several trials have been published recently that centers may not be aware of details regarding data application.
• Some trials have editorials that have been misleading and need clarification.

This refresher course will provide an overview of the treatment of prostate cancer with an emphasis on the role of radiation therapy in the treatment of localized disease, nodal disease, recurrent disease after prostatectomy and treatment of the primary in the setting of oligometastatic disease. It will include discussion of optimal systemic therapy to administer with radiation treatment, incorporating predictive biomarkers into practice, normal tissue constraints and comparative outcomes between radiation, surgery and active surveillance.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Recognize which patients may benefit from microboost, brachytherapy boost and nodal treatment as part of their definitive prostate radiation treatment.
• Identify the optimal systemic therapy to deliver with salvage radiation treatment.
• Describe the data supporting the treatment of the prostate with radiation therapy in the setting of metastatic disease.

References

• Ebell MH, Shaughnessy AF and Slawson DC. Why Are We So Slow to Adopt Some Evidence-Based Practices? Am Fam Physician. 2018 Dec. 15;98(12):709-710.
• Loeb S, Li R, Nolasco TS et al. Barriers and facilitators of germline genetic evaluation for prostate cancer. Prostate. 2021 Aug;81(11):754-764

Potential Challenges/Barriers to Change

• Not having access to required technology
• Lack of expertise to implement
• Not covered by patient’s insurance

Uterine and cervical cancer are the most common gynecologic cancers worldwide. There are frequent changes and updates to their treatment options, radiation planning and radiation techniques. This session will improve the quality of care by educating practicing clinicians in these areas. We will review diagnosis, staging and treatment of uterine and cervical cancers, including surgery, systemic therapy and radiation therapy. Focusing on radiation therapy, we will go through specific indications for radiation therapy. We will also review specific techniques and doses that are required to treat patients with uterine and cervical cancers.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Understand the indications for radiation therapy for uterine and cervical cancer.
• Understand the indications for both surgery and systemic therapy for uterine and cervical cancer.
• Understand the best radiation techniques and doses for uterine and cervical cancer.

References

• Cibula D et al. ESGO/ESTRO/ESP Guidelines for the management of patients with cervical cancer – Update 2023. Int J Gynecol Cancer 2023;33:649-666.
• Concin N et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int J Gynecol Cancer 2021;31:12-39.

Potential Challenges/Barriers to Change

• Lack of facility resources may be a barrier to treating patients correctly. For example, brachytherapy is often required for these patients, and if the physician's facility does not offer this, they may have to refer elsewhere. 
• Some of these cancers can be less common (e.g., locally advanced cervical cancers) and it may limit the participant's ability to remember how to treat these patients. These patients can always be discussed with a specialist who primarily treats gynecologic cancers.

There are many ongoing advances in head and neck cancer in the context of radiation therapy delivery, clinical research on treatment options and advanced techniques in radiotherapy delivery. Failure to stay informed leads to lower quality of care by practicing clinicians.

This is a lecture-based educational format designed to update attendees on the latest evidence-based practice recommendations for head and neck cancer radiation therapy. Scientific updates that inform practice as well as technological advances that are relevant to best outcomes for patients will be addressed.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Discuss the latest evidence-based recommendations for head and neck cancer.
• Implement the latest evidence-based recommendations into head and neck practice. 

References

• Will be provided during presentation

Potential Challenges/Barriers to Change

• Time constraints
• Established practices and treatment paradigms

The treatment approaches for lung cancer are rapidly evolving and include integration of new systemic therapies (e.g., immunotherapy and targeted therapies) into combined modality approaches for non-metastatic disease and ablative radiation therapy approaches for oligometastatic disease. As an example, there is emerging data on immunotherapy combined with chemotherapy as neoadjuvant therapy for surgery in locally advanced non-small cell lung cancer, but no direct head-to-head comparison with chemoradiation plus immunotherapy, which creates a gap in knowledge on how to manage these patients.

This session will review recent literature and guidelines for the treatment of lung cancer, and provide insights into tailoring of different combined modality therapy options for patients. Attendees will learn about the clinical outcomes and toxicity risks, and how to coordinate these new, complex multidisciplinary treatment approaches. Furthermore, this session will review recent insights into toxicity risks for both conventional radiation therapy (especially in the postoperative setting and related to cardiac injury) and stereotactic body radiation therapy (especially for ultracentral tumors), and the implications of radiation therapy toxicity on newer combined modality approaches.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Discuss the literature supporting novel combined modality therapy approaches that include immunotherapy, chemotherapy, surgery and/or radiation therapy in non-metastatic lung cancer.
• Discuss the pros and cons of different modalities of local therapy (surgery versus radiation) for each stage of lung cancer and appropriate situations to consider dual local therapy.
• Understand risk factors for severe radiation-related toxicity, including cardiac injury and central mediastinal structure injury for SBRT, and methods to mitigate these risks.

References

1. 5-year results of PACIFIC trial: https://ascopubs.org/doi/full/10.1200/JCO.21.01308

2. Checkmate 816: https://www.nejm.org/doi/10.1056/NEJMoa2202170

3. KEYNOTE-671: https://www.nejm.org/doi/10.1056/NEJMoa2302983

4. Nordic HILUS trial of ultracentral lung SBRT: https://pubmed.ncbi.nlm.nih.gov/33823286/&

5. SUNSET Trial of ultracentral lung SBRT: https://www.sciencedirect.com/science/article/pii/S0360301623080604

6. Phase II randomized trial of SBRT +/- immunohterapy: https://pubmed.ncbi.nlm.nih.gov/37478883/

Potential Challenges/Barriers to Change

• Communication and coordination of care between disciplines may be more difficult when there is not a consensus on the optimal treatment approach.
• Lack of risk stratification and/or decision support tools to help clinicians personalize treatment optimally.
• Lack of resources and knowledge on how to manage emerging toxicities.

In this session we will review current principles and data supporting the utilization of radiation therapy for patients with hematologic malignancies. We will explore current treatment paradigms as well as modern radiation treatment techniques that are utilized in this patient population. We will examine the indications for cellular therapies and how radiation therapy can serve as a therapeutic partner for the treatment of refractory disease.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Understand the indications for consolidative radiation therapy for patients with early stage Hodgkin lymphoma and Diffuse large B-cell lymphoma. 
• Have knowledge of targeted and cellular therapies used currently for patients with hematologic malignancies and how radiation therapy can serve as a therapeutic partner in several settings. 
• Understand current treatment approaches for indolent B-cell lymphoma.

References

• Dabaja BS, Ng AK, Terezakis SA, et al. Making Every Single Gray Count: Involved Site Radiation Therapy Delineation Guidelines for Hematological Malignancies. Int J Radiat Oncol Biol Phys. 2020 Feb 1;106(2):279-281. 
• Fang PQ, Gunther JR, Wu SY, et al. Radiation and CAR T-cell Therapy in Lymphoma: Future Frontiers and Potential Opportunities for Synergy. Front Oncol. 2021 Mar 25;11:648655.
• Wirth A, Mikhaeel NG, Aleman BMP, et al. Involved Site Radiation Therapy in Adult Lymphomas: An Overview of International Lymphoma Radiation Oncology Group Guidelines. Int J Radiat Oncol Biol Phys. 2020 Aug 1;107(5):909-933. 

Potential Challenges/Barriers to Change

• Lack of knowledge to implement changes in daily practice
• Lack of insurance reimbursement for certain types of radiation therapy delivery approaches
• Lack of referrals of appropriate patients

This session aims to provide a comprehensive update on the latest advancements and evidence-based practices in the management of oligometastatic/oligoprogressive disease. It will include a didactic portion, case studies, and interactive discussions. Participants will enhance their understanding of the biological underpinnings, diagnostic criteria and therapeutic strategies for oligometastatic/oligoprogressive disease. Emphasis is placed on the integration of modern radiation therapy techniques, systemic therapies and multidisciplinary approaches to improve patient outcomes.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Understand the appropriate indication for ablative radiotherapy in oligometastatic/oligoprogressive cancer.
• Know the appropriate dose, volume, and technique for treatment of oligometastatic/oligoprogressive cancer.
• Advocate in the tumor board and work with other colleagues for optimizing local therapy for patients with oligometastatic/oligoprogressive cancer.

References

• Standard-of-care systemic therapy with or without stereotactic body radiotherapy in patients with oligoprogressive breast cancer or non-small-cell lung cancer (Consolidative Use of Radiotherapy to Block [CURB] oligoprogression): an open-label, randomised, controlled, phase 2 study. VOLUME 403, ISSUE 10422, P171-182, JANUARY 13, 2024.
• Stereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers (SABR-COMET): a randomised, phase 2, open-label trial. VOLUME 393, ISSUE 10185, P2051-2058, MAY 18, 2019.

Potential Challenges/Barriers to Change

• Keeping the knowledge up to date regarding latest advances
• Balancing theoretical benefit versus clinical application and patient performance status
• Obtain support from other treating physicians, medical oncologists

There are many advances in the application of AI in contouring and segmentation, as well as patient specific quality assurance. However, it is important to know whether the system is working as intended, and there are implications that should be carefully considered that users may not be aware of prior to implementation. 

Artificial intelligence (AI) is quickly transforming the field of radiation therapy and offers exciting new tools including auto-contouring and patient-specific quality assurance. This presentation will delve into the latest advancements in AI-powered contouring, explore how these tools can automate tasks, improve consistency, and reduce time spent on these tasks. We will also discuss the emerging role of AI in quality assurance, examining how these approaches can help us evaluate accuracy and safety of radiation treatments. We will also explore challenges and risks in implementation.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Discuss the advantages and limitations of AI-powered contouring tools.
• Explain how AI can be used for patient-specific quality assurance.
• Identify potential challenges associated with the use of AI in radiation therapy.

References

• Heilemann et al. Clinical Implementation and Evaluation of Auto-Segmentation Tools for Multi-Site Contouring in Radiotherapy; https://doi.org/10.1016/j.phro.2023.100515
• Shanbhag et al. Integrating Artiicial Intelligence Into Radiation oncology: Can Humans Spot AI? DOI: 10.7759/cureus.50486
• Simon et al. Artificial Intelligence for Quality Assurance. https://doi.org/10.1016/j.canrad.2021.06.012

Potential Challenges/Barriers to Change

• Integration with existing workflows - Integrating these tools seamlessly into current clinical workflows might require additional training and overcoming compatibility issues.
• Lack of trust and transparency - Health care professionals may be hesitant to trust AI-generated results without transparency into the algorithms' decision-making process.
• Bias - Ensuring AI algorithms are unbiased is crucial.
• Cost, Time, and Personnel for training and implementation - Acquiring and maintaining AI software and hardware can be expensive especially for smaller institutions; Also requires training, and personnel to work on integration and ongoing support.

This presentation will cover established and emerging roles of ctDNA as a precision medicine tool to guide radiotherapy. This promising class of noninvasive biomarkers could have an outsized impact on cancer management by meaningfully stratifying patients into risk groups, tracking radiotherapy efficacy during and after treatment, and identifying patients with radiosensitive or radioresistant disease. Current gaps in evidence and practical considerations will be discussed.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Review types of ctDNA tests.
• Summarize evidence for ctDNA tests as tools to guide radiation therapy.
• Understand gaps in current knowledge and clinical implementation of ctDNA in radiation oncology.

References

• De Michino S, Aparnathi M, Rostami A, Lok BH, Bratman SV. The utility of liquid biopsies in radiation oncology. Int J Radiat Oncol Biol Phys. 2020 May 14. pii: S0360-3016(20)31132-9. doi: 10.1016/j.ijrobp.2020.05.008.
• Cescon DW, Bratman SV, Chan SM, Siu LL. Circulating tumor DNA and liquid biopsy in oncology. Nature Cancer. 2020;1(3):276-90. doi: 10.1038/s43018-020-0043-5.
• Sanz-Garcia E, Zhao E, Bratman SV, Siu LL. Monitoring and adapting cancer treatment using circulating tumor DNA kinetics: Current research, opportunities, and challenges. Sci Adv. 2022 Jan 28;8(4):eabi8618. doi: 10.1126/sciadv.abi8618.

Potential Challenges/Barriers to Change

• Insufficient high level evidence for many of the potential future applications of ctDNA as a precision medicine tool. 
• Limited sensitivity of current ctDNA tests to detect residual cancer after radical treatment.
• Practical hurdles including cost and turn-around-time to get a ctDNA result in clinical practice settings. 
• Lack of insurance coverage, regulatory approval, and guideline-based recommendations for the use of ctDNA tests in patients treated with radiation therapy.

This session will review the basic concepts of staging, overall treatment paradigm, radiation specific recommendations, radiation simulation, planning and treatment aspects, and literature regarding extremity and retroperitoneal soft tissue sarcomas. This session will also review literature regarding hypofractionation for extremity soft tissue sarcomas and provide guidance on how best to incorporate this into practice. This session will also review literature regarding the role of radiation therapy for retroperitoneal soft tissue sarcomas and how best to incorporate radiation therapy into practice.

Program Objectives
Upon completion of this live activity, attendees should be able to do the following:

• Understand and implement the treatment paradigm as it relates to radiation therapy for extremity and retroperitoneal soft tissue sarcomas.
• Select patients with sarcoma who may benefit from hypofractionated regimens. 
• Use safe and effective techniques (fractionation, target design, etc.) supported by the prospective data on hypofractionated radiotherapy for sarcoma.

References

• Guadagnolo et al, “Hypofractionated, 3-week, preoperative radiotherapy for patients with soft tissue sarcomas (HYPORT-STS): a single-centre, open-label, single-arm, phase 2 trial” Lancet Oncology 2022. 
• Bedi et al, “Could Five Be the New Twenty-Five? Long-term Oncologic Outcomes from a Phase II, Prospective, 5-Fraction Pre-operative Radiation Therapy Trial in Patients with Localized Soft Tissue Sarcoma” Advances in Radiation Oncology 2022. 
• Bonvalot S, Gronchi A, Le Péchoux C, et. al. Preoperative radiotherapy plus surgery versus surgery alone for patients with primary retroperitoneal sarcoma (EORTC-62092: STRASS): a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol. 2020 Oct;21(10):1366-1377.  
• Callegaro D, Raut CP, Ajayi T, et. al. Preoperative Radiotherapy in Patients With Primary Retroperitoneal Sarcoma: EORTC-62092 Trial (STRASS) Versus Off-trial (STREXIT) Results. Ann Surg. 2022. 

Potential Challenges/Barriers to Change

• Reluctance to deviate from comfortable techniques used for decades
• Fear of side effects associated with hypofractionation
• Uncertainty of how best to incorporate radiation therapy in the treatment of retroperitoneal sarcomas