November, 2018
A Message From the President
Welcome to the November 2018 edition of the American Brachytherapy Society’s BrachyBlast newsletter.

I am pleased to announce that ABS has issued a press release titled Cervical Cancer Treatment – Understanding the Critical Components for Successfully Treating Locally Advanced Disease . ” This is our third press release in our ongoing campaign to bring awareness to the media and the public on the benefits of brachytherapy (all types of brachytherapy) in appropriately selected patient across many disease sites. I truly believe that our unified message of brachytherapy is gaining traction and we are making strides towards providing information directly to a greater number of patients. Our press releases have been viewed positively and have been picked up by and viewed by numerous media outlets. I have spoken to several individuals across the country and the number of patients being provided brachytherapy as a component of their care is increasing. At my institution and in my practice, this is certainly true and we recently added an additional brachytherapist to our staff to keep up with the demand. This feels good. We have the data and by putting it into the hands of educated consumers we are making huge strides forward.
In this month’s BrachyBlast we have featured articles of great interest to our membership. Scott Glaser, MD has provided an article entitled The Most Anticipated Brachytherapy Trials: What’s in the Pipeline? In this piece Dr. Glaser provides us a review of some of the more significant ongoing/yet to be published studies in the radiation oncology and brachytherapy fields.

Also featured this month is a highlight by Sushil Beriwal, MD on a highly debated question on the horizon for our specialty. Dr. Beriwal outlines for us the current training guidelines of our radiation oncology residents and debates enhancing the minimum number of brachytherapy cases that must be performed by residents in an ACGME accredited training program in his article entitled Is it time for us to revisit ACGME requirements for brachytherapy caseloads during residency? This is a topic I am passionate about and is a conversation I will work to ensure we continue to discuss with our sister societies and the ACGME. I believe ABS has a responsibility to the entire profession of radiation oncology to ensure that high quality and safe brachytherapy is available to our patients now and well into the future. If we do not hold others accountable, then who will? We must continue to be the voice that educates and motivates others to choose what is right. We must fight to allow our surgically minded residents the opportunity to emerge proficient in performing brachytherapy and educate all our residents on the merits of brachytherapy so appropriate referrals can be made rather than not offering a patient “all their options.” 

As I approach the halfway mark of my presidency, I have reflected on all that we have accomplished in the past few months and look ahead at all I hope to accomplish in the second half of my presidency. Thank you for your dedication to the ABS, for continuing to partner with us to make patients aware of the efficacy of brachytherapy across many disease sites and for encouraging all of our patients to understand that in healthcare, Knowledge is Power .

As we approach the holidays I want to wish you and your families all the love and joy of the season 

Thank you,
Peter F. Orio III, DO, MS
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Eagerly Anticipated Brachytherapy Trials
What's in the Pipeline?
Ashwin Shinde, MD
Scott Glaser, MD
City of Hope National Medical Center
Despite advances in non-invasive therapies, recent studies such as ASCENDE-RT and retroEMBRACE, have demonstrated the oncologic value of brachytherapy. In this edition of the BrachyBlast, we review relevant brachytherapy trials to keep an eye out for, which will guide the future of breast, gynecological, and prostate brachytherapy.

In breast cancer, RTOG 0416/NSABP B-39 is a phase III randomized trial of either ductal carcinoma in situ or early stage invasive cancer, with up to 3 pathologically positive nodes. Patients were randomized to whole breast irradiation (WBI) using standard fractionation versus partial breast irradiation (PBI). PBI could be delivered using 3D-CRT at 38.5Gy in 10 fractions over 5 days, or intracavitary brachytherapy to a dose of 34Gy in 10 fractions. The accrual for the trial ended on 04/16/2013, and to data only limited toxicity data has been presented. Hopefully 5-year outcomes data will be presented/published within the next year. There are several smaller studies looking into shorter schedules of intracavitary brachytherapy (3-5 fraction), with early data having been presented at ASTRO this year.

In gynecological cancers, EMBRACE II continues to enroll, as a phase II trial that looks to reduce toxicity in early stage patients while maintaining excellent locoregional control rates, and to improve locoregional outcomes in more advanced patients with dose escalation with increasing use of hybrid intracavitary/interstitial applicators. EMBRACE II takes lessons learned from retroEMBRACE and the original EMBRACE protocol showing the benefit of image guided brachytherapy with MRI guidance and attempts to minimize vaginal, bladder, and rectal toxicity while giving sufficient cumulative radiation dose to HR-CTV. EMBRACE II also looks to standardize nodal dose and treatment volume based on multiple criteria. In endometrial cancer, the revamped PORTEC-4 trial looks to replace more traditional clinical high-intermediate risk factors with a molecular-profile risk grouping. Patients of favorable, intermediate, and unfavorable risk per molecular profiling will undergo observation, vaginal brachytherapy, and external beam radiation, respectively.

In prostate cancer, RTOG 0232 was previously presented at the plenary session in ASTRO 2016, showing no difference in biochemical PFS in intermediate risk cancer patients undergoing low-dose rate brachytherapy (BT)monotherapy compared to external beam radiation + brachytherapy (E+BT). The trial was felt to be significant for futility in terms of identifying a difference in bPFS between BT and E+BT, confirming current NCCN guidelines. However, since that trial was originally developed, definitions of intermediate risk prostate cancer have shifted to favorable (FIR) and unfavorable (UIR) subgroups. While RTOG 0232 did not include all intermediate risk patients, it did include Gleason 4 + 3 = 7 patients with a PSA < 10. What will be most interesting in the final publication is whether this patient subset with UIR disease benefits from the external radiation, or show acceptable outcomes using BT monotherapy. In recent years there has been increased utilization of HDR brachytherapy for prostate cancer with advantages including adaptive planning and less radiation exposure. However, a disadvantage of HDR monotherapy has been the requirement of multiple fractions with initial studies of single fraction HDR monotherapy demonstrating suboptimal results.  In the era of multiparametric MRI imaging it is possible to differentially dose the dominant lesion. Recent studies have demonstrated the feasibility of increasing dose to the dominant lesion and future/ongoing studies of single fraction HDR monotherapy will look to improve outcomes by augmenting the prescribed dose. If successful, HDR prostate brachytherapy may become even more popular.

Is it Time for us to Revisit ACGME Requirements for Brachytherapy
Caseloads During Residency?
Sushil Beriwal, MD, MBA
UPMC Hillman Cancer Center
There have been multiple publications in recent times showing declining use of brachytherapy for prostate, gynecological and breast cancers often leading to a detrimental effect on cancer outcomes. Various hypotheses have been proposed for this declining trend. The recent publication of brachytherapy training survey of radiation oncology residents by Kamrava et al . in Red Journal highlights what ails our training programs and sheds light on the barriers for graduating residents who practice or become leaders in brachytherapy. Residents, while valuing brachytherapy, felt low caseloads was the greatest barrier in their training. They felt minimum of 5 cases of interstitial brachytherapy required for training is not enough or adequate for competence. Similarly, even though they are required to perform 15 intracavitary brachytherapy, these could all be cylinder brachytherapy without including a single case of intrauterine tandem based brachytherapy.  Residents confidence in performing brachytherapy mirrored caseloads with declining confidence in performing brachytherapy for gynecologic, prostate, breast, skin. Even though ABS annual meeting and schools offer resources to supplement training, it is time for the caseloads required by ACGME for brachytherapy be revisited by the Resident Review Committee (RRC). These should be based on competence in performing procedure and not arbitrary number of minimum cases to let an expanding number of residency programs and positions meet caseloads requirement. These requirements may be defined with the help of brachytherapy experts. If we don’t act upon it, our future generation of radiation oncologists may lose competence in performing these important lifesaving procedures.
ABS Culture of Safety Practice Survey
Ensuring patient safety and continual practice improvement is critical in a high-quality brachytherapy program. You will receive shortly a link to participate in the ABS Culture of Safety Practice Survey.
The goal of this practice survey is to understand current patient safety policies among ABS members. We hope to identify opportunities to further provide safe, effective, high-quality brachytherapy to our patients, as well as define the scope of interest and needs in educational materials.
This quick survey will query several important features of your practice including types of brachytherapy and departmental policies, your perception of brachytherapy safety culture, meaningful use of incident reporting and learning systems, and what is important to you to understand how the ABS can best improve your practice.
We are excited to have you participate in the Culture of Safety Practice Survey. Your participation is voluntary. Answers are anonymous and held in the strictest confidence. We will present results of this practice survey at the ABS Annual Meeting in June 2019 to promote discussion of how our specialty can best continue to deliver safe and effective brachytherapy.
Neil K. Taunk, MD, MS
University of Pennsylvania

Zoubir Ouhib, MS, DABR
Lynn Cancer Institute

Timothy N. Showalter, MD, MPH
University of Virginia
ABS Quality and Safety Committee

Patient Safety Corner
Sarah Price & Panagiota Galanakou
Graduate Students, Florida Atlantic University
Zoubir Ouhib, MS
Boca Raton Community Hospital
Medical Event Case 0003 Responses and Feedback from Brachyblast Readers

Hello Brachyblast readers! We were again pleased with the responses received regarding Case 0002 presented in the September Brachyblast and the follow up in the October Brachyblast. Our hope is that such feedback will help reduce the occurrence of medical events in the coming years. We would again like to thank you for your participation and encourage you to continue to share your thoughts as your feedback is imperative to this process.

Patient Delivered Radiation Dose to Right Lobe of Liver versus Left Lobe

Introductory Information: Reported to the NRC in 2017 this medical event relates to a patient treated with Y-90 TherasSphere to the liver for ablation therapy.

Error: The patient was administered 1.5 GBq of Y-90 microspheres (TheraSphere) to a 90 cc liver volume for ablation instead of the prescribed 0.629 GBq (17 mCi). The liver received 80,780 cGy (rad) instead of the prescribed 34,000 cGy (rad). The microspheres were administered to the patient too early, before they decayed to the prescribed activity. The cause was an error by a scheduling nurse who used the pretreatment plan rather than the final treatment plan. The physicist’s pre-treatment calculations and a preadministration time-out failed to identify the error. The physician was notified and contacted the patient. To prevent recurrence, the spreadsheet used to calculate patient dose was modified to include a check of the administration vial's calibration activity and date versus the prescribed activity and procedure date. The time-out procedure was also modified to confirm the proper activity prior to administration. Applicable personnel were trained on these changes.

What preventive action(s) could stop reoccurrence of a similar event? Consider both corrective (immediate and long term) and preventive actions.

Please send corrective action suggestions before 12/10/18 to: including the title of the event (or case #), your name, your institution (optional), and your profession (Med. Phys., Rad. Onc., etc.). We intend to acknowledge all individuals who provided feedback. Please include in your response whether you approve of this recognition.

Be sure to check out next month’s BrachyBlast where we will present case 0004.

The 2019 Call for Abstracts is now open. For brachytherapy practitioners, this is the conference of the year to attend - join your colleagues, along with brachytherapy pioneers from around the United States and from around the world, as the latest patient studies, brachytherapy techniques and brachytherapy equipment are reviewed. 

Peter F. Orio, III, DO, MS
President, American Brachytherapy Society

Abstract Submission Details
Submission Types
  • Oral Presentation
  • Poster
  • Either
Submission Categories 
  • Breast
  • GI
  • GYN
  • Head & Neck
  • Physics
  • Prostat
  • Skin
  • Socioeconomics*
  • Miscellaneous (Biology, Intravascular, Pediatrics, Sarcoma, Thoracic)

Submission Deadline: January 11, 2019, 4:00 pm Central
The ABS Wants You!
Want to get more involved with the ABS? Here's your chance! Our goal to reshape the vision and future of the ABS to best serve the industry continues to guide how we approach every aspect of the organization. We've revamped our volunteer opportunities to better meet your needs. If you're interested in being part of one our committees, please feel free to fill out an interest form and return to Melissa Pomerene .
We look forward to working with you!
of Directors 
  2018-2019 ABS Board of Directors

Peter F. Orio, III, DO, MS , President
Daniel G. Petereit, MD, President Elect
Firas Mourtada, PhD, Vice President
Ann Klopp, MD, PhD, Treasurer
Zoubir Ouhib, MS, Secretary
Catheryn Yashar, MD, Chairwoman of the Board
Steven J. Frank, MD, Past Chairman of the Board

Sushil Beriwal, MD
Christopher L. Deufel, PhD
Peter J. Rossi, MD
Timothy Showalter, MD

Meetings and Workshops of Interest