A Message From the President
Welcome to the October 2020 edition of the American Brachytherapy Society’s BrachyBlast.  

Looking back at the October 2019 Brachy Blast President message, Dan Petereit reminded us of the Denver Prostate Workshop on November 1-2, 2019 as well as the Big Sky Summit that occurred last winter. Our Chairman then, Peter Orio, described the visit to Nanjing, China with Dr. Kamrava to represent the ABS at the Chinese Interventional Brachyseed Society. 

So why I am telling you this? As we fast forward to the present time, our world has changed, but I see that is not all bad news. Many of our members are pondering about the three main uncertainties that 2020 will bring upon us: the virus second wave, the finalized RO Model from CMS, and of course the US presidential elections next week. I am optimistic that by working together, we can make our American Brachytherapy Society even stronger. 

We chose to delay our gyn school this Fall, but provided virtual training pathways with more Webinars, VOEs, Chartrounds, GRUs. We quickly realized this element will stay with us, even after the virus is over. We also heard the great news of the CMS delay to the RO Model implementation this January until July 2021, and we are hopeful the delay is the first step to hear our concerns. Again, the ABS embraces value-based brachytherapy, and Drs. Kamrava and Chang share their thoughts on what this means, so please read their article below. And as the Election Day is near, we see democracy in action with many early votes casted. Regardless of your political affiliation, you should be proud to be American first and to stand untied to protect our unique democracy so please vote.  Remember no matter what the outcome is, we are Americans first, we are proud of the ABS members.    

Thank you,  
Firas Mourtada, Ph.D.
ABS President  
 
Follow Us on Twitter:  
@fmourtad

Brachytherapy Education and Training and Jumanji Syndrome
Daniel G. Petereit, MD
ABS Chairman of the Board
First of all, my apologies for writing my contributions on a semi-monthly rather than a monthly basis. My approach is to give the readership a broader perspective. At times I have had a bit of a “writing block” or maybe “COVID” brain!

The upcoming issue of Brachytherapy is dedicated to brachytherapy education and training. Dr. Eric Donnelly and Dr. Beth Erickson did a phenomenal job in organizing this very timely issue. I was also given the opportunity to write an editorial on the 300 in 10 initiative for which I am grateful. The multiple contributions in this special edition chronicle where we have been and where we are going. 300 in 10 is a natural progression of decades of work, especially the ABS schools, and builds on the efforts of countless, selfless individuals in our field.

Dr. Erickson’s summary of the ABS BT schools acknowledges our brachytherapy leaders, especially Dr. Arthur Porter, ABS president 25 years ago, who recognized that many US residents had inadequate BT training. How interesting and disappointing this trend of inadequate BT training and procedural volumes have re-emerged.

While many academic institutions are making it a priority to implement BT programs, the ABS has an ongoing mission to re-invigorate training, provide mechanisms to train new residents and assist former brachytherapists in developing programs.

It must be emphasized that 300 in 10 is actually 600 in 10. The goal is to train 300 competent brachytherapy teams with a radiation oncologist and physicist. Dr. Steven Frank and his team have successfully completed 3 prostate brachytherapy simulation workshops over the last 2 years as detailed in the Journal as well. ABS has made substantial progress with these prostate workshops where we have trained 130 teams with 170 to go. From these workshops, about 80% of these teams have implemented brachytherapy practices within 6 months of the school. So, the investment by both ABS and industry is paying off. ABS is the only US group where we have an established tracking record of training brachytherapy teams. Also, current ABS president, Dr. Firas Mourtada, has had and continues to have a leadership role with AAPM. There is significant synergy between the 2 groups to move 300 in 10 forward.

The reality is that we are well underway with 300 in 10 and have switched the time frame to 300 in 5: training all these teams within 5 years. We will also continue to train GYN teams which is an equally high priority.  

For our industry partners, you will receive a meeting invite in the 1-2 weeks to participate in our first ABS Industry Advisory Council. We view all of you as consultants and keenly desire to discuss the following questions, and probably many more in the context of your expertise in brachytherapy and your company’s priorities: tell what we don’t know, what works, what doesn’t work, what can we do better, how do we educate patients, how do we educate urologists and primary care providers, does it make sense to create a 5 year budget to continue the mission of 300 in 10?

COVID Story/ Jumanji Syndrome
A patient of mine recently relayed a humorous analogy: “every day I wake up is like the movie Jumanji. I spin the wheel and wait to see what disaster/plague awaits me today”. While that is a bit dark, it is somewhat true. The Dakotas are now part of the US epicenter for COVID with virtually all hospitals on diversion. I now have BT patients who are COVID positive, and am trying to work through those issues. Every day I wake up and wonder, am I next… If so, I am optimistic I will recover. I spun the “Jumanji wheel” recently and went fishing on the Missouri River one last time with questionable weather. Unfortunately, I had to “take one for the team” and jumped out of the boat to push it off a sandbar as it snowed – I was much warmer at the ABS winter update in Big Sky last February!

For the fall/winter ABS newsletter, I will highlight our virtual education opportunities. ABS is committed to helping you and our patients during this most trying time. Be safe and be well; hopefully we will get out of the “Jamanji era” soon!

References
Editorial
Adapting to ensure brachytherapy remains a vital component of our future Eric D.Donnelly

The ABS Brachytherapy Schools. Beth Erickson, Juanita Crook, Frank Vicini, Douglas Arthur, Zoubir Ouhi, Bruce Thomadsen, William Bice, Wayne M.Butler, Daniel G.Petereit, Akila N.Viswanathan, 

Development, implementation, and outcomes of a simulation-based medical education (SBME) prostate brachytherapy workshop for radiation oncoloy rresidents. ShaneMesko, Bhavana V.Chapman, Chad Tang, Rajat J.Kudchadker, Teresa L.Bruno, Jeremiah Sanders, Prajnan Das, Chelsea C.Pinnix, Nikhil G.Thaker, Steven J.Frank

The American Brachytherapy Society Prostate Brachytherapy LDR/HDR Simulation Workshops: Hands-on, Step-by-Step Training in the Process of Quality Assurance. Steven J. Frank, MD, Firas Mourtada, PhD, Juanita Crook, MD, Peter F. Orio, DO, Richard G. Stock, MD, Daniel G. Petereit, MD, Peter J. Rossi, MD, Brett W. Cox, MD, Chad Tang, MD, Rajat J.Kudchadker, PhD, Teresa Bruno, MS, Jingfei Ma, PhD, Jeremiah Sanders, PhD, and Mira Keyes, MD
Demonstrating Value In Brachytherapy
Mitchell Kamrava, MD and Albert Chang, MD
on behalf of the Socioeconomic Committee
It seems like everyone is trying to promote value these days. Restaurants have value meals, supermarkets have value deals, and now healthcare wants value based care. What does value mean anyways? Just like the value of a Big Mac, fries, and a soda for $5 is in the eye of the beholder, so is how to define value in radiation oncology. Teckie S et al provide a framework for defining value in radiation oncology through a modification of Porter’s value equation (1). They propose defining value as quality/cost.  In their model they define quality as including considerations of structure (adequacy of facilities, staff and equipment), process (all components of health care delivery), and outcomes.   Measuring outcomes can include objective measures, such as disease control and survival, but can also include things like patient reported outcomes, financial toxicities, and psychosocial impacts of treatment. We are clearly good at measuring and reporting objective outcomes, but we need to improve on evaluating and quantifying patient-centered outcomes.
 
When clinical outcomes are similar between different treatment options, it’s essential to incorporate the patient’s voice. This allows a better understanding of the outcome variable. For example, a recent comparison of patient reported outcomes through 5 years for favorable-risk prostate cancer patients treated with active surveillance, surgery, brachytherapy, or external beam radiation uses radar plots to demonstrate differences in urinary, bowel and sexual function domains over time (2). These charts allow patients to understand what is most likely to happen to them relative to other treatments, independent of bias from their physician’s perspective. In another example, the benefit of a brachytherapy boost in higher-risk prostate cancer on PSA control has been overshadowed by not having seen, to date, an improvement in distant metastasis.   This interpretation of just the objective data discounts the impact of a PSA recurrence on a patient. This can include financial costs associated with additional treatment as well as the psychological impact of ADT on patients and their partners (3,4).  In another disease site like breast cancer, where multiple APBI radiation techniques are available with similar oncologic outcomes, we similarly need to consider patient reported outcomes to help us understand the value of each option. We eagerly await the Breast Cancer Treatment Outcome Scale functional outcomes collected for comparison at the 2-year follow-up in the 3-fraction TRIUMPH-T trial (5). Similar considerations should be made for skin brachytherapy in terms of prospective cosmetic outcomes compared with external beam.  

When clinical outcomes are improved with brachytherapy, like in cervical cancer, there is still added value to understanding the patient’s voice. There are discrepancies between what we, as physicians, think is bothering our patients and what they say is actually happening (6). Incorporating patient reported outcomes adds an important dimension to understanding the long-term impact of our treatments.
 
The purpose of including these non-objective endpoints is not to say that endpoints like overall survival are not important. It is, instead, to point out that other things matter too.  The patient’s perspective is important and needs to be included in determining a treatment’s value. Brachytherapy is an incredible tool with multifaceted attributes. It is our job to make sure we measure important patient centric outcomes so the value of this treatment doesn’t go unnoticed. 

References:
1) Teckie S, McCloskey S, Steinberg M. Value: A framework for radiation oncology. J Clin Oncol, 32(26):2864-2870. 2014. 
2) Hoffman K, Penson D, Zhao Z, et al. Patient-reported outcomes through 5 Years for active surveillance, surgery, brachytherapy, or external beam radiation with or without androgen deprivation therapy for localized prostate cancer. JAMA, 323(2): 149-163. 2020.
3) Vu C, Blas K, Lanni T, et al. Cost-effectiveness of prostate boost with high-dose-rate brachytherapy versus intensity-modulated radiation therapy in the treatment of intermediate-high risk prostate cancer. Brachytherapy, 17(6):852-857. 2018.
4) Donovan K, Walker L, Wassersug R, et al. Psychological effects of androgen-deprivation therapy on men with prostate cancer and their partners. Cancer, 121(24):4286-4299. 2015.
5) Khan A, Chen P, Yashar C, et al. Three-fraction accelerated partial breast irradiation (APBI) delivered with brachytherapy applicators is feasible and safe: first results from the TRIUMPH-T trial. Int J Radiat Oncol Biol Phys, 104(1): 67-74. 2019.
6) Fokdal L, Potter R, Kirchheiner K et al. Physician assessed and patient reported urinary morbidity after radio-chemotherapy for locally advanced cervical cancer. Radiother Oncol, 127(3)”423-430. 2018.
CALL FOR ABSTRACTS!
2021 Annual Conference
Call for Abstracts is Now Open
June 25 - June27
Gaylord National Resort & Convention Center
National Harbor, Maryland

Click here to submit your abstract today!
2021 Renewals Have Begun
Renew your commitment to a community centered around you. The strength of the society relies on individual members like you, who are committed to making an impact in the field of brachytherapy. There is strength in numbers and our voices are heard when we speak in unison. Your dues are allocated in part to work with the ABS Board of Directors, Committees and Task Force Groups to fund some of the following initiatives:

  • 300 in 10
  • Develop and promote standards of education in brachytherapy through our annual meeting and Schools
  • Support direct to market awareness campaigns highlighting the effectiveness of brachytherapy as part of the treatment course of many different types of cancer
  • Improve Radiation Oncology reimbursement services for patients and providers
  • Negotiate with CMS to advocate for fair payments for brachytherapy
  • Advise the NRC in simpler regulatory language around brachytherapy
  • Live webinars offering SA-CME and CME
  • Networking opportunities during our Virtual Outreach Events (VOE) with leading brachytherapy practitioners
  • Address medical events and quality assurance issues for practitioners by keeping members up-to-date on current regulations
  • Enhance and facilitate international learning experiences by networking and communication with other brachytherapy societies around the world
  • Online access to scientific materials, including event recordings from prior meetings, including SA-CME sessions

NEW THIS YEAR! As part of ABS’s 2021 membership renewal campaign—and to fuel our “300 in 10” recruitment effort—ABS will be distributing a set of Virtual Reality Goggles with every renewal and/or join. Follow us on YouTube as we deliver a high-fidelity, immersive, viewer-directed experience that reproduces all of the audio-visual aspects of a procedure for trainees on a remote basis. Beyond the live experience, the tool further allows trainees to revisit and recreate the entire procedure, extending and augmenting the initial, one-on-one training.
UPCOMING EVENTS
Webinar: Prostate Cancer Treatment: Evidence, Controversies and Consensus for the Working Radiation Oncologist and Urologist (**CME and SA-CME will be offered)
November 10, 2020
4:00 pm - 5:00 pm ET
Members: Free (RENEW OR JOIN NOW!)
Click here to register




Virtual Outreach Event (VOE):CMS RO Model Discussion
November 12, 2020
5:00 pm ET
Members and Non-members are free
Click here to register

Virtual Outreach Event (VOE): Physician Burnout
December 3, 2020
5:00 pm ET
Members and Non-members are free
Click here to register

Coming Soon!
  • In depth technical discussion of Brachytherapy for Cervical Cancer
  • Update and review for breast APBI
  • Techniques for cervical cancer treatment & inoperable endometrial cancer update
HAVE YOU HEARD!
The ABS is on YouTube!

Just Posted:

ABS Prostate Cancer Low Dose Rate LDR Brachytherapy Virtual Reality (360VR) 

Dr. Adam Raben of Christiana Care Health System Radiation Oncology and Dr. Steven Terranova of Brandywine Urology perform a Low Dose Rate (LDR) prostate brachytherapy procedure from start to finish using real time intraoperative planning and verification.

**Join or renew today and get your VR goggles!
For more information, please email bradleyl@theragenics.com
2020-2021 ABS Board of Directors

Firas Mourtada, PhD, President
Ann Klopp MD, PhD, President Elect
Peter J. Rossi, MD, Vice President
Brett W. Cox, MD, Treasurer
Christopher L. Deufel, Secretary
Daniel G. Petereit, MD, Chairman of the Board
Peter F. Orio, III, DO, MS, Past Chairman of the Board

Directors-at-Large
  
Kristin Bradley, MD
Mitchell Kamrava, MD
Mira Keys, MD
Timothy Showalter, MD

Meetings and Workshops of Interest