A Message From the President
This issue of the brachytherapy blast is filled with updates and resources that are relevant to all brachytherapyists. You won’t regret scrolling all the way to the end to find out about all the new offerings from ABS. First, Scott Glaser has summarized brachytherapy relevant trials that were presented at ASTRO. Potentially practice-changing results were reported in breast, GU, and Gyn brachytherapy. Wendy Smith from health policy solutions provided an update on the RO Model which may affect reimbursement for many of us. This program has now been delayed to January 2023.

Firas Mourtada, Chairman of the Board, reports on a developing regulatory guide from NRC which could impact the time needed to hold brachytherapy patients after implant due to modification to how exposure rate is calculated. We encourage all ABS members to provide feedback to NRC during the public comment phase. The ABS board will also submit a formal letter stating that this regulation should be modified to allow same-day discharge of LDR brachytherapy patients with the same safety instructions that are routinely provided.

New guidelines for LDR brachytherapy have been published. Martin King and Peter Orio describe the new document which will serve as a useful resource for new and experienced brachytherapists. Junzo Chino reports on the important work being done by the international committee with ways for our members to get involved.

We also present exciting new events hosted by ABS. The Gyn school will be virtual in February. Experts from around the globe will update on practical and fundamental subjects as well as talk about new developments in the field. A course for prostate brachytherapy is online as well as part of ABS’s commitment to providing mastery-level material for all relevant oncology disease sites. The Annual meeting will be in Denver in June. We look forward to welcoming membership back to reconnect.

Finally, two more exciting virtual events are coming up in January. A session on practical brachytherapy cases hosted with ROVER (Radiation Oncology Virtual Education Rotation) for trainees and a session that I will be moderating with our team at MD Anderson with a practical guide on how to do hybrid interstitial insertions. Links to register are below. Join in and send questions for our panel to answer.

I wish everyone a restful holiday break and we look forward to seeing you in 2022!

Ann Klopp, MD, Ph.D.
President, ABS

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Best of Brachytherapy at ASTRO
Scott Glaser, MD, Editor, ABS BrachyBlast
Colton Ladbury, MD
Jason Liu, MD
The annual ASTRO meeting took place in Chicago, October 23-27. For many of us this was the first medical meeting with an in-person option in quite some time. While things weren’t quite the same, it sure was nice to see so many of you face to face (masked of course). For this month’s brachyblast we wanted to highlight four of the research abstracts pertaining to brachytherapy presented at the ASTRO meeting.

TRIUMPH-T: Of interest to breast cancer, the results of the phase II TRIUMPH-T trail was presented.
Historically, breast brachytherapy has been given in 10 bid fractions. In this trials, the investigators evaluated a 3 fraction regimen to a total dose of 22.5 Gy prescribed to 1-2 cm beyond the lumpectomy cavity. This study of 175 patients demonstrated excellent cosmetic outcomes, minimal grade 3+ toxicity, and only 2 local recurrences. This study demonstrates the feasibility of ultra-short breast brachytherapy, offering patients a more convenient option for APBI.

In a less common site for brachytherapy, a retrospective study from India compared IMRT to brachytherapy boost in oropharyngeal malignancies. In this study of 70 patients, patients received either IMRT to 70 Gy (n=35) or IMRT to 50 Gy followed by a 24.5 Gy in 12 fractions boost with interstitial brachytherapy (n=35). The patients in the brachytherapy arm demonstrated significantly better PFS, dysphagia, xerostomia and quality of life. Therefore, although not routinely used in modern clinical practice, this study demonstrates that brachytherapy boost should be an area of interest in future oropharyngeal cancer research as a way to improve outcomes and decrease toxicity.  

RTOG 0256: Salvage options for recurrent prostate cancer after treatment with external beam radiation therapy (EBRT) remain limited. RTOG 0526 was the first prospective multicenter trial to report outcomes of salvage low dose rate (LDR) brachytherapy for local recurrence after EBRT. This study of 100 patients demonstrated favorable biochemical control of 46% at 10 years and acceptable late grade 3+ toxicity around 14%. This study suggests that salvage LDR brachytherapy may be considered in select patients with recurrent prostate cancer after EBRT.

In the GYN section, a retrospective analysis from the GEC-ESTRO working group of patients treated with brachytherapy alone for medically inoperable stage one endometrial cancer was presented. This multi-institutional analysis included 62 patients and found very good control rates for stage IA patients (2-year cancer-specific survival of 97%) while results for stage IB patients (2-year CSS of 78%) suggested there may be more of a role for EBRT in addition to brachytherapy.

Congress Passes Legislation to Delay Radiation Oncology Model and Increase 2022 Conversion Factor
Wendy Smith Fuss, MPH | Health Policy Solutions
Congress recently approved the Protecting Medicare and American Farmers from Sequester Cuts Act to prevent Medicare cuts to health care providers, including a one-year delay of the Radiation Oncology Alternative Payment Model (RO Model) to January 1, 2023.
The Senate recently passed legislation 59-35 to mitigate Medicare payment cuts to providers, clearing the path for the president to sign the bill as providers are already lobbying for longer-term relief next year.
The legislation, which averted payment cuts weeks before they were set to go into effect in 2022, had passed the House earlier in the week.
The legislation would phase in sequester cuts starting after March 2022 with a 1% cut through the end of June, after which the cuts would return to 2%. It would also defer the cost of the American Rescue Plan to the 2023 so-called PAYGO scorecard, mitigate some cuts tied to changes in CMS’ evaluation and management policies under the Medicare Physician Fee Schedule, and delay the start of the radiation oncology model until 2023.
ASTRO commented that "Radiation oncologists across the country applaud our congressional champions for working to protect patient access to cancer care during this pandemic by implementing a one-year delay to the RO Model and mitigating serious Medicare payment cuts. While we are grateful for the delay, our focus remains on the reforms needed for the model to be successful. We continue to support a transition to value-based care, but the current CMS model needs urgent reforms to achieve that goal. This delay creates a critical window of opportunity for Congress to address the RO Model’s flaws, namely the excessively severe discount factor payment cuts, as well as the need for payment stability for all radiation oncology clinics. We are pleased by the momentum building in support of these legislative reforms, and we look forward to working with our congressional champions to address these issues early in the new year."
The legislation also mandates an increase to the 2022 Medicare Physician Fee Schedule conversion factor by 3%.
Before Congress took action, doctors were looking at Medicare payment cuts totaling 9.75% in January 2022: a 4% cut due to PAYGO or "pay-as-you-go," a rule requiring Congress to fully fund any legislation it passes; a 3.75% cut in the Medicare Physician Fee Schedule "conversion factor" -- the multiplier that Medicare applies to relative value units (RVUs) to calculate reimbursement for a particular service or procedure; and a 2% cut from the "sequester," an across-the-board cut to federal programs.
The legislation does not include providers’ calls to avert cuts tied to CMS’ clinical labor policy changes, and some provider groups are continuing to call for relief in that area before the end of the year.

FDA-NRC Workshop on Targeted Alpha-Emitting Radiopharmaceuticals
Firas Mourtada, Ph.D., Chairman of the Board, ABS
IOn Dec 15, 2021, the NRC conducted a webinar meeting of the Advisory Committee on the Medical Use of Isotopes (ACMUI) which may impact LDR brachytherapy. One item on the agenda that ABS members should be aware of the draft revision of Regulatory Guide 8.39 (NUREG-1556, vol 9) “Release of Patients Administered Radioactive Material”. As you know, this regulatory guide provides methods that are acceptable to the US NRC for patient release for both radiopharmaceuticals or seed implants based on an activity or dose-rate thresholds. The change pertains to the assumption of the method to estimate the exposure level to the public from the release of a patient. The total effective dose equivalent (TEDE) limit of 5 mSv (0.5 rem) to the public from exposure from a released patient has not changed. In this revision, threshold calculations assume unity for the occupancy factor when patient-specific information is not known to avoid underestimating exposure when patients have close contact with the public. Updated thresholds for administered activity and measured dose rates are tabulated for individual radionuclides and our ABSA members should examine how these will impact their release method. 

For instance, the dose-rate method is typically used for prostate seed implant patient release. From the new Table 2 the new threshold is 0.24 mR/hr (2.4 mSv/hr) at 1 meter for I-125 seed implant, which is about 25% of the current patient release threshold of 1 mR/hr at 1 meter. The NRC has indicated the need to hold the patient for release until the threshold limit has been met. Given the half-life of sources used in prostate brachytherapy, this would be up to several days which would clearly not be feasible and would threaten the practical implementation of brachytherapy. The new guideline suggests a conservative administrative hold time to be calculated based on the specific radionuclide radioactive decay. Similar threshold reductions were also given for Pd-103 and Cs-131. The ABS will provide a formal letter to the NRC for assessment of the actual impact of this new limit and recommendation that the requirement is modified for patients receiving low dose rate brachytherapy. I encourage the ABS members to also provide feedback directly to the NRC when the public comment phase opens. The ABS supports radiation safety measures to patients, clinicians, and the public, however, the newly proposed calculation method is too conservative and not practical.
ABS Low Dose Rate Prostate Brachytherapy Guidelines
Martin King, MD, Socioeconomics Committee Co-Chair
Peter F. Orio, DO, MS, Past President, ABS
The low dose rate prostate brachytherapy guidelines have now been published in the Brachytherapy journal1. These guidelines, which have been endorsed by the American Brachytherapy Society and the American Society of Radiation Oncology, provide evidence-based consensus statements about the efficacy, toxicity, and quality of life of prostate brachytherapy. The guidelines, which were based on a systemic review of the literature, incorporate recent practice-changing clinical trials, including ASCENDE-RT2 and RTOG 02323. Furthermore, the guidelines provide clinical recommendations based on the contemporary 4-tiered NCCN risk stratification4. Overall, the guidelines offer a balanced assessment of prostate brachytherapy in the monotherapy and boost settings, with respect to alternative competing modalities, for both favorable and unfavorable risk prostate cancer. Our hope is that the guidelines will be utilized as a resource for training the next generation of prostate brachytherapists.

1.          King MT, Keyes M, Frank SJ, et al. Low dose rate brachytherapy for primary treatment of localized prostate cancer: A systemic review and executive summary of an evidence-based consensus statement. Brachytherapy. 2021;20(6):1114-1129. doi:10.1016/j.brachy.2021.07.006
2.          Morris WJ, Tyldesley S, Rodda S, et al. Androgen Suppression Combined with Elective Nodal and Dose Escalated Radiation Therapy (the ASCENDE-RT Trial): An Analysis of Survival Endpoints for a Randomized Trial Comparing a Low-Dose-Rate Brachytherapy Boost to a Dose-Escalated External Beam Boost for High- and Intermediate-risk Prostate Cancer. Int J Radiat Oncol. 2017;98(2):275-285. doi:10.1016/j.ijrobp.2016.11.026
3.          Prestidge BR, Winter K, Sanda MG, et al. Initial Report of NRG Oncology/RTOG 0232: A Phase 3 Study Comparing Combined External Beam Radiation and Transperineal Interstitial Permanent Brachytherapy With Brachytherapy Alone for Selected Patients With Intermediate-Risk Prostatic Carcinoma. Int J Radiat Oncol Biol Phys. 2016;96(2S):S4.
4.          Mohler JL, Antonarakis ES, Armstrong AJ, et al. Prostate Cancer, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Cancer Netw JNCCN. 2019;17(5):479-505. doi:10.6004/jnccn.2019.0023
Events and Collaborations
2022 GYN School
We are very pleased to offer a spectacular group of speakers for the educational program for this year's Gynecologic Brachytherapy School. The fundamentals of brachytherapy for cervical, endometrial, and vaginal cancers will be discussed by world-renowned experts from the U.S. and Europe. Given the central importance of image-guided brachytherapy, the school will feature a treatment planning program, covering safety and quality issues, as well as pitfalls and workflow issues. Treatment of gynecologic cancers with intracavitary, interstitial, and hybrid applicators, as well as discussion of innovative devices, will be part of the

Click here to register.
2022 Annual Conference
As I collaborate with Mitch Kamrava (Scientific Program Co-Chair), the track leads, and others to plan the agenda and details for the 2022 annual meeting, it’s easy to remain inspired by the meeting's theme: “ReConnect, ReEngage, ReDiscover”. What better escape from the reality of the current resurgence of the pandemic than to partner with ABS colleagues to plan the scientific agenda for what I hope will be a wonderful opportunity to share the latest brachytherapy innovations while connecting in person with old colleagues and new connections? I am optimistic that we will all be together in Denver in June, and I am confident that the scientific program will be stimulating and educational.

In addition to the usual scientific sessions that will feature high-impact research contributions from the field, our disease site leads have proposed new panel sessions that will feature the latest innovations in brachytherapy. We plan to host a pre-meeting workshop on June 16th that will feature hands-on training, recommendations for building new programs, and tips for treatment planning in challenging cases. In the spirt of our meeting theme, there will be many opportunities for attendees to participate in interactive sessions to ask questions and to share insights on best practices, evolving payment changes, and staying engaged and fulfilled at work amidst the daily challenges of radiation oncology clinical practice.

Please mark your calendar to join us in Denver in June for the 2022 ABS Annual Meeting, and take the opportunity to ReConnect, ReEngage and ReDiscover with your fellow colleagues.
Click here for more information
ABS & ROVER Present a Brachytherapy Panel
ABS & ROVER presents a Brachytherapy Panel: Case-Based Teaching Sessions with:

  • Albert Chang, MD - Prostate Brachytherapy; Memorial Sloan Kettering Cancer Center
  • Marisa Kollmeier, MD - Prostate Brachytherapy; Cedars Sinai
  • Mitchell Kamrava, MD - Gynecologic Brachytherapy; UCLA
  • Lilie Lin, MD - Gynecologic Brachytherapy; MD Anderson Cancer Center

When: January 7, 2022
Time: 12:00 pm - 1:00 pm PST/3:00 pm - 4:00 PM EST

Practical Strategies for Performing Hybrid Interstitial Applicators for Cervical Cancer Brachytherapy
Hybrid interstitial applicators have been shown to be effective at increasing doses to tumors while preserving or lowering normal tissue doses. The insertion process is more complex however and caution is needed to ensure needles are optimally positioned. We will discuss practical aspects of our own hybrid applicator program, including pre-planning using pre-operative imaging, applicator preparation, needles labeling, insertion techniques, use of intraprocedural image guidance including ultrasounds, CT or MRI, and techniques for optimizing and planning.
Lilie Lin, MD
Samantha, Simiele, MD
Christine Starks, MD
Ann Klopp, MD

When: January 27, 2022
Time: 5:00 pm 6:00 pm EST

Content Corner
Brachytherapy Training & Policies
At current, there is no standard shielding or educational/training protocol for physicians performing brachytherapy. We hope to understand physician concerns regarding brachytherapy training, personal risks of radiation exposure, as well as the utilization of shielding techniques when performing brachytherapy procedures. Please set aside a few minutes to fill out the attached questionnaire. Your answers will help us understand barriers to the continued practice of brachytherapy. Be rest assured your responses will remain anonymous.
Resident Corner
Attention Residents: We are launching a radiation oncology medical and physics resident corner on the BrachyBlast! We are looking for volunteers to showcase their work in brachytherapy, interesting tips that you have learned, and/or perspectives from a resident. The aim for length is 100-300 words. Please contact Jenna Kahn or Melissa Pomerene if you are interested for next month!
International Committee
Lack of access to brachytherapy is an international health care crisis. As a material example, a recent study from Rwanda examined the experience and results for women with cervical cancer during the era when no radiotherapy (RT) including brachytherapy was available (De Boer et al., Gyn Onc 2021,). Women were often referred for international treatment in Uganda or Kenya for treatment, however not all were able to get timely treatment. The long event-free survival rates were 12% for those that were unable to get access to any RT, while for those with access it improved to 66%, even when access was delayed but temporized with interval chemotherapy. When one looks at the overlap of distribution of new cervical cancer cases, and regions where brachytherapy is either inadequate or lacking, the dire need for improved access is clear.

A primary goal of the international committee of the ABS improves these disparities worldwide. This can be facilitated by mobilizing the primary resource of the committee: the dedication and expertise of our membership, to serve as collaborators with teams that are developing brachytherapy programs in regions of need. An example of this is an ongoing monthly meeting with the Bugando Medical Center in Mwanza, Tanzania in conjunction with the International Cancer Expert Corps (ICEC). These meetings have been by necessity virtual given the pandemic, however, in-person visits are planned for this coming year. 
We are also excited to announce the first ABS-supported meeting in a Low to Middle Income Country (LMIC), in conjunction with RadiatingHope: the Greater Horn Oncology Symposium, to be held from June 24th – June 26th, 2022 in Dar es Salaam, Tanzania. This will gather attendees from multiple countries both in the Greater Horn region, and this year will include experts from the ABS for dedicated brachytherapy sessions. For more information, please visit the ABS website or contact the International Committee (see below).

There are many other ongoing initiatives, including collaborations with Rayos Contra Cancer in Latin America, and a guide for developing an HDR brachytherapy program in LMICs in conjunction with the Indian Brachytherapy Society (IBS). To get involved with any of these and other projects at the International Committee, please contact the current chair, Junzo Chino at junzo.chino@duke.edu.  

Long term Outcomes with Prostate Brachytherapy
The American Brachytherapy Society is pleased to announce a new course on Prostate Brachytherapy.

Close to 30 lectures on long-term disease outcomes, toxicity, socioeconomic issues, training, and new developments, organized in 3 modules, are brought to you by the American Brachytherapy Society in partnership with Grand Rounds Urology. This is available online and through Americanbrachytherapy.org.
Part 1 of our free 3-module course includes presentations from the leading experts in the field of brachytherapy to discuss long-term disease outcomes, toxicity, socioeconomic issues, training, and new developments in the field. The module, Long-Term Outcomes with Prostate Brachytherapy, features thorough discussions of the most important topics and prostate cancer care for the multidisciplinary team. A few highlights include discussion on the Myths and Facts of Prostate Brachytherapy from Dr. Stephen Frank, MD, FABS of MDACC, and “Comparative Outcomes: Prostate Brachytherapy Versus EBRT Versus SBRT for Low and Intermediate-risk Prostate Cancer given by Michael Zelefsky MD, FABS of MSKCC.

The lectures can be viewed at your convenience, in the clinic, at home, and with your multidisciplinary team. Once registered in the ABS educational library, you will have immediate access that will not expire.

ABS is committed to creating an online educational library providing mastery-level material from international experts for all oncology disease sites. Please join us. Learn more on the ABS website.

Click here to start watching
2021-2022 ABS Board of Directors

Ann Klopp, MD, Ph.D., President
Peter Rossi, MD, President-Elect
Brett Cox, MD, Vice President
Kristin Bradley, MD, Treasurer
Christopher L. Deufel, Secretary
Firas Mourtada, Ph.D., Chairman of the Board
Daniel Petereit, Past Chairman of the Board

Junzo Chino, MD
Mitchell Kamrava, MD
Mira Keys, MD
Timothy Showalter, MD