A Message From the President
Welcome to the January addition to the brachytherapy blast! We hope you all are staying warm and safe. This newest issue of the brachytherapy blast highlights several relevant and important pieces of content.
This current issue of the Brachytherapy Journal, edited by Nikhil Thaker, Bill Small, Steven Frank, and Mitchell Kamrava, focuses on value-based in brachytherapy.  This issue covers important questions that our field must address, including how to measure quality, improve geographic access and innovate in payment models including addressing the important question of how brachytherapy may interface with bundled payment models.  
Mustafa Al Balushi a PGY-4 at the University of Albert brings us into the future with the development of virtual reality brachytherapy training, a new way of approaching procedural education which is being developed for cervical cancer brachytherapy. The future seems very bright for this approach to help make education a more layered process where 
Dr. Firas Mourtada, Chairman of the Board is participating in an important effort organized by the National Council on Radiation Protection and Measurements (NCRP) to provide guidance for a radiation oncology department’s quality- and safety-oriented practices. It will be of value for external accreditation reviewers as well as for radiation oncology departments’ self-assessment. 
In this same issue, I summarized our recent Webinar sponsored by Elekta on “Practical Strategies for Utilizing Hybrid Applicators for Cervical Cancer Brachytherapy” where my colleagues Lilie Lin, Aradhana Venkatesan, Christine Starks, and Samantha Simiele discussed our own experiences implementing a hybrid applicator program. 
We also remember a brachytherapist whom we lost very young in 2021. Dr. Larissa Lee was a brachytherapist and Associate Professor at Harvard. Her colleagues remember her for being a strong and calm mentor who drew others into the field to follow in her footsteps. Personally, her work was an inspiration to me and I personally feel her loss in our field where her perspectives and thoughtful input was much appreciated. She will be remembered by the many who worked and trained with her and through memorial lectureships which have been established in her honor.
The ABS is working hard at planning a virtual GYN Brachy School led by Drs. Gita Suneja, Beth Erickson, and Akila Viswanathan will deliver the popular content from past schools as well as address new developments in the field in a practical and accessible way which is the tradition of the GYN brachy school. We are also excited about the June Annual Meeting which will return to an in-person format in Denver, June 17th-19th.  Hope to see you there!

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

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Remembering an Extraordinary Mentor
Larissa Lee, MD
January is National Mentoring Month, and this month we remember the legacy of an exceptional mentor and brachytherapist: Dr. Larissa Lee. Dr. Lee was a talented, compassionate, kind radiation oncologist who specialized in the treatment of gynecological cancers at Brigham and Women’s Hospital and Dana-Farber Cancer Institute, and served as an Associate Professor at Harvard Medical School. She was the recipient of the Brigham and Women’s Hospital Junior Faculty Mentor Pillar Award in 2020, and to honor her legacy, the Larissa Lee Outstanding Clinician Award, Harvard Radiation Oncology Program Larissa Lee Mentorship Award, and the Larissa Lee, MD, Memorial Lecture has been established in her name.

Dr. Lee’s legacy of mentorship continues to inspire us to support the next generation of physicians. In memory of Dr. Lee, we share the experiences of some of her many mentees:

“Dr. Larissa Lee was more than a mentor. She was an example of the impact that we can each have on the lives of those around us. Amidst the chaos of a busy hospital day, she was the quiet within the storm. Even now, after a difficult day, I find myself looking back through our prior correspondences. Reminding myself of the importance of listening intently, caring deeply, and being present. Her presence in my life made me a better me, and that's what I strive to do with my mentees.”
-Idalid Franco, MD, MPH, PGY5, Harvard Radiation Oncology Program, USA
“As her former clinical fellow, I keep Dr. Lee in my mind as an ultimate role model for balancing extremely high standards for treatment quality and innovation, thoughtful leadership, personalized mentorship, and dedication to individual patient needs.”
-Pierre-Yves McLaughlin, MD, FRCPC, Lecturer, McGill University Department of Oncology, Gatineau Hospital, Canada, former BWH/DFCI Brachytherapy Fellow
“I have been so blessed to have Larissa Lee as one of my primary clinical mentors when I started as an attending physician in radiation oncology. Throughout my first year on staff, she spent countless hours coaching me on how to manage patients through intensive courses of chemoradiation therapy and MRI-guided brachytherapy. I have such fond memories during my first years here, because of her mentorship, and will do all that I can to continue her legacy as a compassionate and dedicated physician.”
-Martin King, MD, Ph.D., Radiation Oncologist, BWH/DFCI, USA
“I am so grateful to have known Dr. Lee. She made the impossible, possible, and she brought so much kindness and thoughtfulness to all that she did. She continues to be an inspiration to me.
-Lisa Singer, MD, Ph.D., Radiation Oncologist, University of California, San Francisco, USA, a former colleague at BWH/DFCI
Practical Strategies for Performing Hybrid Interstitial Applicators For Cervical Cancer Brachytherapy
Ann Klopp, MD, Ph.D., ABS President
We recently hosted a webinar through ABS on practical tips for using hybrid applications which you can view here. Inspired by the data from the EMBRACE studies highlighting the importance of achieving higher doses for tumor control and lower bladder and rectal doses to minimize the risk of toxicity, we have incorporated hybrid applicators into our practice at MD Anderson. EMBRACE outcomes clearly demonstrate that the highest probability of tumor control is seen with the escalation of HR-CTV doses to upwards of 87 and the lowest probabilities of normal tissue complications come from reducing bladder dose below 80 and rectum below 65[1][2]. Achieving those goals can be difficult for large or asymmetric tumors when using standard intracavitary applicators which produce largely symmetrical dose distributions. Hybrid applicators combine the traditional intrauterine tandem with vaginal ovoid and interstitial needles and allow shaping dose around irregular targets. Using the ring as a template, needles can be advanced into the cervix from the paracervical ring. Various configurations have been developed by multiple vendors.

Despite the persuasive evidence of the benefit of hybrid applicators, they are not widely used in the US, in part due to the learning curve for using these applicators.  In our webinar, we discuss our own experiences with the hybrid applicators, strategies for selecting patients, performing implants, and approaching treatment planning. We discuss the use of different approaches for image guidance including intraprocedural CT, u/s, or MRI.

Selecting patients for hybrid applicators depends on the need to better shape the dose distribution around the cervix to include irregular tumors or avoid interloping normal tissues. The needles need to be able to sit safely within the cervical or tumor tissue and not extend out into the peritoneal space or adjacent normal tissues. Obtaining the best information about the predicted relationships between the applicator and the tumor requires an MRI close to the time of brachytherapy. Treatment responses are so variable that pre-treatment MRI often demonstrates completely different anatomy from the pre-brachytherapy MRI. Treatment response is also a strong prognostic factor.[3] For this reason, we perform pre-brachy MRI for every patient. On this pre-brachytherapy MRI scan, an initial assessment can be made of the relationship between the endometrial canal where tandem will lie and any residual tumor. The projected location of the needles depends on the geometry of the applicator; for example, the smaller ring size in the Venezia will project straight needles 1.3 cm from the tandem, parallel to the trajectory of the tandem. In some cases, it can be difficult to predict where the tandem will lie and whether an intracavitary applicator will produce favorable dose distribution. In these cases, an initial implant with an intracavitary implant can be performed to determine the ratio of doses to target and normal tissues and if hybrid will be necessary, to determine which needles may be safely advanced to improve the dose distribution. Angled needles are more challenging to predict the path of, but careful measurements and applicator models can help to predict the location of these oblique needles also.

As with an intracavitary implant, the first procedural step is sounding the uterus and placing the tandem. Guide tubes and needles are placed into the ring before the ring is secured to the tandem.  Labeling should be performed at this time so that needles can be properly identified after shifting following assembly. Once the applicator is assembled, the needles can be advanced one by one from with the patients’ legs in lithotomy or restored to supine position. Counter traction on the cervical stitch or cranial pressure on the applicator while advancing needles can assure that the advancement of the needles doesn’t displace the ring away from the cervix. Intraprocedural imaging can provide feedback on the needle position and iterative advancement and imaging can be used to optimize the needles.

Treatment planning becomes more complex and impactful as the addition of needles creates more degrees of freedom for treatment planning. We typically start with shifting 10% of the activity in the tandem to the needles and then iteratively adjusting dwell times to achieve goals with the implant to ensure that we are on target to achieve optimal dose constraints for the whole treatment course. 

When removing implants, we first withdraw each needle, leaving the guide tubes in place. The lunar ovoid with the guide tube attached can then be removed one at a time, as with standard ovoids. As with all new processes, we have found that things move more quickly as we become more familiar with the process, but these insertions still take longer to place and plan than a standard intracavitary applicator.

We received a lot of great questions on the webinar, many of which were answered in the chat. Please join us for future ABS webinars on subjects of interest to our society. We welcome you to join the conversation.

1. Potter, R., et al., MRI-guided adaptive brachytherapy in locally advanced cervical cancer (EMBRACE-I): a multicentre prospective cohort study. Lancet Oncol, 2021. 22(4): p. 538-547.
2. Potter, R., et al., The EMBRACE II study: The outcome and prospect of two decades of evolution within the GEC-ESTRO GYN working group and the EMBRACE studies. Clin Transl Radiat Oncol, 2018. 9: p. 48-60.
3. Schernberg, A., et al., Tumor Shrinkage During Chemoradiation in Locally Advanced Cervical Cancer Patients: Prognostic Significance, and Impact for Image-Guided Adaptive Brachytherapy. Int J Radiat Oncol Biol Phys, 2018. 102(2): p. 362-372.

Error Prevention in Radiation Therapy
Firas Mourtada, Ph.D., Chairman of the Board, ABS
It was my honor to participate as the ABS representative for the Stakeholders’ Meeting organized by the National Council on Radiation Protection and Measurements (NCRP) scientific committee (SC) 4-10 on “Error Prevention in Radiation Therapy”. The goal of this effort is to identify the necessary program components for error prevention in radiation therapy and to delineate the objective characteristics of a safety-focused radiotherapy department. This Statement will be concise (about 10 pages) which is intended to provide guidance for a radiation oncology department’s quality- and safety-oriented practices. It will be of value for external accreditation reviewers as well as for radiation oncology departments’ self-assessment. Funding for the project has been provided by a grant through the US Food and Drug Administration (FDA), as well as funding support from the Conference of Radiation Control Program Directors (CRCPD) and the American Board of Radiology (ABR).  
Brachytherapy Journal: Special Issue on Socioeconomics
Mitchell Kamrava, MD, MHDS, Socioeconomics Committee Co-Chair
Understanding the impact of socioeconomic factors on the practice of brachytherapy is important. Especially, with ongoing discussions regarding how best to design payment models utilizing brachytherapy. To explore the intersection between socioeconomics and brachytherapy a special issue on this topic was put together for the Brachytherapy journal (Editors: Nikhil Thaker, Bill Small, Steven Frank, and Mitchell Kamrava)1. This issue includes manuscripts on promoting value-based care by evaluating brachytherapy utilization in prostate and cervical cancers2,3. They report on decreasing rates of prostate brachytherapy utilization as well as increased rates of external beam boost utilization for higher staged cervical cancers. Geographic access to brachytherapy is also explored with higher rates of brachytherapy access in US metropolitan areas compared with non-metropolitan areas4. This geographic mismatch is also reflected in ongoing challenges with recruiting diverse populations into brachytherapy clinical trials5.  

Efforts to improve value-based care will require new innovations in care delivery and payment models. Time-driven activity-based costing (TDABC) presents a model for understanding costs over an entire episode of care. The TDABC process is reviewed and recent data using this approach in brachytherapy is presented6. In a separate study, the TDABC model is used to show how the integration of advanced imaging with MRI could be done in a cost-efficient manner through personnel downshifting and process improvements. 
Another paper in this issue looks at the impact of the originally proposed RO-APM on brachytherapy reimbursements8. This important manuscript gives insight into the weaknesses of the proposed model and areas for us to work on to improve future iterations. Finally, a manuscript evaluating quality metrics for a wide range of brachytherapy sites is presented9. This serves as a starting point for thinking about how to define quality in brachytherapy and how these metrics might be utilized for quality payment incentives. 

This special Brachytherapy issue is an exciting start to exploring research on socioeconomics and brachytherapy. After reading the issue, it’s hopeful that some will be inspired to further investigate this important intersection. 
1) Kamrava M, Thaker N, Small W, et al. Driving accountable care with brachytherapy. Brachytherapy. 2021.
2) Mukherjee K, Small W, Duszak R. Trends and variations in utilization and costs of radiotherapy for prostate cancer: a SEER medicare analysis from 2007 through 2016. Brachytherapy. 2021. 
3) Lu D, Atkins K, Small W, et al. Evaluation of sociodemographic and baseline patient characteristic differences in cervical cancer patients treated with either external beam or brachytherapy boost. Brachytherapy. 2021. 
4) Bates J, Thaker N, Parekh A, et al. Geographic access to brachytherapy services in the United States. Brachytherapy. 2021.
5) Ladbury C, Liu J, Novak J, et al. Age, racial, and ethnic disparities in reported clinical studies involving brachytherapy. Brachytherapy. 2021. 
6) Mulherkar R, Keller A, Showalter T, et al. A primer on time-drive activity-based costing in brachytherapy. Brachytherapy. 2021. 
7) Thaker N, Kudchadker R, Incalcaterra J, et al. Improving efficiency and reducing costs of MRI-guided prostate brachytherapy using time-driven activity-based costing. Brachytherapy. 2021.
8) Thaker N, Meghani R, Wilson C, et al. Impact of the radiation oncology alternative payment model on brachytherapy reimbursement. Brachytherapy. 2021.
9) Shah C, Vicini F, Beriwal S, et al. American brachytherapy society radiation oncology alternative payment model task force: quality measures and metrics for brachytherapy. Brachytherapy. 2021.
Virtual Reality as a Potential Solution to Bridge the Gap in Brachytherapy Education
Mustafa Al Balushi, MD, PGY-4 Division of Radiation Oncology
Cross Cancer Institute, University of Alberta
There is a worrying global trend in the utilization of brachytherapy. The decline is likely multifactorial. However, a large part of it has to do with training. The ABS introduced the ‘300 in 10’ initiative to mitigate this ‘brachytherapy crisis’. As well, the Royal College in Canada established a diploma to standardize brachytherapy training. There is clearly a gap in brachytherapy education, but that wasn’t the reason why I became interested in pursuing a brachytherapy educational project.
The spark was my first cervix brachytherapy procedure as a PGY-2. I reflected on my days as an otolaryngology resident before switching specialties. We had resources to learn the surgeries that we were supposed to know. One excellent resource was a virtual reality (VR) temporal bone drilling simulator. This personal learning need was the impetus for me. With the help of an amazing team and a generous grant from the Women and Children’s Health Research Institute (WCHRI) at the University of Alberta, we developed a hands-on VR cervix brachytherapy simulator.

Researchers in the past have explored using phantoms to train residents in brachytherapy. However, a VR simulator made the most sense to me. Theoretically speaking, physical models are cheaper to acquire and had the advantage of tactile feedback. On the other hand, VR simulators are versatile and low maintenance, you could collaborate with other centers remotely and you could expand your case bank infinitely. As well, residents can use them iteratively without fear that the interstitial needles would ruin them
I don’t foresee simulators or phantoms ever replacing training at brick-and-mortar institutions. However, the hope is that such initiatives would present residents with more training opportunities, and with our world rapidly transitioning to the virtual sphere, remote hands-on VR training might just be the next big thing in medical education.  
Attention Residents: This is the first of our monthly radiation oncology medical and physics RESIDENT CORNER in the BrachyBlast! We are looking for ABS member residents 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 in next month!
2022 GYN School
Early Bird Registration Ends TODAY!
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. Early bird registration ends today!

Click here to register.
2022 Annual Conference - Call for Abstracts
Don't forget that the call for abstracts for #ABSBrachy22 is open! Don't miss this opportunity to attend & present live in Denver! We look forward to seeing all your remarkable work. The deadline to submit is March 3, 2022
Click here for more information
GRU Presents the 32nd International Prostate Cancer Update
Join the International Prostate Cancer Update (IPCU), a multi-day, CME-accredited conference focused on prostate cancer treatment updates. IPCU 32 will feature lectures, interactive panel discussions, debates, and case-based presentations. This conference is led by expert physicians including President-Elect, Peter Rossi, MD, Member at Large, Mira Keyes, MD, and past ABS President, Peter Orio, III, DO, and is designed for urologists, medical oncologists, radiation oncologists, and other healthcare professionals involved in the diagnosis and treatment of prostate cancer.

Click here for more information and register today!
Content Corner

  • Neil K. Taunk, MD, MS, Radiation Oncologist and Assistant Professor of Radiation Oncology at the Perelman School of Medicine at the University of Pennsylvania, demonstrates placement of transperineal fiducial markers and SpaceOAR Hydrogel placement for prostate cancer radiotherapy. Fiducial markers are used to guide prostate cancer radiotherapy. SpaceOAR hydrogel may decrease the amount of rectum exposed to prostate radiotherapy. The transperineal approach is used to reduce the risk of infection substantially.
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 Keyes, MD
Timothy Showalter, MD