Rachel Blitzblau

The NCCN Guidelines for Squamous Cell Skin Cancer provide recommendations for diagnostic workup, clinical stage, and treatment options for patients with cutaneous squamous cell carcinoma. The NCCN panel meets annually to discuss updates to the guidelines based on comments from panel members and the Institutional Review, as well as submissions from within NCCN and external organizations. These NCCN Guidelines Insights focus on the introduction of a new surgical recommendation terminology (peripheral and deep en face margin assessment), as well as recent updates on topical prophylaxis, immunotherapy for regional and metastatic disease, and radiation therapy.

<h4>Purpose/objective(s)</h4>Telehealth (TH) for radiation oncology services has emerged as a new modality for care delivery and will likely persist beyond the COVID pandemic. Data regarding radiation oncology provider satisfaction of TH are limited and essential to the sustainable adoption of this tool.<h4>Materials/methods</h4>An anonymous electronic survey assessing TH experience was distributed in 11/2020 to all clinical radiation oncology physicians and APPs at a single large NCI-designated institution, including affiliate clinics. Those who utilized TH (phone or video) were invited to participate. The provider survey was designed using the technology-acceptance model (TAM), a validated method to predict use and acceptance of technology tools. Survey items included 4 assessing provider role, 1 regarding TH utilization, 26 assessing TH experience on a 5-point Likert scale, and 1 free response assessing current barriers to TH. Percent satisfaction is reported as the percentage of top 2 positive or affirmative responses on the Likert scale as a proportion of all responses.<h4>Results</h4>19 of 34 radiation oncology providers (56%) completed the survey, including 15 attending physicians and 4 APPs. Providers specialized in central nervous system (n = 3), head and neck (n = 2), gastrointestinal (n = 1), breast (n = 2), genitourinary (n = 4), gynecological (n = 2), sarcoma (n = 1), and general oncology (n = 4). Providers reported having 1-10 (n = 5), 11-15 (n = 7), or > 20 years (n = 7) in practice. Providers utilized TH for on-treatment visits (53%), follow-ups (86%), and consults (79%). 56% of providers enjoyed experimenting with new technology and 61% felt that technological advances improved care for patients. Regarding aspects of the TH clinical encounter: providers had high satisfaction with ability to document the visit (89%), obtaining patient history (83%), and ease of discussing radiation treatment decisions (71%). There was lower satisfaction with ability to create rapport (33%), ease of obtaining consent for radiation (33%), and ease of evaluating physical exam findings (19%). Regarding workflow: 39% felt that TH was compatible with existing oncology clinical workflow, 39% felt TH gave them greater control over work, 33% providers felt that TH improved their job efficiency, and 28% felt TH made them more productive. Regarding ease of TH use: 44% felt that interacting with TH services was frustrating and 39% felt that TH services did not require much training. 24% felt the TH adequately replaced face to face visits. Providers identified the following barriers to TH implementation: lack of MA/RN/APP support, interruptions to TH visits by treatment/simulation clinical duties, lack of dedicated TH template, and burden of navigating the electronic medical record.<h4>Conclusion</h4>Radiation oncology providers at our institution expressed mixed satisfaction to incorporating TH into their practice. Current strategies to address barriers, including implementation of a telehealth care coordinator, are underway.

Historically, radiotherapy fractionation for early-stage breast cancer primarily consisted of 1.8-2 Gy per fraction given once daily to a total dose of 45-66 Gy over 5-7 weeks for whole breast treatment. Partial breast treatment employed larger dose per fraction (3.4-3.85 Gy) in 10 fractions given twice daily over 1 week. Radiobiologically, breast cancer is increasingly appreciated as a low alpha-beta ratio malignancy that is best treated with larger dose per fraction. Over the past 10 years, there have been increasing data from multiple large randomized clinical trials that support the use of shorter treatment courses: first hypofractionated regimens consisting of 15-20 treatments, and more recently, ultra-hypofractionated regimens as short as 5 treatments. Simultaneously, data from modern partial breast irradiation (PBI) trials support once daily treatment regimens ranging from 1-5 treatments. Shorter treatment courses represent less treatment burden on patients, reduced financial impact, and potentially improved access to care for patients with transportation and/or socioeconomic barriers. Here we review the evolution of whole and partial breast treatment regimens for early-stage breast cancer.