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BACKGROUND: Metastatic hormone-sensitive prostate cancer (mHSPC) is treatment-resistant and generally considered incurable. The development of prostate-specific membrane antigen positron emission-computed tomography (PSMA PET/CT) has generated immense expectations due to its diagnostic accuracy in prostate cancer (PCa). PSMA expression of the primary tumor, quantified by SUVmax, is a predictor of oncological outcomes. The role of PSMA-PET/CT SUVmax in metachronous mHSPC treated with ADT plus second-generation antiandrogens (ARSI) is unknown. The main aim of this study was to evaluate 68Ga-PSMA-11expression (SUVmax) as a potential prognostic biomarker in patients with metachronous mHSPC treated with ADT and first or second-generation antiandrogens. A second aim was to determine the association between PSMA SUVmax and PSA response to hormone therapy. MATERIAL AND METHODS: Patients diagnosed with metachronous mHSPC between July 2017 and February 2023 who developed biochemical recurrence following radical surgery (with or without salvage radiotherapy and/or ADT) or external radiation therapy (with or without ADT) were included. All patients underwent 68 Ga-PSMA-11 PET/CT imaging and the SUVmax value was determined for all measurable locations. The SUVmax value was used for the semiquantitative analysis. The Wilcoxon method was used to compare responders (PSA reduction ≥ 50%) to non-responders (PSA reduction < 50%). The SUVmax value and hormone therapy were evaluated as independent variables relative to the PSA response rate or PSA reduction using the linear regression method. A mixed-effects model (ANOVA) was used for the comparisons. RESULTS: A total of 82 patients were included. Median follow-up was 11.7 months. On the linear regression analysis, patients with a high SUVmax treated with ADT + ARSI showed a greater PSA response (p = 0.034) than those treated with ADT + first-generation antiandrogens. In the mixed-effects model, SUVmax was significant (p = 0.041). On the univariate analysis, PSA at recurrence (HR, 3.2; 95% CI: 1.07-13.6; p = 0.078) and the number of metastases (HR, 4.77; 95% CI 1.1-26.1: p = 0.002) were associated with the type of hormone therapy administered. CONCLUSIONS: PSMA-PET/CT SUVmax is a prognostic biomarker that can be used to predict a PSA response to ADT + ARSI in patients with metachronous mHSPC. However, these findings need to be confirmed in larger prospective studies.

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Introducción: los pacientes concurren habitualmente a la consulta preguntando por los posibles efectos tóxicos del tratamiento oncológico radiante sobre los tejidos normales. Esta breve revisión bibliográfica en formato de preguntas y respuestas, presenta mediante la evidencia científica y la medicina basada en la evidencia, algunas de las preguntas con las que se encuentra el médico que trata o interactúa con un paciente con cáncer. El objetivo de esta revisión es apoyar en la respuesta que dará el médico general, oncólogo médico, físico médico y tecnólogos en radioterapia a esas interrogantes. Metodología: se realizó una búsqueda bibliográfica no sistemática en Google Scholar, MedLine/PubMed y Scielo limitando a trabajos publicados en los últimos 10 años. Resultados: tras consultas con profesionales directamente relacionados con la radioterapia, se identificaron las dudas recurrentes planteadas por los pacientes. Discusión: con la información recopilada se dan respuesta a las interrogantes más frecuentes establecidas previamente.

Introduction: Patients routinely come to the office asking about the possible toxic effects of radiation oncology treatment on normal tissues. This brief literature review in question and answer format presents, through scientific evidence and evidence-based medicine, some of the questions encountered by the physician who treats or interacts with a cancer patient. The objective of this review is to support the response of general practitioners, medical oncologists, medical physicists and radiotherapy technologists to these questions. Methodology: A non-systematic bibliographic search was carried out in Google Scholar, MedLine/PubMed and Scielo, limiting the search to works published in the last 10 years. Results: After consultation with professionals directly related to radiotherapy, recurrent doubts raised by patients were identified. Discussion: With the information gathered, answers were given to the most frequent questions previously established.

Introdução: Os pacientes chegam rotineiramente à clínica perguntando sobre os possíveis efeitos tóxicos do tratamento oncológico por radiação nos tecidos normais. Esta breve revisão da literatura em formato de perguntas e respostas apresenta, por meio de evidências científicas e da medicina baseada em evidências, algumas das perguntas encontradas pelo médico que trata ou interage com um paciente com câncer. O objetivo desta revisão é apoiar a resposta de clínicos gerais, oncologistas médicos, físicos médicos e tecnólogos em radioterapia a essas perguntas. Metodologia: foi realizada uma pesquisa não sistemática da literatura no Google Scholar, MedLine/PubMed e Scielo, limitando a pesquisa a artigos publicados nos últimos 10 anos. Resultados: após consulta a profissionais diretamente relacionados à radioterapia, foram identificadas as dúvidas recorrentes levantadas pelos pacientes. Discussão: com as informações coletadas, foram dadas respostas às dúvidas mais frequentes previamente estabelecidas.

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Radiation oncology (RO) plays a crucial role in cancer care; cancer patients often undergo their initial diagnostic study by general physicians. However, studies have shown that most physicians are uncomfortable referring cancer patients to radiation therapy (RT). To assess the knowledge of RO among non-oncology physicians, we sent invitations to complete an online survey that required the responders to self-rate their understanding of RT and objective assessment. The survey was targeted at hospitalists and primary care physicians. Forty physicians responded to the survey, and 89.7% practiced primarily as hospitalists, with 67% being Internal Medicine graduates. Fifty percent of physicians have referred patients to RO before, although more than 90% have not done additional CME (continuing medical education) in Oncology. More than 50% of recent graduates (one to five years post-residency) self-rated themselves as "not knowledgeable" when it comes referral process to RO as well as general knowledge regarding RT. Factors, such as "type of cancer," "patients' wishes," and "life expectancy," are most cited as factors influencing the decision for a referral.

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Introduction: Primary vaginal cancer is infrequent, corresponding to 1-2% of all female genital tract cancer diagnoses.Treatment for vaginal cancer varies depending on tumor histology, size, location and staging, and may include one or more of the following: surgical excision, radiation therapy and/or chemotherapy. All treatments negatively affect fertility/pregnancy outcomes.Pelvic radiation therapy, even in doses < 2 Gy, may extinguish up to 50% of immature oocytes. In addition, radiotherapy may cause modifications in cervical length, loss of uterine junctional zone anatomy and lead to myometrial atrophy and fibrosis, increasing the risk for adverse pregnancy outcomes. Methods: Case report of a patient who carried a pregnancy to term after surgery and brachytherapy for vaginal cancer. Results: A 28 year-old woman, presented with a 3 cm right midvagina wall tumor, diagnosed as grade 2, vaginal squamous cell carcinoma - FIGO 2009, stage IB. Computed tomography showed no evidence of lymph node involvement or distant metastasis. The patient underwent surgery followed by 4 fractions of vaginal brachytherapy, once a week, with a dose of 6 Gy at a 5 mm depth, amounting to a total dose of 24 Gy.One year and 9 months after treatment, the patient gave birth to a healthy child at 39 weeks pregnancy. A C-section was needed due functional dystocia during labor. Conclusion: This case report recounts a successful pregnancy carried to term after surgery and brachytherapy for squamous cell vaginal cancer.

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PURPOSE: Radiation Oncology is one of the least-known medical specialties for young graduates at the end of their studies. An in-depth analysis of the strengths and weaknesses of the Radiation Oncology visibility, the training plan, and why it is less attractive for new medical residents during the last years appears as the initial need to turn out this lack of knowledge. MATERIALS AND METHODS: An anonymous pilot survey of 24 questions addressed to specialists in-training in Radiation Oncology in Spain during August and September of 2022. RESULTS: A total of 50 in-training radiation oncologists answered the questionnaire and 90% of them believe that a lack of knowledge, mainly at the School of Medicine, was a major reason why choosing Radiation Oncology was unattractive. All responders were satisfied by choosing Radiation Oncology, and 76% were in favor of extending the residency to 5 years to improve their training. Research activity was considered essential (78%) to complete their training. CONCLUSION: Increasing the presence of Radiation Oncology at the School of Medicine may be one solution to achieve greater attractiveness among future residents. Likewise, extending the training period to five years could help to enhance the learning of all radiotherapy techniques while promoting clinical research.

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INTRODUCTION: A rapid deploy of unexpected early impact of the COVID pandemic in Spain was described in 2020. Oncology practice was revised to facilitate decision-making regarding multimodal therapy for prevalent cancer types amenable to multidisciplinary treatment in which the radiotherapy component searched more efficient options in the setting of the COVID-19 pandemic, minimizing the risks to patients whilst aiming to guarantee cancer outcomes. METHODS: A novel Proton Beam Therapy (PBT), Unit activity was analyzed in the period of March 2020 to March 2021. Institutional urgent, strict and mandatory clinical care standards for early diagnosis and treatment of COVID-19 infection were stablished in the hospital following national health-authorities' recommendations. The temporary trends of patients care and research projects proposals were registered. RESULTS: 3 out of 14 members of the professional staff involved in the PBR intra-hospital process had a positive test for COVID infection. Also, 4 out of 100 patients had positive tests before initiating PBT, and 7 out of 100 developed positive tests along the weekly mandatory special checkup performed during PBT to all patients. An update of clinical performance at the PBT Unit at CUN Madrid in the initial 500 patients treated with PBT in the period from March 2020 to November 2022 registers a distribution of 131 (26%) pediatric patients, 63 (12%) head and neck cancer and central nervous system neoplasms and 123 (24%) re-irradiation indications. In November 2022, the activity reached a plateau in terms of patients under treatment and the impact of COVID pandemic became sporadic and controlled by minor medical actions. At present, the clinical data are consistent with an academic practice prospectively (NCT05151952). Research projects and scientific production was adapted to the pandemic evolution and its influence upon professional time availability. Seven research projects based in public funding were activated in this period and preliminary data on molecular imaging guided proton therapy in brain tumors and post-irradiation patterns of blood biomarkers are reported. CONCLUSIONS: Hospital-based PBT in European academic institutions was impacted by COVID-19 pandemic, although clinical and research activities were developed and sustained. In the post-pandemic era, the benefits of online learning will shape the future of proton therapy education.

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Patients who are diagnosed with breast cancer face multiple challenges and fears: from the diagnosis, the acceptance of the diagnosis and the beginning of the treatments, as well as the side effects that they entail, the most worrying for the patients being the possible anatomical alterations due to surgery, alopecia due to chemotherapy treatment, and radiodermatitis due to radiant treatment. A systematic review was carried out in MedLine/Pubmed following the PRISMA 2020 criteria on the use of antiperspirant during radiant treatment in the axilla and its relationship or not with the increase in acute adverse effects. Based on the analysis of the results of this search and with emphasis on: dosimetric aspects, psychological impact, treatment acceptance, feeling of well-being and adherence. We justify its use.

As pacientes diagnosticadas com câncer de mama enfrentam múltiplos desafios e medos: desde o diagnóstico, a aceitação do diagnóstico e o início do tratamento, bem como os efeitos colaterais que estes acarretam, o mais preocupante para as pacientes são as possíveis alterações anatômicas devidas à cirurgia, alopecia devido ao tratamento quimioterápico e a radiodermatite devido ao tratamento radiante. Foi realizada uma revisão sistemática no MedLine/Pubmed seguindo os critérios do PRISMA 2020 sobre o uso de antitranspirante durante o tratamento radiante na axila e sua relação ou não com o aumento dos efeitos adversos agudos. Com base na análise dos resultados desta busca e com ênfase em: aspectos dosimétricos, impacto psicológico, aceitação do tratamento, sensação de bem-estar e aderência. Justificamos seu uso.

Las pacientes que son diagnosticadas con cáncer de mama se enfrentan a múltiples desafíos y temores: desde el diagnóstico, la aceptación del mismo y el inicio de los tratamientos, así como los efectos secundarios que ellos conllevan, siendo los más preocupantes para las pacientes las posibles alteraciones anatómicas por cirugía, la alopecia por el tratamiento quimioterápico, y la radiodermitis por el tratamiento radiante. Se realizó una revisión sistematizada en MedLine/Pubmed, Google Académico, EMBASE, SciELO y Epistemonikos, siguiendo los criterios PRISMA 2020 del uso de antitranspirante durante el tratamiento radiante en axila y su relación o no con el aumento de efectos adversos agudos. En función del análisis de los resultados de dicha búsqueda y con énfasis en: aspectos dosimétricos, impacto psicológico, la aceptación al tratamiento, el sentimiento de bienestar y la adherencia. Justificamos su uso.

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OBJECTIVE: To evaluate the prognostic impact of clinical and pathological variables and patterns of recurrence in patients with locally advanced cervical cancer with pelvic lymph node involvement (stage IIIC1 according to the 2018 FIGO Staging System). METHODS: We retrospectively analyzed 62 patients with locally advanced cervical cancer treated with curative intent with radiotherapy associated with chemotherapy in AC Camargo Cancer Center from January 2007 to December 2018. RESULTS: Lymph node involvement was assessed by CT, MRI and positron emission tomography (PET)/CT in 28 (45.2%), 20 (32.3%) and 14 (22.6%) patients, respectively. The median tumor size was 5.0 cm and 72.6% of cases were squamous cell carcinomas. The median number of positive pelvic lymph nodes was three, and the median size of lymph nodes was 24 mm. Twenty-two (35.5%) patients had recurrence and 50% had only one site of recurrence. The sites of recurrence were pelvic, para-aortic and distant in 12 (19.4%), 6 (9.7%) and 16 (25.8%) patients, respectively. The 3 year overall and disease-free survival were 70.8% and 64.6%, respectively. Patients with adenocarcinoma had worse disease-free survival (HR 2.38; 95% CI 1.01 to 5.60; p=0.047) and overall survival (HR 2.99; 95% CI 1.14 to 7.75; p=0.025) compared with squamous cell carcinoma. In multivariate analysis, metastatic pelvic lymph node size of >2.5 cm (HR 4.38; 95% CI 1.65 to 11.6; p=0.003) and incomplete response to radiotherapy (HR 5.14; 95% CI 1.60 to 16.4; p=0.006) maintained the negative impact for overall survival. CONCLUSIONS: We found that pelvic lymph node size and incomplete response to radiotherapy negatively impact overall survival in patients with advanced cervical cancer with pelvic lymph node involvement. This finding may help to stratify risk in this group of patients.

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O presente estudo apresenta como cenário o ambulatório de radioterapia de um hospital de referência em Oncologia situado no Estado do Rio de Janeiro, Brasil, em que se realiza a consulta de enfermagem e teve como objetivos específicos: (1) Descrever o trabalho do enfermeiro em teleterapia; (2) Analisar o fluxo de pacientes nas consultas de enfermagem com base em Pavani Junior e Scucuglia (2011); (3) Identificar no mapa do serviço de teleterapia de modo a facilitar o fluxo no atendimento ao paciente; (4) Elaborar o novo fluxo para o atendimento às consultas de enfermagem em teleterapia; (5) Apresentar requisitos para propor o módulo de enfermagem em teleterapia. A investigação foi de abordagem qualitativa e natureza descritiva a partir da observação do fluxo no atendimento do paciente em teleterapia. Os dados foram obtidos por meio da técnica de observação sistemática segundo Gerhardt e Silveira (2009). Os resultados revelaram: fragilidade no fluxo de atendimento do paciente, ocasionado por retrabalho no agendamento das consultas, das movimentações desnecessárias dos pacientes e familiares às consultas de enfermagem por conta da necessidade de trazer a pasta de planejamentos na avaliação dos pacientes, e após entregar no setor de origem, e um sistema de informação que não atende às características de avaliação de enfermagem. Conclui-se que o fluxo existente é inadequado, assim como o processo de informação. Destaca-se a necessidade de organização do fluxo de atendimento ao paciente em teleterapia. Recomenda-se a proposição de um módulo de enfermagem, para ser utilizado no sistema informação existente, de modo a organizar as atividades do enfermeiro nas consultas de teleterapia.

The present study presents as a setting the radiotherapy outpatient clinic of a reference hospital in Oncology, located in the State of Rio de Janeiro, Brazil, where nursing consultations take place. The general objective is to analyze the work process of nurses in teletherapy, to update the information system, in order to improve patient care. And as specific objectives: (1) Describe the work of nurses in teletherapy; (2) A Analyze the flow of patients to nursing consultations based on Pavani Junior and Scucuglia (2011); (3) Identify the teletherapy service map in order to facilitate the flow of patient care; (4) Develop the new flow for attending nursing consultations in teletherapy; (5) Present requirements to propose the teletherapy nursing module. The investigation was based on a qualitative descriptive approach, based on the observation of the flow in patient care in teletherapy. Data were obtained through the systematic observation technique according to Gerhardt e Silveira (2009). The results reveal: weakness in the flow of patient care, caused by rework in scheduling appointments, unnecessary movement of patients and families to nursing appointments due to the need to bring the planning folder in the assessment of patients and after delivering it to the sector origin and an information system that does not meet the characteristics of nursing assessment. It is concluded that the existing flow is inadequate, as well as the information process. The need to organize the flow of care for patients in teletherapy is highlighted. It is recommended to propose a nursing module, to be used in the existing information system, in order to organize the activities of nurses in teletherapy consultations.

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AIM: The aim of this study was to analyze critical success factors (CSFs) for implementation of an incident learning system (ILS) in a radiation oncology department (ROD) and evaluate the perception of the staff members along this process. BACKGROUND: Implementing an ILS is a way to leverage learning from incidents and is a tool for improving patient safety, consisting of a cycle of reporting and analyzing events as well as taking preventive actions. ILS implementation is challenging, requiring specific resources and cultural changes. MATERIALS AND METHODS: An ILS was designed and implemented based on the CSF identified in the literature review. Before starting the ILS implementation, a structured survey was applied to assess dimensions of patient safety culture. After the period of implementation (7 months), the survey was applied again and compared with the initial assessment, and interviews were performed with staff members to evaluate the overall satisfaction with ILS and CSFs. RESULTS: Statistically significant improvements were observed in 5 dimensions (12 totals) of the safety culture survey, considering time points before and after the ILS implementation. According to interviewees, "Facilitating committee", "Efficient data collection", "Focus on improvement", "Just culture" and "Feedback to users" were the most relevant CSFs. CONCLUSIONS: The ILS designed and implemented at ROD was perceived as an important tool to support quality and safety initiatives, promoting the improvement in safety culture. The ILS implementation critical success factors were identified and have shown good agreement between the results of the literature and the users' practical perception.

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OBJECTIVES: To develop a tool that could assess residents' knowledge beyond simple information gathering and evaluate its reliability. METHODS: An assessment tool of 40 objective questions and at least one essay-based question was developed to assess residents' comprehension of general radiation oncology accordingly to validated training curricula beyond level 2 in the Bloom scale. With randomized content, questions were developed such as to be classified as at least 2 in the Bloom scale, so that reasoning and not only information gathering could be assessed. Criteria validation was made using the Classical Test Theory to describe difficulty and discrimination of each item. Reliability was tested by internal consistency using the Cronbach alpha test. RESULTS: Between 2016 and 2019, 24 residents were assessed. Six different versions of the test were made with a total of 240 objective questions and 18 essay-based questions. Five of the six versions were deemed valid and reliable. Comparisons between 1st (PGY-1) and 3rd (PGY-3) year residents were made. Consistently, PGY-3 residents had scores 150% higher than PGY-1 residents. Only two different PGY-3 reached the most complex level of answers in the essay-based questions. The results demonstrated that the major part of the acquired knowledge and retention occurs in the first six months of training rather than in all the following period. CONCLUSION: The instrument can be considered valid. This developed instrument also raised the hypothesis that residents may not assess and analyze their acquired knowledge beyond the application level.

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AIM: To evaluate the state of graduate education in medical physics and progress in radiation oncology (RO) equipment in Mexico since 2000, when conferring degrees from two master's-degree programs in Medical Physics began. BACKGROUND: Medical physics is a Health Profession and there are international recommendations for education, training, and certification. Both programs follow these education guidelines. The most common clinical occupation of graduates is in RO services. Techniques in Mexican RO include traditional and high-precision procedures. METHODS: Academic and occupational information about the programs and their graduates were obtained from official websites. Graduates were invited to respond to a survey that requested information about their present job. We obtained data on RO equipment and human resources from public databases and estimated staffing requirements of medical physicists (MPs). RESULTS: Medical physics programs have graduated a total of 225 MPs. Half of them work in a clinical environment and, of these, about 90 work in RO services. MPs with M.Sc. degrees constitute 36% of the current MP workforce in RO, estimated to be 250 individuals. Survey responses pointed out the main merits and limitations of the programs. The number of MPs in RO has increased fivefold and the number of linacs sixfold in 15 years. The present number of MPs is insufficient, according to published guidelines. CONCLUSION: All MPs in RO services with advanced modalities must be trained following international recommendations for graduate education and post-graduation clinical training. Education and health institutions must find incentives to create more graduate programs and clinical residencies.

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BACKGROUND: There is limited data on access to radiotherapy services for CARICOM nations. METHODS: This was a descriptive mixed-methods observational study which used data collected via survey from staff working in Radiation Oncology in 14 CARICOM countries. Benchmark recommendations from the International Atomic Energy Agency were compared to existing numbers. The Directory of Radiotherapy Centers, World Bank, and Global Cancer Observatory databases were all accessed to provide information on radiotherapy machines in the region, population statistics, and cancer incidence data respectively. Both population and cancer incidence-based analyses were undertaken to facilitate an exhaustive review. RESULTS: Radiotherapy machines were present in only 50% of the countries. Brachytherapy services were performed in only six countries (42.9%). There were a total of 15 external beam machines, 22 radiation oncologists, 22 medical physicists, and 60 radiation therapists across all nations. Utilizing patient-based data, the requirement for machines, radiation oncologists, medical physicists, and radiation therapists was 40, 66, 44, and 106, respectively. Only four (28.6%) countries had sufficient radiation oncologists. Five (35.7%) countries had enough medical physicists and radiation therapists. Utilizing population-based data, the necessary number of machines, radiation oncologists, and medical physicists was 105, 186, and 96 respectively. Only one county (7.1%) had an adequate number of radiation oncologists. The number of medical physicists was sufficient in just three countries (21.4%). There were no International Atomic Energy Agency population guidelines for assessing radiation therapists. A lower economic index was associated with a larger patient/population to machine ratio. Consequentially, Haiti had the most significant challenge with staffing and equipment requirements, when compared to all other countries, regardless of the evaluative criteria. Depending on the mode of assessment, Haiti's individual needs accounted for 37.5% (patient-based) to 59.0% (population-based) of required machines, 40.1% (patient-based) to 59.7% (population-based) of needed radiation oncologists, 38.6% (patient-based) to 58.3% (population-based) of medical physicists, and 42.5% (patient-based) of radiation therapists. CONCLUSION: There are severe deficiencies in radiotherapy services among CARICOM nations. Regardless of the method of comparative analysis, the current allocation of equipment and staffing scarcely meets 50% of regional requirements.

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PURPOSE: Peer review has been proposed as a strategy to ensure patient safety and plan quality in radiation oncology. Despite its potential benefits, barriers commonly exist to its optimal implementation in daily clinical routine. Our purpose is to analyze peer-review process at our institution. METHODS AND MATERIALS: Based on our group peer-review process, we quantified the rate of plan changes, time and resources needed for this process. Prospectively, data on cases presented at our institutional peer-review conference attended by physicians, resident physicians and physicists were collected. Items such as time to present per case, type of patient (adult or pediatric), treatment intent, dose, aimed technique, disease location and receipt of previous radiation were gathered. Cases were then analyzed to determine the rate of major change, minor change and plan rejection after presentation as well as the median time per session. RESULTS: Over a period of 4 weeks, 148 cases were reviewed. Median of attendants was six physicians, three in-training-physicians and one physicist. Median time per session was 38 (4-72) minutes. 59.5% of cases presented in 1-4 min, 32.4% in 5-9 min and 8.1% in ≥ 10 min. 79.1% of cases were accepted without changes, 11.5% with minor changes, 6% with major changes and 3.4% were rejected with indication of new presentation. Most frequent reason of change was contouring corrections (53.8%) followed by dose or fractionation (26.9%). CONCLUSION: Everyday group consensus peer review is an efficient manner to recollect clinical and technical data of cases presented to ensure quality radiation care before initiation of treatment as well as ensuring department quality in a feedback team environment. This model is feasible within the normal operation of every radiation oncology Department.

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INTRODUCTION: The Official Journal of the European Union published on January 17, 2014 the Council Directive 2013/59/EURATOM of December 5, 2013, which establishes basic safety standards for the protection against the dangers derived from the exposure to ionizing radiation, and should have been transposed to the regulations of the member countries of the European Union. METHODS: We carried out and exhaustive review of the Directive, to highlight its aspects referred to radiotherapy, in order to issue recommendations for its adequate and effective application in Spain. RECOMMENDATIONS FOR ITS TRANSPOSITION: A series of recommendations are issued, from highest to lowest organizational level: Legislative, Scientific Societies, Healthcare Centers, Radiation Oncology Departments, Radiation Oncologists and Patients. CONCLUSIONS: The implementation of what the transposition of the Directive to our legal order implies, besides the implication of the professionals, Centers and Administration, a need and a consumption of resources. If not enough are allocated, there is a risk that the innovation and improvement that the transposition would imply in order to raise the level of patient safety and the quality of Radiation Oncology in Spain will remain a paper tiger and, as the Romans said, "Non progredi est regredi", that is, when it does not go forward, it goes backwards.

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PURPOSE: The Working Group on Patient Safety and Quality of the Spanish Society of Radiation Oncology, revised the most relevant national and international recommendations, selecting a series of important aspects for patient safety, evaluating whether they are included in Spanish legislation MATERIALS AND METHODS: We have considered a concept as relevant to the patient safety in radiotherapy if so defined in at least 8 of the 16 documents reviewed. RESULTS: 12 subjects were selected: training and qualification, human resources, protocols, safety culture, communication, peer review, accreditation: audits, checklists, areas without interruptions, maps of processes and risks, prospective risk analysis, notification, registration and incident learning, and quality control of the equipment. CONCLUSIONS: At the legislative level, as well as the professional organizations and the health center directorates, the implementation of safety culture must continue to be fostered. Only in this environment will the tools and measures to increase patient safety be effective. The current Spanish legislation must be revised and updated, in accordance with directive 2013/59/EURATOM and the Patient Safety Strategy 2015-2020 of the Spanish National Health System, introducing the obligation to perform risk analysis and incidents management. Audits and accreditations must be carried out, thus raising the general level of practice of the specialty. In this process, the Spanish Society of Radiation Oncology must continue playing its fundamental role, collaborating with the institutions and the rest of the scientific societies involved in the radiotherapy process, issuing recommendations on patient safety and disseminating the safety culture in our specialty.

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BACKGROUND: Whole breast irradiation reduces loco-regional recurrence and risk of death in patients submitted to breast-conserving treatment. Data show that radiation to the index quadrant alone may be enough in selected patients. AIM: To report the experience with intra-operative radiotherapy (IORT) with Electron-beam Cone in Linear Accelerator (ELIOT) and the results in overall survival, local control and late toxicity of patients submitted to this treatment. MATERIALS AND METHODS: 147 patients treated with a median follow up of 6.9 years (0.1â¿¿11.5 years). The actuarial local control and overall survival probabilities were estimated using the Kaplan Meier method. All tests were two-sided and p â¿¤ 0.05 was considered statistically significant. RESULTS: Overall survival of the cohort in 5 years, in the median follow up and in 10 years was of 98.3%, 95.1% and 95.1%, respectively, whereas local control in 5 years, in the median follow up and in 10 years was of 96%, 94.9% and 89.5%, respectively. Two risk groups were identified for local recurrence depending on the estrogen or progesterone receptors, axillary or margin status and lymphovascular invasion (LVI) (p = 0.016). CONCLUSIONS: IORT is a safe and effective treatment. Rigorous selection is important to achieve excellent local control results.

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BACKGROUND: Assays to identify circulating tumor cells (CTCs) might allow for noninvasive and sequential monitoring of lung cancer. We investigated whether serial CTC analysis could complement conventional imaging for detecting recurrences after treatment in patients with locally advanced non-small-cell lung cancer (LA-NSCLC). PATIENTS AND METHODS: Patients with LA-NSCLC (stage II-III) who definitively received concurrent chemoradiation were prospectively enrolled, with CTCs from peripheral blood samples identified using an adenoviral probe that detects elevated telomerase activity present in nearly all lung cancer cells. A "detectable" CTC level was defined as 1.3 green flourescent protein-positive cells per milliliter of collected blood. Samples were obtained before, during (at weeks 2, 4, and 6), and after treatment (post-radiation therapy [RT]; at months 1, 3, 6, 12, 18, and 24). RESULTS: Forty-eight patients were enrolled. At a median follow-up of 10.9 months, 22 (46%) patients had disease recurrence at a median time of 7.6 months post-RT (range, 1.3-32.0 months). Of the 20 of 22 patients for whom post-RT samples were obtained, 15 (75%) had an increase in CTC counts post-RT. In 10 of these 15 patients, CTCs were undetectable on initial post-RT draw but were then detected again before radiographic detection of recurrence, with a median lead time of 6.2 months and mean lead time of 6.1 months (range, 0.1-12.0 months) between CTC count increase and radiographic evidence of recurrence. One patient with an early recurrence (4.7 months) had persistently elevated detectable CTC levels during and after treatment. CONCLUSION: These results indicate that longitudinal CTC monitoring in patients with LA-NSCLC treated with chemoradiation is feasible, and that detectable CTC levels in many patients meaningfully precede radiologic evidence of disease recurrence.

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PURPOSE: Current cancer treatment options include surgical intervention, radiotherapy, and chemotherapy. The quality of the provision of each of them and their effective coordination determines the results in terms of benefit/risk. Regarding the radiation oncology treatments, there are not stabilised quality indicators to be used to perform control and continuous improvement processes for healthcare services. Therefore, the Spanish Society of Radiation Oncology has undertaken a comprehensive project to establish quality indicators for use with the information systems available in most Spanish healthcare services. METHODS: A two-round Delphi study examines consensus of several possible quality indicators (n = 28) in daily practice. These indicators were defined after a bibliographic search and the assessment by radiation oncology specialists (n = 8). They included aspects regarding treatment equipment, patient preparation, treatment, and follow-up processes and were divided in structure, process, and outcome indicators. RESULTS: After the evaluation of the defined quality indicators (n = 28) by an expert panel (38 radiation oncologist), 26 indicators achieved consensus in terms of agreement with the statement. Two quality indicators did not achieve consensus. CONCLUSIONS: There is a high degree of consensus in Spanish Radiation Oncology specialists on which indicators in routine clinical practice can best measure quality. These indicators can be used to classify services based on several parameters (patients, equipments, complexity of the techniques used, and scientific research). Furthermore, these indicators allow assess our current situation and set improvements' objectives.

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