•BULLETIN•

Volume 17, Number 1 | Winter 2010

•BULLETIN•

INSIDE THIS ISSUE

Is Healthcare a Right? pp 4-6

BU L L E T IN W W W.A C R O.O R G • 1

ACRO is Your OrganizationHelp it

Thrive!To become a member or to sign up a friend, please contact the ACRO office at (301) 718-6515.

Qualitative Research pp 8-9 Headlines pp 12-13

What Does ‘Futile’ ActuallyMean? . . . . . . . . . . . . . . . . . . . 2

ACRO Welcomes NewMembers!. . . . . . . . . . . . . . . . . 3

Who Says Healthcare Is aRight? . . . . . . . . . . . . . . . . . . 4-6

Qualitative Studies UseDifferent Approaches toInvestigate Phenomenon . . 8-9

Enjoy the Benefits of ACROMembership . . . . . . . . . . . . . . 10

Annual Oration Focuses onDiagnostic Radiology–RadiationOncology Teamwork . . . . . . . 11

Headlines 2009/2010 . . . . 12-13

Mark Your Calendar . . . . . . . . 14

2010 Advertising Rates . . . . . 15

EDITORIAL: THE DEATH OF OUR PASTBy A. Robert Kagan, MD, FACRO

Note:The views expressed in the article are not necessarily those of the American College of Radiation Oncology.

See it different? Send a Letter to the Editor, c/o A. Robert Kagan, MD, ACRO Bulletin, KaiserPermanente Medical Group, 4950 Sunset Blvd., Los Angeles, CA 90027.

Clinical medicine has taken a backseat to high-tech medicine. A byproduct of this is lessphysician time spent developing a doctor–patient relationship. No one is better qualified tohave experienced this change than the radiation oncologist. A vast weight of research,development, and manufacture of software, hardware, and imagery, all unflinchingly”precise,” have brought an accuracy to patient positioning and a mock painting of tumorvolumes that have the sharpness and glitter of an industrial diamond. This precision hasincreased the costs of treatment, but it has not met our expectation of increased patientsurvival as occurred when cobalt teletherapy machines replaced kilovoltage in the 1950s.

High-tech radiation therapy is not error-free. Besides missing cancer at the marginaledges, it depends on physician interpretation of radiologic and nuclear images. A major“selling point” of high tech was that, due to the inexactness of radiation relative to surgery,we could better treat the microscopic spread of cancer than could an operative procedure.The devastating evidence of recurrent or persistent cancer at the operated site supportedthis view. Is it not an irony then that today’s planning volumes for intensity modulatedradiation therapy and stereotactic radiation therapy closely approach those of surgery?

Since the 1960s, there has been this attitude in radiation oncology that we defineourselves by the complexity of the equipment and techniques we use. For our pioneers,ideas were critical. Facts were few and equipment primitive. Without the empiricinvestigation of fractionation and radiosensitivity, the specialty of radiation oncology wouldnot have survived.

The Roentgen was accepted as a unit of quantity for clinical dosage in 1931. But cancersof the cervix and larynx were cured before that year by members of the radiation oncology

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TERMINOLOGY RE-EXPLAINED

2 • W W W.A C R O.O R G BU L L E T IN

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Comprehensive socioeconomic, political, and professional news affecting the daily practice of radiation oncology

Editor A. Robert Kagan, MD

Chairman Louis Munoz, MD

President Michael Kuettel, MD, PhD

Vice-President J. Michael Kerley, MD

Secretary/Treasurer William Rate, MD, PhD

Executive Director Norman Wallis, PhD

Managing Editor Stuart J. Birkby

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and length.

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American College of Radiation Oncology.

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•BULLETIN•

WHAT DOES ‘FUTILE’ ACTUALLY MEAN?By A. Robert Kagan, MD, FACRO

Note:The views expressed in the article are not necessarily those of the American College of Radiation Oncology.

Daniel K. Sokol, a lecturer in medical ethics and law at the University of London,once asked a professor of surgery for his definition of “futile.” The answer: “Somethingis futile if I say it is.”

Sokol believes that this subjective term is too often being used as an objectivereason for announcing an end to all treatment. He insists that futility is goal-specific. Asradiation oncologists, if we come to the conclusion that continued therapy is futile,Sokol wants you to ask yourself: “Futile with respect to what?”

Some physicians and scholars have attempted to quantify “futility” by stating thattreatment is futile if it has been unsuccessful in the previous 100 cases. But then, astherapists, we face the problem of defining when a treatment has been unsuccessful.

Consequently, Sokol believes clinicians, specifically those directly involved intherapy, should remember these four points:

1. Futility is goal specific.2. Physiologic futility is when the proposed treatment cannot physiologically

achieve the desired effect. This, says Sokol, is the most objective type of futility judgment.

3. Quantitative futility is when the proposed treatment is highly unlikely to achieve the desired effect.

4. Qualitative futility is when the proposed intervention, if successful, will probably produce such a poor outcome that it is deemed best not to attempt it.

continues on page 6

ACRO WELCOMES NEW MEMBERS!

BU L L E T IN W W W.A C R O.O R G • 3

department of the Curie Foundation in Paris. Using orthovoltageand skin tolerance, Coutard further demonstrated the differencesin radiosensitivity for grade in carcinomas as well as thedifferent radiosensitivity comparing carcinomas to lymphomas.He defined the tolerance of the mucus membranes,vasculoconnective tissues, and bone. Balancing cure andtolerance, he showed that patients were best treated byradiation delivered over six weeks. He laid the clinicalfoundation for radiation oncology without knowing the dose orits precise distribution.

Research in radiation oncology from the 1950s to the 1980ssought a way to widen the small therapeutic ratio existingbetween the normal and malignant cell. The hypoxic cancer cellwas labeled as the most important cause of radioresistance,which led to the idea of using oxygen as a radiosensitizer.Hyperbaric oxygen chambers, breathing carbogen, otherchemical hypoxic radiosensitizers, hyperthermia, and neutronswere investigated to exploit the oxygen effect.

Another research direction was cellular kinetics, whichstudied and investigated the difference between numerous

continued from page 1

ACRO WELCOMES NEW 2009 MEMBERS!

continues on page 7

Carlos Gonzalez-Angulo, MD, Brownsville, TXMichael S. Grossman, MS, Ashland, KYKris M. Guerrier, MD, Lakeland, FLClarissa F. Henson, MD, Elizabeth, NJSophy Y. Hernandez. MD, Maywood, ILPaul Herstein, MD, Seattle, WADaniel Higginson, MD, Chapel Hill, NCJed Howington, MD, Augusta, GAJohn Hyland, MD, Pittsburgh, PARobert Isaak, MD, Des Moines, IARalph Jensen, Tampa, FLJoshua A. Jones, MD, Philadelphia, PAHeather Kaiser, MD, Celina, OHTania B. Kaprealian, MD, San Francisco, CAYogesh Khanal, MD, Seattle, WAYoung H. Kim, MD, Saginaw, MIDarren Klish, MD, Lawrence, KSChristin A. Knowlton, MD, Philadelphia, PAFeng Kong, MD, PhD, Ann Arbor, MIRobert Kyler, MD, Harrisonburg, VAJoseph H. Lanzillo, MD, Crossville, TNJoshua D. Lawson, MD, La Jolla, CAMark Lee, MD, Wichita Falls, TXRichard Y. Lee, MD, PhD, Buffalo, NYMarshal Lieberfarb, MD, Aventura, FLWinston Lien, MD, Los Angeles, CAChristopher R. Loiselle, MD, Seattle, WAMark S. Macher, MD, Lakewood, NJHeath Mackley, MD, Hershey, PAGregory E. Madison, MS, Princeton, WVJames C. Marsh. MD, Chicago, ILDavid Mattson, MD, Buffalo, NYTraci McCormick, MD, Decatur, ALLoren K. Mell, MD, La Jolla, CALuigi Moretti, MD, Nashville, TNJeffrey Morton, MD, Denton, TXMichele A. Nedelka, MD, Richmond, VA

Shannon T. Offerman, MD, Cincinnati, OHMichael J. O’Neill, MD, Rochester, NYCatherine K. Park-Leonard, MD, Tampa, FLAnn C. Pittier, MD, Tacoma, WASachin Patil, MD, Buffalo, NYYuchi P. Peng, MD, Arcadia, CABradley Prestidge, MD, San Antonio, TXMargarita Racsa, MD, PhD, Medford, MAAmar N. Rewari, MD, New Brunswick, NJMary Ann Rose, MD, Encinitas, CAKevin E. Sanders, MD, PhD, Puyallup, WADiane M. Setser, Mt Horeb, WIAmit Shah, MD, York, PARajiv Sharma, MD, Bronx, NYKelly Shaw, MPH, Bellevue, WAFrancisco Solis, MD, Santiago de los

Caballeros, Dominican RepublicShiyu Song, MD, PhD, Richmond, VARandy Sorum, MD, Tacoma, WAThomas C. Sroka, MD, PhD, Tucson, AZLouis Stripling, MD, Atlanta, GAUma Swamy, MD, Brooklyn, NYThomas Tarita, MD, PhD, Chicago, ILKandeepan Thuraisingam, MD, North

Queensland, AustraliaNatasa Townsend, MD, Ft Washington, PAVladimir Valakh, MD, Pittsburgh, PASrinivasan Vijayakumar, MD, Jackson, MSPeter Wall, Hornell, NYJia-Zhu Wang, La Jolla, CABambi Weyers, MD, Bourbonnais, ILShannon White, Zanesville, OHJonathan Whaley, MD, Memphis, TNBrett Willis, Tacoma, WAShuanghu Yuan, MD, Ann Arbor, MILisa Zang, Temple, TX

Irfan M. Ahmed, MD, Tampa, FLMargarita Alamgir, MD, New York, NYAbdulla F. Al-Rashdan, MD, Amman, JordanAlvaro Alvarez-Farinetti, MD, Orlando, FLBenhmidoune Mohamed Amine, DO,

Casablanca, MoroccoKin Au, MD, Abilene, TXJessica Bahari, MD, Orange, CAJoseph Baisden, MD, Louisville, KYAlexander V. Banashkevich, MD, Toronto,

CanadaPatricia Barrett, MD, West Plains, MOJason Berilgen, MD, Houston, TXJames Betler, DO, Pittsburgh, PANathan H. J. Bittner, MD, Tacoma, WAMark Bolton, PhD, MD, Grand Island, NETracy S. Bray, MD, Maywood, ILMichael Bruin, MD. Effingham, ILJoycelin F. Canavan, MD, Halifax, CanadaChristina Chung, MD, Berkeley, CANathan D. Comsia, MD, Maywood, ILAdnan Danish, MD, Red Bank, NJParim Daroui, MD, PhD, New Brunswick, NJLarry C. Daugherty, MD, Glenside, PADenton Davenport, MD, Glendale, AZJoshua Dilworth, MD, PhD, Royal Oak, MIDavid Djajaputra, PhD, Frederick, MDEric D. Donnelly, MD, Chicago, ILMark A. Dosmann, MD, Dothan, ALRobert L. Ebeling, MD, Boston, MAAchilles J. Fakiris, MD, Indianapolis, INDaniel John Ferraro, MD, St Louis, MOLynde A. Florence, RT(R), Orange City, FLEthan B. Foster, MD, Kansas City, KSSurendra Gauchan, MD, Kathmandu City,

NepalKathy Geiger, Nashville, TN

cancers and normal tissues. We thought that kinetic studieswould point the way to the best fractionation schedule for cureand minimal toxicity. This altered fractionation idea persists andforms the basis for recommending CHART for the high-proliferating (hypoxic) cancer, although, generally,chemoradiation schedules have replaced fractionation studies.

In the long term, the buzz of radiobiological research hasnot significantly impacted our management of patients. To fill theresearch gap, we re-oriented our goals to produce high-techconformable–programmed-beam radiation-therapy machines.The top priority is to make the beam precisely correspond to thetumor volume drawn by the physician. The empirical ideas of ourbeginnings have been replaced by the fact-based research ofinverse planning. Much of the current facts of inverse planningdesign come from the input of non–radiation-oncology sources,such as radiologic and nuclear imaging, medical oncology,informatics, meta-analysis, randomized control studies, andvarious statistical analyses. Many of our accepted studies formanagement of patients that have significant p values areclinically weak. Even though there is a separation at the tail endof the survival curves, the number of patients at risk is so small

SPECIAL REPORT: POINT/COUNTERPOINT

4 • W W W.A C R O.O R G BU L L E T IN

WHO SAYS HEALTHCARE

IS A RIGHT?Note:The views expressed in the article are not necessarily

those of the American College of Radiation Oncology.

Editor’s Note: At the heart of the debate over healthcarereform is one critically important question: Is healthcare a right?In this Special Report, gleaned from previously publishedliterature, the ACRO Bulletin attempts to answer the question ina point–counterpoint format and shows how healthcare reformcould be guided by the answer.

Healthcare Is a RightIs healthcare a right to be overseen by the federal

government? Neither the Declaration of Independence nor theConstitution specifically mention healthcare. But our forefatherswere not necessarily against guaranteeing a right to healthcareas part of our pursuit of happiness.

In late 18th century America, healthcare hardly existed.Americans relied more on home remedies and only soughtservices from physicians for the most severe illnesses or injuries.Thomas Jefferson’s personal physician wrote: “[Jefferson] hastold me he would rather trust to the unaided or interfered withefforts of nature than to physicians in general.” And Jefferson’sattitude was not unusual. Americans, in general, distrusteddoctors. Is it any wonder then that the Constitution did notinclude a right to healthcare?

Even by the early 20th century, healthcare was not an issue. Itwas affordable. A visit to the doctor cost about 25 cents. If thephysician made a house call, the charge was 50 cents. Except forthe poorest in society, medical care was accessible.

However, after World War I, those individuals with lowwages and faced with extended hospitalization found thathealthcare was beyond their means. In response to this problem,school teachers in Texas put together the Baylor Plan in whicheach teacher contributed 50 cents a month to cover the costs ofup to 21 days of hospitalization for any individual who was in theplan. This program eventually expanded into the Blue Crossinsurance plan. Similar plans for others soon developed andwere successful as long as medical costs stayed comparativelylow and a limited number of plan members actually used theservice. Unfortunately, as prices rose, these insurance plansbecame less cost effective.

Consequently, Sidney Garfield, MD, devised a system inwhich physicians were to be paid a fixed amount to provideservices to individuals who were part of a payroll deduction planthrough an employer. Dr Garfield believed this would result in ahealthy workforce, and the employee and his or her family

would have access to healthcare. His system was soon knownas the Kaiser Plan. Yet, after World War II, healthcare costs rosesharply and again were becoming unaffordable.

By the middle 1960s, President Lyndon Johnson’s GreatSociety included healthcare coverage for two large portions ofthe American society that were not being covered by employer-based insurance: the retired elderly and the unemployed poor.To close this gap, the government devised Medicare, a socialhealth-insurance program exclusively for senior citizens, andMedicaid, a government-run charity program. These programswere financed through general taxation (except for the MedicareA hospitalization program trust fund, which was supported by apayroll tax).

To put it simply, healthcare today is in crisis becausemedical costs continued to rise. Many employers have beenforced to discontinue healthcare-coverage plans, and taxincentives have not been enough to entice employees to remainpart of a plan. Insurance companies, meanwhile, are increasingpremiums and decreasing services.

Our forefathers could not have envisioned a future like this.Healthcare was not even on their minds in the 1780s. But thatdoes not mean today we can wash our hands of the entirehealthcare-reform issue and say, “Healthcare is not a right. Ifyou cannot afford it, you are out of luck. No medical care foryou.” Today, no government with the means would take thisattitude.

Healthcare, then, is a right for all. Subsequently, thegovernment must be involved in overseeing that right so allAmericans have access to medical care, and it must beresponsible for funding healthcare. Does this suggest auniversal, single-payer healthcare plan? Some suggest that itdoes. What would be required? An additional tax? A forcedfinancial penalty for those who do not join the healthcare plan?A few economists have pointed out that simply delayingretirement age to 66 or, better yet, to 70, would result inadditional years in which individuals pay taxes and do not takefrom Social Security, providing funds for an improvedhealthcare system.

To declare healthcare a right means the government has aresponsibility to reform the healthcare system drastically, notjust fix it with Band-aid–like solutions that will last only a fewyears. But is the government willing to make the hard choices

SPECIAL REPORT: POINT/COUNTERPOINT

BU L L E T IN W W W.A C R O.O R G • 5

needed to develop a long-term solution?Unfortunately, results of the recenthealthcare debate do not indicate that it can.

Healthcare Is Not a RightThe Declaration of Independence—

the basis for the philosophy on which ourgovernment operates—states that we are“endowed” by our Creator with “certainunalienable Rights.” These rights aredefined as life, liberty, and the pursuit ofhappiness. There is no mention ofhealthcare. The next sentence of theDeclaration of Independence states it isthe function of government to “secure”rights against infringement. So ifhealthcare is a right, then the governmentmust guarantee access to medical care toeveryone, equally, regardless of age, pre-existing condition, or ability to pay. In theSeptember 13, 2009, issue of the BostonGlobe, columnist Jeff Jacoby pointed outthat market forces do not influence aright. Religious liberty is a right, he pointsout, so the government does not allowthat right to become a commodity forpurchase. “Do you want to worship thegod of your choice? OK, that will be $500a month to the Religious FreedomInsurance Company.” Obviously, thissounds ridiculous. But if healthcare is aright, why is it being managed as acommodity?

Nevertheless, the belief thathealthcare is a right is nearly a given inour society. Certainly, the late Senator TedKennedy thought so. At his funeral, his12-year-old grandson led mourners inprayer and said, “For what grandpa calledthe cause of his life, that every Americanwill have decent quality healthcare as a

fundamental right and not a privilege, wepray to the Lord.” Also, Americans, ingeneral, believe healthcare is a right. TheHarvard Community Health Plan carriedout a survey a few years ago in which90% of the respondents indicated thateveryone had a right to “the best possiblehealthcare—as good as a millionaire.”

However, Utah’s Senator Orrin Hatchhas a different opinion. “Framing it as amoral question is simply wrong becausehealthcare does not occur naturally and isnot self-evident,” he said this pastOctober, just before his vote as a memberof the Senate Finance Committee againstapproving a healthcare reform bill forfloor debate. Senator Hatch seeshealthcare as a "kind of personal medicalliberty.”

If lawmakers could first clarifywhether healthcare is a right, anentitlement, or a privilege, they mightbetter focus on the critical issues ofhealthcare reform and make betterprogress toward a changed system. Thatis because believing healthcare is not aright does not mean the currenthealthcare crisis should be ignored. Localand national chambers of commerce havefrequently publicized studies showing thatspiraling medical costs will ruin the entireAmerican economy within two decades ifreform is not forthcoming.

But wanting something does notentitle you to it, especially if someoneelse must provide that something. Jacobyexplains that the Constitution guaranteeswhat he calls “negative rights.” They

protect our autonomy and allow us to livelife and pursue happiness “withoutcoercing others or being coerced bythem.” For example, our right to freespeech does not require anotherindividual to spend time and effort toprovide us with that right. In this way,healthcare is different. If it is a right, thensomeone must not only provide but payfor that care. How will this be done?

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Thomas Jefferson, third president of the UnitedStates, had a deep distrust of healthcare.

SPECIAL REPORT: POINT/COUNTERPOINT WHAT DOES ‘FUTILE’ MEAN?

6 • W W W.A C R O.O R G BU L L E T IN

Higher taxes, higher insurance premiums, healthcare rationing,stricter regulations—these are all unpalatable solutions forpoliticians trying to reform medical care.

Of course, to tell a dying patient he or she has no right tohealthcare would be heartless. But Jacoby puts it intoperspective. It would also be heartless to ignore a starvingindividual. Yet access to food is not a right; its availability isdependent on the market. Market forces are what make foodaccessible and affordable to nearly all Americans.

So saying that healthcare is not a right is not a cruel, coldposition to take. This is not an argument to forget about the sick.But it suggests the system that will provide the greatest accessto affordable medical care is one in which we considerhealthcare a product or a service that is managed through thelaws of supply, demand, and competition with little governmentintrusion. n

What side are you on? Express your opinion in a Letter tothe Editor, c/o A. Robert Kagan, MD, ACRO Bulletin, Departmentof Radiation Oncology, Kaiser Permanente Medical Group, 4950Sunset Blvd., Los Angeles, CA 90027.

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Sokol wants to emphasize to therapists that labeling atreatment as “futile” is colored by the opinions of the personmaking the judgment. “Like ‘best interests,’ ‘futility’ exudes aconfident air of objectivity while concealing value judgments,”he wrote in a 2009 article on the subject in the British MedicalJournal (June 13 issue, p. 1,418).

Finally, Sokol advises against using this word in front ofpatients and their families because they are likely to think theword “futile” means “nothing more can be done.” In thissituation, physicians should discuss treatment options bybalancing the expected benefits with the burdens imposed bycontinued medical interventions. He also reminds us that, asphysicians, we can always do something for our patients, even ifit is only to provide comfort. n

Dr Kagan is the Editor of the ACRO Bulletin and past-president of ACRO. Reactions or responses to this article can besent to Dr Kagan at the Department of Radiation Oncology;Kaiser Permanente Medical Group; 4950 Sunset Blvd; LosAngeles, CA 90027.

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THE DEATH OF OUR PAST

BU L L E T IN W W W.A C R O.O R G • 7

that whether the separation is real or notshould be up for discussion, questioningwhether the study should act as a guide todefine standard treatment. The antiquatedfacts of normal-tissue tolerance and thecurative dose have remained withoutmuch change. Bottom line: Our patienttoday is managed based on technique anddose, not so much on the clinical entity asin the past. Intuition and clinicaldiscrimination have metamorphosed intoa sophisticated understanding ofexperimental design and probability. As aresult, radiation oncologists are regardedby their referral doctors more astechnologists providing a service ratherthan clinicians providing a consultation.

Much of our literature is a reflectionof authors’ desires to advance theirpartisan views for their treatment, andthey use the language of science to dojust that. Frankly, unbiased information inradiation oncology does not exist. Usuallythe responsible author reporting results isthe same as the one who treated thepatients. Benjamin Franklin summed upour scientific-literature bias best: “If Jackis in love, he is no judge of Jill’s beauty.”

Social change in our society hasbrought restlessness to our patients.Many have fixed on the false assumptionthat higher cost means better treatment,which will result in increased survival.Chace, writing about college tuition,describes an event similar to thatoccurring in high-tech radiation oncology:

Strange as it may sound, to charge asmuch as one possibly can draws incustomers. This is what selling status,as opposed to product, is all about.Little Ursinus College in Pennsylvanialearned this truth by experimentation.After years of below-market tuitioncosts, it decided to play in the bigleagues. In 2000, it raised its tuitionand fees by almost 18% and wasthrilled to see 200 more applicationsthan the year before. By 2004, thestudent body had increased in size by35%. What some call the “ChivasRegal argument” and others the“audacity model” worked: Ifsomething costs more, consumersthink it has to be better.

Patients seem to trust the newestequipment, not the doctors’ clinicalevaluation, and many American patientshave unrealistic expectations of what wein oncology can accomplish. In addition,there is a level of naïveté among referringphysicians about what we can do. Bothour patients and our referring physicianshave a fascination with technology.Physicians have become profit investorsin medical devices. Lucrative industrialalliances were not common during theearly years of our specialty. Equityinterest in companies that provideradiation-oncology devices has grown tothe point to where it has becomesomewhat tenuous to rely on thejudgment of trusted physicians becausetheir judgment is modified by theircommercial investments.

The U.S. Food and DrugAdministration (FDA) approves our high-

7472_NUCL_Glwng_ArcoBlltn_BW.indd 1 10/26/09 11:51 AM

tech “advances” because they are safeand at least equivalent if not better thanprior technology. There is little or no FDAattention to increased costs or life-qualityeffects. Once FDA approved, com-pensatory reimbursement follows. Sincethe new advance is more costly and time-consuming to operate, re-imbursement ishigher. Radiation oncologists who do notpurchase these high-tech advancementssoon see a drop in referred patients.Furthermore, within months of purchase,a new technique is being used to treatnearly everything, not just for what it wasbest designed to treat.

The follow-the-leader behavior ofradiation oncologists is not all due toincreased reimbursement opportunities.It comes partly from our difficulty indetermining a new product’s value beforeusing it (at least one to two years foracute results and three to four years forcure). For most of the scientific work inradiation oncology, it is difficult orimpossible to predict immediately thefuture value of new equipment.Furthermore, published articles in ourpeer-reviewed journals have, on average,exaggerated results. If our goal isconfined to tightening the isodose curve,we will neglect novel ideas and trulyindependent investigative paths, whichmaintain the individuality of ourspecialty. n

Dr Kagan is the Editor of the ACROBulletin and past-president of ACRO.

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8 • W W W.AC RO.O R G BU L L E T IN

RESEARCH METHODS REVIEW

QUALITATIVE STUDIES USE

DIFFERENT APPROACHES TO

INVESTIGATE PHENOMENON

We are all aware of quantitative research. Basedpredominantly on statistics derived from experimental studies oranalysis using randomization and control groups for datacomparison, this is the type of research with which those in themedical field are most familiar. In contrast, qualitative researchmay be less familiar. Nevertheless, it has become acceptable inthe social sciences as a way to study human behavior, and it isbeing used more frequently in the medical field. Therefore, thosein healthcare must be acquainted with some of the majordifferences between quantitative and qualitative studies.

Differences in PerspectiveQualitative research is usually identified by its descriptive

data. That is, the qualitative researcher deals with words—terminology and concepts described in such a way that theyreveal a richer description of the study than can be attained withnumbers. These descriptions are gained through observation,interviews, document analysis, or historical research, to namejust a few methods.

Perhaps most important is that qualitative inquiry isconsidered an investigation of phenomenon in context. Manyquantitative medical studies are carried out in the laboratory.Qualitative studies are based on the idea that an investigationmay be more valuable if the phenomenon is analyzed in itsnatural setting. In fact, proponents of qualitative research arguethat the quantitative approach might not always be appropriatebecause it isolates the phenomenon to be studied, a processcalled “context stripping” (Mischler, 1979).

In addition, readers must recognize that qualitative researchis emergent. In quantitative studies, a hypothesis and a design totest that hypothesis are developed before the collection of data.

In qualitative studies, however, a hypothesis develops, oremerges, as the research is being carried out. Design can bemodified in the middle of the study. This occurs because, unlikethe quantitative researcher, the qualitative researcher is neversure beforehand what he or she will discover. Subsequently, heor she analyzes the meaning of the information as it is beingcollected and develops working hypotheses to prove or disproveinitial hunches.

Signs of ValiditySince qualitative research deals with data in an emergent,

natural setting, research validity is achieved differently thanwhen carrying out quantitative studies. Some qualitativeresearchers prefer to use the term credibility, rather thanvalidity, to describe the degree to which others believe theirstudy. That is, those who are evaluating qualitative researchmust be convinced that the study “represents accurately thosefeatures of the phenomena that it is intended to describe,explain, or theorize” (Hammersley, 1992). This can be done inseveral ways:

1. Different sources of data are collected, and a relationship isshown between the data. This is called triangulation. If dif-ferent data separately lead to the same conclusions, there is corroboration.

2. Data can be considered valid by consensus among peers. This is not to say that peer review is unimportant for quan-titative research. But, when procedures deal with numeri-cal data, results are not usually questionable. In other words, 2 + 2 always equals 4, and if it does not, a statisticalerror has been made. With qualitative research, however, aright-or-wrong dichotomy is not so obvious. Consequently, validity is established if a large number of peer reviewers agree on the interpretation of results. This is called consensus.

3. If the participants of a study give feedback in which they generally agree with the conclusions a researcher has made about them, the study is valid based on referential evidence.

4. Johnson and Christensen (2000) point out that validity can be achieved based on the extent to which a “theoretical explanation developed from the study seems appropriate for the data collected.” They call this theoretical adequacy.

BU L L E T IN W W W.AC RO.O R G • 9

RESEARCH METHODS REVIEW

5. The biggest cause of invalidity in qualitative study is researcher bias. For example, a qualitative researcher has to guard against tainting data by allowing personal feel-ings or preferences to influence the results. This is why qualitative researchers self-reflect to identify and to isolate those biases that could invalidate a study. This is called reflexivity.

Some experts in research methodology might argue thatqualitative research usually does not have a great degree oftransferability. In many cases, this is true. A qualitativeresearcher, with results gained in one natural setting, might behard pressed to state that the same results would be obtained inanother setting. In quantitative medical studies, this is rarely aproblem. For example, if a specific drug effectively treats diseasein one laboratory, we can safely assume that, if the methods areaccurately replicated, the results would be the same in anotherlaboratory. However, with qualitative studies, the degree oftransferability is extrapolated from how similar one setting(people, situation, and time) is to another.

Keys to Good Qualitative ResearchKuper, Lingard, and Levinson (2008) have concluded that to

evaluate qualitative research one must consider the following:

1. The relationship of the study design to the research question2. The quality of data collection3. The quality of data analysis4. Evidence of transferability or use of triangulation5. Inclusion of reflexivity6. Clarity of the study overall

The quality of both quantitative and qualitative research isjudged on the studies’ validity, reliability, and objectivity.Although quantitative and qualitative inquiries are carried outdifferently, these three factors are critically important in allresearch. n

Selected ReferencesHammersley, M. (1992). What’s wrong with ethnography? Methodological

explorations. London: Routledge.Johnson, B., & Christensen, L. (2000). Educational research: Quantitative and

qualitative approaches. Boston: Allyn & Bacon.Kuper, A., Lingard, L., & Levinson W. (2008). Critically appraising qualitative

research. British Medical Journal 337, 687–689.Mischler, E. G. (1979). Meaning in context: Is there any other kind? Harvard

Educational Review, 49, 2–10.

REPRESENTATIVE DEBBIE

WASSERMAN SCHULTZ TO

DELIVER KEYNOTE ADDRESS

AT ACRO 2010ANNUAL

MEETING

Representative DebbieWasserman Schultz, Democrat fromthe 20th District in Florida, will be akeynote speaker at the 20th AnnualMeeting of the American College ofRadiation Oncology, at 5:00 pm onFriday, February 26, 2010, at the Contemporary Resort, DisneyWorld, Florida.

Rep. Wasserman Schultz will present an address to theconference on "Healthcare Reform in the 111th Congress" and willreceive an award for “Outstanding Services to Cancer Patients”from Michael Kuettel, MD, PhD, president of ACRO.

Now in her third term in Congress, Rep. Wasserman Schultzhas quickly risen to Chief Deputy Whip and a member of theleadership team in the House of Representatives. She also sitson the Appropriations Committee as well as the JudiciaryCommittee. These duties place Rep. Wasserman Schultz in apivotal position to influence legislation in the 111th Congress,including healthcare legislation that has the potential tosignificantly impact radiation oncology. As a breast cancersurvivor, Rep. Wasserman Schultz also brings an importantpersonal perspective to the healthcare debate.

Commenting on Rep. Wasserman Schultz’s interest in theproblems of cancer patients, Dr. Kuettel said “CongresswomanWasserman Schultz displays a great understanding of theproblems facing cancer patients and those of us who care forthem. She has been a strong advocate for cancer care in the USHouse of Representatives and has done a great deal to steer thenation’s attention towards the needs of these patients, to raiseawareness of the various treatment options, and to support newadvances in cancer care.” n

Þwww.acro.org

Check Out Our Web Site

netAdvancing Communication ...

Realizing Opportunities ...

INVITATION TO JOIN

10 • W W W.A C R O.O R G BU L L E T IN

ENJOY THE BENEFITS OF

ACRO MEMBERSHIP

Since 1990, the American College of Radiation Oncology hasfocused its attention on both the clinical and economic aspectsof practicing radiation oncology. As a professional medicalsociety representing a relatively small subspecialty, ACRO hasled the effort to assure appropriate reimbursement for clinicalcare and has provided services to help its members becomebetter clinicians.

Its mission is to strive to ensure the highest quality care forradiation therapy patients and promote success in the practice ofradiation oncology through education, responsiblesocioeconomic advocacy, and integration of science andtechnology into clinical practice.

Just what do you get for your ACRO dues dollar? Check outthese benefits. You’d be hard-pressed to find a better valueanywhere:

• Experienced, effective and intelligent legislative counselKeeping an eye on Washington and CMS while you’retaking care of your patients.

• Proactive Practice Accreditation ProgramACRO-PAP is simple, straightforward and focused onhelping you demonstrate the quality of your practice.

• Online access to the American Journal of ClinicalOncologyProvides you with instant access to articles and a libraryof past issues.

• Discounted medical practice insuranceProvided exclusively for radiation oncology practices, soyou get the attention you deserve and the coverage youneed.

• Comprehensive billing and coding supportResources that help your practice remain fullycompensated by third party payers.

• Practical and dynamic Practice Management GuideDesigned by the experts, published by ACRO, andprovided at a discount to help you practice moresuccessfully.

• A resident-friendly CollegeACRO invests in its future; helping residents transitionsuccessfully to a career and offering scholarships forclinical rotations and attendance at ACRO meetings.

• An opportunity to have an impactYou will be encouraged to get involved, participate oncommittees, and become active in the College.

• Intimate and educational annual meetingsDesigned to create an intimate and interactiveexperience, ACRO’s annual meetings offer you easyaccess to speakers as well as CME and SAM credits.

For more information about joining ACRO, call (301) 718-6515 or visit http://www.acro.org. n

For Information on the ACROPractice AccreditationProgram Please Contact: Jeanne Carroll

Program Administrator

University of Toledo Medical CenterDepartment of Radiation Oncology

3000 Arlington Ave.Toledo, OH 43614

(419) 383-4462

RADIATION THERAPY AT THE RSNA SCIENTIFIC ASSEMBLY

BU L L E T IN W W W.A C R O.O R G • 11

ANNUAL ORATION FOCUSES ON

DIAGNOSTIC RADIOLOGY–RADIATION ONCOLOGY

TEAMWORK

Although predominantly an organization of diagnosticians,the Radiological Society of North America (RSNA) has neverforgotten about those who use radiation for treatment. Everyyear this is reflected at the RSNA Scientific Assembly andAnnual Meeting when a radiation oncologist is chosen to givethe traditional Annual Oration in Radiation Oncology. This yearthe speaker was Bruce G Haffty, MD, professor and chairman ofthe Department of Radiation Oncology at the University ofMedicine and Dentistry of New Jersey’s Robert Wood JohnsonMedical School. He focused on the collaboration neededbetween radiologists and radiation therapists to strengthen thefight against breast cancer.

Dr Haffty noted that newly available genetic information hasfocused on high-penetrance genes, BRCA1 and BRCA2, but thatthe low-penetrance variety is likely to have greater clinicalrelevance. In the meantime, he recommended diagnosticradiologists and radiation oncologists develop clinical databasesand link them to tissue and blood samples. “Radiationoncologists should focus on demographic databases, and

diagnostic radiologists could establish mammographicpatterns,” he said.

Additionally, Dr Haffty described the use of genome-wideassociation studies that would involve genetic testing ofpatients to determine which patients are at high risk for breastcancer and which patients may suffer from a high level ofnormal-tissue complications after radiation exposure.

Dr Haffty is an internationally recognized expert in themanagement of breast cancer. n

Dr Haffty can be reached at the University of Medicine &Dentistry of New Jersey, Robert Wood Johnson Medical School,The Cancer Institute of New Jersey, 195 Little Albany Street, NewBrunswick, NJ 08903; Email address: hafftybg@umdnj.edu.

ÞCheckOutOurWebSite

Advancing Communication ...Realizing Opportunities ...

Founded in 1989 with a current membership of approximately 800, theAmerican College of Radiation Oncology is the essential professionalsociety for success in the practice of radiation oncology.

www.acro.orgDwight Fitch, MD • Website Editor

Because of its size, the Scientific Assembly of the RadiologicalSociety of North America is held every year in Chicago, either in lateNovember or early December.

HEADLINES 2009/2010

12 • W W W.A C R O.O R G BU L L E T IN

BRIEF SUMMARIES OF

IMPORTANT NEWS FOR THE

RADIATION ONCOLOGIST

Radiation Therapy for Cervical Cancer: Bad or Good?Sometimes medical research does not clarify but serves to

confuse further the best course of action for management ofdisease. For instance, take these two reports:

A recently published article in Cancer describes a study thatshows pelvic fractures occurred in 29 of 300 patients (9.7%) whounderwent radiation therapy for cervical cancer. Initially, therecords of 516 women who underwent radiation therapy forcervical cancer between 2001 and 2006 at the M. D. AndersonCancer Center were reviewed. The 300 chosen for extendedstudy had undergone computed tomography or magneticresonance imaging after treatment.

A total of 24 (83%) women had fractures of the sacrum, 3(10%) had fractures of the sacrum and pubic, and 1 (3%) had afracture of the sacrum and acetabulum. After one year, 38%were known to have a pelvic fracture; after two years, 83%.

The median age of the women with fractures was higherthan the median age of the women without (56.6 years and 46.7years, respectively). About 62% of the women weremenopausal.

The researchers remarked that a substantial number ofwomen had fractures, but they did not state the fractures werenecessarily a direct result of the radiation therapy. Instead, theauthors recommended that older women about to undergoradiation therapy for cervical cancer schedule a bone-mineral-density screening ahead of time.

A few weeks later, ScienceDaily claimed that combinationchemotherapy–radiation therapy for cervical cancer improvessurvival. Researchers analyzed the records of 3,452 women.After five years, 66 out of 100 women who had undergonechemotherapy and radiation therapy were still alive, but only 60out of 100 women who had undergone radiation therapy alonewere still alive.

So, which is it? Should an older woman with cervical cancerundergo chemotherapy and radiation therapy? Will she livelonger but suffer a pelvic fracture? As is said at the conclusion ofmany published studies: Further research is needed.

Gingko May Protect against Radiation DamageThe International Journal of Low Radiation

recently reported that the antioxidantextracts from the leaves of the Gingkobiloba tree could protect cells fromradiation damage. Specifically, thecompounds protect the cells from free radicals,as well as other reactive oxidizing species,which are generated normally by the body butcan reach abnormally high levels afterone is exposed to radiation.

The researchers at the Korea Institute of Radiological andMedical Sciences obtained white blood cells from healthyindividuals (age, 18–50 years old). Half of the cells were treatedwith G. biloba; the other half—the control group—were treatedwith a salt solution. The cells were then exposed to gammaradiation from radioactive cesium. Approximately one-third ofthe untreated cells but only one in 20 of the treated cellsunderwent apoptosis. Parallel studies using mice had similarresults.

Role of Hormone Therapy for Survival StudiedRenal & Urology News reported that men with

intermediate-risk localized prostate cancer might survive longerif they undergo four months of total androgen-suppressiontherapy before low-dose radiation therapy. According to aCalifornia study of 1,979 patients, slightly more than half werealive 12 years after receiving the combination therapy,compared to 46% of the patients who received radiationtreatment alone. Because the survival benefit related nearlyexclusively to those in an intermediate-risk category, theresearchers concluded that men with low-risk disease do notneed the hormonal therapy.

Antibody Therapy May EnhanceRadiation Treatment for Lymphoma

Recent cancer research in the United Kingdom has includedan investigation into a combined radiation and antibody therapyto treat lymphoma. In this study, radioactive iodine was attachedto the CNT-25 antibody. The therapy was designed for thosepatients who have not responded to other treatments. Sevenpatients out of 15 responded to this treatment. Unfortunately, anadverse effect of the treatment is a decrease in the white bloodcell and blood platelet count. Consequently, one patient died ofpneumonia. In addition, the validity of the results isquestionable. The study group was small. The objective of thestudy was to determine safe doses for future research, not todiscover an alternative approach to managing lymphoma. Also,no control group was used for comparison. Nevertheless, theresearchers believe their study warrants further investigation todetermine the effectiveness of such treatment in a much largergroup of patients.

HEADLINES 2009/2010

BU L L E T IN W W W.A C R O.O R G • 13

Airport Scanning Safe, SaysNCRP after Christmas Incident

On Christmas Day 2009, an individualwith alleged connections to Al-Qaedaattempted to blow up a passenger planeenroute to Detroit from Amsterdam. Theresponse by the US government to thisfailed act of terror has been to increasesecurity at American airports. TheTransportation Security Administration isnow using low-level radiowaves with tworotating antennae to scan a passengerfrom head to toe.

The National Council on RadiationProtection and Measurement (NCRP)reports that a passenger would need toundergo the scan a least 2,500 times ayear to reach even the level of receiving aNegligible Individual Dose. In fact, apassenger flying over America from coastto coast would be exposed to moreradiation than from this type of airportscreening. The American College ofRadiology agrees with these conclusions. n

MARK YOUR CALENDAR

14 • W W W.A C R O.O R G BU L L E T IN

Mark Your Calendar Some 2010 Meeting DatesPhysicians’ Education Resource3500 Maple Avenue, Suite 700Dallas, TX 75219Telephone (888) 949-0045Website http://www.cancerlearning.com/index.cfm /fuseaction/ conference.showOverview /id/5/conference_id/241

27th Annual Miami Breast ConferenceMarch 3–6, 2010Fontainebleau Miami Beach HotelMiami, FL

Imedex4325 Alexander DriveAlpharetta, GA 30022Telephone (770) 751-7332Website http://perspectivesinlung-cancer.com/2010/contact.html

11th European CongressPerspectives in Lung CancerMarch 5 & 6, 2010Amsterdam RAI Convention CenterAmsterdam, Netherlands

The Michener Institute222 St Patrick Street, Room 744Toronto, Ontario, Canada M5T 1V4Telephone (416) 596-3152Website http://www.radmedtoronto.com

Seventh Annual Radiation Therapy ConferenceInquire, Inspire, InnovateMarch 5 & 6, 2010Chestnut Conference CentreToronto, Ontario, Canada

American Society of Clinical Oncology2318 Mill Road, Suite 800Alexandria, VA 22314Telephone (571) 483-1300Websitehttp://www.asco.org/ASCOv2/Meetings/Genitourinary+Cancers+Symposium

2010 Genitourinary Cancers SymposiumProgress in Multidisciplinary ManagementMarch 5–7, 2010San Francisco MarriottSan Francisco, CA

Physicians' Education Resource 3500 Maple Ave., Ste. 700Dallas, TX 75219Phone (888) 949-0045Websitehttp://www.cancerlearning.com/index.cfm/fuseaction/conference.showOverview/id/5/confer-ence_id/282

Seventh International Symposium on Melanoma and Other Cutaneous MalignanciesMarch 12 & 13, 2010Jumeirah Essex HouseNew York, NY

Society of Gynaecologic Oncologists230 West Monroe Street; Suite 710Chicago, IL 60606Telephone (312) 235-4060Website http://www.sgo.org

Society of Gynaecologic Oncologists 41st Annual Meeting on Women’s CancerMarch 14–17, 2010San Francisco, CA

Physicians' Education Resource 3500 Maple Ave., Ste. 700Dallas, TX 75219Phone (888) 949-0045Website http://www.cancerlearning.com/index.cfm/fuseaction/conference.showOverview/id/5/conference_id/282

Seventh International Symposium on Ovarian Cancer and other Gynecologic MalignanciesMarch 26 & 27, 2010Jumeirah Essex HouseNew York, NY

RGCON 2010Department of Radiation OncologyRajiv Gandhi Cancer Institute andResearch CentreSector-5, RohiniDelhi-110085, IndiaWebsite http://www.rgci.org/rgcon2010/

Strategies for Preservation of Organ Structure and Function in CancerMarch 26–28, 2010India Habitat CentreNew Delhi, India

Congress CarePO Box 4405201 AK’s-HertogenboschThe NetherlandsTelephone 31 73 690 1415Website http://www.colorectal2010.org

European Multidisciplinary Colorectal Cancer CongressMarch 28–30, 2010Acropolis Palais des CongrèsNice, France

Australian Brachytherapy Group c/o Level 1, 120 Railway AvenueRingwood, VIC 3135AustraliaTelephone 61 3 9870 2611Website http://www.abg.org.au

19th Annual Scientific MeetingApril 8–10, 2010Langham HotelMelbourne, Australia

American Brachytherapy Society 12100 Sunset Hills Road, Suite 130Reston, VA 20190Telephone (703) 234-4078Website http://www.american-brachytherapy.org

Annual MeetingApril 29–May 1, 2010Hyatt RegencyAtlanta, GA

American College of Radiology1891 Preston White DriveReston, VA 20191Telephone (703) 648-8900Website www.acr.org

87th Annual MeetingMay 15–19, 2010Hilton Washington HotelWashington, DC

American Society for TherapeuticRadiology and Oncology8280 Willow Oaks Corporate Drive,Suite 500Fairfax, VA 22031Telephone (703) 502-1550Website http://www.astro.org

ASTRO 52nd Annual MeetingOctober 31–November 4, 2010San Diego, CA

Meci International Convention ServicesRoom 1906, 19th floor, Daerung PostTower #1 212-8 Guro-dong, Guro-gu, Seoul, ROK152-790Telephone (82) 2 2082-2310Webite http://www.ifhnos2010.org/con-tact/contact.asp

4th World Congress of International Federation of Head and Neck Oncologic Societies Shifting Paradigms in Head and Neck OncologyJune 15–19, 2010Lotte HotelSeoul, ROK

Radiation Research SocietyPO Box 7050Lawrence, KS 66044Telephone 800-627-0326Website http://www.radres.org/ECOMradres/timssnet/common/tnt_2010_Anual_Meeting.cfm

Radiation Research Socviety 56th

Annual MeetingSeptember 25–29, 2010Grand Wailea Resort Hotel & SpaWailea, Maui, HI

Radiological Society of North America820 Jorie BoulevardOak Brook, IL 60523Telephone (800) 381-6660Website http://www.rsna.org

96th Scientific Assembly and Annual MeetingNovember 28–December 3, 2010McCormick PlaceChicago, IL

2010 ADVERTISING RATES

BU L L E T IN W W W.A C R O.O R G • 15

Advertising Rates & SpecificationsComprehensive socioeconomic, political, and professional news affecting the daily practice of radiation oncology

Official Newsletter of the American College of Radiation Oncology

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Payment must accompany order. Make checks payable to American College of Radiation Oncology (ACRO), or payment may be madeby credit card (MasterCard, Visa, or American Express); call for details. Payments should be submitted to “ACRO BulletinAdvertising” to the address shown above. Advertisers who cancel ads will not receive refunds.

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