the following objectives:(a) V 95% > 95% for each PTV, (b) heart D mean < 26 Gy, and;(c) left lung V 20Gy < 30%. Field-in-field IMRT (FiF), inverse IMRT (IMRT) and Volumetric Modulated Arc Therapy (VMAT) plans were created for each type of target. To reduce variability, one radiation oncologist performed all target delineations and a single medical physicist optimized plans for all patients. Upon meeting the minimum criteria stated above, only five further iterations (over two days) were permitted to improve plan quality, to reflect real-world departmental time constraints. After reaching the iteration limit, the plan with maximum PQM score was selected for analysis. Statistical comparisons for PQM scores was performed by two-way repeated measures analysis of variance, after applying a Bonferroni correction (p < 0.005 was considered significant). Results: A total of 450 plans were generated for the entire cohort and 90 plans were selected based on PQM score and minimum acceptance criteria. Total PQM score of plans for Tangent and ESTRO were comparable for FiF and IMRT techniques (FiF vs IMRT for Tangent: 68.33 AE 6.52 vs 69.61 AE 5.54, p Z 0.637; FiF vs IMRT for ESTRO: 72.80 AE 5.27 vs 75.60 AE 5.89, p Z 0.304), and were also significantly higher compared to VMAT (p < 0.001 for all comparisons). Total PQM score of plans for RTOG revealed that IMRT planning achieved a significantly higher score compared to both FiF and
receiving surgery upfront, nearly half (45.1%) received adjuvant radiation therapy, which is associated with higher toxicity and poorer local control as compared to neoadjuvant treatment, and 40.1% received no adjuvant therapy at all, which could lead to worse cancer outcomes. Further research is needed to better elucidate patient and systems-level factors contributing to these disparities in care.
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