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#ThisIsBrachytherapy: Increasing awareness of brachytherapy

      Abstract

      Purpose

      The use of brachytherapy continues to be a vital application of radiation oncology for various cancers. Despite this, there has been a decrease in the utilization of brachytherapy in many cancers. Social media in medicine facilitates engagement and advocacy. We launched a social media campaign to bring awareness of brachytherapy throughout the world with #ThisIsBrachytherapy hashtag on July 17, 2019.

      Methods and Materials

      #ThisIsBrachytherapy hashtag was registered with Symplur Healthcare Hashtag Project. We collected total tweet counts, retweet counts, impression counts, geolocation, top 10 influencers, associated hashtags, associated words, and word sentiment score.

      Results

      The campaign launched on July 17, 2019, had a total of 145 tweets on that day with 213,416 impressions. Twenty-seven accounts (45%) were identified as physicians. Top countries which tweeted, among those with information available, included the United States, United Kingdom, and Australia. Since July 17, 2019, there has been an increase in tweets using #ThisIsBrachytherapy, with 1990 total tweets with 1,999,248 impressions. Fifty-four percent (1030) of the tweets contained photos and 319 contained links. This was from 462 unique users. Word sentiment was overwhelmingly positive. Associated hashtags with #ThisIsBrachytherapy included most commonly #radonc, #brachytherapy, #brachy, #prostatecancer, and #pcsm.

      Conclusions

      The #ThisIsBrachytherapy inaugural campaign was successful and has continued to grow throughout the months after the initiation. By continuing to advocate for brachytherapy through the social media campaign #ThisIsBrachytherapy, we can empower radiation oncologists, especially trainees, and patients to address underutilization.

      Keywords

      Introduction

      Brachytherapy represents a core technique in the delivery of modern radiation therapy. The use of brachytherapy not only improves oncologic outcomes in certain cancers but is a value-oriented approach as well; however, its application has not been uniform with variable practice patterns seen across both academic and community centers (
      • Viswanathan A.N.
      • Creutzberg C.L.
      • Craighead P.
      • et al.
      International brachytherapy practice patterns: A survey of the Gynecologic Cancer Intergroup (GCIG).
      ,
      • Nag S.
      • Owen J.B.
      • Farnan N.
      • et al.
      Survey of brachytherapy practice in the United States: A report of the clinical research committee of the American endocurietherapy society.
      ). One rationale for this difference may lie in the heterogeneity of brachytherapy training in radiation oncology residency programs as highlighted in surveys in the United States and Canada over the last decade (
      • Gaudet M.
      • Jaswal J.
      • Keyes M.
      Current state of brachytherapy teaching in Canada: A national survey of radiation oncologists, residents, and fellows.
      ,
      • Nabavizadeh N.
      • Burt L.M.
      • Mancini B.R.
      • et al.
      Results of the 2013-2015 association of residents in radiation oncology survey of chief residents in the United States.
      ). In addition, there appears to be a decrease in trainee exposure to certain brachytherapy modalities as evidenced by the decline in the number of chief residents who endorse adequate exposure to brachytherapy from 2005 to 2015 (e.g.: low-dose-rate prostate brachytherapy, 93% vs. 32%) (
      • Nabavizadeh N.
      • Burt L.M.
      • Mancini B.R.
      • et al.
      Results of the 2013-2015 association of residents in radiation oncology survey of chief residents in the United States.
      ,
      • Orio 3rd, P.F.
      • Nguyen P.L.
      • Buzurovic I.
      • et al.
      Prostate brachytherapy case volumes by academic and nonacademic practices: Implications for future residency training.
      ). A recent survey conducted by the Association of Residents in Radiation Oncology assessed brachytherapy training among U.S. radiation oncology residents found that caseload is the greatest perceived barrier to achieving subsequent independence in brachytherapy practice (
      • Marcrom S.R.
      • Kahn J.M.
      • Colbert L.E.
      • et al.
      Brachytherapy training survey of radiation oncology residents.
      ). Furthermore, multiple publications have described a declining brachytherapy utilization rate in the United States over time, without an appropriate replacement treatment in the case of gynecologic cancers. This decrease in brachytherapy training and utilization limits the possible effective treatment modalities that can be offered to patients which in turn may have deleterious effects on oncologic outcomes (ex. cervical cancer) (
      • Han K.
      • Milosevic M.
      • Fyles A.
      • et al.
      Trends in the utilization of brachytherapy in cervical cancer in the United States.
      ,
      • Gill B.S.
      • Kim H.
      • Houser C.
      • et al.
      Image-based three-dimensional conformal brachytherapy for medically inoperable endometrial carcinoma.
      ,
      • Glaser S.M.
      • Dohopolski M.J.
      • Balasubramani G.K.
      • et al.
      Brachytherapy boost for prostate cancer: Trends in care and survival outcomes.
      ).
      The growing adoption of social media in medicine facilitates networking, scientific discussion, and engagement between both physicians and patients (
      • Markham M.J.
      • Gentile D.
      • Graham D.L.
      Social media for networking, professional development, and patient engagement.
      ). Twitter is a microblogging platform that broadcasts messages via tweets which often include hashtags, maximizing exposure to a target audience. A hashtag campaign can represent an information or marketing initiative to gain social media attention and exposure to a topic of interest. In 2018, the Society of Women in Radiation Oncology launched a social media campaign, with the hashtag #WomenWhoCurie to recognize the accomplishments of women in radiation oncology marked by the anniversary of Marie Curie's birthday. Enthusiasm was strong and the passion for women in radiation oncology was recognized with 2774 total tweets (
      • Albert A.A.
      • Knoll M.A.
      • Doke K.
      • et al.
      #WomenWhoCurie: Leveraging social media to promote women in radiation oncology.
      ). In 2019, the American Brachytherapy Society (ABS) Social Media Committee (authors JK, MAK, and CS are members) noted the impact of this social media campaign and sought to raise awareness about the value and utility of brachytherapy in oncology communities around the world in a similar manner. From this, the #ThisIsBrachytherapy campaign was launched in the Spring of 2019 with the first inaugural day on July 17, 2019.

      Methods

      The ABS registered the #ThisIsBrachytherapy hashtag with the Symplur Healthcare Hashtag Project (Symplur LLC, Upland, CA) to facilitate hashtag tracking and gather associated metrics. Symplur is the only social media analytics platform to focus 100% on health care. Symplur has the ability to track total tweet counts, retweet counts, impression counts, geolocation, top 10 influencers, associated hashtags, associated words, and word sentiment score. An “impression” represents the potential impact a tweet has, and is defined by multiplying the number of tweets from each participant by the number of followers the participant has, demonstrating the potential views a tweet may receive (
      • Zarzycki N.
      Reach vs. impressions: What’s the difference (and what should you track)?.
      ). “Influencer” relies on data from SymplurRank based on influential accounts by measuring the number of quality mentions received. The quality of a mention is determined by the account who gave it and the account's own influence on the topic at hand; it represents the overall influence in health care social media. “Word sentiment” was obtained, which processes health care language for positive and negative sentiment. Analytics were obtained from Symplur.com (
      Symplur
      Symplur Health Care Hashtag Project.
      ).

      Results

      The #ThisIsBrachytherapy campaign was shared on Twitter by the ABS Twitter account before July 17th to invite radiation oncologists to join. The campaign was launched on July 17, 2019, and a total of 145 tweets with 213,416 impressions included the hashtag #ThisIsBrachytherapy on the inaugural day. Eighty-one percent of tweets (118) contained photos from 59 users. Twenty-seven accounts (45%) were identified as physicians via their Twitter profile.
      Top influencers for the #ThisIsBrachytherapy inaugural day were classified by those with the highest number of tweets, impressions, and mentions on July 17, 2019 (Fig. 1). The ABS official Twitter account had the largest impact attributed to being tagged in 64 tweets. User location was demonstrated across multiple countries throughout the world. Location data are not known on many Twitter profiles (36.5%). Top countries which tweeted, among those with information available, included the United States, United Kingdom, Australia, Spain, Canada, France, Ireland, Mexico, Belgium, and India. A map of the United States (Fig. 2) reveals top tweets by state.
      Figure thumbnail gr1
      Fig. 1Network analysis of #ThisIsBrachytherapy hashtag campaign. This analysis depicts patterns between the most central Twitter users of the #ThisIsBrachytherapy Campaign. The circles represent each twitter user who participated. The larger the circle, the more influential the user in the campaign. The lines connecting these circles represent the communications between the individuals, with the thickness of the line representing the frequency of communication.
      Figure thumbnail gr2
      Fig. 2#ThisIsBrachytherapy user locations from July 17, 2019, in the United States. The states with darker shades of yellow represent a high total number of tweets. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)
      When evaluating the hashtag #ThisIsBrachytherapy beyond the inaugural campaign held on July 17, 2019, and analyzing the expanded dates from April 1, 2019, to December 1, 2019, there were 1990 total tweets with 1,999,248 impressions. Fifty-four percent (1030) of the tweets contained photos and 319 contained links. There were tweets from 462 unique users, with at least 202 identifying as physicians. Word sentiment was overwhelmingly positive; the most frequent positive word identified in tweets containing the hashtag #ThisIsBrachytherapy was “great.” The most common words associated with #ThisIsBrachytherapy were: brachytherapy, cancer, prostate, great, team, HDR, brachy, patients, and treatment. Associated hashtags with #ThisIsBrachytherapy included most commonly #radonc, #brachytherapy, #brachy, #prostatecancer, and #pcsm.

      Discussion

      The growing influence of social media in radiation oncology has provided a platform to reinvigorate interest in brachytherapy with respect to utilization and education (
      • Shah C.
      Brachytherapy and social media: Why the time is now.
      ). The declining use of brachytherapy and limited trainee experience with this technique is concerning as brachytherapy is a key component of curative treatment for several different malignancies (
      • Marcrom S.R.
      • Kahn J.M.
      • Colbert L.E.
      • et al.
      Brachytherapy training survey of radiation oncology residents.
      ). Although brachytherapy was initially developed because of limitations of external-beam treatment delivery, recent studies have demonstrated that even newer technologies, such as stereotactic body radiation therapy, result in decreased cure rates and high rates of toxicity compared with brachytherapy for patients with cervical cancer (
      • Kamrava M.
      • Chino J.P.
      • Beriwal S.
      SAbR as an alternative boost modality for cervical cancer: A cautionary exercise.
      ,
      • Albuquerque K.
      • Tumati V.
      • Lea J.
      • et al.
      A phase II trial of stereotactic ablative radiation therapy as a boost for locally advanced cervical cancer.
      ). Similarly, despite evidence showing efficacy in the treatment of low- and intermediate-risk prostate cancer, there has also been a decreased utilization of prostate brachytherapy, despite long-term clinical outcomes, single-fraction regimens, and data demonstrating the value of such approaches (
      • Glaser S.M.
      • Dohopolski M.J.
      • Balasubramani G.K.
      • et al.
      Brachytherapy boost for prostate cancer: Trends in care and survival outcomes.
      ,
      • Safdieh J.
      • Wong A.
      • Weiner J.P.
      • et al.
      Utilization of prostate brachytherapy for low risk prostate cancer: Is the decline overstated?.
      ). Brachytherapy utilization in high-risk prostate cancer has also been shown to improve biochemical free failure but like low- and intermediate-risk prostate cancer, there has been a decline in brachytherapy boost (
      • Martin J.M.
      • Handorf E.A.
      • Kutikov A.
      • et al.
      The rise and fall of prostate brachytherapy: Use of brachytherapy for the treatment of localized prostate cancer in the National Cancer Data Base.
      ,
      • Mahmood U.
      • Pugh T.
      • Frank S.
      • et al.
      Declining use of brachytherapy for the treatment of prostate cancer.
      ). Unlike cervical cancer, prostate cancer can be adequately treated with other therapeutic interventions; however, brachytherapy remains the most cost-effective approach for treating prostate and many other kinds of cancer (
      • Shah C.
      • Lanni Jr., T.B.
      • Ghilezan M.I.
      • et al.
      Brachytherapy provides comparable outcomes and improved cost-effectiveness in the treatment of low/intermediate prostate cancer.
      ).
      Although the decreased utilization of brachytherapy is likely multifactorial, this shift is not due to a lack of evidence for its effectiveness or value. However, brachytherapy is a time-intensive technical treatment approach with accurate delivery dependent on the procedural expertise of the radiation oncologist. The use of social media, such as Twitter, has been associated with an increased number of citations and dissemination with added “buzz” to a publication tweeted about (
      • Paradis N.
      • Knoll M.A.
      • Shah C.
      • et al.
      Twitter: A platform for dissemination and discussion of scientific papers in radiation oncology.
      ). The use of social media in a smaller subspecialty such as brachytherapy is important to increase visibility, as many patients and providers use this when gathering information for health care decisions and may otherwise be unaware (
      • Merrick G.S.
      The narrow door of success.
      ).
      Social media advocacy efforts for brachytherapy are important to highlight the need for continued training and education with this modality. Such efforts may also foster passion and a sense of community among trainees and radiation oncologists practicing brachytherapy (
      • Shah C.
      Brachytherapy and social media: Why the time is now.
      ). The educational focus of the campaign is valuable as it can be challenging to recruit trainees to subspecialize in brachytherapy and exposure at individual residency programs can be limited. The ABS has implemented a 10-year strategy called 300 in 10 with a goal of training 30 competent radiation oncologists specializing in brachytherapy per year over the next 10 years using an approach including social media presence and advocacy. The fundamental strategy of increasing physician training and awareness over the next 10 years will allow for an adequate workforce to deliver the technically rigorous brachytherapy techniques needed for quality evidence-based cancer care. An increase in the workforce will also allow for continued outreach with new brachytherapists able to leverage social media and reach students and trainees who are often engaged in various social media outlets such as Twitter (
      • Merrick G.S.
      The narrow door of success.
      ).
      Social media advocacy of brachytherapy is not restricted to physicians and health care professionals; it can also be used to promote patient education (
      • Antheunis M.L.
      • Tates K.
      • Nieboer T.E.
      Patients' and health professionals' use of social media in health care: Motives, barriers and expectations.
      ,
      • Klemm P.
      • Bunnell D.
      • Cullen M.
      • et al.
      Online cancer support groups: A review of the research literature.
      ). Radiation therapy, in general, is unfamiliar to the general population, and brachytherapy has been shown to be included in tweets from patients far less frequently (
      • Thomas J.
      • Prabhu A.V.
      • Heron D.E.
      • et al.
      Twitter and brachytherapy: An analysis of "tweets" over six years by patients and health care professionals.
      ). Twitter, especially with the use of patient friendly graphics, photos, and links can increase patient education and familiarity with brachytherapy. The #ThisIsBrachytherapy campaign may serve to not only unify radiation oncologists, but to also improve patient engagement. The positive sentiment seen in the #ThisIsBrachytherapy campaign, can lend itself to more engagement as seen through the megaphone effect in social media and can have a positive impact on education and engagement (
      • Mcquarrie E.
      • Miller J.
      • Phillips B.
      The megaphone effect: Taste and audience in fashion blogging.
      ). To increase this engagement, we suggest a multifaceted approach. We propose an annual #ThisIsBrachytherapy Day every year on July 17th with a social media campaign, emails, and encouragement of pictures and education. Increasing awareness and improving visualization of publications that are in press from the Brachytherapy Journal is an additional measure that can be taken as seen to increase the “buzz” of an article (
      • Paradis N.
      • Knoll M.A.
      • Shah C.
      • et al.
      Twitter: A platform for dissemination and discussion of scientific papers in radiation oncology.
      ). We also suggest that the ABS encourage social media tweetups and use of Twitter during the annual meeting. The use of Twitter during annual medical conferences has been shown to increase the role of social media as well as dissemination of findings (
      • Pemmaraju N.
      • Thompson M.A.
      • Mesa R.A.
      • et al.
      Analysis of the use and impact of twitter during American society of clinical oncology annual meetings from 2011 to 2016: Focus on advanced metrics and user trends.
      ). In addition to the annual meeting and #ThisIsBrachytherapy events, social media can also be used to provide education about the utility of brachytherapy to other physicians and also for educational of trainees who want to learn about brachytherapy techniques not offered at their institutions.
      There are some limitations to this study. The hashtag that was used for #ThisIsBrachytherapy day is long and can be cumbersome to use. The use of a shorter hashtag such as #brachy may be easier to use and could be a consideration in the future. Compared with other campaigns, such as #WomenWhoCurie which delivered 1.135 million impressions and 2774 tweets, our initial campaign was less influential. A limitation to the initial campaign success is that the announcement of #ThisIsBrachytherapy was not sent out via the BrachyBlast newsletter but rather by emails and Twitter. We foresee future social media campaigns to have more advertisement beforehand.
      Twitter provides a unique platform for patients, physicians, and health care professionals to share knowledge and evidence-based information (
      • McGowan B.S.
      • Wasko M.
      • Vartabedian B.S.
      • et al.
      Understanding the factors that influence the adoption and meaningful use of social media by physicians to share medical information.
      ). The use of the social media campaigns such as #ThisIsBrachytherapy can be influential to increase the visibility, education, advocacy for brachytherapy which can play an important role in addressing the underutilization of brachytherapy in radiation oncology.

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