Treatment Recommendations among Radiation Oncologists in the Treatment of Cutaneous Squamous Cell Carcinoma with Perineural Invasion

Purpose: Post-operative radiotherapy (PORT) for resected cutaneous squamous cell carcinoma (CSCC) with perineural invasion (PNI) is controversial. Therefore, we conducted a survey to review treatment recommendations among Radiation Oncologists (ROs) in the management of CSCC with PNI. Materials & Methods: In March 2011, we contacted all ROs and trainees in the US through email addresses listed in the 2009 ASTRO directory. Our web-based survey presented clinical vignettes involving Mohs micrographically resected CSCC with microscopic PNI (mPNI) or clinical PNI (cPNI). For each vignette, ROs were asked to indicate if PORT was appropriate and to further specify the dose and volume to treat. Results: Three hundred fifty two responses were completed and analyzed. The majority of ROs (72%) had over 10 years of post residency experience. 64% of the sampled ROs had a special interest in treating head and neck cancers, and 64% treated 4 or more cases per year. Approximately 95% recommended PORT for cPNI whereas 59% recommended PORT for mPNI. Post residency experience (10+ yrs vs. <10 yrs) was associated with a greater propensity to recommend PORT for mPNI (48% vs. 30%, p = 0.005) and for mPNI of deep subcutaneous non-named nerve involvement (80% vs. 60%, p = 0.001). ROs treating 8 or more cases per year (vs. <7) were more likely to recommend PORT for mPNI in immunocompromised patients (74% vs. 57%, p = 0.01). Conclusions: Our study demonstrates significant variability among ROs in the management of CSCC with mPNI. For cases of cPNI, an overwhelming majority recommended PORT. In cases of mPNI, there was no consensus for recommending PORT, although experienced practitioners had a lower threshold for offering treatment. These results indicate the need for prospective clinical studies to clarify the role of PORT in CSCC patients with mPNI.

A CASE FOR SERVICE SYSTEMS ENGINEERING

A case is made for further developing a branch of systems engineering that focuses on problems and issues which arise in the service sector. We promulgate this special focus not only because of the size and importance of the service sector but also because of the unique opportunities that systems engineering can exploit in the design and joint production and delivery of services. We begin by considering the economic, technological and demographic contexts within which the service sector has flourished; we then address both services, especially emerging services, and systems engineering, followed by a discussion of how to advance the field of service systems engineering, and concluding with several remarks. In particular, a number of service systems engineering methods are identified to enhance the design and production/delivery of services, especially taking advantage of the unique features that characterize services - namely, services, especially emerging services, are information-driven, customer-centric, e-oriented, and productivity-focused.

ON SERVICES RESEARCH AND EDUCATION

The importance of the services sector can not be overstated; it employs 82.1 percent of the U. S. workforce and 69 percent of graduates from an example technological university. Yet, university research and education have not followed suit. Clearly, services research and education deserve our critical attention and support since services - and services innovation - serve as an indispensable engine for global economic growth. The theme of this paper is that we can and should build services research and education on what has occurred in manufacturing research （especially in regard to customization and intellectual property） and education; indeed, services and manufactured goods become indistinguishable as they are jointly co-produced in real-time. Fortunately, inasmuch as manufacturing concepts, methodologies and technologies have been developed and refined over a long period of time （i.e., since the 1800s）, the complementary set of concepts, methodologies and technologies for services are more obvious. However, while new technologies （e.g., the Internet） and globalization trends have served to enable, if not facilitate, services innovation, the same technologies （e.g., the Internet） and 21st Century realities （e.g., terrorism） are making services innovation a far more complex problem and, in fact, may be undermining previous innovations in both services and manufacturing. Finally, there is a need to define a ＂knowledge-adjusted＂ GDP metric that can more adequately measure the growing knowledge economy, one driven by intangible ideas and services innovation.