Radiate equity: the inclusion of radiation oncology and other specialties in lymphoma collaborative groups

Abstract

There has been a notable decrease in the use of radiation in lymphoma clinical practice and research in recent years. The NRG Hematologic Malignancies Working Group aimed to assess the inclusion of radiation oncology alongside haematology and oncology, pathology and molecular biology, and diagnostic radiology and nuclear medicine in lymphoma academic leadership positions. The haematology and oncology specialty had the highest representation among National Comprehensive Cancer Network lymphoma guideline committees, lymphoma research cooperative groups, lymphoma research foundations, and the editorial boards of seven high-impact haematology journals, with under-representation of radiation oncology and other specialties, such as diagnostic radiology and nuclear medicine. The NRG Hematologic Malignancies Working Group advocates for increased multidisciplinary representation and collaboration to enhance the quality of care and improve outcomes for patients with lymphoma.

Introduction

Although systemic therapy is the main treatment modality for many patients with lymphoma, radiotherapy is also a fundamental modality that improves outcomes in this patient population.¹ Historical radiotherapy approaches that included the use of large radiotherapy fields, high radiotherapy doses, and outdated treatment delivery approaches have contributed to radiotherapy-related toxicities that have dampened enthusiasm for the inte gration of radiotherapy in treatment programmes.^2,3 How ever, the use of contemporary radiotherapy techniques can confer benefit in disease control in the absence of excessive long-term morbidity.^1,4–7 Key questions remain regarding radiotherapy, such as selecting the patients who will benefit most from radiotherapy, identifying the optimal dose in various clinical circumstances,⁸ deter mining the most effective fields, and the integration of new technologies,⁹ such as proton therapy. Addressing these questions underscores the need for continued exploration of radiotherapy in both clinical practice and research, to ensure that its role in lymphoma treatment is optimised and its potential fully realised. However, despite its crucial role in patient management, the use of radiotherapy has seen a marked decline in both clinical settings and research contexts over recent years.^2,3 This decline could be attributed to a range of factors, including advancements in alternative treatment modalities^10–13 and shifts in clinical practice guidelines. However, another contributing factor could be the under-representation of radiation oncology in leadership positions and within lymphoma research and clinical guidelines. The scarcity of representation from radiation oncology professionals in these roles might be contributing to a reduced emphasis on the role of radiotherapy in lymphoma management.

To address this issue, the NRG Hematologic Malignancies Working Group undertook a comprehensive review to assess the extent of radiation oncology representation compared with other specialties in various lymphoma-related academic and research settings. NRG is a clinical research organisation focused on cancer treatment and prevention in the USA that is formed through the merger of three prominent clinical research groups: the National Surgical Adjuvant Breast and Bowel Project, the Radiation Therapy Oncology Group, and the Gynecologic Oncology Group.

Methods

For this assessment, we reviewed the composition of the National Comprehensive Cancer Network (NCCN) lymphoma guideline committees to determine the representation of different specialties (appendix). Data were gathered for various lymphoma categories, including adult B-cell lymphoma (version 3.2024), adult Hodgkin lymphoma (version 4.2024), paediatric aggressive B-cell lymphoma (version 2.2024), paediatric Hodgkin lymphoma (version 1.2024), primary cutaneous lymphoma (version 1.2025), T-cell lymphoma (version 1.2025), lymphoplasmacytic lymphoma (version 2.2025), and small lymphocytic lymphoma (version 1.2025).

To assess the representation of various specialties within lymphoma research, we selected major lymphoma cooperative research groups based on their prominence and influence in the field; namely, the Southwest Oncology Group Cancer Research Network, the National Cancer Institute Lymphoma Steering Committee, the NRG Hematologic Malignancies Working Group, the European Organization for Research and Treatment of Cancer, the German Hodgkin Study Group, and the Lymphoma Study Association (appendix). Accurate and up-to-date information on lymphoma steering committees or members of the ECOG–American College of Radiology Imaging Network Cancer Research Group, Children’s Oncology Group, Alliance for Clinical Trials in Oncology, and Center for International Blood and Marrow Transplant Research could not be obtained and, therefore, these groups were excluded.

We reviewed the representation within major three lymphoma research foundations: Lymphoma Research Foundation, Leukemia and Lymphoma Society, and the American Association for Cancer Research Lymphoma Scientific Committee (appendix).

We also assessed the editorial boards of high impact factor (>7) haematology journals for their composition by specialty. This assessment included seven journals; namely, Blood, The Lancet Haematology, American Journal of Hematology, Blood Cancer Journal, Haematologica, HemaSphere, and Blood Advances (appendix).

Findings

The comprehensive review revealed several key findings regarding the representation of various specialties in lymphoma-related roles.

NCCN lymphoma guideline committees

In the NCCN lymphoma guidelines committees, haematology and oncology professionals had a median rep resent ation of 77% (IQR 62–88). Radiation oncologists had a median involvement of 5% (2–12) and pathologists and molecular biologists had a median involvement of 7% (4–10), while diagnostic radiologists and nuclear medicine physicians (0% [0–7]) and dermatology and plastic surgery professionals (0% [0–11]) had minimal involvement. Patient advocates had a median representation of 3% (0–3). Certain categories exhibit higher radiation oncology involvement, such as adult Hodgkin lymphoma, which has a higher represent ation of 27%, including the committee chair position (table 1).

Table 1:

Distribution of National Comprehensive Cancer Network guidelines committee involvement by specialty and lymphoma category

	Haematology and oncology	Radiation oncology	Pathology	Diagnostic radiology and nuclear medicine	Dermatology and plastic surgery	Patient advocacy
Adult B-cell (N=37)	30 (81%)	4 (11%)	2 (5%)	0 (0%)	0 (0%)	1 (3%)
Adult Hodgkin (N=37)	24 (65%)	10 (27%)	1 (3%)	2 (5%)	0 (0%)	0 (0%)
Pediatrics aggressive B-cell (N=25)	21 (84%)	0 (0%)	2 (8%)	2 (8%)	0 (0%)	0 (0%)
Pediatrics Hodgkin (N=30)	22 (73%)	4 (13%)	2 (7%)	2 (7%)	0 (0%)	0 (0%)
Primary cutaneous (N=37)	22 (60%)	2 (5%)	4 (11%)	0 (0%)	8 (22%)	1 (3%)
T-cell (N=37)	22 (60%)	2 (5%)	4 (11%)	0 (0%)	8 (22%)	1 (3%)
Lymphoplasmacytic (N=34)	32 (94%)	1 (3%)	0 (0%)	0 (0%)	0 (0%)	1 (3%)
Small lymphocytic (N=35)	32 (91%)	0 (0%)	2 (6%)	0 (0%)	0 (0%)	1 (3%)
Median (IQR)	77% (62–88)	5% (2–12)	7% (4–10)	0% (0–7)	0% (0–11)	3% (0–3)

The denominators used to calculate the percentages are stated in the row headings.

Lymphoma cooperative research groups

Among the lymphoma cooperative research groups, haematology and oncology professionals had a median representation of 48% (IQR 33–74), whereas radiation oncology professionals’ involvement was 12% (4–20). Pathology and molecular biology professionals had a median representation of 5% (0–16) and diagnostic radiology and nuclear medicine professionals had a median representation of 2% (0–4). Data for the bio statistics, coordinators, managers, and associates, pharmacy, and patient advocacy specialties are listed in table 2. The NRG Hematologic Malignancies Working Group had the highest radiation oncology representation of 78%. The groups with the next highest representation of radiation oncologists were the German Hodgkin Study Group was 17% and the European Organization for Research and Treatment of Cancer was 20% (table 2).

Table 2:

Representation of specialties across the steering committees of lymphoma cooperative research groups

	Haematology and oncology	Radiation oncology	Diagnostic radiology and nuclear medicine	Pathology and molecular biology	Biostatistics, coordinators, managers, and associates	Pharmacy	Patient advocacy
SWOG (N=26)	9 (35%)	1 (4%)	1 (4%)	1 (4%)	10 (38%)	2 (8%)	2 (8%)
NCI Lyse (N=31)	23 (74%)	2 (7%)	1 (3%)	0 (0%)	3 (10%)	0 (0%)	2 (7%)
NRG (N=9)	2 (22%)	7 (78%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)
EORTC (N=15)	9 (60%)	3 (20%)	1 (7%)	1 (7%)	1 (7%)	0 (0%)	0 (0%)
GHSG (N=52)	17 (33%)	9 (17%)	0 (0%)	8 (16%)	18 (35%)	0 (0%)	0 (0%)
LYSA (N=18)	15 (83%)	0 (0%)	0 (0%)	3 (17%)	0 (0%)	0 (0%)	0 (0%)
Median (IQR)	48% (33–74)	12% (4–20)	2% (0–4)	5% (0–16)	8% (0–35)	0% (0–0)	0% (0–7)

The denominators used to calculate the percentages are stated in the row headings. EORTC=European Organization for Research and Treatment of Cancer. GHSG=German Hodgkin Study Group. LYSA=Lymphoma Study Association. NCI Lyse=Cancer Research Network, National Cancer Institute Lymphoma Steering Committee. NRG=NRG Hematologic Malignancies Working Group. SWOG=Southwest Oncology Group.

Lymphoma research foundations

Haematology and oncology specialists had high representation in lymphoma research foundations, with a median involvement of 75% (IQR 73–80). Radiation oncology had no representation in these foundations, whereas pathology and molecular biology had a median representation of 16% (7–17; table 3).

Table 3:

Representation of specialties across lymphoma research foundations

	Haematology and oncology	Radiation oncology	Pathology and molecular biology	Diagnostic radiology and nuclear medicine	Epidemiology and public health	Biostatistics, coordinators, managers, and associates	Pharmacy
Lymphoma Research Foundation (N=45)	36 (80%)	0 (0%)	7 (16%)	0 (0%)	2 (5%)	0 (0%)	0 (0%)
Leukemia and Lymphoma Society (N=44)	33 (75%)	0 (0%)	3 (7%)	0 (0%)	1 (2%)	3 (7%)	4 (9%)
AACR Lymphoma Scientific Committee (N=29)	21 (73%)	0 (0%)	5 (17%)	0 (0%)	0 (0%)	2 (7%)	1 (3%)
Median % (IQR)	75% (73–80)	0% (0–0)	16% (7–17)	0% (0–0)	2% (0–5)	7% (0–7)	3% (0–9)

Haematology journals

The editorial boards of high impact factor haematology journals had a median representation of 83% (IQR 75–86) for haematology and oncology professionals. Radiation oncology had a median involvement of 0% (0–0), with only one board member with radiation oncology expertise. Pathology and molecular biology professionals were represented with a median of 16% (12–19). Epidemiology and biostatistics had a median representation of 2% (0–5), patient advocacy had a median representation of 0% (0–0), again with only one board member with a background in patient advocacy, and no editorial board members had expertise in diagnostic radiology and nuclear medicine (table 4).

Table 4:

Editorial board specialties across haematology journals

	Haematology and oncology	Radiation oncology	Pathology and molecular biology, biomedicine and genetics, immunology and pharmacology	Diagnostic radiology and nuclear medicine	Epidemiology, and biostatistics and biotechnology	Patient advocacy
Blood (N=118)	89 (75%)	0 (0%)	29 (25%)	0 (0%)	0 (0%)	0 (0%)
The Lancet Haematology (N=25)	18 (72%)	1 (4%)	4 (16%)	0 (0%)	1 (4%)	1 (4%)
American Journal of Hematology (N=49)	42 (86%)	0 (0%)	6 (12%)	0 (0%)	1 (2%)	0 (0%)
Blood Cancer Journal (N=45)	39 (87%)	0 (0%)	6 (13%)	0 (0%)	0 (0%)	0 (0%)
Haematologica (N=51)	44 (86%)	0 (0%)	4 (8%)	0 (0%)	3 (6%)	0 (0%)
HemaSphere (N=75)	59 (79%)	0 (0%)	12 (16%)	0 (0%)	4 (5%)	0 (0%)
Blood Advances (N=84)	67 (80%)	0 (0%)	16 (19%)	0 (0%)	1 (1%)	0 (0%)
Median (IQR)	83% (75–86)	0% (0–0)	16% (12–19)	0% (0–0)	2% (0–5)	0% (0–0)

The denominators used to calculate the percentages are stated in the row headings.

Discussion

The findings from this Viewpoint provide a comprehensive picture of the current state of representation across various specialties in lymphoma research and leadership roles. The dominance of haematology and oncology professionals is evident across all assessed categories, including clinical guidelines, research groups, research foundations, and academic journals. This dominance reflects the central role that haematology and oncology plays in the management and study of lymphoma, but it also highlights the substantial gaps in the inclusion of other specialties, which also play important roles in the multidisciplinary management of lymphomas, particularly radiation oncology and radiology and nuclear medicine.

The minimal representation of radiation oncology professionals is particularly noteworthy, given the pivotal role that radiotherapy can play in the treatment of lymphoma.¹ Radiotherapy is an essential component of comprehensive lymphoma care, offering therapeutic benefits that are not fully addressed by other modalities.¹ Despite its long-established efficacy in providing improve ment in progression-free survival^14–21 and its notable cost-effectiveness,^22,23 radiotherapy often does not receive the same level of attention or advocacy as systemic therapies.¹² However, radiotherapy’s benefits are not consistently recognised or promoted in the same manner. This disparity is problematic, particularly when considering the clinical and financial implications of not integrating radiotherapy more thoroughly into treatment protocols. Adding radiotherapy to systemic therapy could potentially increase cure rates in the frontline setting,^{14–16,18,20} leading to a considerable reduction in the need for costly and clinically intensive interventions, such as stem-cell transplants and CAR T-cell therapy. These advanced therapies, although beneficial, can cause substantial clinical and financial toxicity.^24–26

It is also crucial to acknowledge the long-term toxicity associated with historic radiotherapy approaches, which has substantially affected patient outcomes and contributed to the scepticism surrounding radiotherapy. In an era where radiation was used alone to cure lymphoma, the adverse effects from these older methods have had lasting consequences in the absence of chemotherapy. However, advancements in radiotherapy technology and techniques have substantially reduced these long-term risks, making modern radiotherapy a safer and more effective component of lymphoma treatment.^1,5,6 Despite these improvements, the scarcity of representation of radiation oncology professionals in key decision making and research forums might hinder the integration of these advancements into clinical practice. If radiation oncologists are not included in the discussions and decision-making processes, there is a risk of missing the opportunity to leverage these safer, more effective treat ment options to enhance patient outcomes. Advocating for the updated capabilities of contemporary radiotherapy is essential for ensuring that this valuable treatment tool is used to its full potential.

The scarcity of adequate representation of radiation oncology professionals on the NCCN lymphoma guideline committee could contribute to the observed underuse of radiotherapy in clinical practice. This issue could be exacerbated in the future if radiation recommendations are not properly represented in the guidelines. The same concerns apply to diagnostic radiology and nuclear medicine, which is crucial for assessing disease progression and response to therapy through advanced imaging techniques. As academic radiology and nuclear medicine clinical practices become more specialised, it is possible for imaging physicians to become domain experts, with deeper insights into specific disease progression and understanding of treatment paradigms related to imaging. For example, adaptive treatment, which involves adjusting therapeutic strategies based on radiological findings, is vital for tailoring interventions to individual patient needs. This approach can substantially enhance treatment efficacy and improve patient outcomes by providing real-time insights into how well a patient is responding to therapy.

Prospective research efforts into radiotherapy for lymphoma are scarce at the cooperative group level. Such under-representation of radiation oncologists in research cooperative groups can result in diminished use of radiotherapy in clinical trials, leading to a reduced incorporation of radiotherapy into new standards of care and advancements in lymphoma treatment.

The absence of radiation oncology professionals in key research foundations and high-impact journal editorial boards further exacerbates the issue. Research foundations play a crucial role in funding and guiding research priorities, while academic journals are pivotal in disseminating new knowledge and shaping clinical practices. Low radiation oncology representation in these areas could result in fewer high-quality studies on radiotherapy for lymphoma, hindering its integration into standard treatment protocols. Additionally, it impedes the effective dissemination of radiation’s role in lymphoma treatment and diminishes advocacy for its importance and adoption.

Other factors not accounted for in this study might also play a role; for example, geographical variability in radiotherapy use for lymphoma could introduce a potential bias in treatment patterns. Access to radiation technology and regional health-care infrastructure can influence the frequency and manner in which radiotherapy is used, with disparities observed between high-income countries and low-income or middle-income countries.^27,28 In addition, other factors, such as trends in medical training, advancements in systemic therapies, and technological barriers, can also contribute to the reduced focus on radiotherapy in both clinical practice and research.^29–32

Conclusion

Although haematology and oncology professionals continue to play a predominant role in lymphoma research and management, there is a pressing need to address the under-representation of radiation oncology and other specialties that are crucial for comprehensive, multidisciplinary treatment. The NRG Hematologic Malignancies Working Group is committed to advocating for greater inclusion of radiation oncology and other under-represented fields to foster a more balanced and effective approach to lymphoma care. Through increased representation and collaboration, the clinical and research community can enhance the quality of care and improve outcomes for patients with lymphoma.

Search strategy and selection criteria.

Relevant information was systematically gathered from the official websites of prominent committees, organisations, journals, and research cooperative groups involved in lymphoma research and treatment. All searches were conducted in English on Jan 16, 2025. Relevant and up to date information from official websites was included. In cases where no relevant information was available, representatives from the committees were contacted, and any up-to-date and pertinent information provided was incorporated. Any outdated, irrelevant, or unavailable information was excluded from our analysis.