Postgraduate oncology educational shifts during the COVID-19 pandemic: results of faculty and medical student surveys.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has disrupted clinical practice, research and teaching. During peaks, virtual courses were implemented but these changes are poorly described, especially for oncology postgraduate students and faculty teachers. PATIENTS AND METHODS: We administered two surveys from June 2021 to October 2021 to students and faculty teachers (250 and 80 responses, respectively) who registered at Gustave Roussy School of Cancer Sciences (Université Paris-Saclay) during 3 consecutive university years (October 2018 to October 2021), where a major shift to e-learning was associated with COVID-19 pandemic. RESULTS: Most students were female (53%), attending physicians (50%), aged 30-39 years (54%) and 2020-2021 (66.4%) was the main year of training. Most faculty teachers were male (58%), aged 40-50 years (44%) and had participated in training for at least 3 years (83%). More than half of the students received 100% virtual training [55% versus 45% face-to-face/mixed teaching modalities; online (84%) versus remote teaching (16%)]. Only 34% of students declared >80% 'active listening' and only 16% of teachers considered e-learning to be more suitable (compared with face-to-face) for postgraduate education. Virtual teaching decreased student-teacher interactions as compared with mixed/face-to-face (lessons were sufficiently interactive for 54% students if virtual only teaching versus for 71% if other teaching modalities; P = 0.009). Teachers stated that virtual learning did not lead to any improvements in terms of attendance (68%), interaction (74%) and quality of teaching (68%). However, most faculty (76%) acknowledged that partial e-learning training should be maintained outside the pandemic, if it represents ≤50% of the whole teaching (teachers: 79% versus student: 66%; P = 0.04). CONCLUSIONS: COVID-19 accelerated the transition toward novel practices. Students and faculty teachers agreed on the need for future mixed (≤50% e-learning) teaching modalities. Adequate formation and the use of codified best newer virtual practices are required.

To plan and deliver adjuvant breast radiotherapy over 1 week: 1-week breast workflow implementation

Purpose or Objective To limit hospital visits and transportation of the patients with early breast cancer (BC) especially during the covid-19 pandemic, we aimed to implement a workflow of treatment to prepare and deliver adjuvant breast radiotherapy (RT) within 1 week. Materials and Methods Based on the Fast Forward RT schedule of 5 fractions of 5.2 Gy over 5 days for adjuvant BC, we designed a workflow to perform BC RT over 1 week from the first RT consultation to the end of treatment (figure 1). Patients were seen in consultation on Monday morning. The planning CT was carried out immediately after the consultation. A deep inspiration breath-hold technique was systematically offered to all patients. Automatic delineation using an artificial Intelligence (AI) based model with ART-PlanTM software was first corrected by a junior radiation oncologist (RO) then, independently by a senior RO. As 3D conformal RT failed to achieve dose constraints of the fast forward trial in many cases (due to breast hotspots), we developed a restricted IMRT (rIMRT) technique based on 2 tangential beams (internal and external) using inverse planning restricted optimization parameters to improve the dose homogeneity. Treatment planning was semi-automated by scripting the creation and optimization steps of rIMRT plans. After validation of the reliability of rIMRT treatment delivery by patient-specific quality assurance (PSQA) with gamma index evaluation on 20 patients, we decided to abandon systematic PSQAs. In-vivo dosimetry was validated by end-to-end controls and performed for each patient during the first fraction on Monday afternoon. Daily repositioning was controlled by portal images of the largest segment of each beam. Structured baseline, end of treatment and follow up evaluation forms were used to prospectively collect toxicities and oncological outcomes at each consultation. Patient agreement for data collection and analysis was prospectively obtained. $Φg Results From February 2021 to March 2021, the 1-week breast procedure was proposed to up to 3 patients/week, >65 years, in complete resection after conservative surgery, with pT1-T3 N0 BC, without tumor bed boost or regional lymph nodes irradiation. Six out of seven patients (85.7%) accepted the 1-week breast procedure. All procedures were successfully conducted over 5 days with complete patient and RT team satisfaction. A followup of acute toxicities by online consultation on day 10, structured evaluation forms and management decision trees has been implemented for these patients. No grade >2 acute toxicities (CTACE V4.0) have been reported so far. Conclusion The successful implementation of this comprehensive 1-week breast workflow with AI based delineation and semi-automated rIMRT without PSQA demonstrates the practical feasibility of the whole procedure over 5 days reducing drastically the coming-and-going to the hospital and the overall RT management time per patient. Our work opens the way for further development of comprehensive compact workflows in various settings.

Ventilatory ratio with proning in COVID-19 ards patients: A new tool for an old strategy

INTRODUCTION: Prone positioning is a cornerstone therapy in COVID-19 associated severe Acute Respiratory Distress Syndrome (ARDS). Ventilatory ratio (VR) calculates dead space ventilation, which is independently associated with an increased risk of mortality in ARDS patients. However, no studies so far have demonstrated the changes in VR with proning in such patients. We evaluated VR as a new tool to predict survival in prone positioned COVID -19 ARDS patients. METHODS: This retrospective study included 24 COVID-19 positive ARDS patients admitted to SUNY Downstate Medical Center ICU between April 4, 2020 to May 15, 2020, who had PaO2/FiO2 (PF) ratio < 150, and were proned. Data points of total number of proning days, PaCO2, PF ratio, and VR, were collected before proning, on day 1, and on the last day of proning, along with the mortality data. Statistical analysis was performed in R using student t-test and linear regression. RESULTS: Of the 24 patients included, 80% were male. The median age of the patients was 68 years. With proning, the PF ratio increased by a mean of 0.32 (IQR 0.04,0.54 p<0.01) on day 1 and 0.592 (IQR 0.17,0.91 p<0.001) on last day of proning. VR decreased by a mean of -0.156 (IQR -0.837,+0.09 p=0.15) on day 1 and -0.388 (IQR -0.725,- 0.056 p= 0.15) on last day of proning. PaCO2 is predictive of VR before proning (adjusted R2 =0.69, p<0.001), and on last day of proning (adjusted R2 =0.5, p<0.001). The length of proning had no relationship with change in VR or PF ratio at any time point. VR of < 2 before proning was predictive of overall survival (p < 0.05) with an average survival of 25 days vs 9.8 days for VR > 2. The mortality rate for all patients included was 80% (20/24). CONCLUSIONS: COVID -19 ARDS patients demonstrate impaired ventilation and hypoxemia. Commonly used PF ratio, in proning protocols, has limited prognostic value but deadspace fraction is a powerful predictor of mortality in ARDS. Proning improved PF ratio and VR, however, the latter did not reach statistical significance. PF ratio was not predictive of length of survival, however, VR > 2 before proning is a significant predictor for overall mortality. Hence, VR can function as a new bedside predictive tool with proning in COVID-19 ARDS patients.

[Low-dose irradiation of non-malignant diseases: Did we throw the baby out with the bathwater?] / Irradiation à faible dose des affections non cancéreuses : avons-nous jeté le bébé avec l'eau du bain ?

The irradiation of non-malignant diseases, essentially for anti-inflammatory purpose, have been largely proposed and performed worldwide until the 1970-80s. At that time, the better assessment of the radio-induced malignancies, essentially in children and young patients, as well as the efficacy of the new anti-inflammatory drugs (steroids and non-steroids), led to the almost disappearance of those techniques, at least in France. In contrast, our German colleagues are still going on treating about 50,000 patients per year for non-malignant (more or less severe) diseases. After a short historical overview, the present article suggests that we were possibly going too far in the rejection of those low-dose irradiations for benign lesions. The recent emergence of new preclinical data, the better understanding of the risk of radio-induced secondary tumours (almost nil in the elderly), and the severity of some situations, such as the cytokine storm of the COVID-19, should probably lead us to reconsider those low - and sometimes very low (less than 1Gy) - irradiations for well-selected indications in the elderly.

Screening of COVID-19 disease based on chest CT and PCR for cancer patients undergoing radiotherapy in a French coronavirus hotspot

Background: The coronavirus disease (COVID-19) pandemic has caused 180,000 confirmed cases in France with more than 28, 000 deaths as of May 19. A large part of COVID-19 patients seem asymptomatic and cancer patients may be more vulnerable. We evaluated a screening strategy combining chest computed tomography (CT) and PCR for patients treated with radiotherapy (RT). Methods: A screening strategy was organized from March 18, in our RT department. An inspiratory breath hold chest acquisition was proposed during the CT simulation for RT. Images was reviewed by a radiologist according to the CO-RADS classification. A nasal swab with a polymerase chain reaction (PCR) assay was proposed by the radiation oncologist in case of evocative imaging or clinical context. For patients who were already undergoing RT at this time, a PCR was proposed in case of evocative symptoms and before concomitant chemotherapy. Results: From March 18 to May 1, 2020, 507 CT simulation were performed for 449 patients, including 445 chest acquisition. 237 of the chest CT (53%) showed lung abnormalities, of which 34 (8%) were COVID-19 compatible (CO-RADS ≥ 3). 102 patients were tested by PCR after the chest CT. 24 of the 449 (5.3%) patients were considered as COVID-19 patients: 19 had positive PCR, and five were considered positive on the basis of imaging despite PCR-negative PCR. Four of the patients (17%) were diagnosed during RT: 3 on routine screening before chemoradiotherapy, and one on symptoms. Four patients needed several PCR for the diagnosis of COVID-19 with six confirmed false negative PCR (Sensitivity (Se)= 76 % (19/25)). Three PCR positive patients had no evocative lung images (Se = 84%). During this period, an additional 169 patients whose CT simulation was prior to March 18, were also undergoing RT. Among them, six patients (3.6%) were diagnosed with COVID-19 by PCR during RT, performed for symptoms in 4 cases and on screening for the other 2. Of the 30 COVID-19 patients, only 8 (27%) had symptoms at the time of diagnosis. Twelve patients (40%) reported no symptoms and benefited from screening. Conclusions: This study confirms the high proportion of asymptomatic patients with COVID-19 and suggests the value of screening by CT and PCR during COVID-19 pandemics. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: R. Sun: Travel/Accommodation/Expenses: AstraZeneca. E. Deutsch: Advisory/Consultancy: Roche, BMS, Boehringer, Astrazeneca, Lilly Amgen and Merck-Serono. All other authors have declared no conflicts of interest.