Partnering for Occupational Therapy Telehealth Services: Collaboratively developing telehealth and hybrid occupational therapy student placements

In 2020, in Ireland, challenges associated with the COVID-19 pandemic disrupted occupational therapy student practice education placements availability. New innovative placements were required. A collaboration between University of Limerick (UL), Ireland, and Dyspraxia/DCD Ireland (DDCD Ireland) has to date enabled 30 occupational therapy students to undertake practice education placements via telehealth. Originally, this placement was designed to allow students to meet learning objectives remotely. This case report outlines how an area of innovative practice at an Irish occupational therapy student education programme evolved, during the crisis associated with Covid-19, culminating in the establishment of the Partnering for Occupational Therapy Telehealth Services (POTTS), which is now a hybrid service (telehealth and face-to-face service).

HALT - Targeted Therapy with or without Dose-Intensified Radiotherapy in Oligo-Progressive Disease in Oncogene Addicted Lung Tumours

Introduction: Following initial response to TKI, advanced NSCLC patients with actionable mutations ultimately develop treatment resistance. In a proportion of patients (15-40%), initial, limited progression (≤5 lesions) is observed, termed oligoprogressive disease (OPD). SBRT offers hypofractionated, targeted radiotherapy treatment hypothesised to prolong clinical benefit from TKI prior to widespread disease development. With limited evidence to date, and poor clinical/biological selection criteria, the potential benefit offered by SBRT to ablate OPD sites prior to change in systemic therapy is an important question to address. Methods: HALT is a randomised, multi-centre, phase II/III international trial with seamless transition to phase III incorporated. Eligible patients (stage IV NSCLC, actionable mutation, TKI response prior to OPD) are randomised 2:1 to SBRT/continued TKI or continued TKI alone. Eligibility is confirmed by a virtual MDT (vMDT) comprising trial clinicians and radiologists (confirmation of OPD, SBRT suitability). Follow-up assessments are aligned with routine care at 3-monthly intervals until change in systemic therapy is clinically indicated, with imaging and toxicity assessment at each visit. Results: Recruitment commenced November 2017 with 25 centres (17 UK;8 non-UK) open to date. Following the COVID-19 pandemic, recruitment is recovering with 129 registered and 74 randomised patients. Over the last 4 years, little evidence has emerged to confirm any potential benefit of SBRT in this patient group and the impact on patient toxicity remains unknown. Therefore, with persisting questions around clinical equipoise, HALT remains highly relevant. With an 18-month extension and a recent amendment to the HALT inclusion criteria (≤5 OPD lesions, ≤7cm and OPD assessments by PET-avidity), the target of 110 randomised patients remains achievable. Conclusions: As the first randomised trial assessing SBRT benefit in this mutation-positive NSCLC patient population, HALT will provide valuable treatment efficacy and safety information, informing subsequent trial design and contribute to the development of international guidelines for the identification and clinical management of oligoprogression in mutation positive lung cancer. Keywords: Stereotactic body radiotherapy, NSCLC, Phase II

Concurrent chemoradiotherapy (cCRT) at the Northern Centre for Cancer Care (NCCC): preliminary results from a stage III cCRT database

Introduction: Due to COVID-19, NCCC established a Stage III cCRT review clinic. From April 2020 a prospective audit of patients treated was established. Methods: All lung radiotherapy referrals were scrutinised from January-December 2020. Electronic data was obtained from radiotherapy software. Patients treated with cCRT were analysed for: 1) Toxicity data. 2) Hospital admissions. 3) PDL1 status. 4) Adjuvant durvalumab treatment. Patients who received either unimodality radiotherapy or sequential chemoradiotherapy were reviewed for justification for not treating with cCRT . Results: Of 670 patients treated. 295 received palliative and 375 radical radiotherapy. 141 patients received radical radiotherapy (55Gy in 20#). 55 were Stage III NSCLC, 18 received sequential chemoradiotherapy. 49 patients received cCRT, 41 were stage III NSCLC. 55 stage III patients did not receive cCRT. 8 reason codes were identified: 1) Comorbidity (N=16). 2) Size (N=18). 3) No histopathology (N=3). 4) Consented for cCRT, but disease progression/too big at time of radiotherapy planning (N=6). 5) Relapse (N=3). 6) Reason not annotated (N=5). 7) Patient declined (N=2). 8) Adjuvant RT after surgery (N=2). Of the 41 cCRT NSCLC patients. All patients experienced some toxicity. There were no grade 4 toxicity. 2 patients reported Grade 3 toxicity (nausea and fatigue);dyspnoea, cough, fatigue, oesophagitis and nausea being the most common. 4 out of 41 patients were admitted. Reasons were dehydration, chest infection, oesophagitis, hyponatraemia, neutropenia. 1 patient did not proceed to durvalumab, due to deterioration of performance status. 30 out of 41 patients were PDL1 +, of which 26 were consented for durvalumab. Reasons for no durvalumab were: rheumatoid arthritis, inflammatory bowel disease, interstitial lung disease and deterioration after cCRT. Conclusion: cCRT is an effective delivery as an outpatient. However, ongoing audit is imperative to ensure optimal patient treatment. The data as highlights multidisciplinary input is essential, as most cCRT patients experience toxicity. Disclosure: No significant relationships.

Optimisation of the treatment pathway for stage III non-small cell cancer (NSCLC) patients receiving concurrent chemo-radiation (cCRT)

Introduction: Patients undergoing concurrent chemo-radiation (CCRT) for stage III NSCLC can be clinically and technically challenging to manage due to extensive treatment volumes including lymph nodes, oesophageal and lung radiotherapy tolerances. Patients experience toxicities including: oesophagitis, dehydration, pneumonitis and weight loss. During treatment lung changes can affect tumour position. As a result of Covid-19, our centre optimised the CCRT pathway in April 2020, to formalise a specific cCRT radiographer review clinic, to deliver an outpatient service. Former practice involved delivering inpatient chemoradiotherapy. Aim: To formalise and optimise the cCRT pathway to ensure a resilient streamlined pathway by: 1) Avoid patient admissions by early intervention and management of toxicities. 2) Problem solving of technical imaging challenges while supporting on-treatment radiographers. 3) Supporting clinical consultant oncologists by coordination post cCRT investigations and eligibility for adjuvant immunotherapy. Methods: Treatment consultation included;analysis of daily imaging, dosimetric data, blood results, electronic recording of assessment and management of patients, reviewing medications, arranging fluids, transfusions;timely intervention for chemotherapy. Patient consent for Durvalumab was instigated on the final week of review and any anatomical lung changes from the daily treatment imaging was initiated. Results: Optimisation by combining clinical and technical skills has demonstrated a positive patient and organisational impact. A formalised clinic has ensured the ability to continue to provide a cCRT service, with increasing patient numbers despite Covid-19 . Conclusion: Optimising the pathway has proven cCRT can be delivered as an outpatient service. However, future optimisation is required from the multidisciplinary team to provide prehabilitation and rehabilitation. As the service increases, capacity and resource impact needs consideration. Thus, continual audit of the service is imperative to ensure provision can be maintained. Disclosure: No significant relationships.

A national program for the implementation of lung Stereotactic Ablative Body Radiotherapy (SABR)

Purpose or Objective Following completion of an evaluation program of SABR for primary lung cancer and metachronous extracranial oligometastatic disease, NHS England & NHS Improvement funded a SABR expansion program to increase SABR provision to 50 radiotherapy centres. With reduced access to surgery due to the impact of the COVID-19 pandemic, efforts were focussed on implementing SABR for lung primary and oligometastatic disease in the first instance. Materials and Methods The program consisted of 3 elements, delivered by multi-disciplinary SABR experts from the SABR Consortium and the National Radiotherapy Trials Quality Assurance (RTTQA) Group: Education;Mentorship of RT centres new to SABR by those with extensive experience;QA to ensure the safe and consistent implementation of the technique. A contouring workshop for radiation oncologists was developed by the SABR Consortium Steering Committee. In addition, educational sessions were provided within the SABR Consortium Online Conference, offered free of charge to enable wide access to education and professional development. The Committee produced a Guide for SABR Mentorship, setting out a consistent framework under which mentorship would proceed (Table 1). Mentoring and local protocols followed implementation guidance from the UK SABR Consortium Guidelines. In parallel, RTTQA developed a comprehensive RT QA program (Table 2). Two radiation oncologists and one treatment platform were assessed per hospital. Credentialed clinicians then provided cascade training and education within their departments, formally documenting peer reviews through standard templates provided by RTTQA. (Table Presented) (Table Presented) Results 54 radiation oncologists participated in the contouring workshop. The conference had 1335 registrants, 65% of whom were UK multi-professionals. 15 experienced centres were invited to mentor 24 new SABR sites. Mentors were assigned by equipment for planning and delivery. The mentoring framework was adjusted to accommodate visiting restrictions due to the pandemic and performed remotely through email and video-conferencing instead. The RT QA program commenced in June 2020 with circulation of the facility questionnaire, collecting data on equipment, technique, intention to treat and expected level of mentoring. Responses were used to tailor mentoring and inform what components of the QA program were required for each centre. Contouring submissions were received from 46 radiation oncologists and planning benchmarks were completed by all 24 centres, 22 of which underwent the dosimetry audit. All assessments were reported through standard templates to ensure consistent feedback. Conclusion The implementation of lung SABR was completed in June 2021. Collaboration amongst all stakeholders ensured centres were trained and supported to safely deliver high-quality SABR for lung primary and oligometastatic disease. The education, mentoring and QA program proved effective and has now been rolled out to other oligometastatic sites.

171 HALT: targeted therapy with or without dose-intensified radiotherapy in oligo-progressive disease in oncogene addicted lung tumours

Background: Following initial response to TKI, advanced NSCLC patients with actionable mutations ultimately develop treatment resistance. In a proportion of patients (15-40%), initial, limited progression (<3 lesions) is observed, termed oligoprogressive disease (OPD). SBRT offers hypofractionated, targeted radiotherapy treatment hypothesised to prolong clinical benefit from TKI prior to widespread disease development. The potential benefit offered by SBRT to ablate OPD sites prior to change in systemic therapy is an important question to address, particularly during the current pandemic, where reducing clinic visits is particularly advantageous. Method: HALT is a randomised, multi-centre, phase II/III international trial with seamless transition to phase III incorporated. Eligible patients (stage IV NSCLC, actionable mutation, TKI response prior to OPD) are randomised 2:1 to SBRT/continued TKI or continued TKI alone. Eligibility is confirmed by a virtual MDT comprising trial clinicians and radiologists (OPD, SBRT suitability). Follow-up assessments aligned with routine care at 3-monthly intervals until change in systemic therapy is clinically indicated, imaging and toxicity assessment at each visit. Current status: Recruitment commenced November 2017;27 centres (16 UK;11 non-UK) open to date (09/03/2021), 94 patients registered and 50 randomised. Because of the COVID-19 pandemic, recruitment was temporarily paused on 20/03/2020 and restarted in accordance with national guidelines on 16/06/2020. Of 94 patients registered, vMDT review performed for 74 patients (18 screen fails prior to vMDT);50 randomised, 22 confirmed ineligible via vMDT (inc. >3 lesions, lesion >5cm, intracranial disease identified). Conclusion: The vMDT remains an important, novel aspect of the trial, ensuring robust patient selection ahead of randomisation. As the first randomised trial assessing SBRT benefit in this patient population, HALT will provide valuable treatment efficacy and safety information, informing subsequent trial design and contribute to the development of international guidelines for the identification and clinical management of oligoprogression in mutation positive lung cancer. Disclosure: No significant relationships.

Collaboration in virtual environments: Honouring the métis method of visiting

During COVID-19, many collaborative research teams and community partners pivoted to undertake their work in a virtual way. In this discussion, we capture the mechanics, logic, and situations under which virtual methods became relevant to applied interdisciplinary work. Using a shared voice, we chart the nuances of training and research through the redesign, the reimagining of research protocols, and the nuanced cultural gaps that exist between virtual connection and in-person visiting with community partners, Métis Knowledge Keepers, and experts. Through referencing our reflexive archive of experiences, emails, fieldnotes, and meeting minutes, we address how our attempt to simulate virtual informed consent has consequently provided insights into the value of co-creation and the importance of honouring visiting as a Métis method in virtual environments. © 2021 University of Toronto. All rights reserved.

Real-world outcomes in thoracic cancer patients (pts) with severe acute respiratory syndrome coronavirus 2 (COVID-19): Single UK institution experience

Background: Globally, United Kingdom (UK) has the second highest mortality rate from COVID-19. Risk factors include cancer and lung disease;thus thoracic cancer pts are especially vulnerable. Methods: Thoracic cancer pts diagnosed with COVID-19 (PCR, radiological or clinical) at a UK academic centre between March-May 2020 were included. Data were extracted from pts records. Demographics, treatment and outcomes are described. Results: 27 pts were included, 12 (44%) diagnosed by PCR, 4 (15%) radiologically and 11 (41%) clinically. 89% had advanced thoracic malignancies. Symptoms included dyspnoea (52%), cough (67%), fever (59%), fatigue (37%), confusion (22%), diarrhoea (11%), anosmia (7%). 14 (52%) patients were hospitalised (median 6d);4 (15%) required intensive care (ICU), of which 3 died. 10 (37%) pts required oxygen, 4 (14%) required non invasive ventilation. No pts were intubated. Complications included pneumonia (26%), sepsis (11%) and ARDS (7%). 2 pts required home oxygen at discharge. 5 (19%) pts died;all were smokers. Median time from symptom onset to death was 10d (range 3-13). Cancer therapy was delayed or ceased in 11 (41%) patients. [Formula presented] Conclusions: Despite UK patient shielding and risk-minimizing therapy modifications, the immediate morbidity from COVID-19 remains high in thoracic cancer pts. Rates of hospitalisation and treatment interruption were high. Although numbers were small, no deaths occurred in never smokers or pts on single modality therapy. Continued follow up is needed to better understand the direct and indirect impacts of COVID-19 on morbidity and subsequent mortality. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: A.R. Minchom: Honoraria (self): Loxo Oncology;Honoraria (self): Janssen Pharmaceuticals;Honoraria (self): Faron Pharmaceuticals;Honoraria (self): Bayer Pharmaceuticals;Honoraria (self): Novartis Oncology;Honoraria (self): Merck Pharmaceuticals. M. Ahmed: Advisory/Consultancy, Research grant/Funding (self): BMS;Research grant/Funding (self): MSD;Speaker Bureau/Expert testimony: AstraZeneca. F. McDonald: Speaker Bureau/Expert testimony: Elekta;Advisory/Consultancy, Speaker Bureau/Expert testimony: Astra Zeneca;Advisory/Consultancy: Accuray;Research grant/Funding (institution): MSD. S. Popat: Advisory/Consultancy: BMS;Advisory/Consultancy: Roche;Advisory/Consultancy: Takeda;Advisory/Consultancy: Astra Zeneca;Advisory/Consultancy: Pfizer;Advisory/Consultancy: MSD;Advisory/Consultancy: EMD Serono;Advisory/Consultancy: Guardant Health;Advisory/Consultancy: Abbvie;Advisory/Consultancy: Boehringer Ingelheim;Advisory/Consultancy: OncLive;Advisory/Consultancy: Medscape;Advisory/Consultancy: Incyte;Advisory/Consultancy: Paradox Pharmaceuticals;Advisory/Consultancy: Eli Lilly. All other authors have declared no conflicts of interest.

Reduced Fractionation in Lung Cancer Patients Treated with Curative-intent Radiotherapy during the COVID-19 Pandemic.

Patients treated with curative-intent lung radiotherapy are in the group at highest risk of severe complications and death from COVID-19. There is therefore an urgent need to reduce the risks associated with multiple hospital visits and their anti-cancer treatment. One recommendation is to consider alternative dose-fractionation schedules or radiotherapy techniques. This would also increase radiotherapy service capacity for operable patients with stage I-III lung cancer, who might be unable to have surgery during the pandemic. Here we identify reduced-fractionation for curative-intent radiotherapy regimes in lung cancer, from a literature search carried out between 20/03/2020 and 30/03/2020 as well as published and unpublished audits of hypofractionated regimes from UK centres. Evidence, practical considerations and limitations are discussed for early-stage NSCLC, stage III NSCLC, early-stage and locally advanced SCLC. We recommend discussion of this guidance document with other specialist lung MDT members to disseminate the potential changes to radiotherapy practices that could be made to reduce pressure on other departments such as thoracic surgery. It is also a crucial part of the consent process to ensure that the risks and benefits of undergoing cancer treatment during the COVID-19 pandemic and the uncertainties surrounding toxicity from reduced fractionation have been adequately discussed with patients. Furthermore, centres should document all deviations from standard protocols, and we urge all colleagues, where possible, to join national/international data collection initiatives (such as COVID-RT Lung) aimed at recording the impact of the COVID-19 pandemic on lung cancer treatment and outcomes.