Trends in Radiation Oncology Treatment Fractionation at a Single Academic Center, 2014-2020

Purpose/Objective(s): Recent landmark studies in radiation oncology suggest hypofractionation is appropriate for treatment of many cancers. The COVID-19 pandemic may have increased pressure to adopt hypofractionation because of concerns about disease spread at treatment centers. We know of no recent U.S. study of trends in radiation fractionation that includes comparisons of multiple disease sites and data post-COVID. Therefore, we sought to describe trends in treatment fractionation at a single academic center from 2014-2020. Materials/Methods: From our institutional database, for the years 2014-2020, we extracted the total number of patients treated, total number of fractions delivered, and mean number of fractions per treatment course for all cancers and specifically for treatment of breast cancer, prostate cancer, and bone metastases. For breast and prostate, we included only radiation courses delivered to the primary site. Results: The dataset included 16,224 courses of radiation treatment and 257,352 treatment fractions. The mean number of fractions per treatment course overall declined steadily throughout the study period, from 18.3 in 2014 to 14.9 in 2020. For breast cancer, the mean number of fractions per treatment course was steady from 2014-2016 but began to decline more rapidly from 2017-2020. Fractionation for prostate cancer followed a similar time trend, but there was a more substantial decline from 2014 (mean 36.6 fractions per treatment course) to 2020 (mean 16.7 fractions per treatment course). For bone metastases, fractionation was relatively consistent throughout the study period. For breast patients, during the onset of COVID-19 in 2020, the monthly rate of decrease in number of fractions increased to 0.19 from a historical mean of 0.05, as the mean number of sessions dropped from 22 to 19. For bone metastases, in 2020, the mean number of sessions dropped from 6.3 to 5.3, with a monthly rate of decrease of 0.13 compared to historical mean of 0.03. COVID-19 did not spike the monthly rate of change in number of fractions for prostate which began a steady decline in 2017 with increased use of SBRT. Conclusion: We observed increased adoption of hypofractionation at our institution during the study period for both breast and prostate cancer. For bone metastases, hypofractionation had largely been adopted before the study period. There was evidence of an accelerated trend toward hypofractionation for some cancers during the COVID-19 pandemic.

Patterns in Attending and Resident Remote Work Policies in Academic Radiation Oncology Departments

Purpose/Objective(s): Historically, work from home (WFH) policies were not common in radiation oncology (RO). With the onset of the COVID-19 pandemic and without oversight from professional organizations, many departments individually generated WFH policies. This study reports WFH policies and perceived impact on workflow and work-life balance within United States (US) academic RO departments for both residents and faculty. Materials/Methods: An IRB-approved questionnaire was developed and sent to one resident and one faculty member at each of the 92 US academic RO departments. Purposive sampling for residents and faculty was utilized. For residents, this consisted of the most senior resident and for faculty, a senior faculty member or the program director. If no reply was obtained after 3 weeks, an alternate member was selected. The survey remained open for 75 days. Categorical and continuous variables, along with free-responses were aggregated and reported. Results: 135 responses (residents n = 65, faculty n = 70) were received, representing 70.7% and 77.2% of the 92 programs respectively. A new WFH policy was reported by 83% faculty (58/70) and 92% residents (60/65), predominantly initiated within 2 months of the pandemic (60% faculty and 79% residents respectively). The initial WFH policy allowed moderate WFH for 40% faculty and 46% residents, while minimal WFH was offered for 30% faculty and 32% residents. Full WFH was reported by 14% of respondents in both categories. Policies have since contracted for 39% faculty and 62% of residents, being revoked for 11% of faculty and 22% of residents. 15/70 (21.4%) faculty and 12/65 (18.5%) residents report dissatisfaction with their current WFH policy. 18/70 (25.7%) faculty and 14/65 (21.5%) residents perceived negative sentiments from others regarding utilization of WFH. On a 4-point scale, residents and faculty reported personal/family life, research, and day-to-day productivity were positively impacted by WFH policy, while patient care was perceived as negatively impacted. No difference was reported for leadership or education. Conclusion: A variety of WFH policies have been adopted in RO. Understanding perceptions of the impact of different approaches can help to inform future policy and practice.

'I'm being forced to make decisions I have never had to make before': Oncologists and the conundrums created by COVID-19

Background: The COVID-19 pandemic has created conundrums for physicians. This study examines the experiences of oncologists who engage in complex decision-making regarding the use of chemotherapy in seriously ill persons in the context of the COVID-19 pandemic. Methods: Between January 2020 and August 2020, the authors conducted semistructured, in-depth individual interviews with 22 purposefully sampled oncologists from practices enrolled in the Michigan Oncology Quality Consortium. Transcripts were double-coded and reconciled by consensus using qualitative data analysis software for thematic analysis. Results: Among the thematic clusters we identified, one was related to conundrums created by the COVID-19 pandemic. In this presentation, we report the results pertaining to three themes within this cluster: (1) the ethical dilemmas faced by oncologists due to the COVID-19 pandemic, (2) the need for both patients and oncologists to manage uncertainty and emotions, and (3) the importance and complexity of integrating technology and communication for seriously ill persons. Oncologists grappled with several conundrums including resource scarcity, resource allocation, delays in care, a duty to promote equity and non-abandonment, high levels of uncertainty and fear, and the importance of advanced care directives and end-of-life care planning. Nonabandonment featured as a coping mechanism for increased stress, and integration of communication with telemedicine was frequent and necessary. Conclusions: This study offers an indepth exploration of the conundrums faced by oncologists due to the COVID-19 pandemic and how they navigated them. Optimal decision-making for seriously ill persons with cancer during the COVID-19 pandemic must include open acknowledgement of the ethical dilemmas faced, the heightened emotions experienced by both patients and their oncologists, and the urgent need for integrating technology with compassionate communication in determining patient preferences.