Systematic Evaluation of Studies in the Fields of Diagnosis and Management of Prostate Cancer in Coronavirus Disease 2019 Era

Background: Prostate cancer is one of the most common cancers worldwide. The proper management of this cancer during the coronavirus disease 2019 (COVID-19) or similar outbreaks could be a serious challenge. Proper timing of surgery, radiotherapy, and other medical modalities are essential in providing the most effective treatment. Objective(s): This systematic review aimed at evaluating the proper management of prostate cancer during the COVID-19 outbreak. Method(s): This study was conducted from 2019 to 2022. An internet search was conducted using the keywords: Diagnosis, man-agement, radical prostatectomy, radiotherapy, hormone ablation therapy, chemotherapy and prostate cancer, and COVID-19. The visited databases included PubMed, Scopus, Web of Sciences, Google Scholar, and Scientific Information Database. The review was performed based on the preferred reporting items for a systematic review and meta-analyses (PRISMA) guidelines. Result(s): Postponing the biopsy for up to three months and adopting of non-invasive diagnostic methods were likely reasonable during the COVID-19 pandemic. Patients with cancer were more prone to severe injuries and were more likely to have serious compli-cations. Surgery, radiation therapy, brachytherapy, palliative radiation, hormone ablation therapy, and chemotherapy were among the pre-institutional treatments that had to be performed according to medical protocols as well as health and professional guide-lines. Conclusion(s): It was recommended that the prostate cancer screening should not be performed for asymptomatic men during the COVID-19 outbreak. It was also suggested that the treatment should be performed in the shortest possible time and in the safest way.Copyright © 2023, Author(s).

Implementation of online workshops on image-guided adaptive brachytherapy (interventional radiotherapy) in locally advanced cervical cancer: Experience of BrachyAcademy.

PURPOSE: To provide educational support to brachytherapy users during the COVID-19 pandemic, online workshops were developed and implemented by BrachyAcademy, non-profit peer-to-peer educational initiative in Elekta. METHODS AND MATERIALS: In 2021-2022 two online workshops were organized. Participating teams had to send a clinical case of locally advanced cervical cancer (LACC) including brachytherapy Digital Imaging and Communications in Medicine (DICOM) files and questions to the faculty. During the workshop, feedback was given to each clinical case by five faculty members (two Radiation Oncologists, one Radiologist, two Medical Physicists). Participants competed a post-workshop questionnaire which included combination of qualitative and quantitative questions via yes/no responses, Likert scale, and 1 to 10 scale. RESULTS: Twenty-one teams from eight countries (Europe, Asia, Latin America) participated in two online workshops. The total number of participants was 49. The clinical cases represented LACC with The International Federation of Gynecology and Obstetrics (FIGO) stages from IB3 to IVA. During both, Workshop1 (W1) and Workshop 2 (W2) the following areas of improvement were identified: familiarity with the GEC ESTRO and The International Commission on Radiation Units & Measurements, Report 89 (ICRU 89) recommendations for contouring and planning based on clinical drawings and MRI sequencing choice; appropriate applicator selection; experience with interstitial needles; appropriate applicator reconstruction; dose optimization. The participants rated both workshops with overall scores 8,3 for W1, and 8,5 for W2. In 82% participants the training course fully met expectations for W1, and in 76% in W2. CONCLUSIONS: We successfully implemented the online workshops on image-guided adaptive brachytherapy (IGABT) in LACC. Main performance issues and areas for improvement were identified based on multidisciplinary discussion of participant's clinical cases through all steps of the brachytherapy procedure. We encourage teams to consider online workshops in addition to hands-on training.

Early outcomes of abbreviated multi-fractionated brachytherapy schedule for cervix cancer during COVID-19 pandemic.

PURPOSE: Brachytherapy (BT) for cervix cancer was listed as a level I priority and reduced number of implants and multiple fractions were recommended during COVID-19 pandemic. We present early clinical outcome of this approach. METHODS AND MATERIALS: Patients treated with (chemo)radiotherapy and BT with single implant and multiple fractions BT were included. Treatment protocol included 3-5 fractions of 5-8.5 Gy with an aim to achieve point A dose of 70 Gy EQD210Gy (or HRCTV dose of >80 Gy EQD210Gy) in those undergoing intracavitary (IC) and HRCTV dose >85 Gy EQD2 10Gy in patients undergoing Intracavitary-Interstitial (IC/IS) whereas maintaining bladder (B2cc), rectum (R2cc), sigmoid (S 2cc) doses of 90, 75, and 75 Gy EQD23Gy. Time to event analysis was used to report oncological endpoints. Toxicity was reported using crude proportions. RESULTS: From April 2020 to March, 2021, 64 patients with stage IB2-IV received single implant and multi-fraction BT after external radiation of 45 Gy/25 fractions/5 weeks. Only 76.7% (n = 49) received concurrent chemotherapy. Median overall treatment time (OTT) was 56 days (38-131 days). Overall, 62.5% (n = 40) patients received IC and 37.5% (n = 24) received IC+IS. The median HRCTV was 34.7 cc (IQR 25-41). Median (IQR) point A dose, HRCTV D90, B2cc, R2cc, and S2cc for those undergoing IC was 74 Gy (71-78), 80 Gy (73-84), 86 Gy (82-89), 70 Gy (65-74), 65 Gy (59-73) respectively. For the IC+IS cohort, HRCTV D90, B2cc, R2cc, and S2cc was 84 Gy (78-89 Gy), 89 Gy (86-92), 70 Gy (67-74), 68 Gy (59-76). At a median follow-up of 16 months (5-27) the 2-year local control, pelvic control, cause specific and overall survival was 88%, 85.3%, 92.2%, and 81.3% respectively. Late gastrointestinal and genitourinary grade ≥III toxicities were 14% and 1.5% each. CONCLUSIONS: Abbreviated BT outcomes are encouraging for oncological outcomes despite delays in overall treatment time and omission of chemotherapy. Further mature follow up is needed.

Safety and efficacy of single insertion accelerated MR-image guided brachytherapy following chemo-radiation in locally advanced cervix cancer: modifying our EMBRACE during the COVID pandemic.

BACKGROUND: Utero-vaginal brachytherapy (BT) is an irreplaceable care component for the curative treatment of locally advanced cervix cancer (LACC). Magnetic Resonance Imaging (MRI)-image guided adaptive BT (IGABT) using the GYN-GEC-ESTRO EMBRACE guidelines is the international care standard. Usually following chemo-radiation therapy (CRT), IGABT has high proven utility in LACC but requires significant health system resources. Timely access was disrupted by the COVID-19 pandemic which challenged us to re-design our established IGABT care pathway. METHODS: From April 2020 consecutive patients with LACC were enrolled after CRT in a single arm exploratory non-inferiority study of a modified IGABT (mIGABT) protocol. This delivered an iso-effective IGABT dose (39.3 Gy: EQD2: α/ß10Gy concept) over a 24-h period during a single overnight hospitalisation. RESULTS: Fourteen LACC patients received mIGABT from April 2020 to March 2022. Median age was 62.5 years (37-82 years). LACC histology was primary squamous (9/14) or adeno-carcinoma (5/14). International Federation of Gynaecology and Obstetrics (FIGO) 2018 stages ranged from IB1/2 (N = 3), IIA1/IIB (5), IIIB (2), IIIC1/2 (4) with mean ± standard deviation (SD) gross tumour volume-at-diagnosis (GTV_D) of 37.7 cc ± 71.6 cc. All patients achieved complete metabolic, clinical, and cytologic cancer response with CRT and IGABT. High-risk HPV was cleared by 6-months. Complete MRI-defined cancer response before mIGABT (GTV_Fx1) was seen in 77% of cases (10/13). Only two women developed metastatic disease and one died at 12-months; 13 patients were alive without cancer at mean 20.3 ± 7.2 months follow-up. Actuarial 2-year overall survival was 93%. Compared with our pre-COVID IGABT program, overall mIGABT cost-saving in this cohort was USD 22,866. Prescribed dose covered at least 90% (D90) of the entire cervix and any residual cancer at time of BT (HRCTV_D90: high-risk clinical target volume) with 3-fractions of 8.5 Gy delivered over 24-h (22.8 ± 1.7 h). Total treatment time including CRT was 38 days. The mIGABT schedule was well tolerated and the entire cohort met EMBRACE recommended (EQD2: α/ß10Gy) combined HRCTV_D90 coverage of 87.5 ± 3.7 Gy. Similarly, organ-at-risk (OAR) median: interquartile range D2cc constraints (EQD2: α/ß3Gy) were EMBRACE compliant: bladder (65.9 Gy: 58.4-72.5 Gy), rectum (59.1 Gy: 55.7-61.8 Gy), and sigmoid colon (54.6 Gy: 50.3-58.9 Gy). ICRU recto-vaginal point dose was significantly higher (75.7 Gy) in our only case of severe (G4) pelvic toxicity. CONCLUSIONS: This study demonstrated the utility of mIGABT and VMAT CRT in a small cohort with LACC. Loco-regional control was achieved in all cases with minimal emergent toxicity. Single insertion mIGABT was logistically efficient, cost-saving, and patient-centric during the COVID-19 pandemic.

Comparing dosimetry of locally advanced cervical cancer patients treated with 3 versus 4 fractions of MRI-guided brachytherapy.

PURPOSE: To demonstrate the feasibility of treating cervical cancer patients with MRI-guided brachytherapy (MRgBT) using 24 Gy in 3 fractions (F) versus a standard, more resource-intensive regimen of 28 Gy in 4F, and its ability to meet EMBRACE II planning aims. METHODS AND MATERIALS: A retrospective review of 224 patients with FIGO Stage IB-IVA cervical cancer treated with 28 Gy/4F (n = 91) and 24 Gy/3F (n = 133) MRgBT between 2016-2021 was conducted. Multivariable linear regression models were fitted to compare dosimetric parameters between the two groups, adjusting for CTVHR and T stage. RESULTS: Most patients had squamous cell carcinoma, T2b disease, and were treated with intracavitary applicator plus interstitial needles (96%). The 28 Gy/4F group had higher CTVHR (median 28 vs. 26 cm3, p = 0.04), CTVIR D98% (mean 65.5 vs. 64.5 Gy, p = 0.03), rectum D2cm3 (mean 61.7 vs. 59.2 Gy, p = 0.04) and bladder D2cm3 (81.3 vs. 77.9 Gy, p = 0.03). There were no significant differences in the proportion of patients meeting the EMBRACE II OAR dose constraints and planning aims, except fewer patients treated with 28 Gy/4F met rectum D2cm3 < 65 Gy (73 vs. 85%, p = 0.027) and ICRU rectovaginal point < 65 Gy (65 vs. 84%, p = 0.005). CONCLUSIONS: Cervical cancer patients treated with 24 Gy/3F MRgBT had comparable target doses and lower OAR doses compared to those treated with 28 Gy/4F. A less-resource intense fractionation schedule of 24 Gy/3F is an alternative to 28 Gy/4F in cervix MRgBT.

Features on Endoscopy and MRI after Treatment with Contact X-ray Brachytherapy for Rectal Cancer: Explorative Results.

After neoadjuvant (chemo)radiotherapy for rectal cancer, contact X-ray brachytherapy (CXB) can be applied aiming at organ preservation. This explorative study describes the early features on endoscopy and MRI after CXB. Patients treated with CXB following (chemo)radiotherapy and a follow-up of ≥12 months were selected. Endoscopy and MRI were performed every 3 months. Expert readers scored all the images according to structured reporting templates. Thirty-six patients were included, 15 of whom obtained a cCR. On endoscopy, the most frequently observed feature early in follow-up was an ulcer, regardless of whether patients developed a cCR. A flat, white scar and tumor mass were common at 6 months. Focal tumor signal on T2W-MRI and mass-like high signal on DWI were generally absent in patients with a cCR. An ulceration on T2W-MRI and "reactive" mucosal signal on DWI were observed early in follow-up regardless of the final tumor response. The distinction between a cCR and a residual tumor generally can be made at 6 months. Features associated with a residual tumor are tumor mass on endoscopy, focal tumor signal on T2W-MRI, and mass-like high signal on DWI. Early recognition of these features is necessary to identify patients who will not develop a cCR as early as possible.

COVID-19 testing trends: pre-radiation and throughout cancer care

Introduction: Patients presenting for radiation therapy (RT) at a single institution were analysed regarding treatment delays and disparities during the coronavirus disease 2019 (COVID-19) pandemic. Methods: The study was conducted at an urban multidisciplinary cancer centre. In April 2020, the institution's radiation oncology department implemented universal COVID-19 screening protocols prior to RT initiation. COVID-19 testing information on cancer patients planned for RT from 04/2020 to 01/2021 was reviewed. Trends of other lifetime COVID-19 testing and overall care delays were also studied. Results: Two hundred and fifty-four consecutive cancer patients received RT. Median age was 63 years (range 24-94) and 57·9% (n = 147) were Black. Most (n = 107, 42·1%) patients were insured through Medicare. 42·9% (n = 109) presented with stage IV disease. One (0·4%) asymptomatic patient tested positive for COVID-19 pre-RT. The cohort received 975 lifetime COVID-19 tests (median 3 per patient, range 1-18) resulting in 29 positive test results across 21 patients. Sixteen patients had RT delays. Identifying as Hispanic/Latino was associated with testing positive for COVID-19 (p = 0·015) and RT delay (p = 0·029). Conclusion: Most patients with cancer planned for RT tested negative for COVID-19 and proceeded to RT without delay. However, increased testing burden, delays in diagnostic workup and testing positive for COVID-19 may intensify disparities affecting this urban patient population. © The Author(s), 2022. Published by Cambridge University Press.

Prostate brachytherapy utilization in the COVID-19 era: A cross-sectional study of radiation oncologists in the United States.

PURPOSE: Despite advantages such as abbreviated treatment course, brachytherapy (BT) utilization rates for prostate cancer (PC) in the United States (US) are declining. We surveyed practicing US radiation oncologists (ROs) to determine the proportion who offer BT for PC and whether the COVID-19 pandemic influenced practice patterns. MATERIALS AND METHODS: From July-October 2021, we surveyed practicing US ROs. Provider demographic and practice characteristics were collected. Questions assessing utilization of BT and external beam (EBRT) for patients of varying risk groups and the effect of the pandemic on practice patterns were administered. Descriptive statistics were reported. The bivariate relationships between provider characteristics and likelihood of offering BT were assessed using the Chi-square test (α < 0.05). RESULTS: Six percent of surveyed ROs responded, with 203 meeting inclusion criteria (72% male, 72% white, 53% non-academic, 69% >10 years in practice) and 156 (77%) treating PC. For low-risk, fewer providers offered BT (41% total; 25% low dose rate [LDR], 10% high dose rate [HDR], 6% both) than stereotactic body (SBRT) (54%) and moderately hypofractionated radiation therapy (MHFRT) (83%). For favorable intermediate risk, fewer offered BT (37% total; 21% LDR, 10% HDR, 6% both) than SBRT (48%), MHFRT (87%), and conventionally fractionated EBRT (38%). For high (44%) and very-high (37%) risk, fewer offered EBRT+BT than EBRT alone. For every risk group, academic ROs were significantly more likely to offer BT (all p-values<0.05). <1% of respondents reported increased pandemic-related BT usage. CONCLUSIONS: US ROs, particularly in non-academic settings, do not routinely offer BT monotherapy or boost (<50%). Practice patterns were unaffected by COVID-19. Retraining may be critical to increasing utilization.

Reduced Duration Intracavitary Brachytherapy in Cervix Malignancies: A Comparative Analysis from Single Institute

Purpose: The on-going pandemic has impacted the use of anesthesia and the operating room frequency thereby affecting the brachytherapy treatment in various institutions due to the COVID-19 protocols. This has led to single applications of Intracavitary brachytherapy (ICRT) being used to deliver entire treatment boost in cervix cancer. We present our dosimetric and early clinical outcomes comparing traditional weekly three-fractions ICRT with single application/ two-applications ICRT Material(s) and Method(s): In this retrospective analysis conducted in our department, a total of 39 cases, treated between January 2021 to January 2022 were evaluated for the study. Of these, 15 cases were treated with the traditional once a week applicator insertion for 3 fractions and 24 cases underwent lesser application - 20 cases underwent 2 insertions and 4 cases single insertion (all receiving total 3 fractions of 7Gy each). The dosimetric parameters were compared including CTV D90 and D95 along with rectum, sigmoid and bladder D2cc, 1cc and 0.1cc respectively. The acute toxicity assessment was done using the RTOG scale. The follow-up was undertaken as per the institutional protocol and Mann-Whitney U-test were applied to compare the cohorts. Result(s): With a median follow-up of 6 months, the median CTV was D90%: 81.2 vs. 80.9 Gy and the median CTV volume was 44.3 vs 42.9 cc respectively. The 0.1 cm3 and 2 cm3 to bladder, rectum, and sigmoid were 105.6 vs 104.2 Gy and 85.5 vs 85.9Gy, 89.4Gy vs 88.7Gy and 69.1 vs 67.8Gy, and 84.7 vs 84.1Gy and 71.7 vs 69.9Gy, respectively suggesting no significant difference in the dosimetric outcomes with the two forms of applications. The less than three applications had a shorter overall treatment time with median OTT of 43 days vs. 55 days (p = 0.02). On completion of treatment and 6 months follow-up, local control was achieved in all patients. There was no significant difference in the acute toxicities in terms of cystitis and proctitis in both forms of the application. Conclusion(s): The single application/ twice application ICRT procedure showed similar outcomes as the traditional three-week duration treatment in terms of dosimetric outcomes and acute toxicities and ultimately leading to shortened overall treatment time. It also helped reduce the anesthesia burden and various resources associated with the procedure. Copyright © 2022

Definitive Management of Cervical Cancer Patients at an Urban Institution During the COVID-19 Pandemic - Brachytherapy Treatment During the Surge

Purpose: Locally advanced cervical cancer was defined by an international consensus panel as a high priority malignancy during the COVID-19 pandemic, recommending prompt initiation of definitive treatment and completion of treatment (PMID 32563593). The objective of this study was to study the clinical outcomes of patients (pts) with cervical cancer treated with definitive chemoradiation (CRT) and brachytherapy (BT) at our institution in 2019 (pre-COVID) and in 2020 (peri-COVID). Material(s) and Method(s): This was a retrospective cohort study of pts with FIGO Stage IB2-IVA cervical cancer at our institutions from 1/1/2019 to 12/31/2020. Pts received CRT followed by intracavitary brachytherapy (IC) with two operative insertions one week apart, or interstitial (IS) BT with one operative insertion. BT treatment was planned using image-guided CT or MR delineation. Pre-COVID was defined by initiation of CRT in 1/2019-12/2019, and peri-COVID was defined by initiation in 1/2020-10/2020. Process changes peri-COVID included limited on-site staff (e.g., minimal OR staff, no trainees, remote physics team), universal implementation of COVID-19 testing prior to surgery, and CT instead of MR-delineation based treatment. Outcomes of interest were time to treatment initiation and completion and differences in treatment planning modality or dosimetry. Fisher's exact and Mann Whitney U tests were used with significance p<0.05. Result(s): Thirty-one pts were included, with 18 patients undergoing treatment pre-COVID and 13 peri-COVID. The median age at diagnosis pre-COVID was 57.7 (range 23-77) and for peri-COVID, 45.5 (range 28-62, p=0.06). There were no differences in non-English speaking pts (44% vs 59%, p=0.71) or uninsured pts (11% vs 33%, p=0.184) between the two cohorts. Median time to initiation of treatment from biopsy diagnosis was 52 days (range 13-209) in 2019 and for peri-COVID, 55.5 (range 20-173, p=0.71). During COVID, four pts had delayed initiation to treatment >100 days: two related to fertility, and one due to fear of COVID-19. For this pt, tumor size progressed from 2.3 cm to 4.2 cm maximal dimension. One pt treated in 2020 tested positive following treatment and did not require hospital admission. All pts except one completed CRT with RT: 25 pts pelvic RT (45 Gy), 3 pelvic and para-aortic RT (45 Gy with 57.5 Gy concomitant boost to nodes), 8 pts pelvic RT (45Gy) with sequential parametrial boost (50.4-59.4 Gy) using IMRT with no dose differences between pre and peri-COVID (Table 1). No pts required treatment breaks and the median overall treatment time was 50 days (range 31-85) in 2019 vs 50 days (range 43-63) in 2020 (p=0.710). Conclusion(s): Despite the significant burden of the COVID-19 pandemic on our health care system, all cervical cancer pts receiving CRT met standard of care including CRT and BT within the recommended time frame with no significant differences in dosimetric treatment parameters pre- and peri-COVID. Delays in treatment initiation of treatment initiation were seen in 30% of pts in the peri-COVID period, suggesting that patients may have had increased barriers to access care. More follow-up is needed to determine how the Covid pandemic impacted cervical cancer outcome measures. Copyright © 2022

Racial, Ethnic, and Regional Disparities in the Utilization of Vaginal Brachytherapy in Patients Meeting PORTEC-2 Criteria: A SEER Analysis

Purpose: Brachytherapy remains a critical component of locoregional therapy for many women with gynecologic cancers. Other groups have demonstrated racial disparities in the utilization of brachytherapy. Specifically, black women with locally advanced cervical cancer are less likely to receive brachytherapy compared to non-black women. We hypothesized that similar disparities may exist for the utilization of vaginal brachytherapy (VBT) for women who meet PORTEC-2 criteria for high-intermediate risk (HIR) endometrial cancer. Material(s) and Method(s): Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified patients who were diagnosed with endometrial cancer between 2011 to 2018, who met PORTEC-2 criteria for HIR disease (age 60 or greater with 1) FIGO stage IC (1988) and grade 1-2 disease or 2) FIGO stage IB (1988) and grade 3 disease). We limited our analysis to the year following the initial PORTEC-2 publication (2010) and beyond in order to allow for adoption into routine clinical practice. The impact of race and ethnicity on utilization of VBT versus external beam radiation therapy (EBRT) was analyzed on univariate and multivariate analyses (binary logistic regression, with significance assumed if p<=0.05), as was the impact of marital status, United States (U.S.) Census Bureau region, and whether or not a lymph node dissection was performed. Result(s): A total of 2,182 patients were included in the analysis with a median age of 68 (range 60-97). The majority of patients were White (77.3%), married (50.8%), resided in the Western U.S. (45.1%), diagnosed with adenocarcinoma (97.2%), underwent lymph node dissection (84.7%), and received VBT (75.5%). On UVA, patients who were Hispanic (HR 1.58, CI 95% 1.15-2.16, p=0.005) and Asian or Pacific Islanders (HR 1.47, CI 95% 1.01-2.15, p=0.046) were less likely to receive VBT compared to White patients. There was a non-significant trend for Black patients (HR 1.43, 95% CI 0.98-2.08, p=0.066). Patients in the Southern (HR 1.69, CI 95% 1.24-2.31, p=0.001), Western (HR 1.7, CI 95% 1.31-2.20, p<0.001), and Pacific (HR 2.89, CI 95% 1.09-7.64, p=0.032) U.S. Census regions were less likely to receive VBT compared to the Northeast. Those who were divorced were more likely to receive VBT (HR 0.65, 95% CI 0.43-0.98, p=0.038). Finally, those patients who underwent lymph node dissection were more likely to receive VBT on UVA (HR 0.28, CI 95% 0.22-0.36, p<0.001). On MVA, patients who were Hispanic (HR 1.43, CI 95% 1.01-2.03, p=0.046), lived in the Southern (HR 1.82, CI 95% 1.30-2.55, p=0.001), Western (HR 1.61, CI 95% 1.21-2.14, p=0.001), or Pacific regions (HR 3.04, CI 95% 1.05-8.78, p=0.04) were less likely to receive VBT. Although it did not meet statistical significance, there was a trend for decreased utilization of VBT for Asian or Pacific Islanders (HR 1.45, CI 95% 0.94-2.25, p=0.094) and Black patients (HR 1.42, CI 95% 0.94-2.15, p=0.099), potentially a reflection of small patient numbers. Lastly, patients who underwent lymph node dissection were more likely to receive VBT on MVA (HR 0.27, CI 95% 0.21-0.35, p<0.001). Conclusion(s): Brachytherapy remains a critical component of locoregional therapy for many women with endometrial cancer. VBT provides a significant improvement in local control in the pelvis with an improved toxicity profile compared to EBRT. Efforts should be made to make VBT available to those women in which it is clinically indicated, with apparent disparities based on the patient's race, ethnicity, and/or their geographic location within the U.S. in the setting of HIR disease. These disparities may have been further exacerbated during the ongoing COVID-19 pandemic, which has been shown in other settings to widen many pre-existing healthcare disparities. Copyright © 2022

Comparison of Virtual Reality Platforms to Enhance Medical Education for Gynecologic Brachytherapy

Purpose: Historically, medical education relied on apprentice-based experiences requiring direct observation in patient cases. Simulation-based education has been shown to improve resident confidence but can be time intensive and difficult to coordinate. The COVID-19 pandemic demonstrated the need to develop distributed educational tools. Virtual reality (VR) platform has been shown to improve resident confidence and proficiencies. This pilot study compared educational and cost effectiveness of low-cost cardboard viewer VR (CVVR) and commercially available integrated headset VR (IHVR). Material(s) and Method(s): We created a VR video of an intracavitary brachytherapy case for treatment of cervical cancer. Radiation oncology residents from a single ACGME-accredited training program were recruited and randomized to IHVR or CVVR. Both groups were given unlimited access to their randomized technology. Each resident performed a timed intracavitary procedure on a simulator while 5 implant quality metrics were recorded. A pre- and post-simulation questionnaire assessed self-confidence, procedural knowledge, and perceived usefulness of VR technology. Result(s): There were 13 residents, including four post-graduate year (PGY)-2, three PGY-3, two PGY-4, and four PGY-5, in the study. Seven (53.8%) of residents had previously performed an intracavitary brachytherapy procedure, while six (46.2%) had no prior experience. There were six residents randomized to IHVR and seven residents randomized to CVVR. Both VR technologies improved self-perceived overall confidence, assembly skill, and comfort performing the procedure independently. There were also non-statistically significant improvements in the ability to correctly order the steps of the brachytherapy procedure on post-simulation survey compared to pre-simulation survey in both VR viewer groups. Average time required for implant (mean: CVVR - 200 seconds vs. IHVR - 235 seconds, p=0.38) and median objective proficiencies of implant quality (5/5 in both group, p=0.56) were similar. There was no difference between CVVR and IHVR as useful, enjoyable and engaging educational tool. Both groups would recommend the technology to another trainee. There were differences in the time between last usage of the VR technology with 50% of the residents in the IHVR group completing the last VR SBE more than 2 weeks before the procedure, while the majority of residents in the CVVR group (57%) completed the last VR SBE within 1 hour before the procedure. IHVR-based program would cost ~33x more than CVVR-based program based on an assessment of US-based programs. Conclusion(s): CVVR is a cost-effective alternative to a IHVR as a virtual education tool. Copyright © 2022

Non-invasive treatment of recalcitrant keloids with contact brachytherapy using Phosphorus 32 skin patch and its effectiveness: a pilot study

Aim/Introduction: The keloids are benign dermal fibroproliferative tumors. Recalcitrant keloids are those that are unresponsive or recurred multiple times on the standard routine treatment. We analyzed the effect of the 32P skin patch on recalcitrant keloids in the Indian population. Material(s) and Method(s): 32P skin patch was applied locally for 3 hours, so to deliver 30 Gy of total radiation dose to the patients. Then patients were follow-up at 2 months, 4 months, and 6 months intervals. On each follow-up, HR USG was done for assessing the change in the dimensions of the lesion (thickness, length, and breath). VAS scores of pain and pruritis were also noted in all patients. Result(s): We found that there is a reduction in the thickness of recalcitrant keloids after applying a 32P skin patch with 30 Gy of the total dose in this single-arm trial using RM Anova with the post hoc test. Friedman's test was used for analyzing the VAS for pain and pruritis. Because of missed follow-ups in COVID, we analyzed the patients as two datasets: one with 6 months followup (recalcitrant lesions, n=9) and another with 4 months follow-up (n=24). There was a significant difference in thickness of recalcitrant keloids over 6 months and 4 months(p<0.01). The percent change from baseline on first, second, and third follow-up was 21%,28%, and 43%, respectively, for 9 recalcitrant keloids. The percent change from baseline on first and second follow-up was 22.1 % and 31.1%, respectively, for 24 recalcitrant keloids. So upon 30 Gy of dose by P32 skin patch, it showed a 22- 43% reduction in recalcitrant keloid thickness. However, visually, all patients showed complete resolution. There is a decrease in pruritis upon patch application over 4 months. The pain was uncommentable because 20/27 lesions had no pain during the baseline (VAS score of 0/10). All the patients experienced subjective symptomatic relief in pain and pruritis after the patch therapy. Conclusion(s): The decrease in thickness implies the effect of the 32P skin patch on recalcitrant keloids. Hence there was an optimum change of thickness from baseline with 6 months follow-up. No recurrence up to 6 months was observed during the follow-up. All the patients experienced subjective symptomatic relief in pain and pruritis after the patch therapy. So 32P skin patch is a cheap, non-invasive, effective treatment for recalcitrant keloids.

GSOR21 Presentation Time: 12:10 PM: Racial, Ethnic, and Regional Disparities in the Utilization of Vaginal Brachytherapy in Patients Meeting PORTEC-2 Criteria: A SEER Analysis

Purpose: Brachytherapy remains a critical component of locoregional therapy for many women with gynecologic cancers. Other groups have demonstrated racial disparities in the utilization of brachytherapy. Specifically, black women with locally advanced cervical cancer are less likely to receive brachytherapy compared to non-black women. We hypothesized that similar disparities may exist for the utilization of vaginal brachytherapy (VBT) for women who meet PORTEC-2 criteria for high-intermediate risk (HIR) endometrial cancer. Material(s) and Method(s): Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified patients who were diagnosed with endometrial cancer between 2011 to 2018, who met PORTEC-2 criteria for HIR disease (age 60 or greater with 1) FIGO stage IC (1988) and grade 1-2 disease or 2) FIGO stage IB (1988) and grade 3 disease). We limited our analysis to the year following the initial PORTEC-2 publication (2010) and beyond in order to allow for adoption into routine clinical practice. The impact of race and ethnicity on utilization of VBT versus external beam radiation therapy (EBRT) was analyzed on univariate and multivariate analyses (binary logistic regression, with significance assumed if p<=0.05), as was the impact of marital status, United States (U.S.) Census Bureau region, and whether or not a lymph node dissection was performed. Result(s): A total of 2,182 patients were included in the analysis with a median age of 68 (range 60-97). The majority of patients were White (77.3%), married (50.8%), resided in the Western U.S. (45.1%), diagnosed with adenocarcinoma (97.2%), underwent lymph node dissection (84.7%), and received VBT (75.5%). On UVA, patients who were Hispanic (HR 1.58, CI 95% 1.15-2.16, p=0.005) and Asian or Pacific Islanders (HR 1.47, CI 95% 1.01-2.15, p=0.046) were less likely to receive VBT compared to White patients. There was a non-significant trend for Black patients (HR 1.43, 95% CI 0.98-2.08, p=0.066). Patients in the Southern (HR 1.69, CI 95% 1.24-2.31, p=0.001), Western (HR 1.7, CI 95% 1.31-2.20, p<0.001), and Pacific (HR 2.89, CI 95% 1.09-7.64, p=0.032) U.S. Census regions were less likely to receive VBT compared to the Northeast. Those who were divorced were more likely to receive VBT (HR 0.65, 95% CI 0.43-0.98, p=0.038). Finally, those patients who underwent lymph node dissection were more likely to receive VBT on UVA (HR 0.28, CI 95% 0.22-0.36, p<0.001). On MVA, patients who were Hispanic (HR 1.43, CI 95% 1.01-2.03, p=0.046), lived in the Southern (HR 1.82, CI 95% 1.30-2.55, p=0.001), Western (HR 1.61, CI 95% 1.21-2.14, p=0.001), or Pacific regions (HR 3.04, CI 95% 1.05-8.78, p=0.04) were less likely to receive VBT. Although it did not meet statistical significance, there was a trend for decreased utilization of VBT for Asian or Pacific Islanders (HR 1.45, CI 95% 0.94-2.25, p=0.094) and Black patients (HR 1.42, CI 95% 0.94-2.15, p=0.099), potentially a reflection of small patient numbers. Lastly, patients who underwent lymph node dissection were more likely to receive VBT on MVA (HR 0.27, CI 95% 0.21-0.35, p<0.001). Conclusion(s): Brachytherapy remains a critical component of locoregional therapy for many women with endometrial cancer. VBT provides a significant improvement in local control in the pelvis with an improved toxicity profile compared to EBRT. Efforts should be made to make VBT available to those women in which it is clinically indicated, with apparent disparities based on the patient's race, ethnicity, and/or their geographic location within the U.S. in the setting of HIR disease. These disparities may have been further exacerbated during the ongoing COVID-19 pandemic, which has been shown in other settings to widen many pre-existing healthcare disparities. Copyright © 2022

GSOR17 Presentation Time: 11:50 AM: Comparison of Virtual Reality Platforms to Enhance Medical Education for Gynecologic Brachytherapy

Purpose: Historically, medical education relied on apprentice-based experiences requiring direct observation in patient cases. Simulation-based education has been shown to improve resident confidence but can be time intensive and difficult to coordinate. The COVID-19 pandemic demonstrated the need to develop distributed educational tools. Virtual reality (VR) platform has been shown to improve resident confidence and proficiencies. This pilot study compared educational and cost effectiveness of low-cost cardboard viewer VR (CVVR) and commercially available integrated headset VR (IHVR). Material(s) and Method(s): We created a VR video of an intracavitary brachytherapy case for treatment of cervical cancer. Radiation oncology residents from a single ACGME-accredited training program were recruited and randomized to IHVR or CVVR. Both groups were given unlimited access to their randomized technology. Each resident performed a timed intracavitary procedure on a simulator while 5 implant quality metrics were recorded. A pre- and post-simulation questionnaire assessed self-confidence, procedural knowledge, and perceived usefulness of VR technology. Result(s): There were 13 residents, including four post-graduate year (PGY)-2, three PGY-3, two PGY-4, and four PGY-5, in the study. Seven (53.8%) of residents had previously performed an intracavitary brachytherapy procedure, while six (46.2%) had no prior experience. There were six residents randomized to IHVR and seven residents randomized to CVVR. Both VR technologies improved self-perceived overall confidence, assembly skill, and comfort performing the procedure independently. There were also non-statistically significant improvements in the ability to correctly order the steps of the brachytherapy procedure on post-simulation survey compared to pre-simulation survey in both VR viewer groups. Average time required for implant (mean: CVVR - 200 seconds vs. IHVR - 235 seconds, p=0.38) and median objective proficiencies of implant quality (5/5 in both group, p=0.56) were similar. There was no difference between CVVR and IHVR as useful, enjoyable and engaging educational tool. Both groups would recommend the technology to another trainee. There were differences in the time between last usage of the VR technology with 50% of the residents in the IHVR group completing the last VR SBE more than 2 weeks before the procedure, while the majority of residents in the CVVR group (57%) completed the last VR SBE within 1 hour before the procedure. IHVR-based program would cost ~33x more than CVVR-based program based on an assessment of US-based programs. Conclusion(s): CVVR is a cost-effective alternative to a IHVR as a virtual education tool. Copyright © 2022

Radiotherapy Management of Locally Advanced Cervical Cancer during the COVID-19 Era: A Single Centre Report on Treatment Approach, Brachytherapy Fractionation and Timing

Background: The COVID-19 pandemic had a catastrophic impact on healthcare. Keeping an optimal cancer care routine has been challenging. For cervical cancer (CC) patients external beam radiotherapy (EBRT) and brachytherapy (BT) are key elements for radical treatment. Oncological treatment delays have represented a major issue during the pandemic. Overall treatment time (OTT) is a well-known prognostic factor for CC. Thus, we decided to evaluate radiotherapy timing and modalities, and OTT trends for locally advanced cervical cancer (LACC) patients treated at our center during the Pandemic. Method(s): We retrospectively collected and analyzed data of patients treated for LACC at our Center, (Department of Oncology, Radiation Oncology, S.Anna Hospital, Turin, Italy), during the COVID-19 pandemic. Result(s): Between March 2020 and March 2022, 36 patients were treated. All patients underwent EBRT (median pelvic dose 48 Gray (Gy)). Concurrent chemotherapy (ChT) was administered in 31/36 patients. High Dose Rate (HDR) BT boost was delivered to 32/36 patients. BT schedules adopted were: 28 Gy in 4 fractions (18 cases, 56.2%), 26 Gy in 4 fractions (5 cases, 15.6%), 21 Gy in 3 fractions (4 cases, 12.5%), 18 Gy in 3 fractions (3 cases, 9.3%), 24 Gy in 4 fractions (one case, 3.2%), 12 Gy in 2 fractions plus 11 Gy in 2 fractions (one case, 3.2%). Most of the patients (25/32, 78.1%) received one fraction per week;6 patients (18.1%) 2 fractions per week and one patient 3 fractions per week. Median OTT was 74 days (57-99). The median interval from EBRT to HDR-BT was 14 days (6-54). Four patients tested positive for COVID-19 between EBRT and BT. At a median follow-up of 10.7 months (range 1.8-20.3), a complete response was obtained in 25 patients (69.5%), a partial response in 8 cases (22.2%), and a disease progression in two patients (5.5%). Conclusion(s): in terms of radiotherapy management of LACC, brachytherapy resulted as the most affected by the restrictions due to the pandemic. We adopted different schedules and fractionations to optimize the resources available and to keep providing an optimal care. A be-weekly fractionation emerged as a promising option for LACC during the pandemic, with a good toxicity profile. Copyright: © 2022 The Author(s).

Comparison of Virtual Reality Platforms for Cervical Brachytherapy Procedure Education

Background: Traditionally procedural training requires in-person and hands-on education. However, only about 50% of residents express confidence to develop a brachytherapy practice (Marcrom SR, et al. Int J Radiat Oncol Biol Phys 2019). The COVID-19 pandemic demonstrated the need to develop distributed educational tools for procedural experiences. Virtual reality (VR) platform has been shown to improves resident confidence and proficiencies (Taunk NK. et al. Brachytherapy 2021). Objective(s): We hypothesize that a low-cost cardboard viewer VR (CVVR) has similar educational effectiveness as commercially available integrated headset VR (IHVR). Method(s): We created a VR video of an intracavitary brachytherapy case. Radiation oncology residents from a single ACGME-accredited training program were recruited and randomized to IHVR or CVVR. Both groups were given unlimited access to their randomized technology. Each resident performed a timed intracavitary procedure on a simulator while 5 implant quality metrics were recorded. A pre- and post-simulation questionnaire assessed self-confidence, procedural knowledge, and perceived usefulness of VR technology. Result(s): There were 13 residents, including four post-graduate year (PGY)-2, three PGY-3, two PGY-4, and four PGY-5, in the study. Both VR technologies improved self-perceived overall confidence. Average time required for implant (mean: CVVR-200 seconds vs. IHVR-235 seconds, P=0.38) and median objective proficiencies of implant quality (5/5 in both group, P=0.56) were similar. There was no difference between CVVR and IHVR as useful, enjoyable and engaging educational tool. Both groups would recommend the technology to another trainee. IHVR-based program would cost ~33x more than CVVR-based program based on an assessment of US-based programs. Conclusion(s): CVVR is a cost-effective alternative to a IHVR as a virtual education tool (Figs. 1-3). (Table Presented).

Factors associated with increased financial toxicity after the completion of radiation treatment for gynecologic cancer (512)

Objectives: Financial toxicity (FT) impacts approximately 50% of patients with gynecologic malignancies. Still, little is known about factors that predispose patients receiving radiation therapy to financial distress or what impact the COVID-19 pandemic had on their financial well-being. We evaluated FT in patients with gynecologic cancer treated with radiation before and after the start of the COVID- 19 pandemic. Methods: Patients from an urban, academic gynecologic radiation oncology practice completed a survey one month after completing radiation from August 2019-March 2020 and November 2020-June 2021. The survey included demographic questions, the Comprehensive Score for Financial Toxicity (COST) tool, and the EQ-5D to measure the quality of life (QOL). Pandemic-related questions were added during the second survey period (pandemic cohort). As with our prior work, high FT was defined as a COST score of ≤23. We assessed the correlation of COST scores with QOL. We used logbinomial regression to examine associations between FT and costcoping strategies, adjusting for age and insurance. Results: Of 97 respondents (92% response rate), 49% completed the survey before, and 51% completed it after the pandemic started. Among the participants, 76% identified as White, 11% as Black, and 8% as Asian. Most patients had uterine (64%), followed by cervical (24%) and vaginal (6%) cancer. Two-thirds (60%) received external beam radiation with or without brachytherapy;the remaining 40% had brachytherapy alone. The median COST score was 15 (IQR: 7-19) in the high FT group (n=27) and 33 (IQR: 28-36) in the low FT group (n=70). High FT correlated with worse QOL (r=-0.37, p<0.01) and was associated with younger age and type of insurance (both p <0.03). Patients with high FT were more likely to move from full- to parttime employment (22% vs 1%, p<0.01), six (95% CI: 1.0-36) times more likely to delay/avoid medical care, 14 (95% CI: 3-64) times more likely to borrow money, and seven (95% CI: 2-27) times as likely to reduce spending on basic goods. Patients with high FT were more likely to report that decreased ability to work (48% vs 13%), medical bills (41% vs 13%), and transportation or parking (15% vs 3%) mostly contributed to their financial stress (p<0.05 for all). The pandemic cohort had fewer patients with high FT than the pre-pandemic cohort (20% vs 35%, p=0.10) and a higher median COST score (32 [IQR: 25-35] vs 27 [IQR: 19-34], p=0.07). The use of cost-coping strategies did not differ between cohorts. Conclusions: Privately insured, younger patients who received radiation for gynecologic cancer were at risk for FT. High FT correlated with worse QOL and was associated with delays or avoidance of medical care and other cost-coping strategies. The prevalence of high FT was not statistically different before and during the pandemic, though we observed less FT in the pandemic cohort. More work is needed regarding the impact of the COVID-19 pandemic on the financial well-being of patients with cancer.