Impacts of COVID-19 on proton therapy - Shaping the future of patient selection

Objectives: This scoping review aimed to determine whether the COVID-19 pandemic influenced any modifications to patient selection methods or prioritisation and services provided by proton therapy centres. Method(s): This review was conducted based on the PRISMA methodology and Joanna Briggs Institute scoping review guidelines.1,2 A literature search was performed in Medline, Embase, Web Of Science and Scopus as well as grey literature. Keywords including "COVID-19" and "Proton Therapy" were used. Articles published from 1 January 2020 in English were included. In total, 138 studies were identified of which 14 articles met the inclusion criteria. A scoping review design was chosen to capture the full extent of information published relating to the aim. Result(s): Six of 14 articles included statements regarding treatment of COVID-19 patients. Three publications recommended deferred or alternative treatment, two indicated to treat urgent/emergency patients and one reported continuous treatment for infectious patients. Recurring impacts on PT provision included more frequent use of alternative therapies, reduced referrals, delayed treatment starts and CT simulation, change in treatment volume and staffing limitations due to pandemic restrictions. Consequently, telehealth consults, remote work, reduction in patient visitors, screening procedures and rigorous cleaning protocols were recommended. Discussion/Conclusion: Few publications detailed patient selection or workflow methods used during the pandemic. Further research is needed to obtain more detailed information regarding current global patient selection methods in proton therapy, collecting this data could aid in future planning for proton therapy in Australia.

A narrative review on radiation risk from imaging for COVID-19: Breaking the myths and the mithya

Radiotherapy-induced secondary malignancy is a well-known occurrence. During the COVID-19 pandemic, many people have undergone serial computed tomography (CT) imaging, and concerns have been raised regarding radiation-induced malignancies due to frequent scanning. Accordingly, various low and ultra-low-dose CT (LDCT) thorax protocols have been developed to reduce the dose of radiation. Major governing bodies worldwide have established guidelines regarding the indications for CT scans and chest X-rays during the pandemic. We, therefore, aimed to provide facts about the effects of radiation (both diagnostic and therapeutic). Through this article, we intend to break the myths and 'mithya' (misbeliefs) regarding diagnostic radiation and its association with cancer in this COVID-19 era. For this review, we performed a search in Google using specific keywords pertaining to imaging during COVID-19 and radiation risk. We also included the names of various global governing bodies in the Google search. We included only full text articles and guidelines from authentic websites. From this review, we conclude that if we follow the recommendations of various global governing bodies and use CT scan only in cases of moderate to severe COVID-related symptoms, adhere to the principle of 'as low as reasonably achievable' for radiation protection, and use LDCT scan protocols, we can significantly reduce the mean effective radiation dose delivered and the estimated cancer risk.Copyright © 2023 Cancer Research, Statistics, and Treatment. All rights reserved.

Disparities in pediatric patients receiving proton therapy during the COVID-19 pandemic - A single institutional experience

Introduction: Our institution cares for a largely underserved urban population, treating about 120 children annually with radiation therapy;roughly 10% are referred for proton therapy elsewhere. COVID-19 led to some decreases in medical care due to uncertainties regarding the state of public health. The purpose of this study is to evaluate existing socioeconomic disparities using the University of Wisconsin Area Deprivation Index (ADI) and whether the pandemic impacted this referral pattern. Method(s): Over the last twenty years, approximately 2,275 children have presented to our institution for radiation treatment. A retrospective chart review was conducted and a patient database of demographic and clinical information was created. We used demographic data to obtain the ADI, and compared relative disparity rankings between proton therapy recipients and a random sample of patients from the 25 most common zip codes (representative of over 20% of the total cohort). We compared the number of patients treated only at the closest proton facility before and after the onset of the pandemic. Result(s): The demographic make-up of our patient population is approximately 53.7% Latino, 22.6% White, 9.5% African American, 9.2% Asian, and 5% Other. Of these patients, about 500 had diagnoses typically referred for proton therapy (such as brain tumors, neuroblastoma, sarcomas, and Hodgkin lymphoma). At baseline, we found a statistically significant difference in the median state ADI decile of 3 and 7 for protons and photons, respectively, reflecting lower socioeconomic disadvantage in the proton group. There was a difference in the median household income (based on zip code) of $102,028 and $70,479 between the proton and photon groups (p < 0.0001). There was also a difference in median household income of $57,871 and $76,808 between Latino and Non-Latino patients (p < 0.0001). Demographic data for the proton therapy cohort showed that 46.2% of these patients were White, 15.4% were Latino, 15.4% were African American, 7.7% were Asian, and 15.4% were Other. At the closest proton facility, between 2014-2019, 16 of our patients received radiation therapy. Since the beginning of pandemic associated restrictions in March 2020, 19 patients have received proton therapy at this center. Conclusion(s): Disparities preventing patients from receiving proton therapy have been described. Our work adds granular census block data and uses the ADI which takes into account median family income, unemployment rate, households without access to a vehicle, English language proficiency and more. Those with lower ADI risk rankings were overrepresented in the proton therapy group. Despite the pandemic and added referral challenges, the number of patients able to receive proton therapy did not decrease which we hypothesize may be due to many factors, including the unanticipated flexibility of remote work amongst those with lower ADI rankings. Latinos were least likely to have proton therapy, and further research is needed to ameliorate the disparities and barriers to care which they face.

Socio-economic Barriers to Care and Medical Complexity Leading to a 5-year Diagnostic Delay of Untreated Chronic Diabetes Insipidus and Rapidly Progressive Puberty in a 10-year-old Venezuelan Immigrant

Introduction: Germ cell tumors, including germinomas, account for 10% of pediatric chronic Diabetes Insipidus (DI) cases. Delays in diagnosis of germinomas are generally longer than six months, however, no reported cases of suprasellar germinomas causing chronic DI and precocious puberty have been known to exceed a 5-year delay in both treatment of DI symptoms and a definitive diagnosis. Case Description: A 10-year-old Hispanic male presented with a 5-year history of polydipsia and polyuria. He underwent evaluation in Venezuela, where DI was reportedly 'ruled out';however, no head MRI was performed. After two years in the US struggling to acquire insurance, he presented to his pediatrician with worsening symptoms. A head MRI, ordered to evaluate dilute high-volume urine output, revealed a suprasellar mass. He was admitted for diagnostic evaluation and met the criteria for DI. Notably, he had an elevated Beta-Human Chorionic Gonadotropin (B-HCG) level. Biopsy confirmed the diagnosis of a Central Nervous System (CNS) germinoma. He was treated with DDAVP and proton therapy with subsequent remission of his tumor. Discussion: Throughout the patient's disease course, there were multiple delays in seeking and receiving care. These include a 5-year delay in seeking care despite worsening symptoms, a one-month delay in completing a 24-hour urine collection, a one-month delay in consulting pediatric nephrology, and another month delay before completing a retroperitoneal ultrasound. Multiple medical and socio-economic factors led to these delays. The patient did not present with symptoms more typical of CNS Germinomas like headaches, nausea, and vomiting. He had no visual disturbances despite mass effect on his optic chiasm. His increased stretched penis length and Tanner staging, which were identified later in his disease course, were contradicted by his pre-pubertal testicular volume and bone age. The patient is from a Spanishspeaking/Limited English Proficiency (SSLEP) household. While Spanish interpreters were present at each appointment, the language barrier proved to be a consistent issue. Initially, the child's mother indicated that the diagnosis of DI was 'ruled out' in Venezuela. In reality, the recommended imaging was never performed. Mychart messages left by his father further highlighted communication difficulties. Without access to an interpreter, he was forced to use broken English to relay his concerns. These frantic messages indicated misunderstandings regarding scheduling with various services and completing vital labs. Care only proceeded after significant physician intervention. Poverty in Venezuela, lack of insurance, and anxiety regarding COVID-19 also contributed to these delays. Conclusion: To our knowledge, this is the first case report of a pediatric patient presenting with a 5-year history of untreated polyuria and polydipsia due to undiagnosed DI with a B-HCG secreting CNS germinoma, without spinal metastasis. This study also illustrates the importance of supporting SSLEP families as they grapple with the complicated process of navigating our healthcare system. Sagittal T1 post gadolinium contrast image (A) and axial T2 FLAIR image (B) show an enigmatic, homogeneous, briskly enhancing mass in the suprasellar cistern (red arrow) with mass effect on the optic chiasm which is displaced upward and anteriorly (green arrow).

Radiotherapy Quality Assurance;is volume review all that matters?

Purpose or Objective RTQA practice is known to have significant variation amongst institutions worldwide. It is critical to maintaining patient safety, treatment effectiveness and accuracy. However there is no standard practice, with often only target volume delineation reviewed alone and performed retrospectively. Previous studies have highlighted higher rates of changes made in more complex techniques and subsites. This study aims at evaluating our prospective structured peer review process in a proton beam therapy (PBT) centre. Materials and Methods We reviewed the RTQA cases of all patients treated at The Christie Proton Beam Centre since its opening in November 2018 until February 2021. The RTQA process is carried out weekly, is subsite specific and every case has their target volumes and plans reviewed in detail in the presence of consultants, fellows, physicists and dosimetrists. Since the COVID-19 pandemic, the peer review meetings are now virtual. Every peer review has a standardised RTQA form filled. We classified the peer reviews as having major/minor or no change. A major change was one where the target volumes (GTV and/or CTV) were too small or big;dose fractionation was incorrect to that of the prescription treated and any plan that was changed. A minor change was one where there were minor modifications to the target volumes, OARs or non-essential suggestions in relation to the plan that didn’t result in the plan being altered eg. addition of an OAR. Results There was a total of 1,209 peer reviews for 462 patients. 100% of cases had both volumes and plans peer reviewed prospectively. 591 were reviews of target volumes and 618 were plan reviews. In total there were 208 (17%) major changes, 194 (16%) minor and 807 (67%) with no changes. Of the major changes 137 (66%) were target volumes and 71 (34%) plans. Of the minor changes 174 (90%) were target volumes and 20 (10%) plans. There were more major and minor changes in the brain and head & neck subsites possibly due to their complexity. When diagnoses in the brain were categorised (Table 1) and reviewed against changes using a chi-squared test the resulting p-value = 0.027 suggests a significant relationship between type of diagnoses and likely need for change following peer review.(Table Presented) Conclusion Target volume delineation and radiotherapy plans particularly in brain, head & neck as well as other complex subsites require mandatory prospective review as highlighted above. We have shown this to be practically achievable and successful despite challenging times

Prioritization of Proton Patients in the COVID-19 Pandemic: Recommendations from The New York Proton Center.

It has been well documented from the early days of the 2019 novel coronavirus (COVID-19) pandemic that patients with a diagnosis of cancer are not only at higher risks of contracting a COVID-19 infection but also at higher risks of suffering severe, and possibly fatal, outcomes from the infection. Given that the United States has the greatest number of positive coronavirus cases, it is likely that many, if not all, radiation oncology clinics will be faced with the challenge of safely balancing a patient's risk of contracting COVID-19, while under active radiation treatment, against their risk of cancer progression if treatment is delayed. To address this challenge, the New York Proton Center established an internal algorithm that considers treatment-related, tumor-related, and patient-related characteristics. Despite having suffered staff shortages due to illness, this algorithm has allowed the center to maintain patient treatment volumes while keeping the rate of COVID-19 infection low.

Quantifying the Impact of COVID-19 on Cancer Patients: A Technical Report of Patient Experience During the COVID-19 Pandemic at a High-volume Radiation Oncology Proton Center in New York City.

The COVID-19 pandemic has rapidly spread across the world and now affects more people within the United States than any other country. New York City has emerged as the epicenter of the outbreak in the United States. Both locally and across the country, there is great concern in our ability to deliver appropriate medical care during this time. Radiation therapy is another essential clinical service that cannot afford to suffer prolonged delays without compromising patient outcomes. Early action and guidance are therefore critical to minimize transmission events and ensure safe and timely delivery of radiation therapy. The New York Proton Center (NYPC) is a high-volume free-standing multi-institutional proton center located in Manhattan. The purpose of this report is to describe the institutional patient experience and quantify the impact of treatment delays and interruptions over the first month of the COVID-19 outbreak. We also quantify the incidence of COVID-19 positive patients on census and provide guidance on proactive institutional policies to mitigate patient risk.