Impact of COVID-19 pandemic on delivery of pediatric radiotherapy: A critical review.

The COVID-19 pandemic has prevented the timely diagnosis and treatment of many diseases, including pediatric cancer. Its impact on pediatric oncologic treatments warrants investigation. As radiotherapy is an integral component of cancer care, we reviewed the published data regarding the impact of COVID-19 on the delivery of pediatric radiotherapy to inform actions for future global events. We found that disruptions in radiotherapy were reported amongst interruptions in other therapies. Disruptions were more common in low-income countries (78%) and low middle-income countries (68%) compared with upper middle-income countries (46%) and high-income countries (10%). Several papers included recommendations for mitigation strategies. Altered treatment regimens were common, including increasing the use of active surveillance and systemic therapy to delay local therapies, and accelerated/hypofractionated dose delivery. Our findings suggest that COVID-19 has impacted radiotherapy delivery in the pediatric population globally. Countries with limited resources may be more affected. Various mitigation strategies have been developed. The efficacy of mitigation measures warrants further investigation.

Magnetic resonance imaging organ at risk delineation for nasopharyngeal radiotherapy: Measuring the effectiveness of an educational intervention.

INTRODUCTION: Magnetic resonance imaging (MRI) demonstrates superior soft tissue contrast and is increasingly being used in radiotherapy planning. This study evaluated the impact of an education workshop in minimising inter-observer variation (IOV) for nasopharyngeal organs at risk (OAR) delineation on MRI. METHODS: Ten observers delineated 14 OARs on 4 retrospective nasopharyngeal MRI data sets. Standard contouring guidelines were provided pre-workshop. Following an education workshop on MRI OAR delineation, observers blinded to their original contours repeated the 14 OAR delineations. For comparison, reference volumes were delineated by two head and neck radiation oncologists. IOV was evaluated using dice similarity coefficient (DSC), Hausdorff distance (HD) and relative volume. Location of largest deviations was evaluated with centroid values. Observer confidence pre- and post-workshop was also recorded using a 6-point Likert scale. The workshop was deemed beneficial for an OAR if ≥50% of observers mean scores improved in any metric and ≥50% of observers' confidence improved. RESULTS: All OARs had ≥50% of observers improve in at least one metric. Base of tongue, larynx, spinal cord and right temporal lobe were the only OARs achieving a mean DSC score of ≥0.7. Base of tongue, left and right lacrimal glands, larynx, left optic nerve and right parotid gland all exhibited statistically significant HD improvements post-workshop (P < 0.05). Brainstem and left and right temporal lobes all had statistically significant relative volume improvements post-workshop (P < 0.05). Post-workshop observer confidence improvement was observed for all OARs (P < 0.001). CONCLUSIONS: The educational workshop reduced IOV and improved observers' confidence when delineating nasopharyngeal OARs on MRI.

Research culture in Australian and New Zealand radiation oncology: Fact or fantasy?

INTRODUCTION: Fostering a research culture is a key goal of the Royal Australian and New Zealand College of Radiologists, yet there has never been an organization-wide enquiry into the extent to which this is being realized. The purpose of this work was to address that deficit for the Radiation Oncology (RO) Faculty to serve as a baseline for future comparison. The hypothesis was that such a culture is closer to fact than fantasy. METHODS: With College approval, three de-identified Excel spreadsheets detailing 25 research-related sub-categories of the Faculty's Continuing Professional Development (CPD) database were interrogated for the 2019-21 triennium, accepting that research activity in 2020-21 would be COVID-19 suppressed. The numbers obligated to self-report CPD were 482, 496 and 511, respectively. Primary endpoints were the percentages of ROs claiming at least one research-related activity overall, and in each of the sub-categories individually, by year. Secondary endpoints were the "breadth" (number of sub-categories claimed/individual) and "depth" (percentages solely claiming in one of four lower-level sub-categories), by year. RESULTS: ROs claimed in 23/25 sub-categories. The percentages of ROs claiming at least one research-related activity were 71%, 44%, and 62% in 2019-21, respectively. The median number of sub-categories claimed by these ROs was 2 (range 1-10) in each year. The commonest activity was journal article co-author (25%, 16% and 27%, respectively). For 2019, the most representative year, other common activities were inhouse/local meeting presentation (17%), invited lecture at state level or above (15%), manuscript peer review and research project principal investigator (14% each). The percentages of ROs solely claiming in one lower-level activity ranged between 4.4% and 5.9% per year. CONCLUSION: A culture of research is arguably more fact than fantasy in ANZ. It is likely that Faculty curriculum requirements, research funding and other promotional initiatives have contributed substantively to this.

A novel approach to infectious disease control and radiotherapy risk management.

BACKGROUND: Infectious disease outbreaks have always presented challenges to the operation of healthcare systems. In particular, the treatment of cancer patients within Radiation Oncology often cannot be delayed or compromised due to infection control measures. Therefore, there is a need for a strategic approach to simultaneously managing infection control and radiotherapy risks. PURPOSE: To develop a systematic risk management method that uses mathematical models to design mitigation efforts for control of an infectious disease outbreak, while ensuring safe delivery of radiotherapy. METHODS: A two-stage failure mode and effect analysis (FMEA) approach is proposed to modify radiotherapy workflow during an infectious disease outbreak. In stage 1, an Infection Control FMEA (IC-FMEA) is conducted, where risks are evaluated based on environmental parameters, clinical interactions, and modeling of infection risk. occupancy risk index (ORI) is defined as a metric for infection transmission risk level in each room, based on the degree of occupancy. ORI, in combination with ventilation rate per person (Rp ), is used to provide a broad infection risk assessment of workspaces. For detailed IC-FMEA of clinical processes, infection control failure mode (ICFM) is defined to be any instance of disease transmission within the clinic. Infection risk priority number (IRPN) has been formulated as a function of time, distance, and degree of protective measures. Infection control measures are then systematically integrated into the workflow. Since the workflow is perturbed by infection control measures, there is a possibility of introducing new radiotherapy failure modes or increased likelihood of existing failure modes. Therefore, in stage 2, a conventional radiotherapy FMEA (RT-FMEA) should be performed on the adjusted workflow. RESULTS: The COVID-19 pandemic was used to illustrate stage 1 IC-FMEA. ORI and Rp values were calculated for various workspaces within a clinic. A deep inspiration breath hold (DIBH) CT simulation was used as an example to demonstrate detailed IC-FMEA with ICFM identification and IRPN evaluation. A total of 90 ICFMs were identified in the DIBH simulation process. The calculated IRPN values were found to be progressively decreasing for workflows with minimal, moderate, and enhanced levels of protective measures. CONCLUSION: The framework developed in this work provides tools for radiotherapy clinics to systematically assess risk and adjust workflows during the evolving circumstances of any infectious disease outbreak.

ACR-ARS Practice Parameter on Informed Consent Radiation Oncology.

OBJECTIVES: Consent is a communication process between the patient and a health care provider, in which both parties have the opportunity to ask questions and exchange information relevant to the patient's diagnosis and treatment. The process of informed consent is designed to protect a patient's autonomy in their medical decision-making in the context of an asymmetric relationship with the health care system. A proper consent process assures a patient's individual autonomy, reduces the opportunity for abusive conduct or conflicts of interest, and raises trust levels among participants. This document was developed as an educational tool to facilitate these goals. METHODS: This practice parameter was produced according to the process described under the heading "The Process for Developing ACR Practice Parameters and Technical Standards" on the ACR website ( https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards ) by the Committee on Practice Parameters-Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with the ARS. Committee members were charged with reviewing the prior version of the informed consent practice parameter published in 2017 and recommending additions, modifications, or deletions. The committee met through remote access and subsequently through an online exchange to facilitate the development of the revised document. Focus was given on identifying new considerations and challenges with informed consent given the evolution of the practice of radiation oncology in part driven by the COVID-19 pandemic and other external factors. RESULTS: A review of the practice parameter published in 2017 confirmed the ongoing relevance of recommendations made at that time. In addition, the evolution of the practice of radiation oncology since the publication of the prior document resulted in the need for new topics to be addressed. These topics include remote consent either through telehealth or telephone and with the patient or their health care proxy. CONCLUSIONS: Informed consent is an essential process in the care of radiation oncology patients. This practice parameter serves as an educational tool designed to assist practitioners in optimizing this process for the benefit of all involved parties.

Overcoming Burnout and Promoting Wellness in Radiation Oncology: A Report From the ACR Commission on Radiation Oncology.

Burnout, defined by the presence of emotional exhaustion, depersonalization, and decreased sense of personal accomplishment, impacts a significant portion of radiation oncologists. This has been exacerbated by the COVID-19 pandemic, is notably worse for women, and has been identified as an international concern. Key contributors to burnout within radiation oncology include inadequate clinical and administrative support, imbalanced personal and professional lives including time with family and for self-care, decreased job satisfaction secondary to increased electronic medical record and decreased patient time, unsupportive organizational culture, lack of transparency from leadership and inclusion in administrative decisions, emotionally intensive patient interactions, challenges within the radiation oncology workforce, financial security related to productivity-based compensation and increasing medical training-related debt, limited education on wellness, and fear of seeking mental health services due to stigma and potential negative impacts on the trajectory of one's career. Limited data exist to quantify the impacts of these factors on the overall levels of burnout within radiation oncology specifically, and additional efforts are needed to understand and address root causes of burnout within the field. Strategies should focus on improving the systems in which physicians work and providing the necessary skills and resources to thrive in high-stress, high-stakes work environments.

Diagnostic and Therapeutic Radiology of the GI Tract, Liver, and Pancreas in Patients with COVID.

Coronavirus disease 2019 (COVID-19) pulmonary involvement has been extensively reported in the literature. Current data highlight how COVID-19 is a systemic disease, affecting many other organs, including the gastrointestinal, hepatobiliary, and pancreatic organs. Recently, these organs have been investigated using imaging modalities of ultrasound and particularly computed tomography. Radiological findings of the gastrointestinal, hepatic, and pancreatic involvement in patients with COVID-19 are generally nonspecific but are nonetheless helpful to evaluate and manage COVID-19 patients with involvement of these organs.

Integration of art and technology in personalized radiation oncology care: Experiences, evidence, and perspectives.

Cancer diagnoses expose patients to traumatic stress, sudden changes in daily life, changes in the body and autonomy, with even long-term consequences, and in some cases, to come to terms with the end-of-life. Furthermore, rising survival rates underline that the need for interventions for emotional wellbeing is in growing demand by patients and survivors. Cancer patients frequently have compliance problems, difficulties during treatment, stress, or challenges in implementing healthy behaviors. This scenario was highlighted during the COVID-19 emergency. These issues often do not reach the clinical attention of dedicated professionals and could also become a source of stress or burnout for professionals. So, these consequences are evident on individual, interpersonal, and health system levels. Oncology services have increasingly sought to provide value-based health care, considering resources invested, with implications for service delivery and related financing mechanisms. Value-based health care can improve patient outcomes, often revealed by patient outcome measures while seeking balance with economical budgets. The paper aims to show the Gemelli Advanced Radiation Therapy (ART) experience of personalizing the patients' care pathway through interventions based on technologies and art, the personalized approach to cancer patients and their role as "co-stars" in treatment care. The paper describes the vision, experiences, and evidence that have guided clinical choices involving patients and professionals in a co-constructed therapeutic pathway. We will explore this approach by describing: the various initiatives already implemented and prospects, with particular attention to the economic sustainability of the paths proposed to patients; the several pathways of personalized care, both from the patient's and healthcare professional perspective, that put the person's experience at the Gemelli ART Center. The patient's satisfaction with the treatment and economic outcomes have been considered. The experiences and future perspectives described in the manuscript will focus on the value of people's experiences and patient satisfaction indicators, patients, staff, and the healthcare organization.

The Impact of the COVID-19 Pandemic on the Number of Cancer Patients and Radiotherapy Procedures in the Warmia and Masuria Voivodeship.

(1) Background: It was suspected that the COVID-19 pandemic would negatively affect health care, including cancer treatment. The aim of the study was to assess the impact of the COVID-19 pandemic on the number of radiotherapy procedures and patients treated with radical and palliative radiotherapy in Poland. (2) Methods: The study was carried out in Warmia and Masuria voivodeship. The number of procedures and treated patients one year before and in the first year of the COVID-19 pandemic were compared. (3) Results: In the first year of the COVID-19 pandemic, the number of radiotherapy procedures and cancer patients treated with radiotherapy in Warmia and Masuria voivodeship in Poland was stable compared to the period before the pandemic. The COVID-19 pandemic has not affected the ratio of palliative to radical procedures. The percentage of ambulatory and hostel procedures significantly increased with the reduction of inpatient care in the first year of the COVID-19 pandemic. (4) Conclusion: No significant decrease in patients treated with radiotherapy during the first year of the pandemic in Warmia and Masuria voivodeship in Poland could indicate the rapid adaptation of radiotherapy centers to the pandemic situation. Future studies should be carried out to monitor the situation because the adverse effects of the pandemic may be delayed.

Survival Analysis Using the Covid-death Mean-imputation (CoDMI) Algorithm: A First Clinical Application in Radiation Oncology.

BACKGROUND/AIM: To report long-term survival results after trimodal approach for locally advanced rectal cancer (LARC) in the Covid-19 era. We herein illustrate a clinical application of Covid-death mean-imputation (CoDMI) algorithm in LARC patients with Covid-19 infection. PATIENTS AND METHODS: We analyzed 94 patients treated for primary LARC. Overall survival was calculated in months from diagnosis to first event (last follow-up/death). Because Covid-19 death events potentially bias survival estimation, to eliminate skewed data due to Covid-19 death events, the observed lifetime of Covid-19 cases was replaced by its corresponding expected lifetime in absence of the Covid-19 event using the CoDMI algorithm. Patients who died of Covid-19 (DoC) are mean-imputed by the Kaplan-Meier estimator. Under this approach, the observed lifetime of each DoC patient is considered as an "incomplete data" and is extended by an additional expected lifetime computed using the classical Kaplan-Meier model. RESULTS: Sixteen patients were dead of disease (DoD), 1 patient was DoC and 77 cases were censored (Cen). The DoC patient died of Covid-19 52 months after diagnosis. The CoDMI algorithm computed the expected future lifetime provided by the Kaplan-Meier estimator applied to the no-DoC observations as well as to the DoC data itself. Given the DoC event at 52 months, the CoDMI algorithm estimated that this patient would have died after 79.5 months of follow-up. CONCLUSION: The CoDMI algorithm leads to "unbiased" probability of overall survival in LARC patients with Covid-19 infection, compared to that provided by a naïve application of Kaplan-Meier approach. This allows for a proper interpretation/use of Covid-19 events in survival analysis. A user-friendly version of CoDMI is freely available at https://github.com/alef-innovation/codmi.

Multinational Study to Assess Stress Levels Among the Health Care Workers of Radiation Oncology Community at the Outset of the COVID-19 Pandemic.

PURPOSE: To evaluate stress levels among the health care workers (HCWs) of the radiation oncology community in Asian countries. METHODS: HCWs of the radiation oncology departments from 29 tertiary cancer care centers of Bangladesh, India, Indonesia and Nepal were studied from May 2020 to July 2020. A total of 758 eligible HCWs were identified. The 7-Item Generalized Anxiety Disorder, 9-Item Patient Health Questionnaire, and 22-Item Impact of Events Scale-Revised were used for assessing anxiety, depression, and post-traumatic stress disorder. Univariate and multivariate analysis was done to identify the causative factors affecting mental health. RESULTS: A total of 758 participants from 794 HCWs were analyzed. The median age was 31 years (IQR, 27-28). The incidence of moderate to severe levels of anxiety, depression, and stress was 34.8%, 31.2%, and 18.2%, respectively. Severe personal concerns were noticed by 60.9% of the staff. On multivariate analysis, the presence of commonly reported symptoms of COVID-19 during the previous 2 weeks, contact history (harzard ratio [HR], 2.04; CI, 1.15 to 3.63), and compliance with precautionary measures (HR, 1.69; CI, 1.19 to 2.45) for COVID-19 significantly predicted for increasing anxiety (HR, 2.67; CI, 1.93 to 3.70), depression (HR, 3.38; CI 2.36 to 4.84), and stress (HR, 2.89; CI, 1.88 to 4.43) (P < .001). A significant regional variation was also noticed for anxiety, stress, and personal concerns. CONCLUSION: This survey conducted during the COVID-19 pandemic revealed that a significant proportion of HCWs in the radiation oncology community experiences moderate to severe levels of anxiety, depression, and stress. This trend is alarming and it is important to identify and intervene at the right time to improve the mental health of HCWs to avoid any long-term impacts.

The impact of COVID-19 workflow changes on radiation oncology incident reporting.

BACKGROUND: The Ottawa Hospital's Radiation Oncology program maintains the Incident Learning System (ILS)-a quality assurance program that consists of report submissions of errors and near misses arising from all major domains of radiation. In March 2020, the department adopted workflow changes to optimize patient and provider safety during the COVID-19 pandemic. PURPOSE: In this study, we analyzed the number and type of ILS submissions pre- and postpandemic precautions to assess the impact of COVID-19-related workflow changes. METHODS: ILS data was collected over six one-year time periods between March 2016 and March 2021. For all time periods, the number of ILS submissions were counted. Each ILS submission was analyzed for the specific treatment domain from which it arose and its root cause, explaining the impetus for the error or near miss. RESULTS: Since the onset of COVID-19-related workflow changes, the total number of ILS submissions have reduced by approximately 25%. Similarly, there were 30% fewer ILS submissions per number of treatment courses compared to prepandemic data. There was also an increase in the proportion of "treatment planning" ILS submissions and a 50% reduction in the proportion of "decision to treat" ILS submissions compared to previous years. Root cause analysis revealed there were more incidents attributable to "poor, incomplete, or unclear documentation" during the pandemic year. CONCLUSIONS: COVID-19 workflow changes were associated with fewer ILS submissions, but a relative increase in submissions stemming from poor documentation and communication. It is imperative to analyze ILS submission data, particularly in a changing work environment, as it highlights the potential and realized mistakes that impact patient and staff safety.

Impact of the First Wave of COVID-19 Pandemic on Radiotherapy Practice at Tata Memorial Centre, Mumbai: A Longitudinal Cohort Study.

PURPOSE: Delivery of cancer care during the pandemic required adopting various changes in the standard management. We analyzed the impact of the first wave of the COVID-19 pandemic on radiation oncology treatment practices at Tata Memorial Hospital in India. MATERIALS AND METHODS: From March 1 to October 31, 2020, all consecutive patients who attended the radiation oncology department for radiotherapy treatment were included in this study. Electronic medical records, patient files, and telephonic consult were used to collect patient's data including changes in the standard treatment practice, COVID-19 testing and its results, and subsequent impact on radiotherapy treatment. Comparison was done with the same period data of 2019 for the number of the caseload, radiotherapy regimen, referral rates, and noncompliance rates. RESULTS: Our study included 4,256 patients with a median age of 52 years (interquartile range 41-61 years). There was a significant drop in the new-patient registrations (approximately 63%), radiotherapy consultations (44.9%), and referrals to other centers (27.8%). The reduction in the caseload was highest for genitourinary cases (-58.5%) and the lowest for breast cases (-11.5%) when compared with the 2019 cohort. Among those treated with radical intent, the noncompliance rate was 15%. Hypofractionation was the commonly adopted regimen across all sites. Compared with 2019, the maximum reduction in the average fractions per patient was seen in the breast cancer cases (-8.2 fraction), followed by genitourinary cases (-4.9 fraction). Of the 27.8% of patients tested for COVID-19, 13.4% turned positive and 3.4% died due to the disease. CONCLUSION: The COVID-19 pandemic adversely affected the number of radiotherapy consultations and treatments at our institute. However, our department offered uninterrupted services despite grave challenges. Hypofractionated regimen was used across disease sites to minimize patient visits and allow planned treatment completion. Radiotherapy was delivered safely, and patients experienced low rates of COVID positivity during radiotherapy and even lower mortality.

Near-Peer Teaching in Radiation Oncology: a Proof of Principle Study for Learning Treatment Planning.

Radiotherapy techniques are expanding in range and complexity; therefore, protecting learning environments where residents nurture treatment planning skills is critical. The evidence base for 'near-peer' teaching (NPT), where professionals at a similar career stage assist in each other's learning, is growing in hospital-based disciplines, but has not been reported in radiation oncology. The feasibility of a resident-led teaching programme for developing treatment planning skills was investigated herein with quality improvement (QI) methodology. Following consultation with attendings (n = 10) and all residents (n = 17) at the two cancer centres in the region, a regular NPT session focused on planning skills was initiated at the largest centre, with video-linking to the second centre. Tutorials were case-based and pitched at the level of qualifying examinations. Plan-Do-Study-Act (PDSA) cycles were designed based on primary and secondary improvement drivers derived by group consensus among residents, with tutorials adopted accordingly. Participation, content, and satisfaction were monitored for 20 months. Six PDSA cycles reformed the tutorial format, leading to logistical and pedagogical benefits including interprofessional contributions and enhanced interactivity. Tutorials occurred on 85% prescribed occasions (n = 45) during the subsequent 18-month follow-up, with 25 distinct tumour sites featured. Resident participation and satisfaction increased, independent of resident seniority. Tutorials were paused for the first 2 months of the SARS-CoV-2 pandemic only. A high-quality and cost-effective regional, trainee-led teaching programme on treatment planning was feasible and cost-effective in this study.

Failure to attend radiation oncology appointments during COVID-19: Analysis of data from an Australian public hospital.

INTRODUCTION: COVID-19 has impacted lives worldwide. Public health guidance has advocated for minimisation of infection risk by encouraging social isolation and physical distancing. In response, many health services have changed delivery practices to increased use of telehealth. We undertook an audit of hospital attendance data collected from a radiation oncology service in a large public hospital in Victoria, Australia between January and September in 2019, and the same period in 2020. The aim was to discern the impact of COVID-19 on attendance at appointments and whether attendance rates differed by appointment type. METHODS: Attendance data and appointment type for the two targeted periods (a total of 62,528 appointments for 3383 patients) were extracted from the database maintained by the radiation oncology service. Logistic generalised estimating equation (GEE) models were run with the final model including the COVID-19 period (pre, during) and all patient and appointment characteristics. RESULTS: Results indicated a small decrease in attendance in 2020 (OR = 1.13, 95% CI 1.01-1.25, P = 0.026) with this predominantly reported for the non-treatment appointments, which consisted of follow-up appointments, nurse appointments, and treatment review appointments. CONCLUSION: Attendance for radiation oncology treatment was largely unaffected by COVID-19 although other services experienced slight reductions. Changes to work practices, specifically the increased use of telehealth, may have moderated the impact. Given the focus on one service in one location, it is not possible to generalise these results and future research should closely monitor both patient and staff satisfaction with services delivered via modified processes.