A two-center experience: The impact of COVID-19 on two brachytherapy programs in Ontario - virtual care, service suspension and radiation therapy workflow.

INTRODUCTION: Most brachytherapy (BT) procedures require general anesthesia and are therefore considered aerosol generating medical procedures (AGMPs). The COVID-19 pandemic impacted BT as services were prioritized by balancing the harm associated with COVID-19 infection versus the effect of delay of potentially curative treatment. This article summarizes the impact of the pandemic on BT programs in two cancer centers in a Canadian province. METHODS: As part of a quality assurance project, a retrospective study was conducted for the first five months of the pandemic (March 1 to July 31, 2020). Chart review and COVID-19 related mitigation strategies were identified by BT Clinical Specialist Radiation Therapists (bCSRT) in each center using electronic medical records, departmental reports, policies and procedures. RESULTS: Impact included start of virtual care (VC), shortened fractionation, suspension of services and workflow changes.  Both centers implemented VC strategies to reduce clinic visits: "same-day size and treat" strategy for post-operative endometrial cancer patients and virtual patient education for all patients. BT services that were suspended were low-dose-rate and high-dose-rate (HDR) prostate treatments (Center 1), lung and esophagus HDR treatments (Center 2).  Workflow changes that affected staff and patients in both centers included COVID-19 screening and the use of personal protective equipment. The centers were marginally different in workflow adjustments for AGMP procedures.  Those considered high-risk AGMP and low-risk cancer were suspended temporarily with alternate treatment strategies sought for some patients. Others had temporizing treatment such as androgen deprivation therapy to facilitate oncological safe deferral of procedures. CONCLUSION: Both BT programs delivered treatment to most patients with minimal delays and cancellations, where feasible. Some of the pandemic workflow changes continued to the current state of the pandemic. Long-term follow-up is needed to assess the impact of COVID-19 and treatment interruptions on oncologic outcomes.

The impact of COVID-19 on Brachytherapy Workflow: a two-centre experience

The COVID pandemic has impacted radiotherapy (RT) workflow, including brachytherapy (BT). BT is an integral part of RT, many BT procedures require the support of general anesthesia and are considered aerosol generating medical procedures (AGMPs). During COVID pandemic, AGMPs required additional infection control precautions. This work summarized the impact of the COVID-19 pandemic on the BT program in two distinct cancer centres, located in Ontario, Canada. The study period was March 1 to July 31, 2020, the 'first wave' of pandemic. The two centres are 73 km apart and located in a city with population of 2.79 million (Centre 1) and 0.7 million (Centre 2) respectively. BT services offered by these centres were high-dose-rate (HDR) treatments to post-operative endometrial cancers (Centre 1&2), cervix cancer (Centre 1), prostate cancer (Centre 1), lung cancer (Centre 2), esophagus cancer (Centre 2) and low-dose-rate (LDR) treatments to prostate cancer (Centre 1) and ocular cancer (Centre 1). A retrospective program audit was conducted as part of a quality assurance project. Data sources were identified by the BT Clinical Specialist Radiation Therapist (CSRT) in each centre using the radiation therapy electronic medical records (RT-EMR) system, electronic medical records and departmental reports, policies and procedures. COVID impact on BT services and workflow were recorded. BT SERVICES: Both centres continued to treat non-AGMP for post-operative endometrial cancer patients. However, BT services for AGMP procedures were on hold: LDR and HDR prostate treatments (Centre 1), HDR lung and esophagus treatments (Centre 2). The lung and esophagus cancer patient group had the most impact as patient were offered non-BT treatments for symptoms relieve. WORKFLOW: both centres implemented virtual care strategies for review and follow up appointments where telephone consultation were used. Both centres had a 'no visitor' policy in their hospital. Both centres adopted a "size and treat" strategy for non-AGMP HDR treatment to the vaginal vault. The strategy was implemented to eliminate one hospital visit required by post-operative endometrial cancer patients. Both centres used appropriate personal protective equipment (PPE) to reduce occupational exposure to staff. For AGMP (Centre 1), there is a change in anesthesia workflow where only anesthesia staff remained in the BT procedure room with doors closed during intubation and extubation. At the end of the procedure, the doors were closed for 30 minutes to allow sufficient room air exchange. Centre 1 and 2 had differences in asymptomatic COVID screening & test requirement for AGMP and non-AMGP. The centres were marginally different in their approaches to adjusting their BT workflows in AGMP and non-AGMP procedures. BT treatments that are considered high-risk AGMP and low-risk cancer were on hold temporarily. Both BT program delivered treatment to most patients with minimal delays and cancellations.

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.

FIGHTING THE EDUCATION REVERSAL FROM COVID-19: STEPPING UP TO SUPPORT ELEMENTARY AND HIGH SCHOOL STUDENTS WITH EXTRACURRICULAR ACTIVITIES

COVID-19 has affected student learning to a daunting extent. The United Nations projects that the pandemic could wipe out the progress achieved in education over the past 20 years. Worldwide, the pandemic is expected to lead to more than 100 million students in grades one through eight falling below minimum reading proficiency, with similar results expected for mathematics proficiency. In the US, such negative educational outcomes have disproportionately fallen on minority and socioeconomically disadvantaged students. Regardless of the pandemic, limitations on the number of teachers and other resources have long created a roadblock in the fight for "quality education for all." Here, Chan focuses on the need to support elementary and high school students with extracurricular activities to fight the educational reversal from COVID-19.

How Education Brings Us Together

Chan discusses the transition to remote teaching in the midst of the COVID-19 pandemic. March 2020 marked a historical moment for educators in the US and around the world. The World Health Organization (WHO) declared the COVID-19 a pandemic and almost instantaneously, many postsecondary institutions started suspending on-campus, face-to-face classes and transitioning to remote instruction to support social distancing practices. Administrators, instructors, students and their families worked together, with education binding us, to work on a common goal--to continue to empower and be empowered with knowledge in the midst of COVID-19. With uncertainty on whether we will be able to move back to campus in the upcoming fall semester, it is time to look at some lessons learned to prepare for the path forward.