Radiation Oncology Department Research Articles

Assessment of Pain Management in Patients Referred to Radiation Oncology for Palliation of Acute Pain Symptoms

<h3>Purpose/Objective(s)</h3> More than half of cancer patients experience pain during their disease course. The three-step analgesic ladder developed by the World Health Organization promotes appropriate escalation from non-opioid analgesics to increased strength opioids. Despite these established guidelines, patients are often under-treated for their intensity of pain. The aim of this study is to investigate whether patients sent to a tertiary center Radiation Oncology department for acute pain symptoms are appropriately pharmacologically managed before and after presenting for a consultation. <h3>Materials/Methods</h3> This retrospective review of cancer patients seen in consultation for palliative radiation analyzed patients seen in consultation for acute pain management between July 23, 2020, and July 23, 2021. Clinical data including patient and treatment characteristics, cancer type, pain scores and medication lists were abstracted for all identified patients. Statistical analysis was performed using univariate and multivariate logistic regression models to assess patient characteristics associated with severe pain. <h3>Results</h3> The mean overall pain score was 5.95 (SD 2.53). Patients were stratified into mild to moderate pain (pain score 1-6) or severe pain (pain score 7-10). Among 137 patients, 54.7% (n=75) presented with mild to moderate pain and 45.3% (n=62) presented with severe pain. In patients presenting with severe pain, 67% had been prescribed morphine milligram equivalents (MME) of less than 50, and 35% had been prescribed MME of less than 25. Patients who identified as African American (OR 3.35, p=0.008) were more likely to present with severe pain compared to Caucasian patients, and patients insured by Medicaid (OR 3.61, p=0.018) were more likely to present with severe pain compared to patients with private insurance. Age, gender, marital status, and establishment of medical oncology care prior to consultation did not predict severe pain. <h3>Conclusion</h3> Patients presenting for a consultation to receive palliative radiotherapy for acute pain management are often not on adequate pain medications and have not been provided with pain/palliative care referrals. Patients who are African American present at higher rates of severe pain in comparison to Caucasian patients. Patients insured with Medicaid present at higher rates of severe pain than patients with private insurance. Our findings add to a body of literature, highlighting the inequities in providing adequate pain management to all populations. The findings of this study should promote the development of standardized protocols for cancer patients receiving palliative care for pain.

Patients Seen in Radiation Oncology Who Use Cannabis Are More Likely to Also Have Active Prescriptions for Opiates or Benzodiazepines

<h3>Purpose/Objective(s)</h3> With changes in state legal frameworks governing cannabis access, more people in the United States have begun using cannabis. Individuals with cancer endorse many reasons for cannabis use in the face of limited data. Some have suggested that cannabis may serve as an alternative to prescription medications such as opioids, benzodiazepines, and sleep aids for symptom management. We hypothesized that patients with cancer using cannabis would be less likely to have active prescriptions for these medication classes commonly used to manage pain, anxiety, and insomnia, respectively. <h3>Materials/Methods</h3> Clinician-collected cannabis history data documented via an electronic medical record-embedded form were abstracted using Michigan Radiation Oncology Analytics Resource (M-ROAR) for adult patients seen in an academic radiation oncology department from 10/2020 to 11/2021 under an IRB-approved protocol. Logistic regression was used to explore associations between recent cannabis use and prescriptions for narcotics, benzodiazepines, and sleep aids. <h3>Results</h3> Data were available for 3059 unique patients, including 343 (11.2%), 235 (7.7%), and 2481 (81.1%) endorsing recent (in the last month), non-recent only (use of cannabis in the past but not in the last month) and no history of cannabis use, respectively. Among those who recently used cannabis, 6.1% used cannabis more than 1 time per day, 54% used cannabis daily, and 21% used cannabis at least weekly but not every day. Most patients smoked cannabis (46%) or used edible forms of cannabis (35%). The most common reasons for cannabis use were pain (27%), insomnia (18%), and anxiety (15%), so we examined concurrent use of cannabis along with prescription opiates, sleep aids, and benzodiazepines. Patients who recently used cannabis were more likely to have an active prescription for an opioid medication (OR: 1.52; 95% CI: 1.21, 1.905; p <0.001) than patients who did not report recent cannabis use. There was no relationship between sleep aid medication prescription and recent cannabis use (OR: 0.62; 95% CI: 0.27, 1.43; p=0.261), but individuals using cannabis were more likely to have an active prescription for a benzodiazepine (OR: 1.40; 95% CI: 1.07, 1.82; p = 0.013). <h3>Conclusion</h3> The use of prescription opiates and prescription benzodiazepines is more prominent in patients who endorse cannabis use. Our data therefore do not support the hypothesis that cannabis use eliminates the need for medications to manage pain or anxiety. This suggests that for many patients, cannabis is used as an adjunct alongside conventional evidence-based therapies for symptom control and not as an alternative to such agents. Patient education is key to help individuals with symptoms locate evidence-based therapies and optimize them for safety and efficacy as we await high quality evidence that supports or refutes the efficacy of cannabis for management of many symptom classes in patients with cancer.

Evaluating the Short-Term Environmental and Clinical Effects of a Radiation Oncology Department's Response to the COVID-19 Pandemic (STEER COVID-19)

Purpose/Objective(s)During the COVID-19 pandemic, hypofractionated regimens and virtual care was adopted by our institution to preserve hospital capacity and reduce foot traffic. This study's primary objective was to assess the collective environmental impact of these strategic changes by identifying sources of carbon dioxide equivalents (CO2e). As sustainable healthcare is only justifiable if the quality of the care is maintained, we also evaluated the rate of radiation-related acute adverse event.Materials/MethodsAll patients treated with external beam radiation therapy from April 1, 2019 to March 31, 2021 at our single institution were identified (n=10,175) along with their radiotherapy visits (176,423 fractions), and visits to the radiation nursing clinic (RNC) or emergency (ER) department. A treatment regimen was considered hypofractionated if the dose per fraction was ≥ 240 cGy. If the dose per fraction was ≥ 600 cGy and the total dose of the treatment regimen was > 2000 cGy, then the treatment regimen was classified as SBRT. Out-patient hospital and virtual visits (n=75,853) during this same period were also analyzed. Environmental impact measures, including linear accelerator power usage, patient travel distances, and personal protection equipment (PPE) consumption were all converted into CO2e. A waiver of individual patient consent was granted for this study by our institution's Research Ethics Board (REB).ResultsThe use of curative hypofractionated regimens increased from 17% to 27% during the pandemic year. Twelve out of 15 cancer sites increased their use of hypofractionated regimens. Carbon footprint was reduced by 39% during the pandemic year (1,332,388 kg CO2e) as compared to the pre-pandemic year (2,024,823 kg CO2e). For comparison, the 744 tonnes of CO2e saved during the pandemic year equates to the CO2e produced by the annual energy consumption of 182 Canadian households or the CO2e sequestered by 12,000 seedling trees planted and grown for 10 years. On average 121 kg CO2e and 100 kg CO2e were emitted per radiation regimen delivered during the pre-pandemic and pandemic year, respectively. Comparing patients in the pre-pandemic vs. pandemic year, there was a significant reduction in the proportion of hypofractionated patients who needed a visit to either the RNC (39% vs. 25%; p<0.001) or ER (6% vs. 2%; p<0.001) during and within 90 days of radiotherapy.ConclusionThis study demonstrated the environmental benefits of increased use of hypofractionated regimens and virtual care, while assuring that there was no added acute radiation-related adverse event. Our findings support their continued use as one of many long-term strategies to reduce the environmental footprint of healthcare delivery. Treatment efficacy and side-effects will need to be assessed in subsequent years to further support the sustainability of these strategies.

Integration of Telemedicine Consultations into a Tertiary Radiation Oncology Department: Predictors of Treatment Yield and Changes in Patient Population Compared to the Pre-Pandemic Era

Purpose/Objective(s)The COVID-19 pandemic has proven telemedicine to be an efficient and safe method of healthcare delivery with the potential to increase accessibility for underrepresented groups. Given the anticipated permanence of telemedicine in radiation oncology practice, we aimed to understand the demographic and treatment characteristics of patients presenting for consultation via telemedicine, the predictors of patients opting to receive radiation therapy (RT) at our center, and the differences in patient and treatment characteristics compared to 2019, when consultations were exclusively in person.Materials/MethodsWe included all patients who had telemedicine consultations from March 2020 to February 2021. Treatment yield was calculated by dividing the number of patients who ultimately received RT by the total number of consults. New consultations seen in 2019 were reviewed and compared to the telemedicine cohort. Chi-square tests were used to identify differences.ResultsFrom 2020 to 2021, a total of 1,069 patients had telemedicine consultations (86% video, 14% phone). Most (64%) were male. Median age was 63 years. The most common disease sites included genitourinary (GU) (41%), breast (14%), and CNS (9%). Six-hundred forty-five (60%) had private insurance, while 424 (40%) had Medicare/Medicaid. Patients lived a median of 241 miles (IQR 96-481 miles) from the radiation oncology center. Forty-four percent of telemedicine patients ultimately received RT. These patients underwent photon RT (54%), proton RT (35%), brachytherapy (7%), stereotactic radiosurgery (3%), or intraoperative RT (1%). No differences were noted in age, sex, race/ethnicity, or insurance type between patients who did and did not receive RT. Patients who received RT lived closer to the center (median 287 vs. 189 miles, p<0.001). For patients within 100 miles of our center, 58% received RT, compared to only 32% of those who lived at least 500 miles away. Patients with gynecologic (76%) and hematologic (72%) malignancies were most likely to receive RT. Compared to 2019 when all 6,116 patients were seen in person, treatment yield was lower with telemedicine (67% vs. 44%, p<0.001). Telemedicine patients were more likely to be male (56% vs. 64%, P<0.001), white (93% vs. 95.0%, p=0.024), have private insurance (55% vs. 60%, p=0.0053), have a GU malignancy (24% vs. 41%, p<0.001), and live further from the center (median 241 vs. 139 miles, p<0.001).ConclusionPatients seen in telemedicine consultations lived further away and were less likely to receive RT at our tertiary care radiation oncology center. Telemedicine visits did not appear to improve healthcare access for underrepresented groups. Further analysis is warranted to identify gaps and opportunities in remote care.

Usefulness of the G8 Screening Tool in Determining Treatment Strategies for Definitive Radiotherapy of Esophageal Cancer in the Elderly

<h3>Purpose/Objective(s)</h3> Recent clinical trials for chemoradiotherapy (CRT) in esophageal cancer, such as ARTDECO and CONCORDE used elective nodal irradiation (ENI). However, it is often difficult to perform standard CRT for the elderly in the real world, and also there is no clear consensus on the criteria for this decision. Recently the G8 screening tool for geriatric assessment has been attracting attention in the oncology field. This study aimed to investigate the relationship between the treatment strategy of definitive RT and the G8 score for esophageal cancer in the elderly. <h3>Materials/Methods</h3> We analyzed 81 esophageal cancer patients aged ≥65 years (27 aged ≤74 years, 26 aged 75-79 years, and 28 aged ≥80 years) who received definitive RT between 2018 and 2021. The G8 screening tool was performed at the first visit to the radiation oncology department. The treatment strategy was decided by a conference between the radiation oncologist and esophageal surgeon, and the G8 score was not used to determine the treatment strategy. Standard RT was defined as ENI and a total dose ≥50 Gy, and standard chemotherapy (ChT) was defined as two cycles of platinum (70 mg/m2) and 5FU (700 mg/m2 for 4 days) concurrently. Patients who underwent standard RT and standard ChT were defined as the standard group and the rest as the non-standard group. The Mann-Whitney U test was used to compare the two groups, and statistical significance was set at p<0.05. The Receiver Operating Characteristic (ROC) curve was used to calculate the cutoff value. <h3>Results</h3> The mean G8 scores by age were 12.7 (range: 7-17) for ≤74 years, 12.9 (range: 7-17) for 75-79 years, and 10.4 (range: 4.5-15) for ≥80 years, and significantly lower scores for ≥80 years, but no significant difference between ≤74 and 75-79 years. There were 26 patients in the standard group, of which only one was ≥80 years. In the patients ≤79 years, the G8 score was significantly higher in the standard group (mean: 13.9 points in the standard group and 11.6 points in the non-standard group) (p<0.01), but age was not significantly different between the standard and non-standard groups (p=0.94). The cut-off value of the G8 score calculated by the ROC curve was 13 points. In patients ≥80 years, 10 patients received CRT (1 standard ChT, 9 reduced ChT), and 15 of 18 patients in the RT alone group received only local RT. In the patients ≥80 years, the G8 score was significantly higher in the CRT group (mean: 12.5 points in the CRT group and 9.2 points in the RT group) (p<0.01), but age was not significantly different between the CRT and RT groups (p=0.08). The cut-off value of the G8 score calculated by the ROC curve was 12 points. <h3>Conclusion</h3> Our results suggest that the G8 screening tool may be useful in determining the treatment strategy of definitive RT for esophageal cancer in the elderly. Future investigation of the relationship between the G8 score and treatment outcomes is required.

From Alpha to Omicron: A Tertiary Care Hospital-Based Radiation Oncology Network's COVID-19 Response Experience

Purpose/Objective(s)The COVID-19 pandemic completely altered access to medical care, severely limiting or halting outpatient procedures over long periods of time. However, it was clear that radiation therapy needed to remain available to patients. We implemented asymptomatic testing algorithms and constructed negative air pressure CT simulator and treatment rooms within our tertiary care hospital-based Radiation Oncology network to accommodate the safe treatment of patients affected by the COVID-19 pandemic.Materials/MethodsOur Radiation Oncology department undertook dedicated construction to convert select CT simulator rooms and treatment vaults into negative pressure environments, including one CT simulator room and photon-based linear accelerator treatment vault at the main campus in 5/2020; and one CT simulator room, two photon-based linear accelerator vaults, and a single proton therapy gantry between two regional campuses in 12/2021. From 5/18/20 to 9/7/21, an asymptomatic screening protocol was implemented for all patients prior to initiation of radiation therapy. Patients with COVID-19 infection and Persons Under Investigation (PUIs) could undergo simulation and/or treatment in the newly constructed biocontainment environments at the discretion of the treating physician with guidance from a predefined priority scale. A biocontainment treatment protocol delineated specific roles within a treatment team of one Nursing Safety Officer, one Direct Contact Radiation Therapist, and one Indirect Contact Radiation Therapist. Safety drills were performed to establish and practice safe pathways for escorting patients directly from their car to the treatment room, and vice versa, for the last treatment slot(s) of the day. Patients who were treated under COVID-19 protocol from 6/2020 to 1/2022 were chart reviewed to assess utilization of our newly constructed and developed biocontainment resources.ResultsA total of 6,525 patients were treated from 6/2020 through 1/2022 across our 5 campuses. During this time, 42 patients were treated under the COVID-19 biocontainment protocol. All but 3 had documented personal COVID-19 positivity, while the others were designated as PUI, typically for COVID-positive household contacts. For 61.9% of patients, these safety measures mitigated the need for extended breaks during treatment courses that had already been initiated. The majority (64.3%) of patients were being treated with curative intent, while 10 patients (23.8%) were treated as a result of an inpatient palliative consult. A third (35.7%) were transferred from a regional campus to the main campus for management prior to expansion of biocontainment resources. The median number of biocontainment sessions required by each patient was 6 (range: 1-15).ConclusionThe construction of negative pressure environments and development of a COVID-19 biocontainment protocol have helped to mitigate the impact of the pandemic on our patients and to maximize efforts in protecting our staff.

Improving Radiation Quality Through the Implementation of Prospective Peer Review

<h3>Purpose/Objective(s)</h3> Quality assurance (QA) is critical to the successful delivery of radiation therapy (RT) for cancer patients and also impacts outcomes. The present study reports the longitudinal results of a prospective peer review evaluation system (PES) implemented at a major academic health system as an integral part of RT QA. <h3>Materials/Methods</h3> All patient cases treated with RT by one of 32 physicians at 14 treatment locations within our radiation oncology department undergo prospective peer review in daily rounds. Each case is assigned a grade (A, B, C) based on the following criteria: clinical suitability for RT, prescription, contours, and treatment plan, where applicable. "A" cases require no changes, "B's" require minor modification, and "C's" require major modification with re-review prior to treatment planning. The present study is a longitudinal analysis of grade trends over time by hospital, plan type, and physician. The Wilcoxon-signed-ranked test was used to compare grades during the baseline PES period (2013-2016) to the follow-up period (2017-2021). A p-value below 0.05 is considered significant. <h3>Results</h3> A total of 20,069 cases for 14,300 patients were reviewed from September 2013 to November 2021. Of the total cases, 15,659 (78%) were curative and were included in the present analysis; 5,868 from the baseline period and 9,791 in the follow-up period. The fraction of A cases decreased from 74.8% (baseline) to 64.5% (follow-up), while the fraction of B's increased from 19.4% (baseline) to 35.4% (follow-up), and the fraction of C's decreased from 5.8% (baseline) to 0.1% (follow-up). The main hospital site contributed 54.8% of all cases and 48.1% of all B grades. IMRT plans accounted for 55.4% of all plans and 68.2% of all B scores, while 3D-conformal plans accounted for 24.4% of cases and 15.4% of all B scores. When normalized by total department A/B/C scores, there were no statistically significant changes in percent A/B/C scores over the time period studied (p-value> 0.05). However, for the 13 physicians with cases throughout the study period, there was a statistically significant increase in the fraction of B scores (p value = 0.01) and decrease in the fraction of C scores (p value < 0.01) between the two time periods when individual physician grades were normalized to their individual caseload. <h3>Conclusion</h3> PES improves the identification of quality-related factors that can impact downstream radiation treatment plan quality. The diminishing fraction of C grades over time indicates amelioration of ‘major failures,' which were addressed in the startup years of PES. The proportional increase in B's, at the cost of fewer putative A's, suggests increased scrutiny of cases, as well as findings-based improvements in contouring and planning, over time. Peer review rounds upstream of treatment planning provides valuable RT QA and should be considered by other departments to enhance the quality and consistency of RT.

Radiation Oncology Microclerkship: A Day in Radiation Oncology as a Component of Other Related Clerkships

<h3>Purpose/Objective(s)</h3> Many US medical students have opportunities for clinical exposure to medical oncology, surgical oncology (or other surgical subspecialties) during the required internal medicine, pediatrics, surgery, and OB/GYN clerkships. However, radiation oncology (RO) lacks a similar natural pathway into the clinical clerkships, and only a small percentage of students choose to rotate in RO, thus substantially limiting a broader understanding of the role of radiation therapy in multidisciplinary cancer care among other practicing physicians. The hypothesis of this study is that incorporating a 1-day "microclerkship" exposure in RO as part of other related clerkships will be feasible, and perceived as valuable to participating students. <h3>Materials/Methods</h3> The RO clerkship director at a single institution partnered with clerkship directors in medical oncology, palliative care, and radiology so that every 3^rd or 4^th year student rotating in those specialties would spend 1 day in RO during those clerkships. Students were given educational materials to review beforehand, a 30-minute introductory recorded presentation about general principles of RO to watch, as well as a slide deck or article describing how radiation therapy is relevant to patient care for the subspecialty of the primary clerkship they were on. At minimum, the day in RO included shadowing a single radiation oncologist in clinic, and the therapists as patients were treated, but sometimes also included tumor board, brachytherapy or treatment planning if part of the attending's day. Students completed a follow-up electronic survey about their experience afterwards. <h3>Results</h3> Pilot data of 18 students are reported, of whom 4 reported being 3rd year medical students and 12 reported being 4th year medical students. Only 1 had ever seen a prior lecture from a radiation oncologist and 1 had visited a RO department. On a 5-point Likert-type scale, 16 students (89%) rated the experience a 4 or 5 (quite or extremely valuable). Seventeen students (94%) felt moderately to extremely more knowledgeable about the role of radiation therapy in cancer management. Ten students (63%) were potentially more interested in doing a full RO rotation, and 4 students (25%) were more interested in a career in RO, after this experience. <h3>Conclusion</h3> Preliminary data suggest a valuable role of incorporating RO exposure into other related medical student clerkships. In the coming months, more students will participate from these clerkships as well as others, and the project will be expanded to multiple institutions. We believe that utilizing this approach will drastically improve the amount of RO exposure for US medical students, and all subsequently have a positive impact on referral patterns and multidisciplinary patient care.

A Comprehensive Overview of Academic Radiation Oncology Departmental Efforts in Diversity, Equity, and Inclusion

<h3>Purpose/Objective(s)</h3> Consistent and intentional promotion of diversity, equity, and inclusion (DEI) efforts within healthcare is a critical step to eliminate health inequities. While health systems and medical schools have traditionally promoted such efforts through dedicated offices and leaders, individual departments within institutions are increasingly organizing to create formal, department-level DEI initiatives. Although considerable work has been done to examine and improve DEI efforts in radiation oncology (RO), little data are available describing current departmental-level DEI efforts. The purpose of this study was to examine and describe current RO departmental-level DEI efforts, obstacles, successes, and perceived impact. <h3>Materials/Methods</h3> Department chairs and or program directors from 124 RO departments with affiliated medical schools were contacted to inquire whether their department had a formal DEI leader. An invitation to participate in an anonymous survey was sent to DEI leaders from June to July 2021. Electronic surveys consisted of multiple choice, five-point Likert-type scale, and open-ended free-text questions regarding demographics of RO DEI leaders, existence of a DEI committee, involvement of other department members, connection with the institution, departmental DEI activities, support for DEI activities, barriers to success, and perceptions of impact. Descriptive statistics and qualitative summary of free text responses were reported. <h3>Results</h3> Among the 124 RO departments contacted, there were 85 respondents (68.5% response rate). Of the respondents, 48 (56.5%) reported having a departmental DEI leader and were invited to participate with a total of 34 (70.8%) participants completing the survey. DEI leadership demographics included 25 women (73.1%), 28 assistant or associate professors (82.2%), and 18 identifying as of non-White race or Hispanic ethnicity (53.6%). Of the 19 (55.9%) departmental DEI committees, over half (n=10, 52.6%) started in 2020 or later. Resources for DEI efforts were not commonly provided, with only a few respondents reporting receipt of administrative support (38.2%), funding (29.4%), protected time (23.5%), or increased compensation (23.5%). Among respondents, the perceived impact of DEI initiatives included an increased culture of respect (89.7%) and an improved awareness of both healthcare inequities (75.9%) and systematic/structural racism (79.3%). <h3>Conclusion</h3> Departmental DEI efforts are increasingly common within RO, however, the structure, resources, and recognition associated with DEI work are variable. Additional dedicated resources and recognition for these efforts will help ensure a culture of inclusive excellence for the RO workforce and patients.

The prevalence and genetic disorders spectrum of thalassemia among breast cancer patients in Jiangxi province, China.

Background: Thalassemia is a common inherited hematological disease with genetic disorders characterized by imbalanced synthesis of the globin chains. Due to the improvement of treatment methods, patients with thalassemia can survive for a long time. Therefore, it is not uncommon for patients with thalassemia suffering from malignant tumors. However, there are quite few reports on thalassemia patients complicated with breast cancer. Herein, we try to investigate the prevalence and genetic disorders spectrum of thalassemia in patients with breast cancer. Methods: Blood routing tests and serum ferritin analysis were conducted in 1887 breast cancer patients treated in the department of radiation oncology during 1 April 2020 and 30 March 2022. The suspected thalassemia carriers with small mean corpuscular volume (MCV), mean corpuscular hemoglobin content (MCH) or mean corpuscular hemoglobin concentration (MCHC) but the concentration of serum ferritin within normal limits were further investigated by polymerase chain reaction (PCR) and flow through hybridization gene chip to detect common mutations of α-globin and β-globin genes using Thalassemia Geno Array Diagnostic Kit. The prevalence and genetic mutation spectrum of thalassemia among breast cancer patients were analyzed. Results: Four hundred and eighty-nine suspected thalassemia carriers were detected by complete blood cell counts and serum ferritin analysis among 1887 breast cancer patients. One hundred and seven cases (5.7%) were identified as carriers of thalassemia, of which 55 cases (51.4%) were α-thalassemia, 50 cases (46.7%) were β-thalassemia, and 2 cases (1.9%) were co-inheritance of α-thalassemia and β-thalassemia simultaneously. In α-thalassemia, the most prevalent genotype is -SEA/αα; as for β-thalassemia, βIVS-II-654/β is the most common genotype. The degree of anemia is more severe in β-thalassemia than in α-thalassemia. Conclusion: This is the first comprehensive molecular epidemiological investigation on thalassemia among breast cancer patients. Our data indicated that thalassemia was not uncommon in breast cancer patients. The physicians should have the knowledge to avoid misdiagnosis as iron deficiency anemia.

Optimizing outpatient oncology consult workflow using time-driven activity-based costing: Efficiency and financial impacts.

9 Background: Clinical efficiency is a key component of value-based healthcare, patient satisfaction, staff burnout, and institutional operational capacity. The objective of this study was to identify clinic inefficiencies using time driven activity-based costing (TDABC) and evaluate the implementation of a new clinical workflow in high volume, outpatient radiation oncology clinics. Methods: We conducted an IRB-approved quality improvement study in the Gastrointestinal (GI), Genitourinary (GU), and Thoracic Radiation (TRO) Oncology departments at a large academic cancer center and four additional network sites (HALs). TDABC methodology was used to create process maps and optimize consult workflow. Patient encounter metrics were captured utilizing a real-time status function in the electronic medical record (Epic Systems). Anonymous patient satisfaction telephone surveys were administered to patients at the HALs. Hourly wages were determined based on 2021 U.S. Bureau of Labor Statistics. Pre- vs post-implementation metrics were compared using the Mann-Whitney U test. Results: Consult data for 1328 patients pre-intervention and 1234 post-intervention across all sections was included. Median overall cycle time was reduced by 21% in GI (19 min, p &lt; 0.001), 18% in GU (16 min, p &lt; 0.001), and 12% in HALs (9 min, p &lt; 0.001). The median interval between rooming and being seen by the attending physician decreased by 13% in GI (7 min, p &lt; 0.001), 16% in GU (9 min, p &lt; 0.001), 21% in TRO (10 min, p &lt; 0.001), and 9% in HALS (4 min, p &lt; 0.005). For each consult, there was a median financial savings of $29 for GI, $24 for GU, $5 for TRO, and $14 for HALs per consult. From patient satisfaction surveys (95/177), 99% of patients reported their providers spent adequate time with them, 85% reported their appointment began on time, and 91% reported being seen by a care provider in a timely manner. Conclusions: TDABC is a successful method to identify opportunities to improve clinical efficiency. Implementing workflow changes based upon these findings led to substantial reduction in overall encounter cycle times and patient wait times across multiple departments. Furthermore, patient satisfaction was high and there were significant financial savings with the new workflow. These findings may also have implications for reducing staff burnout and expanding clinical capacity across the magnitude of clinical enterprise.[Table: see text]

REVIEW OF THE ROLE OF BRACHYTHERAPY IN THE MANAGEMENT OF ORAL CAVITY CANCERS

From the day of invention of Radium, brachytherapy has been practised worldwide. Can any technological advancement in external beam radiotherapy replace brachytherapy? Answer probably no, especially in Gynaecological cancers as categorically stated by GEC-ESTRO experts. External beam radiation therapy using contemporary conformal techniques and brachytherapy play a signicant role in the management of oral cavity cancer. Small sized tumors in most of the oral cavity sites can be managed with brachytherapy alone either with intraoral cone or interstitial brachytherapy in order to minimize exposure of normal tissue. As these techniques do not treat regional lymph node basins, they are only appropriate to use as a single modality in selected stage I and II patients. The risk of occult nodal involvement in stage I and II is very low. External beam radiation therapy to the draining lymph node regions is used as the primary mode of irradiation when regional lymph nodes are at signicant risk for subclinical involvement, and brachytherapy may be added as a boost to the primary tumor. Since head and neck cancers are Surgeons domain, number of patients reporting to Radiation Oncology department is too low to carry out large randomized trial. Most of the patients report to Radiation Oncology department in either in late stage or in an early stage with poor general condition. This paves the way for selection bias and, of course, inferior results when compared with other modality. To evaluate the role of this therapy in treatment of head and neck cancers, we have reviewed its outcomes with oral cavity cancer. In conclusion, brachytherapy with or without EBRT can be an alternative to surgery in early and locally advanced oral cavity cancers although concrete evidence is yet to be produced with a sophisticated study in a reproducible manner

Treatment Interruption and Hospital Admission in Head and Neck Cancer Patients during Concurrent Chemoradiotherapy with or without Prophylactic Nasogastric Tube Feeding

Background: Worldwide, head and neck cancer (HNC) was the 6th most common cancer in 2020 in all ages and both sexes. In Bangladesh, lip and oral cavity cancer was the 2nd most common cancer in 2020. Up to 60% of HNC patients presents with locally advanced disease. Aim and Objective: To determine treatment Interruption and hospital admission in head and neck cancer patients during concurrent chemoradiotherapy with or without prophylactic nasogastric tube feeding. Materials and Method: A quasi-experimental study was performed in Radiation Oncology Department of National Institute of Cancer Research &amp; Hospital from 1st January 2020 to 31st December 2020. A total number of 68 Patients (34 patients in each arm) was included in this study according to inclusion and exclusion criteria by purposive Sampling technique. All patients in Arm A and Arm B were planned for total 66 Gray in 33 daily fractions, 2 Gray per fraction, 1 fraction per day, 5 fractions per week over 6½ weeks and inj. Cisplatin 40mg/m² was given intravenously 2 hours before radiotherapy on 1st day and then weekly. All the information’s were recorded in a pre-tested and semi-structured questionnaire. The analysis was done by using independent sample t test for continuous variables and chi-square test for categorical variables and data were presented in tables and graphs. Results: In this study, mean age was 52.5 ± 8.5 years and male: female ratio was 4.2: 1 among all patients. The Incidence of treatment interruption was significantly lower in Arm A compared with Arm B (29.4% in Arm A and 70.6% in Arm B, p-value &lt; 0.05). There were fewer patients who required hospitalization in Arm A (23.5% in Arm A and 55.9% in Arm B) and length of hospital stay was less too (5.3 ± 1.7 in Arm A and 10.0 ± 1.9 in Arm B, p value &lt;0.05). There were no significant differences in treatment response and toxicities between the two groups. Conclusion: Prophylactic nasogastric tube feeding at the beginning of CCRT in head and cancer patients is beneficial in terms of preventing treatment break and reducing hospital admission.

Non-invasive prognostic biomarker of lung cancer patients with brain metastases: Recurrence quantification analysis of heart rate variability.

Background: It has previously been shown that the time-domain characteristic of heart rate variability (HRV) is an independent prognostic factor for lung cancer patients with brain metastasis (LCBM). However, it is unclear whether the nonlinear dynamic features contained in HRV are associated with prognosis in patients with LCBM. Recurrence quantification analysis (RQA) is a common nonlinear method used to characterize the complexity of heartbeat interval time series. This study was aimed to explore the association between HRV RQA parameters and prognosis in LCBM patients. Methods: Fifty-six LCBM patients from the Department of Radiation Oncology, the First Affiliated Hospital of Bengbu Medical College, were enrolled in this study. Five-minute ECG data were collected by a mini-ECG recorder before the first brain radiotherapy, and then heartbeat interval time series were extracted for RQA. The main parameters included the mean diagonal line length (Lmean), maximal diagonal line length (Lmax), percent of recurrence (REC), determinism (DET) and Shannon entropy (ShanEn). Patients were followed up (the average follow-up time was 19.2 months, a total of 37 patients died), and the relationships between the RQA parameters and survival of LCBM patients were evaluated by survival analysis. Results: The univariate analysis showed that an Lmax of >376 beats portended worse survival in LCBM patients. Multivariate Cox regression analysis revealed that the Lmax was still an independent prognostic factor for patients with LCBM after adjusting for confounders such as the Karnofsky performance status (KPS) (HR = 0.318, 95% CI: 0.151–0.669, p = 0.003). Conclusion: Reduced heartbeat complexity indicates a shorter survival time in patients with LCBM. As a non-invasive biomarker, RQA has the potential for application in evaluating the prognosis of LCBM patients.

EP10.01-009 The Impact of the COVID-19 Pandemic on Palliative Care for Cancer: A Preliminary Cross-Country Survey of Clinical Oncologists

IntroductionPalliative care is a crucial intervention to improve the quality of life for patients with cancer, although the impacts of the COVID-19 pandemic on palliative care remain unclear. This preliminary survey across China aims to investigate the influence of COVID-19 on palliative care, from the perspective of oncologists.MethodsElectronic questionnaire surveys were distributed to clinicians in China. Participants working in cancer-related departments are eligible. Data was collected including demographic characteristics, subjective perception, and personal suggestions.ResultsA total of 37 oncologists participated in the survey, 78% of whom were male. The median age was 40 (22-56). A large proportion of them have doctor degrees (68%) currently working in urban areas (81%). One-third participants are from the department of radiation oncology (33%) and 24% from medical oncology. They usually practice palliative care in professional medical centres or hospitals (70%), yet 57% had only non-accredited training experience. Most agree that COVID-19 has a significant negative impact on their clinical work (76%) and palliative care practice (65%). 73% of them believe the current palliative care system is underdeveloped in China, and 78% think other factors besides COVID-19 relate to this inadequacy. Participants further tabled suggestions (Figure 1), such as more online guidance on palliative care for patients (35%), strengthening remote multidisciplinary cooperation (29%), promoting home-based palliative care (18%), and involving more information on COVID-19 in palliative care guidelines (6%).ConclusionsKeywordsPalliative care, COVID-19, Cancer IntroductionPalliative care is a crucial intervention to improve the quality of life for patients with cancer, although the impacts of the COVID-19 pandemic on palliative care remain unclear. This preliminary survey across China aims to investigate the influence of COVID-19 on palliative care, from the perspective of oncologists. Palliative care is a crucial intervention to improve the quality of life for patients with cancer, although the impacts of the COVID-19 pandemic on palliative care remain unclear. This preliminary survey across China aims to investigate the influence of COVID-19 on palliative care, from the perspective of oncologists. MethodsElectronic questionnaire surveys were distributed to clinicians in China. Participants working in cancer-related departments are eligible. Data was collected including demographic characteristics, subjective perception, and personal suggestions. Electronic questionnaire surveys were distributed to clinicians in China. Participants working in cancer-related departments are eligible. Data was collected including demographic characteristics, subjective perception, and personal suggestions. ResultsA total of 37 oncologists participated in the survey, 78% of whom were male. The median age was 40 (22-56). A large proportion of them have doctor degrees (68%) currently working in urban areas (81%). One-third participants are from the department of radiation oncology (33%) and 24% from medical oncology. They usually practice palliative care in professional medical centres or hospitals (70%), yet 57% had only non-accredited training experience. Most agree that COVID-19 has a significant negative impact on their clinical work (76%) and palliative care practice (65%). 73% of them believe the current palliative care system is underdeveloped in China, and 78% think other factors besides COVID-19 relate to this inadequacy. Participants further tabled suggestions (Figure 1), such as more online guidance on palliative care for patients (35%), strengthening remote multidisciplinary cooperation (29%), promoting home-based palliative care (18%), and involving more information on COVID-19 in palliative care guidelines (6%). A total of 37 oncologists participated in the survey, 78% of whom were male. The median age was 40 (22-56). A large proportion of them have doctor degrees (68%) currently working in urban areas (81%). One-third participants are from the department of radiation oncology (33%) and 24% from medical oncology. They usually practice palliative care in professional medical centres or hospitals (70%), yet 57% had only non-accredited training experience. Most agree that COVID-19 has a significant negative impact on their clinical work (76%) and palliative care practice (65%). 73% of them believe the current palliative care system is underdeveloped in China, and 78% think other factors besides COVID-19 relate to this inadequacy. Participants further tabled suggestions (Figure 1), such as more online guidance on palliative care for patients (35%), strengthening remote multidisciplinary cooperation (29%), promoting home-based palliative care (18%), and involving more information on COVID-19 in palliative care guidelines (6%). Conclusions KeywordsPalliative care, COVID-19, Cancer Palliative care, COVID-19, Cancer

Breast Cancer Subtypes and Prognosis: Answers to Subgroup Classification Questions, Identifying the Worst Subgroup in Our Single-Center Series

PurposeMany studies report the triple negative breast cancer (TNBC) as the worst subgroup, as such patients do not benefit from anti-hormonal therapy and human epidermal growth factor receptor 2 (HER2) antagonists. While HER2 overexpression was a poor prognostic factor in breast cancer before trastuzumab (Herceptin) was available, TNBC is often reported as the worst BC subgroup since targeted therapy is currently not possible. Since the patience-specific experiences and the current literature did not always align, we aimed to determine the BC subgroup with the shortest survival in our center.MethodsThe records of patients with BC who were admitted to Trakya University Faculty of Medicine Department of Medical and Radiation Oncology between July 1999 and December 2019 were reviewed. Patients were divided into four main groups (Luminal A, Luminal B, TNBC, and HER2-enriched) according to the St Gallen International Consensus Panel and four subgroups in accordance with estrogen receptor, progestin receptor and HER2 positivity. Patient characteristics, treatment characteristics and clinical outcomes of the four main subgroups were evaluated. Survival curves were generated using the Kaplan–Meier method, and the significance of survival differences among the selected variables was compared by using the Log rank test. Factors affecting disease-free survival (DFS) and overall survival (OS) were analyzed by Cox regression analysis.ResultsStatistical analysis was performed on 2017 patients, after excluding patients with phyllodes tumor, carcinoma-in-situ and missing information from a total of 2474 patients with BC. There were 952 (47.1%) patients in the Luminal A group, 236 (34.1%) in the Luminal B group, 236 (11.7%) in the TNBC group and 142 (7.1%) patients in the HER2 enriched group. HER2-enriched patients had the shortest survival (p < 0.001), with 113.70 ± 7.17 months of DFS and 125.45 ± 3.03 months of OS. For patients who received Herceptin, DFS was 101.50 ± 6.4 months and OS was 118.14 ± 6.16. Patients who did not receive Herceptin had 92.79 ± 18 months of DFS and 94.44 ± 15.23 months of OS.ConclusionThe HER2-enriched subgroup had the worst prognosis despite receiving targeted therapy. While the duration of DFS and OS had no significant difference between TNBC and Luminal A-B subgroups, HER2 enriched subgroup had significantly shorter survival when compared to any other subgroup. HER2-enriched subgroup had a 10-fold greater risk of death compared to the Luminal A subgroup.

112: An”Early Adopter” of CPQR’s Patient Reported Outcome (PRO) Initiative: Lessons Learned Through Implementation of an Electronic PRO Platform Across a Mulit-Center Radiation Oncology Department

112: An”Early Adopter” of CPQR’s Patient Reported Outcome (PRO) Initiative: Lessons Learned Through Implementation of an Electronic PRO Platform Across a Mulit-Center Radiation Oncology Department

Role of Metastatic Lymph Nodes to Totally Removed Lymph Nodes Ratio in Breast Cancer?

Abstract To determine prognostic ratio of metastatic lymph nodes to totally removed lymph nodes (MLN/TRLN) on overall and progressionfree survival with diagnosis of breast cancer. Radiation Oncology department of Kayseri Training and Research Hospital, relationship of MLN/TRLN between prognosis and other prognostic factors was evaluated in T1-3 and N1-3 non-metastatic breast cancer patients. Two hundred female patients and 5 male patients with an average age of 56 years were enrolled in this study. Of all patients, 63.4% of the patients were postmenopausal and modified radical mastectomy was performed in 96.6% of them. While 93.2% of the patients were diagnosed with invasive ductal carcinoma, 52.7% of them had clinical N1 disease, 62% of them were staged as T2, 94% of them received chemotherapy and 57.1% of them received hormonal therapy. Metastatic lymph node ratio below 0.2 was 48.8%, between 0.21-0.65 it was 35.1% and above 0.65% it was 16.1%. Five-year Overall survival and progressionfree survival rates were 76% and 58% respectively. Statistically significant difference was found between MLN/TRLN and age (p=0.044), chemotherapy (p=0.039), pathological lymph nodes (p &lt;0.001) according to Pearson's Chi-Squared test. Factor affecting overall survival was Progesterone receptor status (p=0.021) and for progression-free survival they were gender (p=0.003) and human epidermal growth factor receptor 2 (p=0.018). Univariate and multivariate analysis found that gender (p=0.04, OR 5.9, CI: 1.7-19.6) and lymph node (p=0.05, OR: 1.4, CI: 0.9-2.1) were significant factors affecting progressionfree survival. MLN/TRLN was shown to have no effect on prognosis in non-metastatic breast cancer patients due to small number of patients and short follow-up period.

Readiness for Radiation Treatment Continuity: Survey on Contingency Plans Against Cyberattacks

PurposeCyberattacks on health care systems have been on the rise over the past 5 years. Formulation and implementation of a robust postattack business continuity plan and/or contingency plan (CP) is essential for minimal disruption to patient care. The level of awareness and planning within the radiation oncology community for cyberattacks is not clear. This study was undertaken to survey and assess cyberattack CP awareness and preparedness. Methods and MaterialsA survey instrument comprising 5 questions on awareness and preparedness of cyberattack CPs was e-mailed to 150 radiation oncology departments. Recipients included 105 institutions with residency programs in therapeutic medical physics, as listed by the Commission on Accreditation of Medical Physics Education Program (usually either school-based or large institutional settings), and 45 additional smaller settings within the United States, representing community practices. ResultsForty-three responses were deemed evaluable for analysis. Forty-two percent (18 respondents) of respondents responded that they are well-aware of the concept of a cyberattack CP. A large discrepancy in awareness exists between larger hospitals (LH) that have 5 or more treatment machines and smaller hospitals (SH) that have 4 or fewer, 54% versus 24 % (P < .05). Fifty-eight percent of respondents considered it “essential” to have such a plan in place, and 28% considered it “desirable” to do so but not practical. Nine percent regarded a cyberattack CP as unnecessary. No significant differences in responses were noted among different types or sizes of institutions on this issue. Sixty-two percent of LH responded that they were either preparing or evaluating a CP, compared with only 29% of SH (P = .03). However, no respondents explicitly replied that they already had a CP in place in their practices. ConclusionsThe importance of cyberattack preparedness and implementation does not seem to be well-recognized in radiation oncology. Both the awareness and the preparedness of SH are substantially less than those of LH. Specific and ongoing education efforts in parallel with development of appropriate programs are needed to counter the increasingly pervasive and complex threat of cyberattacks.

58: Evaluating the Short-Term Environmental and Clinical Effects of a Radiation Oncology Department’s Response to the COVID-19 Pandemic (STEER COVID-19)

58: Evaluating the Short-Term Environmental and Clinical Effects of a Radiation Oncology Department’s Response to the COVID-19 Pandemic (STEER COVID-19)