Advances in radiotherapy technology for pediatric cancer patients and roles of medical physicists: COG and SIOP Europe perspectives.

Over the last two decades, rapid technological advances have dramatically changed radiation delivery to children with cancer, enabling improved normal-tissue sparing. This article describes recent advances in photon and proton therapy technologies, image-guided patient positioning, motion management, and adaptive therapy that are relevant to pediatric cancer patients. For medical physicists who are at the forefront of realizing the promise of technology, challenges remain with respect to ensuring patient safety as new technologies are implemented with increasing treatment complexity. The contributions of medical physicists to meeting these challenges in daily practice, in the conduct of clinical trials, and in pediatric oncology cooperative groups are highlighted. Representing the perspective of the physics committees of the Children's Oncology Group (COG) and the European Society for Paediatric Oncology (SIOP Europe), this paper provides recommendations regarding the safe delivery of pediatric radiotherapy. Emerging innovations are highlighted to encourage pediatric applications with a view to maximizing the therapeutic ratio.

The 3 Bs of cancer care amid the COVID-19 pandemic crisis: "Be safe, be smart, be kind"-A multidisciplinary approach increasing the use of radiation and embracing telemedicine for head and neck cancer.

Because of the national emergency triggered by the coronavirus disease 2019 (COVID-19) pandemic, government-mandated public health directives have drastically changed not only social norms but also the practice of oncologic medicine. Timely head and neck cancer (HNC) treatment must be prioritized, even during emergencies. Because severe acute respiratory syndrome coronavirus 2 predominantly resides in the sinonasal/oral/oropharyngeal tracts, nonessential mucosal procedures are restricted, and HNCs are being triaged toward nonsurgical treatments when cures are comparable. Consequently, radiation utilization will likely increase during this pandemic. Even in radiation oncology, standard in-person and endoscopic evaluations are being restrained to limit exposure risks and preserve personal protective equipment for other frontline workers. The authors have implemented telemedicine and multidisciplinary conferences to continue to offer standard-of-care HNC treatments during this uniquely challenging time. Because of the lack of feasibility data on telemedicine for HNC, they report their early experience at a high-volume cancer center at the domestic epicenter of the COVID-19 crisis.

Managing patient flows in radiation oncology during the COVID-19 pandemic : Reworking existing treatment designs to prevent infections at a German hot spot area University Hospital.

PURPOSE: The described work aimed to avoid cancellations of indispensable treatments by implementing active patient flow management practices and optimizing infrastructure utilization in the radiation oncology department of a large university hospital and regional COVID-19 treatment center close to the first German SARS-CoV­2 hotspot region Heinsberg in order to prevent nosocomial infections in patients and personnel during the pandemic. PATIENTS AND METHODS: The study comprised year-to-date intervention analyses of in- and outpatient key procedures, machine occupancy, and no-show rates in calendar weeks 12 to 19 of 2019 and 2020 to evaluate effects of active patient flow management while monitoring nosocomial COVID-19 infections. RESULTS: Active patient flow management helped to maintain first-visit appointment compliance above 85.5%. A slight appointment reduction of 10.3% daily (p = 0.004) could still significantly increase downstream planning CT scheduling (p = 0.00001) and performance (p = 0.0001), resulting in an absolute 20.1% (p = 0.009) increment of CT performance while avoiding overbooking practices. Daily treatment start was significantly increased by an absolute value of 18.5% (p = 0.026). Hypofractionation and acceleration were significantly increased (p = 0.0043). Integrating strict testing guidelines, a distancing regimen for staff and patients, hygiene regulations, and precise appointment scheduling, no SARS-CoV­2 infection in 164 tested radiation oncology service inpatients was observed. CONCLUSION: In times of reduced medical infrastructure capacities and resources, controlling infrastructural time per patient as well as optimizing facility utilization and personnel workload during treatment evaluation, planning, and irradiation can help to improve appointment compliance and quality management. Avoiding recurrent and preventable exposure to healthcare infrastructure has potential health benefits and might avert cross infections during the pandemic. Active patient flow management in high-risk COVID-19 regions can help Radiation Oncologists to continue and initiate treatments safely, instead of cancelling and deferring indicated therapies.

50 Years of the IAEA/WHO postal dose audit programme for radiotherapy: what can we learn from 13756 results?

Background: The IAEA/WHO postal dose audit programme has been operating since 1969 with the aim of improving the accuracy and consistency of dosimetry in radiotherapy in low-income and middle-income countries world-wide. This study summarises the 50 years' experience of audits and explores the quality of reference dosimetry in participating radiotherapy centres throughout the years.Material and methods: During the IAEA/WHO postal audits the dose determined from the mailed dosimeter is compared with that stated by the participant. Agreement to within ±5% is regarded acceptable whilst deviations outside ±5% limits trigger follow-up actions. Of particular interest in this study was the dependence of clinical dosimetry quality on factors related to the centre infrastructure and expertise in dosimetry of its staff.Results: The IAEA/WHO dose audit programme noted great increase in the overall percentage of acceptable results from about 50% in its early years to 99% at present, although there is some variability of results amongst participating countries. Whereas results for younger radiotherapy machines show the agreement rate between the measured and the stated doses well above 90%, for those over 20 years old the rate dropped to <80%. Linac dosimetry was always better than 60Co dosimetry and multi-machine centres generally performed better than single machine centres equipped with cobalt alone. Second and subsequent participation in audits showed higher quality dosimetry than the first participation. The implementation of modern dosimetry protocols resulted in more accurate dosimetry than the use of the older protocols.Conclusions: Over the 50 years that the IAEA has accumulated dosimetry audit data, practices in radiotherapy centres have significantly improved. Higher quality dosimetry confirmed in audits is generally associated with better infrastructure and adequate dosimetry expertise of medical physicists in participating centres.

An IAEA survey of radiotherapy practice including quality assurance extent and depth.

Background: The IAEA recommends a quality assurance program in radiotherapy to ensure safe and effective treatments. In this study, radiotherapy departments were surveyed on their current practice including the extent and depth of quality assurance activities.Methods: Radiotherapy departments were voluntarily surveyed in three stages, firstly, in basic facility information, secondly, in quality assurance activities and treatment techniques, and thirdly, in a snapshot of quality assurance, departmental and treatment activities.Results: The IAEA received completed surveys from 381 radiotherapy departments throughout the world with 100 radiotherapy departments completing all three surveys. Dominant patterns were found in linac-based radiotherapy with access to treatment planning systems for 3D-CRT and 3D imaging. Staffing levels for major staff groups were on average in the range recommended by the IAEA. The modal patient workload per EBRT unit was as expected in the range of 21-30 patients per day, however significant instances of high workload (more than 50 patients per day per treatment unit) were reported. Staffing levels were found to correlate with amount of treatment equipment and patient workload. In a self-assessment of quality assurance performance, most radiotherapy departments reported that they would perform at least 60% of the quality assurance activities itemized in the second survey, with particular strength in equipment quality control. In a snapshot survey of quality assurance performance, again equipment quality control practice was well developed, particularly for the treatment equipment.Conclusions: The IAEA surveys provide a snapshot of current radiotherapy practice including quality assurance activities.

Radiotherapy in Southern Italy at the time of COVID-19: options for radiation oncology units.

INTRODUCTION: The outbreak of coronavirus disease 2019 (COVID-19) has spread to many countries and has been declared a global health emergency. Our center is located in the south of Italy where the infection rates were low and the clusters of COVID-19 positive patients were small and inhomogeneous. The aim of this short report is to share our experience as a starting point for the management of the steady state of the pandemic. METHODS: The safety of the patients and department staff required a strict plan to minimize the risk of infection between operators whose absence would have made it impossible to carry out the radiotherapy treatments. The head of the radiotherapy unit and members of the Hospital Crisis Unit have put in place a series of measures to manage the emergency. RESULTS: A "clean" team has been established whose members are kept out of the radiotherapy unit for 2 weeks on rotation. Several separate work areas have been made in order to reduce direct contact between the staff. Each staff member has to wear protective equipment if close contact with patients is required. Before confirming a radiotherapy consult or a follow-up visit, telephone clinical and epidemiological screening is performed by nurses through a questionnaire regarding the presence of respiratory symptoms or eventual social contacts with COVID-19 positive people. Once the patients arrive in the hospital, a triage point at the entrance to the hospital performs a second screening and a temperature check. CONCLUSIONS: This management experience of a radiotherapy unit in Southern Italy could serve as a useful example for the future. In fact, in the steady state of infection many centers may face epidemiologically contagious numbers similar to those that we currently have in our region. These numbers require the maintenance of alert and precautionary measures which in our case seem to have worked.

Radiation oncology outpatient medication management needs and service gaps - A cross-sectional study of patients and clinicians.

BACKGROUND: Patients receiving radiotherapy for the treatment of cancer can have complex medication requirements related to the management of side-effects and impaired swallowing ability. This study surveyed patients and clinicians to identify service gaps and unmet medication management needs. METHODS: Patient and clinician surveys were developed by a multidisciplinary team based on previously validated questionnaires. The patient survey focused on medication use and adherence. The clinician survey was based around a clinical case study and focused on identifying service gaps and practice variations. This survey was disseminated to radiation oncologists, pharmacists and nurses involved with the care of head and neck or lung cancer patients in Victoria. RESULTS: A total of 93 surveys were completed including 53 patient surveys and 40 clinician surveys. Radiotherapy patients reported high medication usage with up to 53% taking five or more medications daily. When asked the same set of questions relating to medication education requirements, patients receiving polypharmacy reported greater needs (72%) than recognised by the surveyed multidisciplinary clinician group (58%). They also reported a non-adherence rate of 46%. In addition, further disparities were identified in clinician practices and their approach to clinical situations which may result in conflicting advice and confusion for patients. CONCLUSION: While recognising deficiencies relating to the provision of medication information, oncologists, nurses and pharmacists underestimated patient needs for medication information, education and follow-up. Findings support the rationale for integration of pharmacy services within the radiotherapy clinics to support patient care and bridge service gaps relating to medication management.

Mitigating disruptions, and scalability of radiation oncology physics work during the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic has led to disorder in work and livelihood of a majority of the modern world. In this work, we review its major impacts on procedures and workflow of clinical physics tasks, and suggest alternate pathways to avoid major disruption or discontinuity of physics tasks in the context of small, medium, and large radiation oncology clinics. We also evaluate scalability of medical physics under the stress of "social distancing". METHODS: Three models of facilities characterized by the number of clinical physicists, daily patient throughput, and equipment were identified for this purpose. For identical objectives of continuity of clinical operations, with constraints such as social distancing and unavailability of staff due to system strain, however with the possibility of remote operations, the performance of these models was investigated. General clinical tasks requiring on-site personnel presence or otherwise were evaluated to determine the scalability of the three models at this point in the course of disease spread within their surroundings. RESULTS: The clinical physics tasks within three models could be divided into two categories. The former, which requires individual presence, include safety-sensitive radiation delivery, high dose per fraction treatments, brachytherapy procedures, fulfilling state and nuclear regulatory commission's requirements, etc. The latter, which can be handled through remote means, include dose planning, physics plan review and supervision of quality assurance, general troubleshooting, etc. CONCLUSION: At the current level of disease in the United States, all three models have sustained major system stress in continuing reduced operation. However, the small clinic model may not perform if either the current level of infections is maintained for long or staff becomes unavailable due to health issues. With abundance, and diversity of innovative resources, medium and large clinic models can sustain further for physics-related radiotherapy services.

De-Identification of Radiomics Data Retaining Longitudinal Temporal Information.

We propose a de-identification system which runs in a standalone mode. The system takes care of the de-identification of radiation oncology patient's clinical and annotated imaging data including RTSTRUCT, RTPLAN, and RTDOSE. The clinical data consists of diagnosis, stages, outcome, and treatment information of the patient. The imaging data could be the diagnostic, therapy planning, and verification images. Archival of the longitudinal radiation oncology verification images like cone beam CT scans along with the initial imaging and clinical data are preserved in the process. During the de-identification, the system keeps the reference of original data identity in encrypted form. These could be useful for the re-identification if necessary.

The state of survivorship care in radiation oncology: Results from a nationally distributed survey.

BACKGROUND: Survivorship care has become an increasingly critical component of oncologic care as well as a quality practice and reimbursement metric. To the authors' knowledge, the current climate of survivorship medicine in radiation oncology has not been investigated fully. METHODS: An institutional review board-approved, Internet-based survey examining practices and preparedness in survivorship care was distributed to radiation oncology practices participating in the American College of Radiology Radiation Oncology Practice Accreditation program between November 2016 and January 2017. A total of 78 surveys were completed. Among these, 2 were nonphysicians, resulting in 76 evaluable responses. RESULTS: Radiation oncologists (ROs) frequently reported that they are the primary provider in the evaluation of late toxicities and the recurrence of primary cancer. Although approximately 68% of ROs frequently discuss plans for future care with survivors, few provide a written survivorship care plan to their patients (18%) or the patients' primary care providers (24%). Patient prognosis, disease site, and reimbursement factors often influence the provision of survivorship care. Although ROs report that several platforms offer training in survivorship medicine, the quality of these resources is variable and extensive instruction is rare. Fewer than one-half of ROs believe they are expertly trained in survivorship care. CONCLUSIONS: ROs play an active role within the multidisciplinary team in the cancer-related follow-up care of survivors. Investigation of barriers to the provision of survivorship care and optimization of service delivery should be pursued further. The development of high-quality, easily accessible educational programming is needed so that ROs can participate more effectively in the care of cancer survivors. Cancer 2018;124:2653-60. © 2018 American Cancer Society.

Dosimetric comparison of five different techniques for craniospinal irradiation across 15 European centers: analysis on behalf of the SIOP-E-BTG (radiotherapy working group).

PURPOSE: Conventional techniques (3D-CRT) for craniospinal irradiation (CSI) are still widely used. Modern techniques (IMRT, VMAT, TomoTherapy®, proton pencil beam scanning [PBS]) are applied in a limited number of centers. For a 14-year-old patient, we aimed to compare dose distributions of five CSI techniques applied across Europe and generated according to the participating institute protocols, therefore representing daily practice. MATERIAL AND METHODS: A multicenter (n = 15) dosimetric analysis of five different techniques for CSI (3D-CRT, IMRT, VMAT, TomoTherapy®, PBS; 3 centers per technique) was performed using the same patient data, set of delineations and dose prescription (36.0/1.8 Gy). Different treatment plans were optimized based on the same planning target volume margin. All participating institutes returned their best treatment plan applicable in clinic. RESULTS: The modern radiotherapy techniques investigated resulted in superior conformity/homogeneity-indices (CI/HI), particularly in the spinal part of the target (CI: 3D-CRT:0.3 vs. modern:0.6; HI: 3D-CRT:0.2 vs. modern:0.1), and demonstrated a decreased dose to the thyroid, heart, esophagus and pancreas. Dose reductions of >10.0 Gy were observed with PBS compared to modern photon techniques for parotid glands, thyroid and pancreas. Following this technique, a wide range in dosimetry among centers using the same technique was observed (e.g., thyroid mean dose: VMAT: 5.6-24.6 Gy; PBS: 0.3-10.1 Gy). CONCLUSIONS: The investigated modern radiotherapy techniques demonstrate superior dosimetric results compared to 3D-CRT. The lowest mean dose for organs at risk is obtained with proton therapy. However, for a large number of organs ranges in mean doses were wide and overlapping between techniques making it difficult to recommend one radiotherapy technique over another.

COMP report: CPQR technical quality control guidelines for radiation treatment centers.

The Canadian Organization of Medical Physicists (COMP), in close partnership with the Canadian Partnership for Quality Radiotherapy (CPQR) has developed a series of Technical Quality Control (TQC) guidelines for radiation treatment equipment. These guidelines outline the performance objectives that equipment should meet in order to ensure an acceptable level of radiation treatment quality. The TQC guidelines have been rigorously reviewed and field tested in a variety of Canadian radiation treatment facilities. The development process enables rapid review and update to keep the guidelines current with changes in technology. This announcement provides an introduction to the guidelines, describing their scope and how they should be interpreted. Details of recommended tests can be found in separate, equipment specific TQC guidelines published in the JACMP (COMP Reports), or the website of the Canadian Partnership for Quality Radiotherapy (www.cpqr.ca).

Assessment of cancer control capacity and readiness: the role of the International Atomic Energy Agency.

During the past six decades, the International Atomic Energy Agency (IAEA) has helped to address the growing cancer burden, by delivering substantial cancer-related assistance to low-income and middle-income member states. IAEA assistance has primarily been facilitated through sustainable radiotherapy and nuclear medicine programmes to establish safe and effective diagnostic imaging, nuclear medicine, and radiotherapy capacity to safely treat patients with cancer. Planning of a National Cancer Control Programme starts with a needs assessment of all aspects of cancer control in the country to ensure evidence-based strategies are adapted to the country's specific needs. The IAEA offers its member states a tool, known as an integrated mission of Programme of Action for Cancer Therapy Review, to assess the status of national capacities for implementation and delivery of cancer control plans and activities and the readiness to develop and implement a long-term radiation medicine infrastructure and plan to improve capacity.

Developing a Palliative Radiation Oncology Service Line: The Integration of Advance Care Planning in Subspecialty Oncologic Care.

Within radiation oncology, there is often minimal attention on radiotherapy with palliative benefits due to the overlying focus on curative treatments. Historically at the University of Pennsylvania, advanced-stage patients are cared for by cancer site-specific teams rather than a more rapid treatment service model that focuses on patients' symptom needs and larger clinical issues within a palliative framework. Thus, the University of Pennsylvania created a designated palliative radiation oncology team to focus on the complex medical and relational issues of metastatic cancer patients. Social workers play a critical role in patient and family conversations about advance directives, care needs, and end-of-life goals and fears as treatment regimens and outcomes continue to unfold. The palliative radiation oncology social worker developed and instituted a new, formalized assessment tool called the "palliative radiation oncology psychosocial care plan" in the electronic medical record. A retrospective analysis of 26 palliative radiation oncology patients under treatment between February and August 2016 was conducted. Of these patients treated with palliative radiation, 19% completed an advance directive after the social work intervention. This model highlights advance care planning as a best practice and encourages end-of-life discussions as a routine part of the oncology workflow.

Radiotherapy in the multidisciplinary treatment of liver cancer: a survey on behalf of the Italian Association of Radiation Oncology.

PURPOSE: To report the results of the first Italian survey investigating the role of liver-directed radiotherapy in the multidisciplinary approach of primary and metastatic liver cancer. MATERIALS AND METHODS: A 21-item, two-section questionnaire was sent to all Italian radiotherapy centers on June 2014. The two sections aimed at: (1) evaluating the presence of a multidisciplinary liver tumor board and describing the role of radiation oncologists within the latter, (2) analyzing Radiotherapy treatment details and differences between centers. RESULTS: A total of 37 centers completed the survey. A multidisciplinary liver tumor board was available in most centers (73 %), with a radiation oncologist routinely attending the latter in the majority of cases (85 %). Most of the respondents considered liver-directed Radiotherapy as the third line choice when other therapies were not indicated or technically suitable. 18 centers reported the use of liver-directed radiotherapy. The majority of centers started liver irradiation after 2010. The most adopted motion management strategy was abdominal compression. The most adopted GTV-CTV expansion was 0 and 5 mm for metastases and hepatocellular carcinoma, respectively. Stereotactic body radiotherapy was the technique of choice; several treatment schedules were registered, being 45 Gy in three fractions the most reported fractionation scheme. Dose was prescribed at the PTV margin in most cases. CONCLUSION: Liver-directed radiotherapy represents a new field of interest which is currently adopted by 10 % of all Italian Centers. The technical equipment seems adequate. The variations observed in the treatment regimens reflect the lack of a well-established standard schedule.

Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department.

BACKGROUND: Incident learning programs have been recognized as cornerstones of safety and quality assurance in so-called high reliability organizations in industries such as aviation and nuclear power. High reliability organizations are distinguished by their drive to continuously identify and proactively address a broad spectrum of latent safety issues. Many radiation oncology institutions have reported on their experience in tracking and analyzing adverse events and near misses but few have incorporated the principles of high reliability into their programs. Most programs have focused on the reporting and retrospective analysis of a relatively small number of significant adverse events and near misses. To advance a large, multisite radiation oncology department toward high reliability, a comprehensive, cost-effective, electronic condition reporting program was launched to enable the identification of a broad spectrum of latent system failures, which would then be addressed through a continuous quality improvement process. METHODS: A comprehensive program, including policies, work flows, and information system, was designed and implemented, with use of a low reporting threshold to focus on precursors to adverse events. RESULTS: In a 46-month period from March 2011 through December 2014, a total of 8,504 conditions (average, 185 per month, 1 per patient treated, 3.9 per 100 fractions [individual treatments]) were reported. Some 77.9% of clinical staff members reported at least 1 condition. Ninety-eight percent of conditions were classified in the lowest two of four severity levels, providing the opportunity to address conditions before they contribute to adverse events. CONCLUSIONS: Results after approximately four years show excellent employee engagement, a sustained rate of reporting, and a focus on low-level issues leading to proactive quality improvement interventions.