Patients' and caregivers' experiences of hospitalization under COVID-19 visitation restrictions.

BACKGROUND: During the COVID-19 pandemic, hospitals did not allow caregiver visitation. Little is known about how caregivers' absence affected patients' care. OBJECTIVE: This study aimed to describe visitation restrictions' impact on patients and their caregivers experiences. DESIGN: We used a sequential explanatory mixed-methods study design. First, we randomly selected 200 adult patients with cancer or heart failure hospitalized before (n = 100) and during visitor restrictions (n = 100) and abstracted data from the electronic medical record on communication between medical teams and caregivers and the topics discussed. Results from the quantitative analysis guided our thematic analysis of semi-structured interviews conducted with a subsample of patients hospitalized during visitor restrictions and their caregivers to understand the impact of visitor restrictions on their experiences. RESULTS: Compared to prerestrictions, caregivers under visitation restrictions communicated less frequently with the medical team (29% vs. 37% of hospitalized days; p = .04), fewer received discharge counseling (37% vs. 52%; p = .04), and disproportionately more had no contact with the medical team (36% vs. 17%; p < .01). Video conferencing was documented for caregivers of only five patients. Qualitative analysis revealed that both caregivers and patients experienced emotional distress, increased conflict, and decreased perception of quality of care because of visitation restrictions. CONCLUSIONS: Hospital visitor restrictions significantly reduced caregivers' communication with patients' medical team, causing caregivers and patients emotional distress. Protocols that facilitate communication between caregivers and care teams may benefit caregivers who cannot be physically present at care facilities, including distance caregivers.

Patterns of Recurrence Among Higher-Risk Patients Receiving Daily External Beam Accelerated Partial-Breast Irradiation to 40 Gy in 10 Fractions.

PURPOSE: The 2016 American Society for Radiation Oncology consensus guidelines for the use of accelerated partial-breast irradiation (APBI) define "suitable," "cautionary," and "unsuitable" populations for this adjuvant breast radiation therapy technique. We sought to determine whether patients in the cautionary group exhibited adverse outcomes after APBI compared with their suitable counterparts. METHODS AND MATERIALS: We identified 252 consecutively treated patients from a single institution with in situ or early-stage invasive breast cancer who underwent APBI between 2008 and 2017. Treatment technique was uniform throughout the population, consisting of 3-dimensional conformal radiation therapy to 40 Gy administered in 10 daily fractions. RESULTS: One hundred seventy-eight patients (70%) were classified as suitable, 69 (27%) as cautionary, and 5 (2.0%) as unsuitable. Because unsuitable patients were few and had no recurrences, they were excluded from analysis. At a median follow-up time of 3.9 years, 97.2% of patients were free of recurrence. Four patients (1.5% overall; 3 suitable and 1 cautionary) experienced ipsilateral in-breast recurrences, and 1 cautionary patient developed an ipsilateral regional recurrence in an axillary lymph node. There was no significant difference in the rate of ipsilateral breast recurrence (2.4% vs 1.0%) between cautionary and suitable groups. CONCLUSIONS: Local recurrences are rare among guideline-defined cautionary patients with in situ or invasive breast cancer treated with APBI delivered via daily 3-dimensional conformal radiation therapy to 40 Gy. At a median follow-up of 3.9 years, no significant differences in local control were noted between cautionary and suitable patient groups. Further study is needed to characterize long-term disease outcomes among various risk groups.

Daily Fractionation of External Beam Accelerated Partial Breast Irradiation to 40 Gy Is Well Tolerated and Locally Effective.

PURPOSE: Most studies examining accelerated partial breast irradiation (APBI) have used twice-daily fractionation. Cosmesis with this approach has produced mixed results, and the optimal fractionation scheme remains unknown. We sought to evaluate the safety and efficacy of APBI with a total dose of 40 Gy in 10 daily fractions. METHODS AND MATERIALS: Between 2010 and 2014, we prospectively enrolled 106 patients to receive APBI after lumpectomy for invasive or in situ node-negative breast cancer. Radiation was administered via 3-dimensional conformal techniques. RESULTS: The median age was 62 years (range, 39-85), and all patients underwent APBI per protocol. With a median follow-up of 58 months, we evaluated patient-reported local toxicity and recurrence outcomes. Of 106 patients, 16 (15%) experienced grade ≥2 skin toxicity. The most common significant toxicities were acute cutaneous changes at 4 to 9 weeks after radiation therapy, including grade 2 erythema in 2 patients (1.8%) and skin color changes in 4 patients (3.8%). Only 2 instances of grade 3 toxicity were reported, including 1 patient with acute moist desquamation after radiation therapy and another with fibrosis at 2 years. Planning target volume and breast V20 were significantly predictive of skin/subcutaneous toxicity, with evidence that limiting breast V20 to <45% may improve tolerability. Overall, 3 breast cancer recurrences arose: 1 local recurrence in the original quadrant (3 years after APBI), 1 in a different ipsilateral quadrant (5 years after APBI), and 1 with distant disease 2 years after APBI. CONCLUSIONS: In an appropriately selected group of patients with early stage breast cancer, APBI to a dose of 40 Gy in 10 daily fractions was well tolerated, with most patients (99%) reporting excellent/good cosmesis. Planning target volume and breast V20 should be carefully constrained to limit local morbidity. Longer follow-up will be needed to establish efficacy and subsequent local recurrence rates.

Long-Term Pulmonary Outcomes of a Feasibility Study of Inverse-Planned, Multibeam Intensity Modulated Radiation Therapy in Node-Positive Breast Cancer Patients Receiving Regional Nodal Irradiation.

PURPOSE: Multibeam intensity modulated radiation therapy (IMRT) enhances the therapeutic index by increasing the dosimetric coverage of the targeted tumor tissues while minimizing volumes of adjacent organs receiving high doses of RT. The tradeoff is that a greater volume of lung is exposed to low doses of RT, raising concern about the risk of radiation pneumonitis (RP). METHODS AND MATERIALS: Between July 2010 and January 2013, patients with node-positive breast cancer received inverse-planned, multibeam IMRT to the breast or chest wall and regional nodes, including the internal mammary nodes (IMNs). The primary endpoint was feasibility, predefined by dosimetric treatment planning criteria. Secondary endpoints included the incidence of RP grade 3 or greater and changes in pulmonary function measured with the Common Terminology Criteria for Adverse Events version 3.0 scales, pulmonary function tests and community-acquired pneumonia questionnaires, obtained at baseline and 6 months after IMRT. Clinical follow-up was every 6 months for up to 5 years. RESULTS: Median follow-up was 53.4 months (range, 0-82 months). Of 113 patients enrolled, 104 completed follow-up procedures. Coverage of the breast or chest wall and IMN was comprehensive (median 48.1 Gy and 48.9 Gy, respectively). The median volume of lung receiving a high dose (V20Gy) and a low dose (V5) was 29% and 100%, respectively. The overall rate of respiratory toxicities was 10.6% (11/104), including 1 grade 3 RP event (0.96%). No differences were found in pulmonary function test or community-acquired pneumonia scores after IMRT. The 5-year rates of locoregional recurrence-free, disease-free, and overall survival were 93.2%, 63.6%, and 80.3%, respectively. CONCLUSIONS: Multibeam IMRT in patients with breast cancer receiving regional nodal irradiation was dosimetrically feasible, based on early treatment planning criteria. Despite the large volume of lung receiving low-dose RT, the incidence of grade 3 RP was remarkably low, justifying inverse-planned IMRT as a treatment modality for patients with high-risk breast cancer in whom conventional RT techniques prove inadequate.