A comparative dose-escalation analysis for reirradiated cancer patients with and without appropriate dose mapping.

This study aims to compare dose escalation between two groups of reirradiated cancer patients, one with the previous contour and radiotherapy plan available on the treatment planning system and the other without. First group is identified as DICOM-group, while the other one is called non-DICOM group. The current study included 89 patients, 57 in the DICOM, and 32 in the non-DICOM group, who received reirradiation for recurrent or second primary tumours between 2019 and 2021. For the DICOM group, doses to 0.2cc volume for spine, brainstem, and optic apparatus from first radiation were converted into structures and transferred to reirradiation CT using deformable registration. First, one radiotherapy plan was created using the doctor prescribed dose (baseline prescription RxD_B); further an escalated dose (RxD_E) plan, taking into account all the dose volume parameters from previous radiation, was created only for DICOM group. In non-DICOM group patients were planned only for RxD_B. The maximum accepted dose escalation was 21 Gy. Radiotherapy prescription dose during earlier (first) treatment in DICOM and non-DICOM groups were 61 ± 5.6 Gy and 30-66 Gy, respectively. DICOM and non-DICOM groups had nearly identical baseline doses: 52.5 ± 10.7 Gy and 50.6 ± 6.9 Gy (difference 1.9 ± 12.7 Gy). Dose escalation was possible for 51 out of 57 patients in the DICOM-group. Average escalated dose in DICOM-group was 59.2 ± 6.2 Gy, with an incremental dose of 6.7 ± 12.4 Gy from the baseline prescription. No dose escalation was opted for in the non-DICOM group due to the unavailability of dose volume information from previous radiation. Reirradiation for head and neck cases allowed for a moderate to high dose escalation, facilitated by the presence of pertinent DICOM information from the initial radiotherapy.

Customizing Treatment Scheduling Windows with a Time Margin Recipe: A Single-institutional Study.

Purpose: Rising cancer incidences, complex treatment techniques, and workflows have all impacted the radiotherapy scheduling process. Intelligent appointment scheduling is needed to help radiotherapy users adapt to new practices. Materials and Methods: We utilized van Herk's safety margin formula to determine the radiotherapy department's treatment scheduling window (TSW). In addition, we examined the influence of in-room imaging on linac occupancy time (LOT). Varian Aria™ software version 15.1 was used to collect retrospective data on LOT, treatment site, intent, techniques, special protocol, and in-room imaging. Results: Treatment scheduling windows varied across treatment sites. The mean TSW using van Herk's formalism was 31.5 min, significantly longer than the current TSW of 15 min (P = 0.036), with the pelvic site having the longest (43.8 min) and the brain site having the shortest (12 min). 28% of patients exceeded the in-practice TSW of 15 min. 46.2% of patients had multiple images per fraction, with the proportion being highest in pelvic patients (33%). Patients treated with palliative intent, intensity-modulated radiotherapy, special protocols (bladder protocol and gating), and multiple in-room images per fraction had significantly higher LOT. High treatment time uncertainty was observed in the pelvic and thorax sites, indicating the impact of in-room imaging frequency and on-couch treatment decisions on overall treatment time and indicating that current treatment practices should be reviewed and modified if necessary. Conclusions: The time margin recipe can customize the treatment scheduling window and improve treatment practices. This formalism can help manage the radiotherapy department's workload and reduce patient wait times.

Calculation of set-up margin in frameless stereotactic radiotherapy accounting for translational and rotational patient positing error.

Context: Rotation corrected set-up margins in stereotactic radiotherapy (SRT). Aims: This study aimed to calculate the rotational positional error corrected set-up margin in frameless SRT. Settings and Design: 6D setup errors for the steriotactic radiotherapy patients were converted to 3D translational only error mathematically. Setup margins were calculated with and without considering the rotational error and compared. Materials and Methods: A total of 79 patients of SRT each received >1 fraction (3-6 fractions) incorporated in this study. Two cone-beam computed tomography (CBCT) scans were acquired for each session of treatment, before and after the robotic couch-aided patient position correction using a CBCT. The postpositional correction set-up margin was calculated using the van Herk formula. Further, a planning target volume_R (PTV_R) (with rotational correction) and PTV_NR (without rotational correction) were calculated by applying the rotation corrected and uncorrected set-up margins on the gross tumor volumes (GTVs). Statistical Analysis Used: General. Results: A total of 380 sessions of pre- (190) and post (190) table positional correction CBCT was analyzed. Posttable position correction mean positional error for lateral, longitudinal, and vertical translational and rotational shifts was (x)-0.01 ± 0.05 cm, (y)-0.02 ± 0.05 cm, (z) 0.00 ± 0.05 cm, and (θ) 0.04° ± 0.3°, (Φ) 0.1° ± 0.4°, (Ψ) 0.0° ± 0.4°, respectively. The GTV volumes show a range of 0.13 cc-39.56 cc, with a mean volume of 6.35 ± 8.65 cc. Rotational correction incorporated postpositional correction set-up margin the in lateral (x), longitudinal (y) and vertical (z) directions were 0.05 cm, 0.12 cm, and 0.1 cm, respectively. PTV_R ranges from 0.27 cc to 44.7 cc, with a mean volume of 7.7 ± 9.8 cc. PTV_NR ranges from 0.32 cc to 46.0 cc, with a mean volume of 8.1 ± 10.1 cc. Conclusions: The postcorrection linear set-up margin matches well with the conventional set-up margin of 1 mm. Beyond a GTV radius of 2 cm, the difference between PTV_NR and PTV_R is ≤2.5%, hence not significant.

Efficient and Reliable Data Extraction in Radiation Oncology using Python Programming Language: A Pilot Study.

Background and Purpose: In recent years, data science approaches have entered health-care systems such as radiology, pathology, and radiation oncology. In our pilot study, we developed an automated data mining approach to extract data from a treatment planning system (TPS) with high speed, maximum accuracy, and little human interaction. We compared the amount of time required for manual data extraction versus the automated data mining technique. Materials and Methods: A Python programming script was created to extract specified parameters and features pertaining to patients and treatment (a total of 25 features) from TPS. We successfully implemented automation in data mining, utilizing the application programming interface environment provided by the external beam radiation therapy equipment provider for the whole group of patients who were accepted for treatment. Results: This in-house Python-based script extracted selected features for 427 patients in 0.28 ± 0.03 min with 100% accuracy at an astonishing rate of 0.04 s/plan. Comparatively, manual extraction of 25 parameters took an average of 4.5 ± 0.33 min/plan, along with associated transcriptional and transpositional errors and missing data information. This new approach turned out to be 6850 times faster than the conventional approach. Manual feature extraction time increased by a factor of nearly 2.5 if we doubled the number of features extracted, whereas for the Python script, it increased by a factor of just 1.15. Conclusion: We conclude that our in-house developed Python script can extract plan data from TPS at a far higher speed (>6000 times) and with the best possible accuracy compared to manual data extraction.

Peer reviewers from low- and middle-income countries(LMIC) for open access journals in oncology can improve the equity in cancer research and clinical trials.

Open access journals (OAJ) in biomedicine are promoted to improve the reach and distribution of global health research (GHR). However, in the last 20 years, article publishing charge (APC) is attracting and publishing the vast majority of papers from high-income countries (HIC) in "oncology" journals under OAJ. This paper outlines the impediments for cancer research and publication from low-and middle-income countries (LMIC): (a) existing disparities in cancer care facilities and survival outcomes between HIC and LMIC, (b) more than 70 % of OAJ in 'oncology' subject levy APC, becoming unaffordable for scientists and clinicians from LMIC, (c) impactful OAJ in oncology engage less than 10 % of members from LMIC in editorial board or as peer reviewer, whereas two-third of cancer diagnosis and management occur in these countries. Peer review serves the editors by recommending the relevant papers. Thus, peer reviewers from developing countries working for the OAJs in "oncology" can increase the diversity in publication, improving the GHR in cancer management. The cancer research and clinical trials which can bring to notice the challenges and hurdles faced by researchers, clinicians and cancer patients in LMIC will be served to some measure by engaging peer reviewers from those countries who understand the ecosystem.

Clinical management of stage III non-small cell lung cancer in India: An expert consensus statement.

Non-small cell lung cancer (NSCLC) is considered the most common type of lung cancer (>80% of all lung cancers); patients are often diagnosed at advanced stages of the disease. The management of NSCLC is considered challenging owing to variations in size, an extension of the tumors, involvement patterns, and classification. Although adequate literature and guidelines are available on the management of NSCLC in several countries, an Indian perspective on stage III NSCLC management is lacking. We used the modified Delphi approach to form consensus statements. A thorough literature search was done. The authors then convened and deliberated over published literature, available guidelines, and clinical judgment. Recommendation statements were formed for different clinical scenarios. These statements were sent as a form of survey to other oncologists, and their responses were recorded and mentioned. Evidence-based statements were formed for diagnosing and managing stage III NSCLC. These recommendation statements cover various aspects-surgical, radiation, and medical treatment in various clinical scenarios including adjuvant, neoadjuvant, and consolidation therapies.

Audit of radiation oncology practice: Lessons from a new private hospital in Delhi, India.

Aims: The objective of this audit was to analyze the radiotherapy (RT) practice in a newly established tertiary private hospital. With increasing radiation oncology (RO) facilities in private sector, this report is the first audit from a private health organization in India. Subjects and Methods: The audit of all consecutively registered patients in RO has focused to extract data from the time of RT simulation planning till the completion of RT course. The patient and disease characteristics,RT-related treatment factors and compliance were analyzed in-depth. Results: In this newly established RO department, the vendor-supplied equipment, e.g., RT planning system, treatment delivery (linear accelerator and brachytherapy), and RO information system (ROIS), are integrated with enterprise-wide hospital information system into unified paperless workflow management for the patient care records in a prospective manner. This analysis comprised consecutive 328 patients who consented for RT simulation and planning from April 20, 2018, to December 31, 2019. RT course compliance was 94.8% (311/328 patients), and treatment intent-wise: curative plus adjuvant in 60.2% and palliative RT in 36%. RT technique was conformal in all 100%, with volumetric arc radiotherapy (VMAT) delivered to 66.6% of patients. With overall median RT course duration of 29 days (range 1-81 days), the patients were delivered a median of 20 fractions. Conclusions: Compared to the previously published audit from an academic RO department in Delhi, this audit from a private hospital has shown (i) lesser waiting time, (ii) improved treatment compliance, (iii) utilization of higher techniques, and (iv) a lower duration of RT course.

Ensuring quality in contextualised cancer management guidelines for resource-constraint settings: using a systematic approach.

To address the wide variation in access to cancer care in India requires strengthening of infrastructure, trained oncology workforce, and minimisation of out-of-pocket expenditures. However, even with major investments, it is unlikely to achieve the same level of infrastructure and expertise across the country. Therefore, a resource stratified approach driven by evidence-based and contextualised clinical guidelines is the need of the hour. The National Cancer Grid has been at the forefront of delivery of standardised cancer care through several of its initiatives, including the resource-stratified guidelines. Development of new guidelines is resource and time intensive, which may not be feasible and can delay the implementation. Adaptation of the existing standard guidelines using the transparent and well-documented methodology with involvement of all stakeholders can be one of the most reasonable pathways. However, the adaptation should be done keeping in mind the context, resource availability, budget impact, investment needed for implementation and acceptability by clinicians, patients, policymakers, and other stakeholders. The present paper provides the framework for systematically developing guidelines through adaptation and contextualisation. The process can be used for other health conditions in resource-constraint settings.

An audit of Grade III or more skin reactions in consecutively assessed patients at a modern radiation oncology center.

Purpose: Radiation dermatitis is most common and debilitating side effects of radiotherapy leading to treatment interruption, thereby compromising the local control, and effecting quality of life. With the invent of modern imaging and recent advances in megavoltage radiotherapy, radiation-related side effects have reduced. In this audit, we report the risk factors associated with Grade III dermatitis in modern centers. Materials and Methods: We analyzed 172 patients treated with volume modulated arc therapy (VMAT) and static field intensity-modulated radiotherapy (SFIMRT) at our center. All head and neck, breast, gynecological, GU malignancies, and sarcoma patients treated with a dose of >45 Gy from April 2018 to December 2019 were included in the study. On couch, treatment verification was done with cone-beam computer tomography (CBCT). Slice-by-slice verification of planning target volume (PTV) with CBCT was done in the first three fractions and weekly thereafter. Skin evaluation was done using CTCAE v. 5. Statistical analysis was done using SPSS v. 22. Results: Of the 172 patients treated with VMAT and SFIMRT, 15 patients (8.7%) had Grade III dermatitis. Grade III dermatitis was mostly seen in breast cancer followed by head-and-neck patients. More reactions were observed in patients with advanced stage disease. Treatment verification is important at the later course of treatment, especially in head-and-neck cases where the treatment volume is large and PTV may extend outside skin. Contributing factors of radiation dermatitis at modern radiotherapy center are gene mutation, use of concurrent chemoradiotherapy, and bolus. Conclusion: We hereby conclude that PTV mismatch in weekly treatment verification, genetic mutations, concurrent chemo-radiotherapy, use of thermoplastic mask, and bolus are the contributing factors for Grade III dermatitis in modern radiotherapy centers.

Relevance of multi-disciplinary team approach in diagnosis and management of Stage III NSCLC.

Lung cancer is reported as the leading cause of cancer-related mortality worldwide. Non-small cell lung cancer (NSCLC) constitutes 80%-85% of all lung cancers. Diagnosis of NSCLC is a complex multistep process. The prognosis of NSCLC is poor as most of the patients are presented at the metastatic stage. The management of these patients needs the expertise of different specialists. A multidisciplinary team (MDT) comprising specialists from different disciplines has a substantial role in improving outcomes in these patients. This is feasible through extensive discussions, accurate evaluation of patients, reviewing medical records, implementing ideal treatment strategies, and merging local treatments with systemic treatment concepts. Therefore, the MDT approach for stage III NSCLC management can enable early treatment initiation, optimal treatment modalities, and reduce healthcare expenditure. Studies have shown that MDT can provide multimodality care facilitating the diagnosis and treatment of stage III NSCLC, resulting in survival benefit of these patients. Thus, it is imperative to collate scientific evidence to get an insight into the MDT approach in advanced NSCLC treatment. This review aims to summarize the impact of MDT on treatment rates, survival outcome, treatment guideline adherence, and quality of life (QoL) of stage III NSCLC patients.

Challenges faced by female radiation oncologists (FRO) in South Asia.

AIM: This study was designed to evaluate the personal challenges, work environment, and financial satisfaction of female radiation oncologists (FRO) in South Asia. MATERIAL AND METHOD: A 28-point online survey was answered by 296 FRO from south Asia. The study comprised of seven sections: personal, professional, family, economic, workplace burnout, research/academic components, and challenges exclusive to being a working woman. RESULTS: The distribution of the participants was 73.4%, 14.8%, 7.9%, and 3.9% from India, Bangladesh, Nepal, and Pakistan, respectively. Age distribution was>50 y 12.1%, 30-50 y 61.1%, and<30 y 26.8%. Out of 296 respondents 206 (69.6%) and 176 (59.5%) were married and mothers respectively. 43.8% (77) of all mothers were denied maternity leave partially.45.9% (136) of all respondents and 68.7% (121) of all mothers found motherhood the principal obstacle to career growth. Total 60.1% encounter a gender bias in the department, and 34.8% reported they were either gained or lost a job/training because of their gender. 43.3%, 36.9%, 30.6%, and 25.5% of responders felt they could have done well in professional, financial, social, and academic perspectives, respectively, had they been of the opposite gender. 28.5%, 31%, and 16.4% FRO have income ½, equal and>1.5 times than their partners. 58.9% of FRO have a similar income to male colleagues in the city, and 43% of participants are financially satisfied. CONCLUSION: This study shows a fraction of FRO in south Asia faces a substantial gender disparity in the workplace. They are partially satisfied as a woman, as RO, as mother, and as lone-earner in the family. FROs need well deserved support for optimum delivery in their professional and personal lives.

Medulloblastoma outcomes in tertiary care set-up in India using contemporary treatment protocols - A retrospective study.

Background: Medulloblastoma is the commonest embryonal brain tumor in children. It has shown improved outcomes with combined modality treatment. We aimed to study patient characteristics and survival outcomes of patients with this disease across two tertiary care centers in India. Methods: We analyzed data of patients with histological diagnosis of medulloblastoma treated from January 2010 to January 2016. Patient characteristics and follow-up data were retrieved from hospital records. Descriptive statistics were used to describe clinical and pathological characteristics. Overall survival (OS) was calculated from date of diagnosis to death due to any cause. Relapse-free survival (RFS) was calculated from date of diagnosis to occurrence of relapse or death. Result: Out of 26 patients treated, 24 were children and 2 were adults. Median age was 10 years (range = 0.8-22 years). Twenty (76.9%) patients were male. Fifteen (57.7%) patients were stratified as high-risk (HR), rest 11 (42.3%) were categorized as average risk (AR). Histopathology showed classical variety in majority of patients except for 4 (15%) cases, 3 with desmoplastic and 1 with anaplastic subtype. Median follow-up was 49.7 months (range= 4.2-102.5 months). Overall, eight (30.8%) patients relapsed and six (23%) deaths occurred. Five (33.3%) patients in HR category and 3 (27.3%) patients in AR group showed relapse. Median RFS and OS were not yet reached. Five-year RFS was 69.2% whereas five-year OS was 76.9%. Conclusion: This study highlighted patient characteristics and treatment outcomes in Indian patients. With adherence to standard treatment, high remission rates and improvement in mortality rates were achieved.

A mathematical formulation for volume expansions in contouring for radiotherapy planning.

CONTEXT: This research describe the characteristic volume expansion of a moving target as a function of differential margins. AIM: We aimed to ascertain the volume change after giving margin for clinical and set up uncertainties including generating internal target volume (ITV) for moving target. MATERIALS AND METHODS: Settings and Design - Spheres of diameter (0.5-10 cm) with differential expansion of 1-15 mm were generated using a mathematical formula. Moving targets of radius 1-5 cm were generated, and the resultant volume envelopes with incremental motion from 1 to 20 mm were obtained. All relative volume change results were fitted with mathematical functions to obtain a generalized mathematical formula. STATISTICAL ANALYSIS USED: None. RESULTS: The percentage increase in volume (%ΔVp) was much more pronounced for smaller radius target. For moving target with relatively smaller radius, %ΔVp is predominant over the absolute volume change and vice versa in case of larger radius. Mathematical formulae were obtained for %ΔVp as a function of radius and expansion and for %ΔVp in ITV volume as a function of radius and tumor movement. CONCLUSIONS: This study provides an idea of volume change for various expansions for various size targets and/or moving target for different range of movements. It establishes a correlation of these volume changes with the changing target size and range of movements. Finally, a clinically useful mathematical formulation on volume expansion has been developed for rapid understanding of the consequence of volume expansion.

Daily waiting and treatment times at an advanced radiation oncology setup: A 4-year audit of consecutive patients from single institution.

PURPOSE: We present our data for every single fraction for every patient treated at our center for the past 4 years, analyzing the waiting and treatment times. MATERIALS AND METHODS: Between January 2014 and February 2018, all patients and their corresponding recorded measurements of waiting time and machine treatment time were analyzed. Times recorded included actual arrival time, designated arrival time, linac entry time, and last beam treatment time. The complete waiting time information was divided into two categories (1) first day treatments and (2) subsequent day treatments. SPSS version 18 was used for statistical calculations, correlations, and assessing significance. RESULTS: First day treatments - of 1982 patients following treatments were carried out; 1557 volumetric-modulated arc therapy (78.6%), 88 three-dimensional conformal radiotherapy (RT) (4.4%), 14 electron (0.7%), 10 intensity-modulated RT (0.5%), 264 stereotactic irradiation (13.3%), 17 stereotactic body RT (0.7%), and 32 total body irradiation (1.6%). The mean (± standard deviation) times for early/late time, total spent time (TST), wait time gross (WTG), and wait time net (WTN) were 11.0 ± 49.6 min, 74.7 ± 44.8 min, 47.46 ± 43.9 min, and 24.1 ± 44.4 min, respectively. Subsequent day treatments - a total of 34,438 sessions of treatment delivery were recorded. Overall average WTG was 37.4 ± 32.7 min. Overall WTN was 12.1 ± 62.7 min. Overall mean total spent time (TST) was 52.4 ± 33.0 min, overall mean setup and treatment time was 15.1 ± 10.9 min. CONCLUSION: We have presented our results of patient-related times during RT. Our study covers the daily waiting times before RT as well as the actual treatment times during modern-day RT. This consecutive patient data from a large series shall be an important resource tool for future planners and policymakers.