Planning for a pandemic: Mitigating risk to radiation therapy service delivery in the COVID-19 era.

The novel coronavirus (COVID-19) has rapidly impacted all of our lives following its escalation to pandemic status on 11 March 2020. Government guidelines and restrictions implemented to mitigate the risk of COVID-19 community transmission have forced radiation therapy departments to promptly adjust to the significant impact on our ability to deliver best clinical care. The inherent nature of our tri-partied professions relies heavily on multidisciplinary teamwork and patient-clinician interactions. Teamwork and patient interaction are critical to the role of a radiation therapist. The aim of this paper is to describe the experience of the Peter MacCallum Cancer Centre's (Peter Mac) radiation therapy services during the preliminary stages of the COVID-19 pandemic in minimising risk to patients, staff and our clinical service. Four critical areas were identified in developing risk mitigation strategies across our service: (a) Workforce planning, (b) Workforce communication, (c) Patient safety and wellbeing, and (d) Staff safety and wellbeing. Each of these initiatives had a focus on continuum of clinical care, whilst minimising risk of cross infection for our radiation therapy workforce and patients alike. Initiatives included, but were not limited to, establishing COVID-Eclipse clinical protocols, remote access to local applications, implementation of Microsoft Teams, personal protective equipment (PPE) guidelines and virtual 'Division of Radiation Oncology' briefing/updates. The COVID-19 pandemic has dictated change in conventional radiation therapy practice. It is hoped that by sharing our experiences, the radiation therapy profession will continue to learn, adapt and navigate this period together, to ensure optimal outcomes for ourselves and our patients.

Complementary therapy use in metropolitan and regional Australian radiotherapy centres; do patients report effective outcomes?

PURPOSE: Complementary and alternative medicine (CAM) is increasingly used with radiotherapy treatment for cancer. This study aimed to explore patient expectations of concurrent CAM, positive/negative outcomes and any variation of use across regional and metropolitan demographics. METHODS: An ethics-approved survey was provided to radiotherapy outpatients in regional and metropolitan Victoria, Australia. The survey enquired about demographical details, CAM uptake, perceived benefits/effects, source of CAM information and disclosure of use. RESULTS: Two hundred sixty-five patients were recruited across both sites. Patients reporting concurrent CAM use were 45 % (regional site, April-August 2012) and 47 % (metropolitan site, January-May 2013). More patients at the regional centre reported living away from home during treatment (35 vs 8 %) though this did not impact upon CAM uptake. For both sites, 60 % of CAM users felt they had been provided with sufficient CAM information with family/friends the most common source. The highest reported rationale for CAM use was the patient's choice (61 and 52 %). Only 19 % of patients at either site claimed the recommendation of a doctor was the reason for CAM use. 'Improving immune system' was the most common expectation of CAM at both sites (39 and 50 %). More than half of CAM users felt that it was effective (51 and 54 %). CONCLUSIONS: CAM use across regional and metropolitan Australia is equivalent, constitutes a substantial proportion of radiotherapy outpatients and is largely considered effective by CAM users. Healthcare professionals need to improve knowledge, communication, reporting and awareness of concurrent CAM in radiotherapy practice.

Dose planning objectives in anal canal cancer IMRT: the TROG ANROTAT experience.

INTRODUCTION: Intensity modulated radiotherapy (IMRT) is ideal for anal canal cancer (ACC), delivering high doses to irregular tumour volumes whilst minimising dose to surrounding normal tissues. Establishing achievable dose objectives is a challenge. The purpose of this paper was to utilise data collected in the Assessment of New Radiation Oncology Treatments and Technologies (ANROTAT) project to evaluate the feasibility of ACC IMRT dose planning objectives employed in the Australian situation. METHODS: Ten Australian centres were randomly allocated three data sets from 15 non-identifiable computed tomography data sets representing a range of disease stages and gender. Each data set was planned by two different centres, producing 30 plans. All tumour and organ at risk (OAR) contours, prescription and dose constraint details were provided. Dose-volume histograms (DVHs) for each plan were analysed to evaluate the feasibility of dose planning objectives provided. RESULTS: All dose planning objectives for the bone marrow (BM) and femoral heads were achieved. Median planned doses exceeded one or more objectives for bowel, external genitalia and bladder. This reached statistical significance for bowel V30 (P = 0.04), V45 (P < 0.001), V50 (P < 0.001), external genitalia V20 (P < 0.001) and bladder V35 (P < 0.001), V40 (P = 0.01). Gender was found to be the only significant factor in the likelihood of achieving the bowel V50 (P = 0.03) and BM V30 constraints (P = 0.04). CONCLUSION: The dose planning objectives used in the ANROTAT project provide a good starting point for ACC IMRT planning. To facilitate clinical implementation, it is important to prioritise OAR objectives and recognise factors that affect the achievability of these objectives.

Comparison of four 3D conformal treatment techniques to optimise radiotherapy treatment for anal cancer.

INTRODUCTION: Chemoradiotherapy is the standard of care for anal cancer. Sizeable target volume leads to significant toxicity. We compared four different 3D conformal radiotherapy (3DCRT) techniques with the aim of finding the best technique to achieve the lowest dose to the organs at risk (OAR) without compromising the planning target volume (PTV) coverage. METHODS: Fifteen computed tomography (CT) data sets from previously treated anal cancer patients (five male and 10 female) were re-contoured according to the Australasian Gastrointestinal Trials Group (AGITG) anal cancer contouring guidelines for N3 disease. Four different 3DCRT plans for each CT data set (standard, V-shape, diamond shape and alternate diamond shape) were generated. Comparisons of the radiation dose to non-rectal bowel (NRB), urinary bladder, genitalia, and femurs were performed. RESULTS: V-shape technique achieved significantly lower NRB V40 (mean = 59.6% SD = 11%) than diamond (63.8% SD = 13%), standard (63.8% SD = 11%) and alternate diamond (63.6% SD = 12%) techniques. V-shape technique achieved the lowest mean bladder dose (mean = 45.3 Gy SD = 1.4 Gy). Diamond technique achieved the lowest femur V40 (mean = 32.4%) P < 0.001 for all comparisons between diamond and all other techniques. For genitalia V40, diamond technique (mean = 26.4% SD = 20%) and alternate diamond technique (mean = 27.6% SD = 20%) achieved significantly lower dose than V-shape technique (mean = 43.2% SD = 26%) and standard technique (mean = 76.1% SD = 16%) P < 0.001 for all comparisons. CONCLUSIONS: Sophisticated 3DCRT techniques are superior to conventional techniques. Different 3DCRT techniques provide varying levels of dose reduction to OAR, with none of the four techniques investigated capable of reducing dose to all OAR. A combination of techniques may provide the best solution. Further refinement of these techniques should be explored.