"Eat to Live"-Piloting a Culinary Medicine Program for Head & Neck Radiotherapy Patients.

BACKGROUND: Head and neck radiotherapy (H&N RT) patients are at risk for malnutrition following treatment due to dysphagia and alterations in taste quality. This project studied feasibility of a food skills intervention strategy support food preparation, cooking confidence, and individualized dietary choices to support nutritional status in this patient population. METHODS: We piloted a monthly cooking class (called "Eat to Live") from November 2018 to January 2019. Every class included cooking and nutrition domains, organized around a specific meal of the day (i.e., breakfast, lunch, or dinner). Seven participants (4 patients, 3 caregivers) attended at least one class, with four participants (3 patients, 1 caregiver) completing all three classes. Pre- and post-study measures (self-administered questionnaires) assessed changes in cooking behavior, dietary choices, and taste sensation before and after the intervention. RESULTS: Healthful eating scores increased modestly from start to finish of the class (1.5 to 1.7 on a 3-point scale), with averaged patient preference scores for healthy foods increasing incrementally. This took place despite physical taste scores declining across the 3-month study. After completing the class, participants were more likely to select fresh fruits and vegetables, grains, lean cuts of meat, and dairy products. Patients also adopted positive behavioral modifications to their diets, such as eating out at restaurants less often and baking/grilling foods instead of frying. CONCLUSIONS: To our knowledge, this is the first published report on feasibility and patient acceptance of an evidence-based culinary medicine intervention in H&N RT patients. We observed objective improvements in dietary choices and cooking confidence in a small cohort of patient/caregiver dyads. This pilot work justifies follow-on development of a more comprehensive intervention optimized for patient convenience and longitudinal support.

Low-kilovolt x-ray intraoperative radiotherapy for pT3 locally advanced colon cancer: a single-institution retrospective analysis.

BACKGROUND: Patients with locally advanced colon cancer (LACC) treated with surgery had a high risk of local recurrence. The outcomes can vary significantly among patients with pT3 disease. This study was undertaken to assess whether low-kilovolt (kV) x-ray intraoperative radiotherapy (IORT) can achieve promising results compared with electron beam IORT (IOERT) and whether specific subgroups of patients with pT3 colon cancer may benefit from low-kV x-ray IORT. METHODS: We retrospectively reviewed 44 patients with pT3 LACC treated with low-kV x-ray IORT. Clinicopathologic characteristics were analyzed to identify patients that could potentially benefit from low-kV x-ray IORT. The Kaplan-Meier survival analysis was used to assess overall survival (OS) and progression-free survival (PFS). Correlation analysis was used to discover the association of multiple factors to the results of treatment represented by the values of OS and PFS. RESULTS: The median follow-up of patients was 20.5 months (range, 6.1-38.8 months). At the time of analysis, 38 (86%) were alive and 6 (14%) had died of their disease. The 3-year Kaplan-Meier of PFS and OS for the entire cohort was 82.8% and 82.1%, respectively. At median follow-up, no in-field failure within the low-kV x-ray IORT field had occurred. Locoregional and distant failure had occurred in 2 (5%) patients each. The rate of perioperative 30-day mortality was 0%, and the morbidity rate was 11%. Five patients experienced 7 complications, including 4 early complications (30 days) and three late complications (> 30 days) leading early and late morbidity rates of 9% and 7%, respectively. CONCLUSION: Patients with LACC who had undergone an additional low-kV x-ray IORT can achieve encouraging locoregional control, PFS, OS, and distant control without an increase in short-term or long-term complications. Low-kV x-ray IORT can be considered as part of management in pT3 LACC.

Definitive Pelvic Radiotherapy and Survival of Patients With Newly Diagnosed Metastatic Anal Cancer.

Background: Chemotherapy with or without pelvic radiotherapy (RT) is included in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for metastatic anal cancer (MAC), despite limited clinical evidence for RT in this setting. In addition, increasing evidence shows that local therapies, including RT, may increase patient survival for some types of metastatic cancers. The purpose of this study was to evaluate the patterns of care and association between definitive pelvic RT and overall survival (OS) for patients with MAC. Methods: The National Cancer Database was analyzed to evaluate OS of patients with newly diagnosed MAC treated with chemotherapy with or without pelvic RT. Those who did not undergo treatment, treated with surgery, or without baseline variables were excluded. OS was analyzed using the Kaplan-Meier method, log-rank test, Cox proportional hazards models, and propensity score-matched analyses. Results: From 2004 through 2015, 437 patients received chemotherapy alone and 1,020 received pelvic chemoradiotherapy (CRT). At a median follow-up of 17.3 months, CRT was associated with improved OS on univariate (P<.001) and multivariate analysis (hazard ratio [HR], 0.70; 95% CI, 0.61-0.81; P<.001). Propensity score-matched analysis demonstrated superior median survival (21.3 vs 15.9 months) and 2-year OS rates (46% vs 34%) with CRT compared with chemotherapy alone (P<.001). Landmark analyses limited to long-term survivors of ≥1, ≥2, and ≥4 years showed improved OS with CRT in all subsets (all P<.05). CRT with therapeutic doses (≥45 Gy) was associated with longer median survival than palliative doses (<45 Gy) and chemotherapy alone (24.9 vs 10.9 vs 15.6 months, respectively; P<.001). The benefit of CRT was present among not only those with distant lymph node metastasis (HR, 0.63; P=.04) but also those with distant organ disease (HR, 0.74; P<.001). Conclusions: In this large hypothesis-generating analysis, patients with newly diagnosed MAC who received definitive pelvic RT with chemotherapy lived significantly longer than those who received chemotherapy alone. Prospective trials evaluating definitive local RT for MAC are warranted.

Minimal mask immobilization with optical surface guidance for head and neck radiotherapy.

PURPOSE: Full face and neck thermoplastic masks provide standard-of-care immobilization for patients receiving H&N IMRT. However, these masks are uncomfortable and increase skin dose. The purpose of this pilot trial was to investigate the feasibility and setup accuracy of minimal face and neck mask immobilization with optical surface guidance. METHODS: Twenty patients enrolled onto this IRB-approved protocol. Patients were immobilized with masks securing only forehead and chin. Shoulder movement was restricted by either moldable cushion or hand held strap retractors. Positional information, including isocenter location and CT skin contours, were imported to a commercial surface image guidance system. Patients typically received standard-of-care IMRT to 60-70 Gy in 30-33 fractions. Patients were first set up to surface markings with optical image guidance referenced to regions of interest (ROIs) on simulation CT images. Positioning was confirmed by in-room CBCT. Following six-dimensional robotic couch correction, a new optical real-time surface image was acquired to track intrafraction motion and to serve as a reference surface for setup at the next treatment fraction. Therapists manually recorded total treatment time as well as couch shifts based on kV imaging. Intrafractional ROI motion tracking was automatically recorded by the optical image guidance system. Patient comfort was assessed by self-administered surveys. RESULTS: Setup error was measured as six-dimensional shifts (vertical/longitudinal/lateral/rotation/pitch/roll). Mean error values were -0.51 ± 2.42 mm, -0.49 ± 3.30 mm, 0.23 ± 2.58 mm, -0.15 ± 1.01o , -0.02 ± 1.19o , and 0.06 ± 1.08o , respectively. Average treatment time was 21.6 ± 8.4 mins). Subjective comfort during surface-guided treatment was confirmed on patient surveys. CONCLUSION: These pilot results confirm feasibility of minimal mask immobilization combined with commercially available optical image guidance. Patient acceptance of minimal mask immobilization has been encouraging. Follow-up validation, with direct comparison to standard mask immobilization, appears warranted.

Online dosimetric evaluation of larynx SBRT: A pilot study to assess the necessity of adaptive replanning.

PURPOSE: We have initiated a multi-institutional phase I trial of 5-fraction stereotactic body radiotherapy (SBRT) for Stage III-IVa laryngeal cancer. We conducted this pilot dosimetric study to confirm potential utility of online adaptive replanning to preserve treatment quality. METHODS: We evaluated ten cases: five patients enrolled onto the current trial and five patients enrolled onto a separate phase I SBRT trial for early-stage glottic larynx cancer. Baseline SBRT treatment plans were generated per protocol. Daily cone-beam CT (CBCT) or diagnostic CT images were acquired prior to each treatment fraction. Simulation CT images and target volumes were deformably registered to daily volumetric images, the original SBRT plan was copied to the deformed images and contours, delivered dose distributions were re-calculated on the deformed CT images. All of these were performed on a commercial treatment planning system. In-house software was developed to propagate the delivered dose distribution back to reference CT images using the deformation information exported from the treatment planning system. Dosimetric differences were evaluated via dose-volume histograms. RESULTS: We could evaluate dose within 10 minutes in all cases. Prescribed coverage to gross tumor volume (GTV) and clinical target volume (CTV) was uniformly preserved; however, intended prescription dose coverage of planning treatment volume (PTV) was lost in 53% of daily treatments (mean: 93.9%, range: 83.9-97.9%). Maximum bystander point dose limits to arytenoids, parotids, and spinal cord remained respected in all cases, although variances in carotid artery doses were observed in a minority of cases. CONCLUSIONS: Although GTV and CTV SBRT dose coverage is preserved with in-room three-dimensional image guidance, PTV coverage can vary significantly from intended plans and dose to critical structures may exceed tolerances. Online adaptive treatment re-planning is potentially necessary and clinically applicable to fully preserve treatment quality. Confirmatory trial accrual and analysis remains ongoing.

Enhancing Health Care Accessibility and Equity Through a Geoprocessing Toolbox for Spatial Accessibility Analysis: Development and Case Study.

BACKGROUND: Access to health care services is a critical determinant of population health and well-being. Measuring spatial accessibility to health services is essential for understanding health care distribution and addressing potential inequities. OBJECTIVE: In this study, we developed a geoprocessing toolbox including Python script tools for the ArcGIS Pro environment to measure the spatial accessibility of health services using both classic and enhanced versions of the 2-step floating catchment area method. METHODS: Each of our tools incorporated both distance buffers and travel time catchments to calculate accessibility scores based on users' choices. Additionally, we developed a separate tool to create travel time catchments that is compatible with both locally available network data sets and ArcGIS Online data sources. We conducted a case study focusing on the accessibility of hemodialysis services in the state of Tennessee using the 4 versions of the accessibility tools. Notably, the calculation of the target population considered age as a significant nonspatial factor influencing hemodialysis service accessibility. Weighted populations were calculated using end-stage renal disease incidence rates in different age groups. RESULTS: The implemented tools are made accessible through ArcGIS Online for free use by the research community. The case study revealed disparities in the accessibility of hemodialysis services, with urban areas demonstrating higher scores compared to rural and suburban regions. CONCLUSIONS: These geoprocessing tools can serve as valuable decision-support resources for health care providers, organizations, and policy makers to improve equitable access to health care services. This comprehensive approach to measuring spatial accessibility can empower health care stakeholders to address health care distribution challenges effectively.

Towards an Explainable AI Platform to Study Interruptions in Cancer Radiation Therapy.

Radiation therapy interruptions drive cancer treatment failures; they represent an untapped opportunity for improving outcomes and narrowing treatment disparities. This research reports on the early development of the X-CART platform, which uses explainable AI to model cancer treatment outcome metrics based on high-dimensional associations with our local social determinants of health dataset to identify and explain causal pathways linking social disadvantage with increased radiation therapy interruptions.

History Repeating-How Pandemics Collide with Health Disparities in the United States.

Across the United States, public health responses to the COVID-19 pandemic have fallen short. COVID-19 has exacerbated longstanding public health shortfalls in disadvantaged communities. Was this predestined? Understanding where we are today requires reflection on our longer journey. Disparities cataloged during COVID-19 reflect the same unequal host exposure and susceptibility risks that shaped previous pandemics. In this review, we provide historical context to better understand current events and to showcase forgotten lessons which may motivate future action to protect our most vulnerable citizens.

Defining Radiation Treatment Interruption Rates During the COVID-19 Pandemic: Findings From an Academic Center in an Underserved Urban Setting.

PURPOSE: Our purpose was to characterize radiation treatment interruption (RTI) rates and their potential association with sociodemographic variables in an urban population before and during the COVID-19 pandemic. METHODS AND MATERIALS: Electronic health records were retrospectively reviewed for patients treated between January 1, 2015, and February 28, 2021. Major and minor RTI were defined as ≥5 and 2 to 4 unplanned cancellations, respectively. RTI was compared across demographic and clinical factors and whether treatment started before or after COVID-19 onset (March 15, 2020) using multivariate logistic regression analysis. RESULTS: Of 2,240 study cohort patients, 1,938 started treatment before COVID-19 and 302 started after. Patient census fell 36% over the year after COVID-19 onset. RTI rates remained stable or trended downward, although subtle shifts in association with social and treatment factors were observed on univariate and multivariate analysis. Interaction of treatment timing with risk factors was modest and limited to treatment length and minor RTI. Despite the stability of cohort-level findings showing limited associations with race, geospatial mapping demonstrated a discrete geographic shift in elevated RTI toward Black, underinsured patients living in inner urban communities. Affected neighborhoods could not be predicted quantitatively by local COVID-19 transmission activity or social vulnerability indices. CONCLUSIONS: This is the first United States institutional report to describe radiation therapy referral volume and interruption patterns during the year after pandemic onset. Patient referral volumes did not fully recover from an initial steep decline, but local RTI rates and associated risk factors remained mostly stable. Geospatial mapping suggested migration of RTI risk toward marginalized, minority-majority urban ZIP codes, which could not otherwise be predicted by neighborhood-level social vulnerability or pandemic activity. These findings signal that detailed localization of highest-risk communities could help focus radiation therapy access improvement strategies during and after public health emergencies. However, this will require replication to validate and broaden relevance to other settings.

The Role of Dental Practitioners in the Management of Oncology Patients: The Head and Neck Radiation Oncology Patient and the Medical Oncology Patient.

This narrative review addresses the role of a dentist in the management of oncology patients, highlighting the oral complications that arise in head and neck radiation oncology patients and medical oncology patients. The prevention and management of these complications are discussed.

Expanding research on the impact of financial hardship on emotional well-being: guidance of diverse stakeholders to the Emotional Well-Being and Economic Burden of Disease (EMOT-ECON) Research Network.

The Emotional Well-Being and Economic Burden (EMOT-ECON) Research Network is one of six research networks funded by the National Institutes of Health (NIH) to advance research about emotional well-being (EWB), and the only one that focuses on addressing how economic burden due to disease or illness affects EWB. The network convened researchers, patients, patient advocates, health care providers and other stakeholders from across the US to discuss the significance of addressing the impact of the economic burden of disease on EWB, the complexity of this prevalent problem for patients and families, and the research gaps that still need to be studied to ultimately develop strategies to reduce the impact of economic burden of disease on EWB and health. Participants identified some important future areas of research as those investigating: (i) prevalent and relevant emotions for patients experiencing economic burden of disease and financial hardship, and how their broader outlook on life is impacted; (ii) constructs and contexts that influence whether the economic burden is stressful; (iii) strategies to deal and cope and their positive or negative effects on EWB and health; and (iv) multi-level and multi-stakeholder interventions to address economic factors (e.g., costs, ability to pay), administrative burdens, education and training, and especially patients' emotional as well as financial status.

Current progress in adaptive radiation therapy for head and neck cancer.

Head and neck intensity-modulated radiotherapy (IMRT) remains toxic, and cannot compensate for anatomic changes or tumor response that occur during treatment. Adaptive radiotherapy (ART) is a novel approach to correct for variations in geometry of tumor and bystander anatomy with repeated imaging-based modification of treatment delivery. Technical limitations have hampered introduction of ART into routine practice. This review summarizes investigational challenges impacting development of head and neck ART, describes findings from early clinical testing of an automated ART platform, and highlights emerging directions of ongoing research.

Variable Effect of the COVID-19 Pandemic on Radiation Oncology Practices in the United States.

PURPOSE: Early in the pandemic, the American Society for Radiation Oncology surveyed physician leaders at radiation oncology practices in the United States to understand how the field was responding to the outbreak of COVID-19. METHODS AND MATERIALS: Surveys were repeated at multiple points during the pandemic, with a response rate of 43% in April 2020 and 23% in January 2021. To our knowledge, this is the only longitudinal COVID-19 practice survey in oncology in the United States. RESULTS: The surveys indicate that patient access to essential radiation oncology services in the United States has been preserved throughout the COVID-19 pandemic. Safety protocols were universally adopted, telehealth was widely adopted and remains in use, and most clinics no longer deferred or postponed radiation treatments as of early 2021. Late-stage disease presentation, treatment interruptions, shortages of personal protective equipment, and vaccination barriers were reported significantly more at community-based practices than at academic practices, and rural practices appear to have faced increased obstacles. CONCLUSIONS: Our findings provide unique insights into the initial longitudinal effect of the COVID-19 pandemic on the delivery of radiation therapy in the United States. Downstream lessons in service adaptation and improvement can potentially be guided by formal concepts of resilience, which have been broadly embraced across the US economy.

Impact of the COVID-19 Pandemic on Canadian Radiation Oncology Practices.

PURPOSE: To survey Canadian radiation oncology (RO) practice leaders to determine the effect of the COVID-19 pandemic on radiation services and patient and staff issues in the early phase of the pandemic and 1 year later. METHODS AND MATERIALS: The RO leader (department or division head) from every Canadian cancer center with radiation services was identified. Two surveys were circulated to the identified leader via email from the Canadian Association of Radiation Oncology central office, using the SurveyMonkey survey tool: the first closed in June 2020 and the second (expanded) survey in June 2021, representing 2 points in time of the COVID-19 pandemic. Questions included patient volume, service interruptions and delays, and changes in scheduling and telemedicine use. Additional questions were included in the follow-up survey to determine further effects on disease presentation, volume, vaccination and access, and personnel issues. RESULTS: Telemedicine was widely adopted early in the pandemic and continued to be a common technique to communicate and connect with patients. Although many centers were deferring or delaying certain disease sites early in the pandemic, this was not as prevalent 1 year later. Reduced cancer screening and patients presenting with more advanced disease were concerns documented in the 2021 survey. A high level of concern regarding stress among health care professionals was identified. CONCLUSIONS: Canadian RO centers have faced numerous challenges during the COVID-19 pandemic but continued to provide timely and essential cancer care for patients with cancer. Future evaluation of RO center practices will be important to continue to document and address the effect of the COVID-19 pandemic on issues relevant to RO leaders, patients, and staff.

The Memphis Pandemic Health Informatics System (MEMPHI-SYS)-Creating a Metropolitan COVID-19 Data Registry Linked Directly to Community Testing to Enhance Population Health Surveillance.

The current coronavirus disease (COVID-19) pandemic has placed unprecedented strain on underfunded public health resources in the Southeastern United States. The Memphis, TN, metropolitan region has lacked infrastructure for health data exchange.This manuscript describes a multidisciplinary initiative to create a community-focused COVID-19 data registry, the Memphis Pandemic Health Informatics System (MEMPHI-SYS). MEMPHI-SYS leverages test result data updated directly from community-based testing sites, as well as a full complement of public health data sets and knowledge-based informatics. It has been guided by relationships with community stakeholders and is managed alongside the largest publicly funded community-based COVID-19 testing response in the Mid-South. MEMPHI-SYS has supported interactive Web-based analytic resources and informs federally funded COVID-19 outreach directed toward neighborhoods most in need of pandemic support.MEMPHI-SYS provides an instructive case study of how to collaboratively establish the technical scaffolding and human relationships necessary for data-driven, health equity-focused pandemic surveillance, and policy interventions.

Independent Predictors for Hospitalization-Associated Radiation therapy Interruptions.

Purpose: Radiation treatment interruption associated with unplanned hospitalization remains understudied. The intent of this study was to benchmark the frequency of hospitalization-associated radiation therapy interruptions (HARTI), characterize disease processes causing hospitalization during radiation, identify factors predictive for HARTI, and localize neighborhood environments associated with HARTI at our academic referral center. Methods and Materials: This retrospective review of electronic health records provided descriptive statistics of HARTI event rates at our institutional practice. Uni- and multivariable logistic regression models were developed to identify significant factors predictive for HARTI. Causes of hospitalization were established from primary discharge diagnoses. HARTI rates were mapped according to patient residence addresses. Results: Between January 1, 2015, and December 31, 2017, 197 HARTI events (5.3%) were captured across 3729 patients with 727 total missed treatments. The 3 most common causes of hospitalization were malnutrition/dehydration (n = 28; 17.7%), respiratory distress/infection (n = 24; 13.7%), and fever/sepsis (n = 17; 9.7%). Factors predictive for HARTI included African-American race (odds ratio [OR]: 1.48; 95% confidence interval [CI], 1.07-2.06; P = .018), Medicaid/uninsured status (OR: 2.05; 95% CI, 1.32-3.15; P = .0013), Medicare coverage (OR: 1.7; 95% CI, 1.21-2.39; P = .0022), lung (OR: 5.97; 95% CI, 3.22-11.44; P < .0001), and head and neck (OR: 5.6; 95% CI, 2.96-10.93; P < .0001) malignancies, and prescriptions >20 fractions (OR: 2.23; 95% CI, 1.51-3.34; P < .0001). HARTI events clustered among Medicaid/uninsured patients living in urban, low-income, majority African-American neighborhoods, and patients from middle-income suburban communities, independent of race and insurance status. Only the wealthiest residential areas demonstrated low HARTI rates. Conclusions: HARTI disproportionately affected socioeconomically disadvantaged urban patients facing a high treatment burden in our catchment population. A complementary geospatial analysis also captured the risk experienced by middle-income suburban patients independent of race or insurance status. Confirmatory studies are warranted to provide scale and context to guide intervention strategies to equitably reduce HARTI events.

Outcomes of primary radiotherapy with or without chemotherapy for advanced oral cavity squamous cell carcinoma: Systematic review.

BACKGROUND: Surgery with adjuvant radiotherapy is the accepted standard for treatment of advanced oral cavity squamous cell carcinoma (OCSCC); however, alternative evidence suggests that definitive (chemo)radiotherapy may have similar outcomes. METHODS: Systematic review was performed to assess the therapeutic value of radiotherapy or chemoradiotherapy as a primary modality for treating OCSCC. Meta-analysis of outcomes was performed between articles comparing radiotherapy and primary surgical treatment. RESULTS: Meta-analysis showed less favorable results of radiotherapy compared to surgery: overall survival at 3-years (odds ratio [OR] = 0.51; 95% confidence interval [CI] = 0.34-0.77) and 5-years (OR = 0.42; 95% CI = 0.29-0.60); disease-specific survival at 3-years (OR = 0.55; 95% CI = 0.32-0.96) and 5-years (OR = 0.55; 95% CI = 0.32-0.96). Odds of feeding tube dependency were higher in primary radiotherapy group (OR = 2.67; 95% CI = 1.27-5.64). CONCLUSIONS: Results of this study support the current perspective favoring primary surgical treatment for OCSCC in the absence of surgical contraindications.

The selective hypoxia inducible factor-1 inhibitor PX-478 provides in vivo radiosensitization through tumor stromal effects.

Hypoxia inducible factor-1 (HIF-1) promotes tumor cell adaptation to microenvironmental stress. HIF-1 is up-regulated in irradiated tumors and serves as a promising target for radiosensitization. We initially confirmed that the orally bioavailable HIF-1 inhibitor PX-478 reduces HIF-1 protein levels and signaling in vitro in a dose-dependent manner and provides direct radiosensitization of hypoxic cancer cells in clonogenic survival assays using C6 glioma, HN5 and UMSCCa10 squamous cells, and Panc-1 pancreatic adenocarcinoma cell lines. However, PX-478 yields striking in vivo tumor sensitization to single-dose irradiation, which cannot be explained by incremental improvement in direct tumor cell killing. We show that PX-478 prevents postradiation HIF-1 signaling and abrogates downstream stromal adaptation in C6 and HN5 reporter xenografts as measured by serial ultrasound, vascular magnetic resonance imaging, and hypoxia response element-specific micro-positron emission tomography imaging. The primacy of indirect PX-478 in vivo effects was corroborated by our findings that (a) either concurrent or early postradiation sequencing of PX-478 provides roughly equivalent sensitization and (b) constitutive vascular endothelial growth factor expression maintains refractory tumor vessel function and progression following combined radiation and PX-478. These results confirm that disruption of postradiation adaptive HIF-1 signaling by PX-478 imparts increased therapeutic efficacy through blockade of HIF-1-dependent reconstitution of tumor stromal function. Successful translation of targeted HIF-1 radiosensitization to the clinical setting will require specific consideration of tumor microenvironmental effects and mechanisms.

The Evolving Role of Radiotherapy for Head and Neck Cancer.

The length and quality of head and neck cancer survivorship continues to meaningfully improve. Radiotherapy has been central to this process through advances in treatment delivery, fractionation schemas, radiosensitizing systemic therapy, and thoughtful interplay with technical surgical improvements. The future looks brighter still, with ongoing progress in targeted biologic therapy, immuno-oncology, and molecular-genetic tumor characterization for personalized treatment. Head and neck cancer, a disease once fraught with nihilism and failure, is evolving into a major success story of modern multidisciplinary cancer care.

COVID's Impact on Radiation Oncology: A Latin American Survey Study.

PURPOSE: The impact of the COVID-19 pandemic on Latin American radiation therapy services has not yet been widely assessed. In comparison to centers in Europe or the United States, the scarcity of data on these terms might impair design of adequate measures to ameliorate the pandemic's potential damage. The first survey-based analysis revealing regional information is herein presented. METHODS AND MATERIALS: From May 6 to May 30, 2020, the American Society for Radiation Oncology's COVID-19 Survey was distributed across Latin America with support of the local national radiation therapy societies. Twenty-six items, including facility demographic and financial characteristics, personnel and patient features, current and expected impact of the pandemic, and research perspectives, were included in the questionnaire. RESULTS: Complete responses were obtained from 115 (50%) of 229 practices across 15 countries. Only 2.6% of centers closed during the pandemic. A median of 4 radiation oncologists (1-27) and 9 (1-100) radiation therapists were reported per center. The median number of new patients treated in 2019 was 600 (24-6200). A median 8% (1%-90%) decrease in patient volume was reported, with a median of 53 patients (1-490) remaining under treatment. Estimated revenue reduction was 20% or more in 53% of cases. Shortage of personal protective equipment was reported in 51.3% of centers, and 27% reported personnel shortage due to COVID-19. Reported delays in treatment for low-risk entities included early stage breast cancer (42.6%), low-risk status prostate cancer (67%), and nonmalignant conditions (42.6%). Treatment of COVID-19 patients at designated treatment times and differentiated bunkers were reported in 22.6% and 10.4% of centers, respectively. Telehealth initiatives have been started in 64.3% of facilities to date for on-treatment (29.6%) and posttreatment (34.8%) patients. CONCLUSIONS: Regional information regarding COVID-19 pandemic in Latin America may help elucidate suitable intervention strategies for personnel and patients. Follow-up surveys will be performed to provide dynamic monitoring the pandemic's impact on radiation therapy services and adoption of ameliorating measures.