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Parotid sparing adaptive radiotherapy (PSART) is resource intensive to implement. Selection criteria for using ART and its impact on quality of life (QoL) is poorly reported. This has been addressed in our study.Patients planned for curative radiotherapy for Head Neck Cancers were recruited following informed consent in a prospective cohort study. PSART was planned if the mean dose to index parotid(s) increased by 2% from the baseline approved plan. To assess the resource requirements of PSART manpower and time required for treatment planning both for initial as well as PSART was documented. Patient reported QoL using QualiXeQLS and EORTC QLQ C30 and HN35 were obtained pre radiotherapy, and at 3 and 9 months post radiotherapy.Of the ninety patients accrued, 87 were evaluable. 45 (51%) received PSART based on the prespecified criteria. The average time spent in contouring (276 min versus 133 min) and treatment planning (293 min versus 108 min) were almost doubled when PSART was implemented. XeQoL scores at 3 months were significantly worse in those receiving PSART (mean 2.3 vs 1.2, p 0.002). Despite this, xerostomia related QoL recovered to near baseline scores by 9 months after receiving PSART.Implementation of PSART is resource intensive. The proposed cutoff for implementing PSART identifies a higher risk population that have worse xerostomia related quality of life. This study lays the foundation for a randomized trial to determine the efficacy of PSART on xerostomia related QoL.

PURPOSE A COVID-19 lockdown in India posed significant challenges to the continuation of radiotherapy (RT) and systemic therapy services. Although several COVID-19 service guidelines have been promulgated, implementation data are yet unavailable. We performed a comprehensive audit of the implementation of services in a clinical oncology department. METHODS A departmental protocol of priority-based treatment guidance was developed, and a departmental staff rotation policy was implemented. Data were collected for the period of lockdown on outpatient visits, starting, and delivery of RT and systemic therapy. Adherence to protocol was audited, and factors affecting change from pre-COVID standards analyzed by multivariate logistic regression. RESULTS Outpatient consults dropped by 58%. Planned RT starts were implemented in 90%, 100%, 92%, 90%, and 75% of priority level 1-5 patients. Although 17% had a deferred start, the median time to start of adjuvant RT and overall treatment times were maintained. Concurrent chemotherapy was administered in 89% of those eligible. Systemic therapy was administered to 84.5% of planned patients. However, 33% and 57% of curative and palliative patients had modifications in cycle duration or deferrals. The patient’s inability to come was the most common reason for RT or ST deviation. Factors independently associated with a change from pre-COVID practice was priority-level allocation for RT and age and palliative intent for systemic therapy. CONCLUSION Despite significant access limitations, a planned priority-based system of delivery of treatment could be implemented.

IntroductionPeer review of target volume is recommended as an important step for ensuring high quality radiotherapy. The Royal College of Radiologists considers gynecological cancers as one of the sites where peer review of individual target volumes is required. We report results of an on-demand peer review system for gynecological cancers in our institute. MethodsPeer review was planned for gynecological cancer cases planned for curative intent radiotherapy. On demand peer review was conducted by two senior clinical oncologists specializing in gynecological cancers after segmentation was completed by junior clinical oncologists. Peer review discussions were recorded prospectively in an electronic database. In the present study, data of patients planned from radiotherapy between 15th September 2021 - September 2022 is audited. The compliance to the audit process, proportion of patients requiring major and minor modifications in target volumes, direction of changes noted as well as factors influencing the changes have been reported.ResultsIn the study period, 230 patients underwent planning for curative intent radiotherapy and 204 (88.3%) patients had at least one peer review. Major target volume changes were required in 108 patients, with the majority of changes reported in the nodal CTV. Analysis of P-charts showed a rapid change in proportion of patients requiring major modifications with stabilization at the end of 3 months to 38.2% and 28% for nodal and primary CTV respectively. Modifications were primarily required in the para-aortic and common iliac region for nodal CTV. Multivariable analysis showed that major modifications were associated with the use of extended field radiotherapy and use of radical radiation in non-cervical primaries. ConclusionAn on-demand peer review system was feasible and resulted in clinically meaningful changes in 53% of patients.

IntroductionThe COVID-19 pandemic has affected cancer care worldwide. We audited adherence to 19 predefined quality indicators (QI) of treatment in patients with carcinoma cervix in our institute. MethodsPatients with carcinoma cervix treated with curative intent radical radiotherapy were eligible for this study. Patients who started treatment between 24 March 2019 and 24 March 2021 were evaluated. We divided participants into two groups, the pre pandemic period between 24 March 2019 and 23 March 2020, and the period of pandemic from 24 March 2020 - 24 March 2021. Adherence to 19 predefined QI was evaluated for each patient’s treatment course. Multivariable analysis of adherence to QI was performed using proportional odds regression. Results154 patients underwent treatment, of whom 83 (53.9%) received treatment during the pandemic. 17 patients had COVID-19 infection before or during treatment. Adherence to QI decreased during the pandemic, primarily driven by delays in the start and delivery of treatment. The median number of QI adhered to in the pre pandemic period was 17 (IQR: 16 - 17.5) versus 17 during the pandemic (IQR: 16 - 17). Multivariable analysis showed that treatment during the pandemic period was associated with a lower adherence to QI (Odds ratio 3.30, 95% confidence intervals 1.70 - 6.50). ConclusionsThe COVID-19 pandemic was associated with reduced adherence to QI. Treatment delivery was affected not only by COVID-19 infection, but also logistic challenges due to restrictions related to the pandemic.

Aims There is a paucity of long-term data on outcomes of high-risk prostatic adenocarcinoma after moderately hypofractionated radiotherapy with elective nodal treatment and long-term androgen deprivation therapy (ADT). We report long-term control and toxicity outcomes and analyse the predictors of failure and toxicity. Materials and methods The records of 120 consecutive high-risk prostate cancer patients treated in a single institution between February 2012 and December 2016 were retrospectively analysed. A moderately hypofractionted radiotherapy (HypoRT) regimen of 60 Gy in 20 fractions over 4 weeks with simultaneous elective pelvic irradiation to 44 Gy in 20 fractions with intensity-modulated radiotherapy was used, together with long-term ADT with either orchiectomy or medical castration for a total duration of 2–3 years. We analysed biochemical control, metastasis-free survival and late toxicities and their predictive factors using survival analysis. Results Patients had locally advanced cancers (cT3 77.5%, median pretreatment prostate-specific antigen 30 ng/ml, Gleason score 8–10 in 45.8%). The median follow-up time was 70 months. The 3- and 5-year probability of freedom from biochemical progression was 93% and 80%, respectively. The 5-year probability of freedom from local relapse/intra-pelvic nodal relapse/distant metastases as the site of first failure was 96%/97%/86%, respectively. Gleason score 8–10 and medical ADT for 2–3 years (as opposed to orchidectomy) were independent risk factors for distant metastases. A total of 18 grade 2 and above late gastrointestinal toxicity events and a total of 23 grade 2 and above late genitourinary toxicity events were documented. Patients who underwent a transurethral resection of prostate prior to radiotherapy had worse urological toxicity. Conclusions HypoRT with elective nodal treatment results in excellent pelvic control. Distant metastases are the primary mode of failure. Risk of metastases is associated with Gleason score and the duration of ADT. Late urinary toxicities are more common in those with prior transurethral resection of prostate.

INTRODUCTION: A COVID19 lockdown in India posed significant challenges to the continuation of radiotherapy (RT) and systemic therapy services. While several COVID19 service guidelines have been promulgated, implementation data is yet unavailable. We performed a comprehensive audit of the implementation of services in a clinical oncology department.METHODS AND MATERIALS: A departmental protocol of priority-based treatment guidance was developed and a departmental staff rotation policy was implemented. Data was collected for the period of lockdown on outpatient visits, starting, and delivery of RT and systemic therapy. Adherence to protocol was audited, and factors affecting change from pre-COVID standards analyzed by multivariate logistic regression.RESULTS: Outpatient consults dropped by 58%. Planned RT starts were implemented in 90%, 100%, 92%, 90% and 75% of priority level 1-5 patients. While 17% had a deferred start, the median time to start of adjuvant RT and overall treatment times were maintained. Concurrent chemotherapy was administered in 89% of those eligible. Systemic therapy was administered to 84.5% of planned patients with 33% and 57% of curative and palliative patients receiving modified or deferred cycles. The patient’s inability to come was the commonest reason for RT or ST deviation. Factors independently associated with a change from pre-COVID practice was priority level allocation for RT and age and palliative intent for systemic therapy.CONCLUSIONS: Despite significant access limitations a planned priority-based system of delivery of treatment could be implemented.

In this study, we have analysed pretreatment positron-emission tomography/ computed tomography (PET/CT) images of head and neck squamous cell carcinoma (HNSCC) patients. We have used a publicly available dataset for our analysis. The clinical features of the patient, PET quantitative parameters, and textural indices from pretreatment PET-CT images are selected for the study. The main objective of the study is to use classifiers to predict the outcome for HNSCC patients and compare the performance of the model with the conventional statistical model (CoxPH).We have applied a 40% fixed SUV threshold method for tumour delineation. Clinical features of each patient are provided in the dataset, and other features are calculated using LIFEx software. For predicting the outcome, we have implemented three classifiers - Random Forest classifier, Gradient Boosted Decision tree (GBDT) and Decision tree classifier. We have trained each model using 93 data points and test the model performance using 39 data points. The best model - GBDT is chosen based on the performance metrics.It is observed that typically three features: MTV (Metabolic tumour Volume), primary tumour site and GLCM_correlation are significant for prediction of survival outcome. For testing cohort, GBDT achieves a balanced accuracy of 88%, where conventional statistical model reported a balanced accuracy of 81.5%.The proposed classifier achieves higher accuracy than the state of the art technique. Using this classifier we can estimate the HNSCC patient's outcome, and depending upon the outcome treatment policy can be selected.

e24037 Background: Anatomical changes during the course of parotid sparing IMRT for head and neck cancer can lead to an increase in the actual dose absorbed by the parotid glands, which may be controlled with the use of interval adaptive replanning. In this prospective assessment of adaptive replanning for parotid dose changes, we explored the feasibility of carrying out adaptive replanning based on predefined objective dosimetric criteria at specified time points. We sought to assess the impact of this measure using a clinically meaningful endpoint of patient reported quality of life outcomes. Methods: 90 patients with head and neck radiotherapy indicated for definitive management or adjuvant therapy who had at least one parotid gland receiving a mean dose (MD) of between 25-30Gy were accrued in the study. The index parotid was delineated on the images acquired on 14th and 19th day and the MD was determined by overlaying the verification image on the planned CT. If the MD had increased by 2% of the initial intended dose, an adaptive plan was attempted with an aim to reduce MD by 2% without compromising PTV coverage; this plan was then used to deliver the remaining treatment. Patients were invited to complete QoL questionnaires: EORTC-QLQC30 with HN35 module, and XeQoL score at baseline, at 3 and 9 months after completion of treatment. Results: 46 out of 90 patients met the threshold for adaptive replanning and were switched to the new plan during treatment. Adaptive replanning was triggered at D14 for 31 patients and D19 for the remaining 15. Need for adaptive replanning was associated with receipt of concurrent chemotherapy and weight loss in the first two weeks of RT. QoL was evaluable for 50 patients at 3 months post treatment. In patients who required adaptive replanning per protocol, Mean XeQoL scores at 3 months showed significantly worse scores for overall scores (1.1 vs 2.3, p 0.001) and for the component individual physical, pain, psychological, and social domains. EORTC QLQ-C30 and HN35 questionnaires at 3 months also demonstrated significantly worse mean symptom scores of the relevant domains of mouth dryness (39 vs 60), stickiness (32 vs 54) and swallowing (39 vs 60) in patients who required adaptive replanning versus those who did not. No significant QoL trends were observable in the 31 patients who were evaluable at 9 months post treatment. The average time required for each step in the planning process was comparable for both the initial planning workflow and adaptive replanning process. Conclusions: The trigger criteria for replanning identified a population of patients who have significantly worsened quality of life due to radiation induced xerostomia. The benefits of adaptive replanning strategies based on weekly evaluation, binary thresholds and standard planning procedures is doubtful Clinical trial information: CTRI/2017/11/010683.