COVID-19 pandemic has adversely affected general healthcare delivery systems and cancer care throughout the world. The management of locally advanced cervical cancer presents specific challenges in this context, especially brachytherapy and completion of radiotherapy treatment, without compromising the overall treatment time and anticipated outcomes. This article presents in detail the issues and possible solutions with currently available literature for COVID-19 and radiation, in particular brachytherapy management of locally advanced cervical cancers. The review attempts to provide possible explanations and pathways based on COVID-19 testing, brachytherapy processes including application, imaging, and fractionation, keeping in mind the overall treatment time.

To analyze treatment interruptions due to acute hematological toxicity in patients of medulloblastoma receiving cranio-spinal irradiation (CSI). Prospectively collected data from case records of 52 patients of medulloblastoma treated between 2011 and 2014 was evaluated. Blood counts were monitored twice a week during CSI. Spinal irradiation was interrupted for patients with ≥grade 2 hematological toxicity and resumed after recovery to grade 1 level (TLC >3000; platelet count >75,000). Treatment interruptions and hematological toxicity were analyzed. Median age was 11 years. All patients received adjuvant CSI of 36 Gy, followed by boost of 18 Gy to posterior fossa, at 1.8 Gy per fraction. Concurrent chemotherapy was not given. Adjuvant chemotherapy was given after CSI for high risk patients. Spinal fields were interrupted in 73.1% of patients. Cause of first interruption was leucopenia in 92.1%, thrombocytopenia in 2.6%, and both in 5.3%. Median number of fractions at first interruption was 8, with 25% of interruptions in first week. Median duration for hematological recovery after nadir was 5 days for leucopenia and 3 days for thrombocytopenia. Half of the patients had at least 2 interruptions, and 19% subsequently developed grade 3 toxicity. On multivariate analysis, significant correlation with duration of delay was observed for pre-treatment haemoglobin, number of fractions at first interruption, grade and duration of recovery of leucopenia. Acute hematological toxicity with CSI is frequently under-reported. Patients with low pre-treatment hemoglobin, early onset leucopenia, profound leucopenia and prolonged recovery times are at a higher risk of having protracted courses of irradiation. Frequent monitoring of blood counts and timely interruption of spinal fields of irradiation at grade 2 level of hematological toxicity minimizes the risk of grade 3 and grade 4 toxicity, while reducing the interruptions in irradiation of the gross tumour bed.

Background Though conformal partial-brain irradiation is the standard adjuvant treatment for glioblastoma, there is no consensus regarding the optimal volume that needs to be irradiated. European Organisation for Research and Treatment of Cancer (EORTC) and The University of Texas MD Anderson Cancer Center (MDACC) guidelines differ from the Radiation Therapy Oncology Group (RTOG) in their approach toward peritumoral edema, whereas RTOG and MDACC guidelines differ from EORTC in the concept of boost phase. A scarcity of randomized comparisons has resulted in remarkable variance in practice among institutions. Methods Fifty glioblastoma patients were randomized to receive adjuvant radiotherapy using RTOG or MDACC protocols. Apart from dosimetric and volumetric analysis, acute toxicities, recurrence patterns, progression-free survival (PFS), overall survival (OS), and quality of life (QoL) were compared using appropriate statistical tests. Results Both groups were comparable with respect to demographic characteristics. Dosimetric analysis revealed significantly lower boost-phase planning treatment volumes and V60 Gy in the MDACC arm (chi-squared, P = .001 and .013, respectively). No significant differences were observed in doses with respect to organs at risk, acute toxicity, or recurrence patterns (chi-squared, P > .05). On the log-rank test, median PFS (8.8 months vs 6.1 months, P = .043) and OS (17 months vs 12 months, P = .015) were statistically superior in the MDACC group. Age, extent of resection, and proportion of whole brain receiving prescription dose were associated with improved PFS and OS on regression analysis. QoL of patients was significantly better in the MDACC group in all domains except cognitive, as assessed with the EORTC Quality of Life Questionnaire (QLQ-C30) and Brain Cancer Module (QLQ-BN20) (general linear model, P < .05). Conclusions Use of limited-margin MDACC protocol can potentially improve survival outcomes apart from QoL of glioblastoma patients, as compared with the RTOG protocol.

Purpose:The present study was planned to record the distressing symptoms of newly diagnosed cancer patients and evaluate how the symptoms were addressed by the treating oncologists.Materials and Methods:All newly diagnosed cancer patients referred to the Department of Radiotherapy during May 2014 were asked to complete a questionnaire after taking their consent. The Edmonton symptom assessment scale-regular questionnaire was used to assess the frequency and intensity of distressing symptoms. The case records of these patients were then reviewed to compare the frequency and intensity documented by the treating physician. The difference in the two sets of symptoms documented was statistically analyzed by nonparametric tests using SPSS software version 16.Results:Eighty-nine patients participated in this study, of which only 19 could fill the questionnaire on their own. Anxiety was the most common symptom (97.8%) followed by depression (89.9%), tiredness (89.9%), and pain (86.5%). The treating physicians recorded pain in 83.1% whereas the other symptoms were either not documented or grossly underreported. Anxiety was documented in 3/87 patients, but depression was not documented in any. Tiredness was documented in 12/80 patients, and loss of appetite in 54/77 patients mentioning them in the questionnaire. Significant statistical correlation could be seen between the presence of pain, anxiety, depression, tiredness, and loss of appetite in the patients.Conclusion:The study reveals that the distressing symptoms experienced by newly diagnosed cancer patients are grossly underreported and inadequately addressed by treating oncologists. Sensitizing the oncologists and incorporating palliative care principles early in the management of cancer patients could improve their holistic care.

Background: There is a geographical, socioeconomical and logistic diversity among the cancer patients who reach a regional cancer center. In a developing economy like that of India's, only a minority of patients have medical insurance. So in our setup a cancer patient is met with time, distance and financial challenges. These intangible factors theoretically are expected to influence the ultimate outcome of cancer treatment. Aim: To evaluate the prevailing demographic and economic variables of cancer patients visiting our RCC and to look for any correlation among each other. Methods: The demographic details of cancer patients registered at our RCC between August 2017- September 2017 were retrieved retrospectively. Distance traveled to get to the RCC and get a diagnosis of cancer, time taken for diagnosis and initiation of treatment, and the source of finances for treatment were collected. A correlation among these factors was attempted to be identified. Statistical correlation was identified using Student t-test. Results: Among 591 patients who were analyzed, the median age of patient was 55 years old. The median time taken for the patient to reach the RCC from permanent residence after the beginning of cancer related complaints was 3.19 months. The median distance traveled for the same was 131 km. The source of income was private employment for 223 patients and government employment for 164 patients and self-employment for 200 patients. Only 164 patients had some kind of structured health scheme to manage their health care expenses. Among these, 96 patients had private insurance/reimbursement and 64 patients had government reimbursement. 384 (64%) of patients presented with advanced and locally advanced stage disease while 114 (19%) patients presented to us with early stage disease. However a correlation between delay in presentation to the RCC, distance traveled to reach the RCC, source of income and advanced stage of disease couldn't not be established. Conclusion: Majority of patients visiting our RCC is from far off places and most of these patients pay for the cancer treatment themselves without any support from government or private insurances. All these factors may be responsible for late or advanced stage presentation of cancer patients.

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Background and purpose: Radiotherapy treatment planning of radical doses for concurrent chemoradiation in Stage III non-small-cell lung cancer (NSCLC) presents many challenges. This dosimetric study aimed to analyse the impact of spatial location of tumour and nodal burden in limiting the achievement of normal organ constraints and the use of appropriate radiotherapy technique to address it. Materials and methods: Fifteen Stage III NSCLC patients underwent 18 F-fluorodeoxyglucose-positron emission tomography (FDG-PET)/computed tomography (CT) based treatment planning. VMAT (Volumetric Modulated Arc Radiotherapy) plans were made for all patients treated by 3D-CRT (3-Dimensional Conformal Radiotherapy). A binomial logistic regression was performed to ascertain the tumour and nodal characteristics that decreased the likelihood of being planned to 60 Gy. Results: Inability to achieve normal tissue constraints, particularly spinal cord dose to less than 50 Gy, during initial planning by the assigned treatment technique was the primary dose limiting factor in four patients (p = 0.02). Alternate VMAT plans could achieve the dose constraints where 3D-CRT was unsuccessful in patients with bulky central disease in two patients. This technique fell short when there was gross vertebral body erosion. Conclusions: For tumours with bulky central disease, VMAT should be preferred. With gross vertebral body erosion, even VMAT falls short if the planning target volume includes the spinal cord. In a subset of Stage III NSCLC upfront chemoradiation to radical doses may not be feasible.

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