Purpose: Simulation-free radiation therapy (sim-free RT) uses diagnostic computed tomography scans in place of dedicated computed tomography simulations for treatment planning, potentially expediting palliative radiation therapy (PRT) while optimizing resource utilization. Broader adoption has been limited by the absence of standardized implementation guidance. This study aimed to establish expert consensus on key clinical, technical, and educational considerations for sim-free RT in PRT practice. Methods and Materials: A modified Delphi process was conducted with international experts in sim-free RT, including radiation oncologists (n = 7), medical physicists (n = 2), a radiation therapist, and a PhD candidate specializing in PRT. The process included an open-ended first round followed by 3 Likert-scale survey rounds across 12 domains. Consensus was defined as ≥75% agreement; ≥90% agreement indicated strong support. “Trend toward agreement” was defined as 67% to 74%. Results: Nine respondents, representing 11 individual experts from 8 institutions in 5 countries, completed all study rounds. Experts from the same institution responding as a group were considered as 1 participant. Consensus was achieved for 95% of statements. Strong support was observed for sim-free RT in palliative-intent treatments at low-risk sites (eg, thoracic/lumbar spine, pelvis) using conventional dose-fractionation. Recommended prerequisites included recent high-quality diagnostic scans (≤3 mm slice thickness, 100-140 kVp), robust image quality assurance, and multidisciplinary oversight. Areas of limited agreement included the use of older scans, application to cervical spine targets, and integration with intensity modulated radiotherapy/volumetric modulated arc therapy planning. Conclusions: This Delphi study provides expert-driven recommendations to support safe implementation of sim-free RT in palliative practice. Findings highlight suitable indications, workflow safeguards, and training needs while underscoring the need for further dosimetric validation and broader evaluation across diverse practice settings.

Simulation-free radiation therapy (SFRT) is an emerging patient-centered paradigm for palliative radiation therapy. Feasibility and clinical benefits have been demonstrated by several groups; however, guidance to overcome technical barriers to adoption is limited. This report describes practical recommendations for offline preliminary studies, patient selection, image selection and formatting, planning and treatment considerations, and quality control. These suggestions aim to enable safe, scalable, and effective clinical implementation of SFRT.

Purpose/Objective(s) The feasibility of simulation-free radiotherapy (SFRT) has been demonstrated but information regarding its impact on routine care is lacking. The hypothesis was that SFRT is scaleable and beneficial in routine care. Key endpoints of this single institution study were SFRT utilization, impact on consultation-to-RT time and on-couch treatment duration. Materials/Methods All patients receiving palliative RT in the study period were eligible for consideration of SFRT unless mask immobilization, a stereotactic technique, or a definitive dose was required. Timing metrics were compared to a contemporary local cohort that received simulation-based palliative RT using unadjusted medians (Wilcoxon rank-sum test) and a propensity score-weighted regression. Electronic patient-reported outcomes (ePROs) captured 2-week toxicity and pain response. Results Between April 2018 and February 2024, there were 2845 palliative radiation courses were delivered, of which 1904 were eligible for this study. One thousand of the 1904 courses (52.5% SFRT utilization) were treated using the SFRT protocol, including 668 with IMRT/VMAT. Median patient age was 71 years with 60% being male and 32% being ECOG 2-4. SFRT reduced median consultation-to-RT time from 7.0 to 5.1 days (P < 0.0001) corresponding to an adjusted average treatment effect (aATE) of -2.3 days (95% CI = -2.9 to -1.7). SFRT increased median on-couch treatment duration from 16 min to 18 min (P < 0.0001; aATE 2.0 min, 95% CI = 0.2 to 3.9). SFRT utilization in eligible courses increased from 41% to 54% between the years 2018 and 2019 and 2022 and 2024. PRO-CTCAE grade 3 acute toxicity was 9% and at 4 weeks post RT patients with moderate/severe pain at baseline (≥ 5/10) had had a mean pain reduction of 3.5 points (7.1 to 3.6). Conclusion Using widely available technologies the SFRT-1000 cohort demonstrates routine care scalability with patient-centered and workflow benefits. SFRT is an attractive new palliative RT paradigm implementable in most settings.

BACKGROUND:The COVID-19 pandemic disrupted health systems around the globe. Lessons from health systems responses to these challenges may help design effective and sustainable health system responses for future challenges. This study aimed to 1/ identify the broad types of health system challenges faced during the pandemic and 2/ develop a typology of health system response to these challenges. METHODS:Semi-structured one-on-one online interviews explored the experience of 19 health professionals during COVID-19 in a large state health system in Australia. Data were analysed using constant comparative analysis utilising a sociotechnical system lens. RESULTS:Participants described four overarching challenges: 1/ System overload, 2/ Barriers to decision-making, 3/ Education or training gaps, and 4/ Limitations of existing services. The limited time often available to respond meant that specific and well-designed strategies were often not possible, and more generic strategies that relied on the workforce to modify solutions and repair unexpected gaps were common. For example, generic responses to system overload included working longer hours, whilst specific strategies utilised pre-existing technical resources (e.g. converting non-emergency wards into COVID-19 wards). CONCLUSION:During the pandemic, it was often not possible to rely on mature strategies to frame responses, and more generic, emergent approaches were commonly required when urgent responses were needed. The degree to which specific strategies were ready-to-hand appeared to dictate how much a strategy relied on such generic approaches. The workforce played a pivotal role in enabling emergent responses that required dealing with uncertainties.

PURPOSE:The feasibility of simulation-free radiation therapy (SFRT) has been demonstrated but information regarding its routine care impact and scalability is lacking. METHODS AND MATERIALS:In this single-institution, retrospective cohort study, all patients receiving palliative radiation therapy at an Australian tertiary cancer center were eligible for consideration of SFRT unless mask immobilization, a stereotactic technique, or a definitive dose was indicated. Coprimary endpoints were SFRT utilization, impact on consultation-to-RT time, and on-couch treatment duration. Timing metrics were compared with a contemporary local cohort that received simulation-based palliative radiation therapy using unadjusted Wilcoxon rank-sum tests and a propensity score-matched regression. Electronic patient-reported outcomes captured 2-week toxicity and pain response.  RESULTS:  Between April 2018 and February 2024, 2849 palliative radiation courses were delivered, of which 1904 were eligible. Of the 1904 courses, 1000 (52.5% SFRT utilization) received SFRT, including 668 using intensity-modulated radiation therapy/volumetric-modulated arc therapy. A total of 788 individual patients received SFRT and the median age was 71 years (IQR, 61-80) with 59% being male and 42% being Eastern Collaborative Oncology Group 2-4. SFRT utilization increased from 41% to 54% between years 2018-2019 and 2022-2024.  SFRT reduced median consultation-to-RT time from 7.0 to 5.1 days (P < .0001) corresponding to an adjusted average treatment effect in the treated of -2.1 days (95% CI, -2.8 to -1.3). SFRT increased median on-couch treatment duration from 17.8 to 20.5 minutes (P < .0001; adjusted average treatment effect in the treated 2.6 minutes, 95% CI, 1.3-3.9). Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events grade 3 acute toxicity was 9% and at 4 weeks after RT, patients with moderate/severe pain at baseline (≥5/10) had a mean pain reduction of 3.5 points (7.1-3.6; P < .0001).  CONCLUSIONS:  Using widely available technologies, the SFRT-1000 cohort demonstrates routine care scalability with patient-centered and workflow benefits. SFRT is an attractive new paradigm implementable in most settings following adaptation to local requirements. Thus, SFRT opens new avenues to potentially improve access to palliative RT, which remains a global area of need.

BACKGROUND:Health systems underwent substantial changes to respond to COVID-19. Learning from the successes and failures of health system COVID-19 responses may help us understand how future health service responses can be designed to be both effective and sustainable. This study aims to identify the role that innovation played in crafting health service responses during the COVID-19 pandemic. METHODS:Semi-structured interviews were conducted online, exploring 19 health professionals' experiences in responding to COVID-19 in a large State health system in Australia. The data were collected from April to September 2022 and analysed utilising constant comparative analysis. The degree of innovation in health service responses was assessed by comparing them to pre-pandemic services using 5 categories adopted from the IMPISCO (Investigators, Methods, Population, Intervention, Setting, Comparators and Outcomes) framework, which classifies interventional fidelity as: 1/ Identical: No differences are found between health services; 2/ Substitution with alternatives that perform the same function, 3/ In-class replacement with elements that delivers roughly the same functionality, 4/ Augmentation with new functions, 5/ Creation of new elements. Services were decomposed into bundles and fidelity labels were assigned to individual bundle elements. RESULTS:New services were typically created by reconfiguring existing ones rather than being created de novo. The presence of pre-existing infrastructure (foundational technologies) was seen as critical in mounting fast health service responses. Absence of infrastructure was associated with delays and impaired system responses. CONCLUSIONS:The need to reconfigure rapidly and use infrastructure to support this suggests we reconceive health services as a platform (a general-purpose service upon which other elements can be added for specific functions), where a common core service (such as a primary care practice) can be extended by adding specialised functions using mediators which facilitate the connection (such as virtual service capabilities). Innovation can be costly and time consuming in crises, and during the COVID-19 pandemic, innovations were typically patched together from pre-existing services. The notion of platforms seems a promising way to prepare the health system for future shocks.

Background: Emerging digital health approaches could play a role in better personalized palliative care. Aim: We conducted a feasibility study testing wearable sensor (WS)-triggered ecological momentary assessments (EMAs) and electronic patient-reported outcomes in community palliative care with patient-caregiver dyads. Design: All wore consumer-grade WS for five weeks. Sensor-detected "stress" (heart rate variability algorithm) that passed individualized thresholds triggered a short smartphone survey. Daily sleep surveys, weekly symptom surveys (Integrated Palliative care Outcome Scale), and a poststudy experience survey were conducted. Setting/Participants: Fifteen dyads (n = 30) were recruited from an outpatient palliative care clinic for people with cancer. Results: Daytime sensor wear-time had 73% adherence. Participants perceived value in this support. Quantity and severity of "stress" events were higher in patients. Sleep disturbance was similar but for different reasons: patients (physical symptoms) and caregivers (worrying about the patient). Conclusions: EMAs are feasible and valued in community palliative care.

Journal of Palliative MedicineVol. 25, No. 6 Letters to the EditorFree AccessLetter to the Editor: Sleep Disturbances in People with Advanced Cancer and Their Informal Caregivers: A Digital Health ExplorationThilo Schuler, David Currow, Katherine Clark, and Michael BackThilo SchulerAddress correspondence to: Thilo Schuler, MD, MHInf, Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Reserve Road, Sydney, New South Wales 2065, Australia E-mail Address: thilo.schuler@health.nsw.gov.auDepartment of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.Search for more papers by this author, David CurrowFaculty of Science, Medicine, and Health, University of Wollongong, Wollongong, New South Wales, Australia.Search for more papers by this author, Katherine ClarkNSLHD Supportive and Palliative Care Network, Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.Search for more papers by this author, and Michael BackDepartment of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia.Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.Search for more papers by this authorPublished Online:18 May 2022https://doi.org/10.1089/jpm.2022.0125AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Dear Editor:The recent large-scale study by Currow et al. in Australian palliative care recipients described a high prevalence of sleep-related distress and its strong association with physical symptoms.1 This important study confirms and strengthens findings in smaller studies, concluding that sleep needs increased attention by clinicians and researchers to better understand and address this problem.We are currently in the analysis phase of a pilot study to investigate the feasibility of digital health-enabled approaches in routine care. Utilizing an emerging method known as ecological momentary assessment we provided consumer-grade wearable “fitness” sensors to recipients of palliative care services and their informal caregivers to explore sleep, physical activity, and distress patterns.2 This letter shares early data that are both congruent with and expand on the findings of highly prevalent sleep-related distress in palliative care.1We hypothesized that emerging digital health approaches, including wearables and ecological momentary assessments, may provide tools for better understanding and treating sleep-related distress in people with advanced cancer and their caregivers. This study included the following: 1.Posing small surveys “in-the-moment” including when a potential noteworthy event has just happened will overcome the issue of recall bias and may reveal contextual factors that otherwise may have not been mentioned.2.Including the caregiver as a formal research subject allows the dyadic inter-relationships affecting sleep, as well as other symptoms causing distress for the care recipient and the caregiver, to be uncovered.3.Digital health methods provide additional opportunities for patient management such as passive monitoring for “yellow flags” using digital biomarker profiles (e.g., persistent change in sleep parameters) combined with risk-adapted patient support mechanisms when those yellow flags appear (e.g., just-in-time provision of helpful online resources for improving sleep or a phone call by a member of the clinical team).Fifteen dyads were recruited from recipients of community palliative care and their primary informal caregiver (n = 30). For five weeks both dyad members wore a consumer-grade wearable sensor linked to their smart phone. For the pilot's ecological momentary assessment component participants were prompted every morning to complete a two-question survey about the preceding night on their phone. When the sensor breached an individualized “stress” level during daytime hours another two-question survey was triggered.The mostly female (80%) palliative care recipients had advanced cancer from 10 different primary sites. Their median age was 59 years with an Australian-modified Karnofsky Performance Status of 60 to 80.3 Caregivers had the same median age and all but three were spousal partners.Analysis of the granular longitudinal dataset so far has revealed, consistent with Currow et al., that in 11% (30/261) of the daily survey responses the person with advanced cancer reported “quite a bit” or “very much” sleep disturbance with the majority providing physical symptoms as the key reason. The corresponding rate for the caregivers was similar at 12% (21/179). However, mental reasons such as worrying predominated in this group (see Fig. 1).FIG. 1. Responses to daily sleep survey from palliative care recipients and their caregivers: severity of sleep disturbance (A1) and reasons by severity level (A2). EMA, ecological momentary assessment.We are in the process of further analyzing the collected dataset, with a focus on feasibility of routine care translation.References1. Currow DC, Davis W, Connolly A, et al.: Sleeping-related distress in a palliative care population: A national, prospective, consecutive cohort. Palliat Med 2021;35:1663–1670. Crossref, Medline, Google Scholar2. Thong MSY, Chan RJ, van den Hurk C, et al.; MASCC EMA Working Group: Going beyond (electronic) patient-reported outcomes: Harnessing the benefits of smart technology and ecological momentary assessment in cancer survivorship research. Support Care Cancer 2021;29:7–10. Crossref, Medline, Google Scholar3. Abernethy AP, Shelby-James T, Fazekas BS, et al.: The Australia-modified Karnofsky Performance Status (AKPS) scale: A revised scale for contemporary palliative care clinical practice [ISRCTN81117481]. BMC Palliat Care 2005;4:7. Crossref, Medline, Google ScholarFiguresReferencesRelatedDetails Volume 25Issue 6Jun 2022 InformationCopyright 2022, Mary Ann Liebert, Inc., publishersTo cite this article:Thilo Schuler, David Currow, Katherine Clark, and Michael Back.Letter to the Editor: Sleep Disturbances in People with Advanced Cancer and Their Informal Caregivers: A Digital Health Exploration.Journal of Palliative Medicine.Jun 2022.851-852.http://doi.org/10.1089/jpm.2022.0125Published in Volume: 25 Issue 6: May 18, 2022PDF download

We commend Roos et al on their survey documenting the limited uptake of Rapid Access Palliative Radiotherapy (RAPRT) clinics in Australia and New Zealand (ANZ). 1 Roos PD, James DM, Lah DM, et al. Rapid access palliative radiotherapy clinics—the evidence is there, but where are the clinics? An Australian and New Zealand perspective. Int J Radiat Oncol Biol Phys. https://doi.org/10.1016/j.ijrobp.2021.07.034. Accessed August 3, 2021. Google Scholar The RAPRT concept was developed in Canada and successfully reduced waiting times for palliative radiation therapy (RT). However, since then, we have witnessed advances in RT planning and delivery, including deformable registration techniques, cone beam computed tomography (CT), image guidance, and, where appropriate, complex techniques such as stereotactic body RT.

PURPOSE:Our purpose was to report outcomes of a novel palliative radiation therapy protocol that omits computed tomography simulation and prospectively collects electronic patient-reported outcomes (ePROs).METHODS AND MATERIALS:Patients receiving extracranial, nonstereotactic, linear accelerator-based palliative radiation therapy who met inclusion criteria (no mask-based immobilization and a diagnostic computed tomography within 4 weeks) were eligible. Global pain was scored with the 11-point numerical pain rating scale (NPRS). Patients were coded as having osseous or soft tissue metastases and no/mild versus severe baseline pain (NPRS ≥ 5). Pain response at 4 weeks was measured according to the international consensus (no analgesia adjustment). Transition to ePRO questionnaires was completed in 3 phases. Initially, pain assessments were collected on paper for 11 months, then pilot ePROs for 1 month and then, after adjustments, revised ePROs from 1 year onwards. ePRO feasibility criteria were established with reference to the paper-based process and published evidence.RESULTS:Between May 2018 and November 2019, 542 consecutive patients were screened, of whom 163 were eligible (30%), and 160 patients were successfully treated. The proportion of patients eligible for the study improved from approximately 20% to 50% by study end. Routine care pain monitoring via ePROs was feasible. One hundred twenty-seven patients had a baseline NPRS recording. Ninety-five patients had osseous (61% severe pain) and 32 had soft tissue (25% severe pain) metastases. Eighty-four patients (66%) were assessable for pain response at 4 weeks. In the 41 patients with severe osseous pain, overall and complete pain response was 78% and 22%, respectively.CONCLUSIONS:By study completion, 50% of patients receiving palliative extracranial radiation therapy avoided simulation, streamlining the treatment process and maximizing patient convenience. Pain response for patients with severe pain from osseous lesions was equivalent to published evidence.

Introduction: RapidPlan (RP), a knowledge-based planning system, aims to consistently improve plan quality and efficiency in radiotherapy. During the early stages of implementation, some of the challenges include knowing how to optimally train a model and how to integrate RP into a department. We discuss our experience with the implementation of RP into our institution. Methods: We reviewed all patients planned using RP over a 7-month period following inception in our department. Our primary outcome was clinically acceptable plans (used for treatment) with secondary outcomes including model performance and a comparison of efficiency and plan quality between RP and manual planning (MP). Results: Between November 2017 and May 2018, 496 patients were simulated, of which 217 (43.8%) had an available model. RP successfully created a clinically acceptable plan in 87.2% of eligible patients. The individual success of the 24 models ranged from 50% to 100%, with more than 90% success in 15 (62.5%) of the models. In 40% of plans, success was achieved on the 1st optimisation. The overall planning time with RP was reduced by up to 95% compared with MP times. The quality of the RP plans was at least equivalent to historical MP plans in terms of target coverage and organ at risk constraints. Conclusion: While initially time-consuming and resource-intensive to implement, plans optimised with RP demonstrate clinically acceptable plan quality, while significantly improving the efficiency of a department, suggesting RP and its application is a highly effective tool in clinical practice.

We read the excellent topical review of patient-reported outcome measures (PROMs) in palliative radiotherapy (RT) [ [1] Oldenburger E. Oldenburger F. Coolbrandt A. Isebaert S. Neyens I. Sevenants A. et al. The use of patient reported outcome measures (PROMs) in palliative radiotherapy: a topical review. Radiother Oncol [Internet]. 2020; ([cited 2020 May 3];0(0). Available from: https://www.thegreenjournal.com/article/S0167-8140(20)30226-7) PubMed Google Scholar ] with much anticipation. We agree with the exciting potential as well as the current translation gap of PROMs in palliative RT as demonstrated by the review [ [1] Oldenburger E. Oldenburger F. Coolbrandt A. Isebaert S. Neyens I. Sevenants A. et al. The use of patient reported outcome measures (PROMs) in palliative radiotherapy: a topical review. Radiother Oncol [Internet]. 2020; ([cited 2020 May 3];0(0). Available from: https://www.thegreenjournal.com/article/S0167-8140(20)30226-7) PubMed Google Scholar ]. We would like to share our perspectives, including results from our study of routine PROMs in this setting [ [2] Schuler T, Hruby G, Wong S, Grimberg K, Kneebone A, Eade T. Patient-reported outcome measures during routine care palliative radiotherapy: Implementation experience and completion rates. In: The Royal Australian and New Zealand College of Radiologists (RANZCR), 71th Annual Scientific Meeting, 15–18 October 2020, Melbourne, Australia. 2020 (submitted). Google Scholar ]. Response to Schuler et al. patient-reported outcome measures (PROMs) in palliative radiotherapyRadiotherapy and OncologyVol. 154PreviewWe've read the letter to the editor with great interest and would firstly like to thank the authors for their kind appraisal of our review on behalf of all authors [1,2]. Indeed, ePROM based follow-up, not only relying on the patients’ input, results in high completion rates. Especially the last finding, which is flexible and pragmatic, should be a priority in this diverse and often frail population [1]. In our review we excluded papers using by-proxy assessment in the follow-up. Studies have shown that there can be a discrepancy in the opinion of patients and their family. Full-Text PDF

Poster: "2018 ASM / R-0107 / Comparing comprehensiveness and accuracy of data between radiotherapy databases for breast and prostate cancer at the same institution" by: "T. Schuler1, T. Liu2, G. Lamoury2, M. Morgia2, S. Carroll2, G. Hruby2, A. Kneebone2, T. Eade2, C. Brown2, B. Gallego2; 1Sydney/AU, 2NSW/AU"