UK clinician update, 21st May

Dear Colleagues

This week is a very special one as we celebrate our entrance into the U.S Market, with the acquisition of 21st Century Integrated Oncology, the 1st in radiotherapy provider in the U.S Market operating across 19 states and in 140 centres. Our global network has just got bigger, with 196 radiotherapy treatment centres across 4 countries (U.S, Spain, UK, Australia) and 443.000 patient treatments per year.

GenesisCare is bringing people and teams together on a global scale, investing in new technology and technological expertise, maximising digital and other forms of innovation in order to make a positive impact on cancer patient outcomes worldwide. We will do this because of our passion for clinical excellence, patient and staff safety and by scaling up our Service of the Future Strategic Model of Care in the U.S, following its successful implementation in the UK, Spain and Australia.

This is a fantastic opportunity for us to replicate our successful UK model in a new Market, including rolling out a Linac replacement programme and investment on MR-Linacs, Digital platforms, e MDT, automation, research and clinical trials. Most importantly, we have the greatest opportunity to connect with world class clinician leaders and academics, share knowledge and expertise and engage each other in high quality research.

Updates on radiotherapy protocols 

The following protocols have been recently endorsed by the Royal College of Radiologists:

Head and neck

• Consider radical radiotherapy if surgery not possible especially oral SCC, paranasal sinus and laryngeal tumours. Hypo-fractionated regimes (20#) and SIB-IMRT to boost nodes ± chemotherapy appropriate
• Consider short RT regimes in palliative cases and oral pembrolizumab as 1stline metastatic instead of chemotherapy
• Full PPE needed when treating those patients
• If patient tests +ve for Covid-19 prior to RT, treatment should be delayed until recovery, if patient develops mild symptoms during RT and tests +ve, treatment should continue and if patient develops severe symptoms during treatment, it should be interrupted until recovery

• Lung radiotherapy hypofractionation: SABR 54Gy/3# for tumours within 2.5cm from chest wall with consideration of 48Gy/3# if abutting chest wall to minimise toxicity
• SABR for moderately central tumours <2cm from bronchial tree, trachea, major vessels, heart, esophagus, brachial plexus or ultracentral tumours with PTV abutting trachea or main bronchi: 4-5# (ASTRO, 40-50Gy) or 8# UK SABR Consortium (60Gy)
• Central or ultra-central tumours not suitable for SABR, consider hypo# regimes (50-60Gy in 15#)
• SABR for tumour >5cm possible depending on OAR dose should be discussed with our SABR clinical reference group
• Extreme hypofractionation such as 30-34Gy/1# SABR for tumours ≤2cm and >1cm from chest wall and which are outside the no-fly zone, should be discussed with the SABR reference group

Virtual consultations are here to stay and below are few tips around the governance of consenting patients in a virtual setting.

• If you are using the online booking form and consent form, ensure the patient understands the following and that risks and benefits are documented in the consent form ± MOSAIQ electronic health record:

1. The reason for their treatment and what exactly it entails (eg. breast radiotherapy and SCF/IMC treatment for lymph node positivity)
2. The benefits of the treatment and the risks of not having treatment (eg. local and/or distant recurrence and survival)
3. The risks associated with the treatment including risk of contracting Coronavirus (3% community risk) and complications from contracting the virus (individual risk based on comorbidities and performance status).
4. How to take any medication that they are prescribed
5. Acute Oncology information, including GenesisCare 24h nurse line

• If you are using a paper consent form, follow the steps below:

1. Oral consent to treatment explaining the above 1-5 points
2. If patients agree to be emailed the consent form (which includes risks and benefits of treatment as per points 1-3 above), ensure this is documented on their MOSAIQ record together with their email address.
3. Patient will bring the signed consent form to their radiotherapy planning appointment or first SACT treatment and consent will be reconfirmed.
4. If patients don’t agree to have the consent form emailed to them, it can be posted to them and they can bring it to their first appointment

• The presence of a pacemaker and whether dependent or not dependent should be clearly stated on the booking form and clinic letter. The lack of such information upfront may delay the CT planning and treatment start date
• If your patient has gone through the GenesisCare e MDT process, please state in the online or paper booking form along with the date of the MDT. If your patient has been through the NHS MDT, please provide a report or advise how we can retrieve it
• Your patients will soon be approached to have a nasal and oral PCR swab test on a regular basis (see next section for more details). If you have any concerns or you don’t want your patient to be tested, be inform your centre leader

As we move to the post pandemic phase, GenesisCare’s focus is to deliver access to quality rapid testing for all employees, doctors and patients in order to ensure the safety of staff and patients.

The swab PCR weekly testing program which has been rolled out successfully to staff and doctors on site since the 23rd of April, will eventually evolve into a hybrid testing approach utilising:

1. Point of care (POC) test for the Antibody (Ab) to determine who has been exposed to the SARs-CoV-2 virus.
2. The laboratory-based Reverse transcriptase Polymerase Chain Reaction (RT-PCR) test which will identify patients with current infection.

This week, we are piloting asymptomatic patient testing in our Milton Keynes centre using oral and nasal swab PCR, as per the following schedule:

Asymptomatic patients

• On Chemotherapy – testing will be done no longer than 6 days prior to each chemotherapy cycle. Patients will get tested weekly or 3-weekly or depending on the chemotherapy schedule
• Radiotherapy – patients will get tested prior to fraction 1 and on demand thereafter (if they develop symptoms)
• Haematology patients – testing follows the same principles as with chemotherapy patients
• Diagnostic patients will be screened through questionnaires and temperature checks as per our standard procedures

Positive patient result and treating Covid-19 patients at GenesisCare centres

A positive patient result will be communicated to yourselves as referring clinicians as soon as we receive it. According to our partnered lab policy, they will report any positive test results to Public Health England and can provide microbiology advise to you if you so need it. Please discuss this requirement with your centre leader and we will arrange this.

We are supportive of treating well patients with Covid-19 in our centres, if you decide as clinicians to do so. Once a positive patient result is through to us, we will discuss with you on an individual patient basis the operational aspects of treating this patient safely on site. If your patient has already started radiotherapy treatment, we will discuss with you about changing treatment timing for your patient until later on the day. If you wish to delay patient radiotherapy, our expert dosimetrists and physicists will support you around a compensatory dose protocol.

Positive asymptomatic staff results at GenesisCare centres

We test all staff members every week for every centre and the GenesisCare UK research team is leading the testing process, in collaboration with our Director of Operations and Head of People and Culture.

In case of a positive swab test for staff, we advise them a 7-day isolation and we provide a back-up team to cover the service as per our Business Continuity Plan. The staff members get re-tested after their 7-day isolation period and if negative and asymptomatic, they return back to work as normal.

The current rate of positive tests in asymptomatic staff aligns with the prevalence of Covid-19 in the community which is 3% currently.

As UK Leadership team, we are continuing the weekly COBRA calls to ensure that we maintain adequate PPE for staff and patients, adequate cleaning stock, thermometer stock and any defects are replenished immediately. During this call, we share and action with the teams any government or PHE updates and we ensure we share learnings from other centres nationally and internationally.

Antibody (Ab) testing

A validated Antibody testing will soon be introduced to the above protocol for (a)symptomatic staff and patients, to complement the PCR swab test. The protocol for testing is currently subject to ethics approval and will be shared once it is approved.

eMDT updates

With Breast and Haematology e-MDTs now up and running at GenesisCare, more patients have access to our clinical expert forums which follow national and international evidence-based protocols. Access to our e MDT will negate the need for these patients to wait longer for treatment until they are discussed in the NHS MDTs.

You will all soon receive an email from your Referrer Engagement Manager (REM) to sign up to the GenesisCare e-MDT in your area. The MDT report will be saved on MOSAIQ patient electronic health record and will be shared with insurers if requested for treatment authorisation purposes.

Our e-MDT platform is safe and easy to use and enables synchronous (virtual forum) and asynchronous decision making. For the Terms of Reference of your local e-MDT, please ask you centre leader or REM.

DoctorHub updates

Don’t forget to visit our new DoctorHub site for the latest updates on clinical protocols, safety and governance processes in centres, business updates and many more.

We would love to hear from you any suggestions for improvement or any specific updates you would like to see more often.

BAUS guidelines webinar

Following the updated BAUS and RCR guidance on how to manage patients during Covid-19, Philip Charlesworth, Surgical Clinical Director and Philip Camilleri, Uro-oncology Clinical Director hosted a webinar to discuss GenesisCare’s response on how this may impact on our private patients wishing to access treatment at during Covid-19. The webinar discusses our intent today, and moving forward as we work through the challenges presented.

Please don’t hesitate to contact either of us directly should you have any further questions.

Kind regards

James McArthur

General Manager – UK

Penny Kechagioglou 

Chief Medical Officer – UK