UK Clinician information: 17th April

With Easter now past and moving swiftly towards summer, our centres are getting busier with new outpatient clinics being set up in Oxford and new services being built, including our new One Stop Breast and Urology Clinics in Cambridge and Windsor. Our 14 centres are open, COVID-19 clean and with our workforce stronger than ever to provide great care to our patients using all our modalities in diagnostics, chemotherapy and radiotherapy. 

As the safety of staff, doctors and patients is our number one priority at GenesisCare, we ensure on a daily basis that adequate PPE is available for all staff.  Stocks are reviewed and replenished on a weekly basis when necessary and we have started PCR testing for members of staff in isolation and their close relatives. Our research team is systematically collecting outcome data from those tests and correlating them with symptoms to help us understand the effectiveness of those tests in detecting the virus and the optimal timing of the test.

From next week, we will be in the fortunate position to be able to test our staff and patients with the antibody finger prick test, utilising a robust pathway that we have designed with the support of global infection control experts. The detailed roll out of the testing will be communicated in due course.

Treating cancer patients during COVID-19 and beyond

Basic Principles

  • It is clear from all clinical guidance that has recently been published that diagnostic and treatment work should continue despite COVID-19 when there is capacity to do so, which is exactly what we have managed to do at GenesisCare.
  • At GenesisCare, we have maintained all our departments open, including our Linacs, MR-Linac, SRS, PET-CT, MRI, mammography, ultrasound, chemotherapy and One Stop Clinic services and we have introduced Telehealth and eMDT facilities for clinicians to practice safely in a remote environment.
  • The timing of onset of radiotherapy can have a profound impact on the chance of cure for triple negative breast cancers, head and neck, lung, cervical and anorectal cancers as well as high risk prostate cancers, whereas patients with oligometastases, hepatobiliary and brain tumours can receive excellent palliation and long term survival with SABR or SRS. We believe that it is our duty to continue to treat our cancer patients with the right treatment modality at the time of presentation

Stereotactic radiotherapy

In recent guidelines brain metastases are not considered a priority cancer treatment during COVID-19. At GenesisCare, we are challenging that approach in that a single fraction (SRS) or hypo-fractionated brain radiotherapy (SRT) can improve quality of life for patients and may delay neurological deterioration from growing tumours. Patients can experience a seamless service at GenesisCare with scanning, simulation and treatment all completed within the same week, avoiding unnecessary delays in treatment.
A recent case using the GenesisCare SRS Service in Oxford
The case of a 46y old man, with known renal cell carcinoma, with a very good response to immunotherapy and performance status 0-1 presented with seizures, with a CT scan and MRI head showing multiple brain metastases. The case was referred to our weekly GenesisCare UK Neuro-Oncology MDT and the outcome was to offer SRS. The patient was treated with SRS to 9 brain metastases and seen 6 weeks after treatment, continuing immunotherapy for his extracranial disease, in low dose steroids, without any focal neurology and performance status 0.

The referral process has been simplified and is supported by our wonderful SRS coordinator, Lisa Meade. The Neuro-Oncology MDT Team reviews cases weekly via the ContextHealth platform, on Sunday nights, with the SRS Huddle of physicists, radiographers, dosimetrists. The Neuro-Oncology MDT is comprised of Neuroradiologists, Neurosurgeons and Neuro-Oncologists. If the Neuro-Oncology MDT ratifies the decision to treat then this proceeds immediately; if not, the referrer is invited to a Zoom MDT call for a live discussion with the MDT.

Breast cancer

Patients with breast cancer currently face great dilemmas when making decisions about cancer treatment and our teams at GenesisCare have tried to make it simple for clinicians and patients to navigate through those treatment choices.

As such, we have kept our standard breast radiotherapy protocols and techniques, including 15# for advanced node positive disease, VMAT IMC, SIB when boost is required, partial breast irradiation (PBI) and we have also adopted the hypo-fractionated regime (26Gy/5) for selected patients who would benefit.

DIBH is still used for all left sided cancers and selected right sided cancers, including IMC, SIB and PBI treatments.

Prostate cancer

We have listened to our patient feedback and we firmly believe that our patients should be given the choice to start radiotherapy treatment sooner rather than later. Our patient experience forums have told us that the side effects from hormonal treatment can be debilitating and non-comparable to the minor side effects from 5# prostate treatment on the MRL or indeed 20-37# with SpaceOAR(r) Hydrogel insertion.

Our COVID-19 clean centres and our well-trained teams in infection control practices, from our taxi drivers to the receptionists and radiographers, will ensure our patient comfort and treatment safety throughout the treatment course.

SABR

Patients with early stage inoperable lung cancer treated with stereotactic body radiotherapy have a survival benefit compared to patients treated with conventional radiotherapy or no radiotherapy. SABR cause less lymphopenia than traditional dose fractionations, making it a safer treatment modality during COVID-19.

Gomez et al (JCO, 2019) reported their multi-institutional outcomes from Local Consolidative SBRT vs Maintenance Systemic Therapy or Observation for Patients with Oligometastatic Non-Small Cell Lung Cancer. Accrual stopped early due to significant Progression Free Survival benefit of SBRT vs systemic treatment maintenance or no treatment.

Rudra et al (2019, Cancer Medicine) looked at the use of adaptive magnetic image-guided radiation therapy for treatment of inoperable pancreatic cancer. High dose SBRT, only possible on the MR Linac, improves overall survival versus low dose RT (49% 2y OS vs 30% 2y OS) in locally advanced pancreatic cancer.

Palma D et al (2019, The Lancet 393:2051-2058) demonstrated at their randomised phase 2 trial (SABR-COMET) that SABR versus standard of care palliative treatment in patients with oligometastatic cancers offers a significant overall survival advantage of 13 months and a doubled progression-free survival, with no detriment in quality of life.

How to refer a patient for SABR

Simple SABR
Refer to any clinical oncology colleague at your local GenesisCare centre with the appropriate credentialing. Your centre manager will be able to provide a list of SABR approved Consultants.

Complex SABR
You can refer these cases in the same process if your local centre also delivers Complex SABR. Otherwise you can refer to a centre delivering Complex SABR via the SABR Coordinator, Lisa Meade, lisa.meade@genesiscare.co.uk, 07391392605

Cancer surgery versus radiotherapy

We have heard about the reduction in theatre space for all types of cancer in the NHS and the private sector during this pandemic and we believe that whenever possible, patients should be offered a suitable alternative such as radiotherapy. Our centre managers, referrer engagement managers and teams on site are inviting you to discuss your patient treatment priorities, so that we can find together an individualised treatment solution that best suits your patient circumstances.

Telehealth (Zoom) security 

Following concerns that have been raised by the media regarding security of Zoom, we’re going to be implementing additional security steps to maintain a secure platform. Our IT team are in regular contact with Zoom’s leadership and security teams to further understand these concerns relating to the current encryption mechanisms, we can confirm zoom-to-zoom calls are encrypted, as a further measure we’re going to be implementing a six digit password policy. You should expect to receive a communication next week covering all details on how to get started with the new security process. 

Patient reported outcome measures (PROMiNET)

Patient Reported Outcome Measures (PROMs) are the gold standard of patient outcome data.  They’re provided directly by the patient and avoid the inherent bias’ that comes with clinician reported outcomes.

GenesisCare is excited to announce the launch of our own PROMs programme. This will be done largely through the launch of a dedicated GenesisCare branded App called PROMiNET.

Over the last few months, our UK Clinical Reference Groups (breast, prostate, SABR and haematology) have reviewed a number of platforms and have agreed a preferred list of patient reported outcome tools. These vary from validated tools such as the EORTC BR45 for breast cancer to a bespoke list of toxicity questions based on CTCAE-PROMs for patients receiving stereotactic radiotherapy on the MRIdian MR-linac, as well as a mixture of standard tool and bespoke questions for haematology patients on chemotherapy and prostate cancer patients receiving radiotherapy treatment. The expectation is that eventually this offering will extend to other disease sites.

Patients will be supported by centre staff and encouraged to download the free App, onto their smartphone or tablet. Once registered, they will be asked to fill out the specific question sets according to their treatment. The App is designed to send out reminder emails with clickable links which will take the patient to their secure question sets.

The introduction of the App commences later this month and will be rolled out across all GenesisCare centres throughout the Spring.

The data will be available to GenesisCare who will then be responsible for the analysis of the data collected. The collection of this data is central to GenesisCare’s value proposition of leading with quality in all that we do.

James McArthur

General Manager, UK

Penny Kechagioglou

Chief Medical Officer, UK

Related articles

The technological benefits of prostate radiotherapy on the MRIdian

UK Clinician update: Friday 8th May

Clinician update: Brain stereotactic radiosurgery (SRS)

Clinician update: BAUS guidance