153 PROSPECTIVE ASSESSMENT OF AN OUTPATIENT PALLIATIVE CARE INTERVENTION IN PATIENTS WITH METASTATIC CANCER

S48 difficult to predict the end result. The free hand smoothing tool was used for this study. Materials and Methods: Twenty IMRT plans for head and neck cancer patients were used for the study. Free hand fluence smoothing was applied to these plans. The dose distribution for both smoothed and unsmoothed plans were reviewed by a radiation oncologist (RO) and a planner for target coverage and critical organ doses. The dose distribution, Monitor Units (MU), Maximum. Dose and the conformity number (CN, ideal value = 1) were compared between the smoothed and unsmoothed plans. The plan selected by a RO was used for the treatment. The viewers were composed of four ROs and seven planners. One planner and one RO reviewed one plan at a time. Results: The mean CN was 0.77 ± 0.04 with the smoothed plan and 0.76 ± 0.04 for the unsmoothed plan. All the ROs selected the smoothed plans over the non smoothed plans. The planners opted 18 smoothed plans out of twenty plans. There was a reduction of (11.0±6.2) % in total MU for the smoothed plan. The Maximum dose was reduced by (1.3+1.4-1.2) % when compared with unsmoothed plans. Since the average total MUs for these plans was as high as 1241±458, a reduction of 11% in MU was quite significant. This will reduce the probability of a secondary cancer for these patients treated with smoothed IMRT plans. We are currently using this flurence smoothing for routine IMRT planning. 150 TOMOTHERAPY IN THE TREATMENT OF ANAL CANCER: ACUTE TOXICITY DATA S. Loewen, K. Joseph, C. Small, A. Syme, H. Warkentin, E. Gaetz, K. Tankel, D. Severin, N. Usmani, C. Field, T. Nijjar Cross Cancer Institute, Edmonton, AB Purpose: Tomotherapy may provide adequate local control and increased conformality while minimizing dose and toxicity to surrounding structures. The study is to assess acute toxicity of patients with anal cancer treated radically with tomotherapy and concurrent chemotherapy. Materials and Methods: A Phase II study using tomotherapy to treat patients with anal cancer to limit acute toxicity is currently enrolling patients at the Cross Cancer Institute. All patients received 54 Gy in 30 fractions to the tumour PTV and 48 Gy in 30 fractions to the nodal PTV over 6 weeks with concomitant 5-fluorouracil/mitomycin C. Six patients have completed treatment and analysis of acute toxicity has been collected using the CTCAE v3.0 toxicity criteria. Results: Treatment was well tolerated. There were no Grade 3 or higher non-hematological toxicities to peritoneal cavity, bladder, genitalia, skin and bone marrow. Maximum hematological toxicity recorded was Grade 2. None of the patients required a treatment break and all patients received 2 cycles of chemotherapy with no dose reductions. Conclusion: Our early results indicate patients with anal cancer treated with tomotherapy report no incidences of Grade 3 or higher toxicity.

CARO 2009 study compares delivered IMRT treatment plans to retrospectively generated VMAT plans for spinal SBRT. Materials and Methods: VMAT plans were generated for 10 patients previously treated for spinal metastases with IMRT delivering 18 Gy in one fraction or 20-30 Gy in five fractions. The following parameters were compared between IMRT and VMAT plans: maximum dose (dmax) to the spinal cord and PTV, volume of PTV receiving 95% of prescribed dose (V95), monitor units (MU) and treatment delivery time. The average difference between each specified parameter for VMAT and IMRT plans ± the standard deviation (SD) were reported. Results: All VMAT plans met treatment planning criteria for plan acceptability. In comparing VMAT to IMRT, on average superior target coverage per the V95 was observed by 3.9% ± 6.0%. However, on average a marginally higher dmax to the spinal cord of 0.1 ± 0.9 Gy, as well as a higher dmax within the PTV by 0.4 ± 1.7 Gy, was observed. Average time for fraction delivery was reduced by 7.3 ± 4.1 min with VMAT and this results in an overall 45.6% reduction in delivery time as compared to IMRT. Furthermore, less MU (986.9 ± 1662.5 MU) were required per plan with VMAT planning. Conclusion: Superior target coverage was observed with VMAT at the expense of a marginal increase in spinal cord dose. The major gain for VMAT planning is in reducing treatment delivery time which may have the added clinical benefit of less potential for intra-fraction motion. 152 AN EVALUATION OF PATTERNS OF RADIOTHERAPY PRACTICE FOR PATIENTS WITH RIB METASTASES: A SINGLE INSTITUTION STUDY L. Dalimonte, E. Sinclair, A. Lightstone Odette Cancer Centre, Toronto, ON Purpose: To describe the patterns of practice for patients with rib metastases who were treated with radiation therapy for pain relief. Can treatment burden and wait times for this patient population improve with the utilization of orthovoltage treatment machine? Materials and Methods: Cancer registry data for patients with rib disease and radiation therapy technique were collected from January 2007 to January 2009. The data was examined to establish the utilization rate of orthovoltage treatment. Results: The data demonstrated that orthovoltage treatment is an underutilized technique for the palliative treatment of rib disease. More than half of the patients were treated with high energy (6MV) photon beam with either a single direct photon field (16.2%) or a two-field photon technique (47.4%). Electron beam technique represented 35.1% of treatments while orthovoltage constituted only 1.2% of rib treatments. Conclusion: The use of orthovoltage X-ray beams has been demonstrated to be an underutilized radiotherapy treatment technique at this institution. Orthovoltage treatment is a simple radiotherapy technique with a short set-up time that may be a solution for minimizing treatment burden for an already overburdened patient population.

151 TREATMENT PLANNING WITH VOLUMETRIC MODULATED ARC THERAPY FOR STEREOTACTIC BODY RADIOTHERAPY (SBRT) OF SPINAL/PARASPINAL TUMOURS E.L. Marchand, A. Sahgal, B.A. Millar, J. Publicover, M. Sharpe, D. Moseley, D. Létourneau University of Toronto, Princess Margaret Hospital, Toronto, ON

153 PROSPECTIVE ASSESSMENT OF AN OUTPATIENT PALLIATIVE CARE INTERVENTION IN PATIENTS WITH METASTATIC CANCER M. Follwell, D. Burman, L. Le, K. Wakimoto, D. Seccareccia, J. Bryson, G. Rodin, C. Zimmermann University of Toronto, Princess Margaret Hospital, Toronto, ON

Purpose: Hypofractionated SBRT planned with intensity modulated radiotherapy (IMRT) is an effective treatment modality for metastatic spinal tumours. However, this technique is associated with long treatment times which may subject the patient to a greater risk of intrafractional motion. Volumetric modulated arc therapy (VMAT) allows the radiation dose to be delivered in a single gantry rotation with variable dose rate to shorten delivery time. This treatment planning

Purpose: There is increasing support for timely symptom control in patients with cancer, however few studies have assessed outpatient palliative care clinics. This study assessed prospectively the efficacy of an Oncology Palliative Care Clinic (OPCC) in improving patient symptom distress and satisfaction with care. Materials and Methods: Eligible patients were new referrals to an OPCC, had metastatic cancer with a prognosis of >1 month,

CARO 2009 were well enough and sufficiently fluent in English to provide informed consent and complete questionnaires. Patients received a consultation by a palliative care team. The primary end points of symptom control and patient satisfaction were assessed using the Edmonton Symptom Assessment Scale (ESAS) and patient-adapted Family Satisfaction with Advanced Cancer Care (FAMCARE) scale at baseline, one week and one month. Initial and follow up scores were compared using paired t-tests. Results: Of 150 patients enrolled, 123 completed one-week assessments, and 88 completed one-month assessments. At baseline, the mean ESAS Distress Score (EDS) was 39.5. The mean improvement in EDS was 8.8 points (p<0.0001) at one week and 7.0 points (p<0.0001) at one month. Statistically significant improvements were observed for pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, dyspnea, insomnia, and constipation at one week (all p<0.005) and one month (all p<0.05). The mean improvement in FAMCARE score was 6.1 points (p<0.0001) at one week and 5.0 points (p<0.0001) at one month. Conclusion: This prospective study demonstrates efficacy of an OPCC for improvement of symptom control and patient satisfaction with care. Randomized controlled trials earlier in the disease course are indicated to further evaluate the effectiveness of specialized outpatient palliative care. 154 HEALTH SYSTEM CHARACTERISTICS ASSOCIATED WITH PATTERNS OF PALLITIVE CARE USE IN ONTARIO J. Sussman1, L. Barbera2, D. Howell2, A. Husain2, D. Bainbridge1 1 McMaster University, Hamilton, ON 2 University of Toronto, Toronto, ON Background: Patterns of care research has illustrated significant variations in the utilization of health resources for cancer patients in the end of life period. While data from administrative sources give insights into determinants of use, these do not clearly inform the development of palliative care programs and interventions at the health system level. Purpose: To determine health system characteristics associated with better acute care health system utilization patterns. Materials and Methods: A comparative case study of four representative health regions in Ontario was carried out. Regions were selected as exemplars of high and low acute care utilization patterns. The research team developed a template of factors to inform study instrument to capture structure and process elements in three domains: capacity, access and coordination. Key informants in each region completed study instruments. Data was summarized using qualitative techniques and an exploratory factor pattern analysis was carried out. Results: Forty participants were recruited representing clinical and administrative perspectives. Pattern analysis revealed 6 factors that discriminated between regions: Overall planning and needs assessment, a common chart, standardized patient assessments, 24/7 palliative care team access, advanced practice nursing presence and mechanisms to support pronouncement of death in the community. Conclusion: The findings of this study further inform health system planners on important features to incorporate into palliative care models. Future work is planned to validate our findings in other regions. 155 CURRENT PRACTICE FOR THE PROPHYLAXIS AND MANAGEMENT OF RADIATION INDUCED SKIN REACTIONS J. Pang, J. Nguyen, N. Salvo, S. Culleton, D. Breen, A. Giotis, T. Barnes, C. DeAngelis University of Toronto, Toronto, ON Purpose: Radiotherapy, a standard treatment for a variety of cancers, commonly induces radiation-induced skin reactions (RISR). These reactions range from mild erythema, through to

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dry or moist desquamation and ulceration; complications include itching, burning and infection. Surveys suggest large variation in treatments used to prevent and manage RISR. Our goal was to understand the current practices at the Odette Cancer Centre (OCC). Materials and Methods: Radiation oncologists, nurses, and therapists were provided with an online survey that assessed their current practices for prevention and management of RISR. The survey focused on breast, head and neck and skin cancers. Results: Fifty-two of 232 responded: eight oncologists, 30 therapists, and 14 nurses. Oncologists and radiation therapists (88% and 52% respectively), felt 91-100 % of their patients would experience an RISR of any grade while only 35% of nurse respondents believed so. As to when a patient would be counseled to start a topical agent, the overall consensus of respondents, 83%, is to recommend use prior to radiation. One hundred percent of oncologists would counsel patients to start using a topical agent at the development of erythema. Glaxal Base® was the most common topical agent used for prevention and treatment of RTOG grade 1 or 2 RISR (61% and 71% respectively). For severe skin reactions in breast and head and neck patients; flamazine would be recommended by 28%. Saline soaks would be recommended by 29% of the respondents for skin cancer patients. Only 45% of respondents use a standardized tool to assess skin reactions, 59% favouring the RTOG Grading Scale. Conclusion: At OCC, radiation oncology staff should agree on standardized treatment plans for prevention and management of RISR. Staff should consider the use of one standardized assessment tool so that the rate of occurrence and effectiveness of prevention strategies can be evaluated in a consistent reproducible manner. 156 IMPACT OF RTT INITIATED BOOKING GUIDELINES ON WAIT TIMES FOR NON MELANOMA SKIN CANCER PATIENTS D. Breen, E. Barnes University of Toronto, Toronto, ON Purpose: To see if these clearly defined new patient booking guidelines combined with the triaging of all new patient referrals by the Clinical Specialist radiation therapist (CSRT) reduced the time from referral to consult for non-melanoma skin cancer patients. Materials and Methods: The non-melanoma skin clinic (NMSC) is a multidisciplinary clinic which includes radiation oncology, dermatology and plastic surgery. Each week we routinely see 10–12 new patients, 30–40 follow ups and six to 10 patients for surgery. The clinic became routinely overbooked with as many as 14–16 new patients in order to accommodate urgent patients. This resulted in the clinic running over into the afternoon clinic and long patient waits. New booking guidelines were developed by the CSRT. Patients were prioritized according to pathology into three categories. • Priority 1 to be seen within four weeks • Priority 2 to be seen within six weeks • Priority 3 to be seen within 12 weeks The CSRT reviewed all NMSC referrals for appropriateness and assigned a booking priority. The referrals for a three month period pre- and post-implementation of the new guidelines were analyzed. The referrals from the pre-implementation period were prioritized for comparison purposes. Results: A preliminary analysis of one month pre- and postguidelines shows the average wait time reduced from 53.9 days to 46.2 days. Conclusion: Based on the preliminary analysis triaging of the NMSC new patient referrals by the CSRT reduced the wait time from referral to consult. The complete analysis will be reported at the meeting.