COVID Update 1/30/21

Wow, it's been almost a year. Here are some updates from our practices at University of Maryland.  We have successfully treated both PUIs and COVID+ patients at all of our practices. We have yet to have a patient to staff (or staff to patient) transmission. We do not break patients if they become COVID+ or a PUI unless they are clinically unstable.

PPE precautions:

Per hospital policy, all staff wear surgical masks and eye protection at all times once you enter your the building. Use of both of these prevents any exposure from being considered 'high-risk'. All PUI's and COVID+ patients are treated in full PPE. 

Group Living Patients/Prisoners:

Our main campus has the contract with the prison system. Due to the high COVID positivity rates in the prison and all group living facilities (nursing homes, etc), we treat ALL of these patients in full PPE. This has served in our favor as on at least 3 occasions these patients became positive in the middle of their treatments due to a facility outbreak. We continued with treatment for these patients without interruption. 

Staffing:

We have continued to have almost all non-clinical staff to telework. Faculty are allowed to work from home on their administrative/non-clinic days, however, they are to remain available as if they were at work (for plan review, etc). Fortunately, we have not had to call anyone in for clinic issues when working from home, however, faculty are periodically reminded of this. 

Dosimetry continues to have a small on-site presence. At our downtown clinic where the majority of our procedures are performed, there are typically 2 dosimetrists present; at our proton center 2 are typically onsite and at the community practices 1 on site. This rotates and the remainder work from home. We have had some challenges with dosimetry hours. The dosimetrists at one point took to very flexible hours, so for example, if there was a late sim, the images were not being brought in promptly. This was causing some workflow challenges and so we had to work with dosimetry leadership to re-enforce 'hours' even while teleworking. We also had some challenges with excessive overtime from dosimetrists who were working from home. We had to re-educate the group on this topic (again re-enforcing work hours).

Telehealth:

Compared to other practices, we have a low percentage of telehealth visits. We have found this utilization to be very disease site specific. We have also found in our institution that many other providers are doing telehealth and at some point, the patient needs the exam (i.e. breast exam). We have not adopted telehealth OTVs. We continue to offer this service and on a weekly basis, the doc/team review their list of patients to see who may or may not be a candidate for telehealth services. We have also found that many patients continue to want to come in person.

Vaccination:

Many of our docs and staff have received their 1st vaccination and have recently received their 2nd. Most patients have not yet received a vaccine. At the present time, even if you are fully vaccinated, there is no change in the PPE requirements/policies. Vaccination is not mandatory.

All radonc patients are being encouraged to get the vaccine unless a leukemia patient or a transplant patient. The idea being 'if you would get the flu shot you should get the COVID vaccine'. Like many states, however, there is a supply issue and so only a small minority of patients have received a shot yet. Our hospital has developed a very robust, streamlined vaccination process and so patients are vaccinated at that location (on campus) and not in our clinic.

Hope this information is helpful to people!

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Here is what we are doing (University of Maryland, Baltimore). I have divided it up into different sections. These are copies of emails I have sent. Happy to update as we distribute more info. Hope this helps others!

Dosimetry Staffing:

Beginning Monday, 3/16 on site staffing will be as follows:

1 photon dosimetrist on site at each photon clinic

4 dosimetrists on site at proton center

All others will work from home. Will rotate on-site people but some who specialize in procedures will come in on those days.

Phys Staffing:

Beginning Monday, 3/16 on site staffing will be as follows:

1 phys on site for all photon centers

2 phys on site for proton center

Additional phys on site for special procedures (SIRT, GK, brachy, etc).

All others will work from home. Will rotate on-site people but some who specialize in procedures will come in on those days.

Plan for Reduced Therapy Staffing:

We are currently not planning to break patients at this point in time. If we have reduced staffing, we will close a machine down (or close it down early) so as to maintain 2 therapists per machine (or treatment room for protons). We will also implement shifting patients across our photon sites if needed, as all of our photon clinics are beam matched. So if we have a site that has to shut down or shut down early, we have the ability to offer uninterrupted treatment at another photon site.

Follow-Ups:

Effective Monday, March 16th, we will be implementing a new process for routine follow up patients in an effort to minimize patient and staff exposures.

What will happen:

- Each week physicians and NPs will review their follow-up schedule for the next 1-2 weeks. 

- Physician/NP to review schedule and decide which patients must be seen and which patient appointments can be delayed (per clinically appropriate decision making).

Ex: 5 year survivor of breast cancer returning for yearly follow up can be deferred; 12 week follow up for lung cancer patient receiving chemoRT cannot be deferred.

- For patients who need to be seen: the front desk will contact the patient the day before their visit to screen them for respiratory symptoms/fever. If these symptoms are present, patient appointment will be deferred for 2 weeks.

- For patients whose appointments are going to be delayed: the patient will be contacted by a nurse/MA and screened for any symptoms. Scripting will be provided:

"Hi Ms/Mr. X. You have an appointment scheduled with Dr. X on XX. We are calling to find out how you are doing? We would like to delay your appointment for 3 months in light of the ongoing Coronavirus and our commitment to protecting all of our patients and staff."

If on screen, any potentially concerning symptoms are identified, these will be discussed with the provider and a decision can be made regarding the timing of the appointment.

- Any patient appointment delays MUST be documented in EPIC through a telephone encounter.

MD staffing: 

Dear All,

As we continue into/through the COVID-19 pandemic, I anticipate we will have challenges with staffing our practices, both in terms of potential people infected and the impact of school closures, etc. I ask that you contact me immediately if you become sick (whether COVID or not) so that I can address staffing across our practices. I also ask that you contact me if you are in a situation where you are unable to come to work due to lack of child care. At the present time, Dr. XX will serve as my back up. 

With expected shortages in staffing I may need to do the following to ensure patient care delivery:

• Only have one physician at a site
• Pull you from your research/administrative day to cover the clinic
• See another provider’s patients
• Pool resources for special procedures (cover another site)
• Ask you to come in to cover even though you may have had approved time off

I will do my best to respect approved time off and schedules but ask that we support one another through this time. Please contact me anytime by cell for any questions or concerns. Calling or texting is the quickest and best way to reach me. If I do not respond quickly, please do not hesitate to call me again.

Managing patients:

Dear Rad Onc Family:

The department has developed a plan on how to manage COVID-19 positive patients, as well as a potentially infected patient as per below. This process has been discussed with the appropriate hospital leadership and will be subject to change as we gain more information to ensure the safety of our patients and staff. 

COVID-19 positive patient OR if patient has a COVID-19 positive family member:

- Patient should be moved to end of day treatment. This should continue for 14 days after positive diagnostic test. 

- Patient should wear a mask.

- Patient should be isolated to a room while waiting for treatment (not in waiting room). This room should not be used by other oncology patients for the rest of the day. The room is to be cleaned at end of the day.

- Staff should wear appropriate protective equipment (droplet precautions).

- Treatment table and room should be wiped down.

- If patient is a palliative patient and the clinical team determines that there is an acceptable medical alternative, RT treatment can be discontinued at the discretion of the treating physician.

- No visitors.

- Follow up patient visits should be deferred for at least 2 weeks. This must be documented in EPIC.

PUI (person/patient under investigation):

- Patient and visitor (if present) should wear mask.

- Staff should wear appropriate protective equipment (droplet precautions).

- If patient tests positive, revert to process above.

- If patient tests negative, patient should continue to wear a mask until respiratory symptoms have resolved.

- Radiation Oncology will not be offering COVID-19 testing.

- Follow up patient visits should be deferred for at least 2 weeks. This must be documented in EPIC

In addition, we are implementing the following:

- All patients including under-treatment patients should be screened daily for symptoms. This should occur PRIOR to patient coming back to treatment/clinic area. Please use hospital-approved screening process. 

- If a patient screens positive (see above).

- We are currently evaluating our follow up treatment paradigm and will update the Department soon.

Rad Onc town hall:

Good Afternoon,

On Tuesday, March 17^th at noon, we will be hosting a live video/phone session where all faculty and staff are invited to participate. We will be available to answer any and all questions regarding COVID-19 and its impact to our patients/staff/families.

Please see further details on Monday regarding conference call information. Questions can be submitted via Zoom’s live chat functionality. For faculty and staff who are unable to participate, please submit questions to your supervisor or XX. We will also be recording this session.

We look forward to addressing any questions or concerns you may have.

There are many good sources like the CDC for best practices. Nevertheless, I do want to share some thoughts more relevant to our field:

As radiation oncologists, COVID-19 and radiation share the same principles of ALARA: time, distance, and shielding. 

Time: we should minimize the time patients spend in the clinic with efficient scheduling, rescheduling non-essential follow-ups (a patient doesn’t need to come in to be told their PSA is stable or lower, ...), minimizing relatives/friends accompanying patients always considering the patient’s emotional needs, ...

Distance: anyone in the waiting area should ideally be sitting 6 feet from each other. This means creative rearranging of the seats, strategic scheduling of patients, and perhaps smaller clinics used to finishing earlier in the day extending the day to reduce the patient density in the waiting areas. Although not feasible for all, perhaps we should have sick versus well entrances and areas as I have seen in some pediatric clinics. What is the shortest path to your clinic minimizing crowded areas?

Shielding: we are familiar with the protective equipment precautions when we know a patient is sick, sick patients wearing a face mask, ...

Strategic scheduling of patients:

For strategic scheduling, first consider these graphs.

Anyone older than 60, especially with hypertension, diabetes, cardiovascular disease, chronic respiratory disease, and of course cancer, are the most likely to succumb from COVID-19, up to a 14.8% death rate in those older than 80.

These high risk patients should be protected as much as possible. Perhaps they should be treated first in the day when the clinic is less crowded and the surfaces are the least likely to be contaminated. Any infected patients should be treated last with all the necessary precautions and should wait in separate areas, and perhaps be allocated to one specific machine if the clinic can afford to do so. Treating at the end of the day means fewer patients in the clinic and reducing exposure to subsequent patients who may be treated in that vault.

In my ignorance, I first thought that after our first case in Saint Louis we were going overboard with precautions. Yet, Saint Louis taught us an incredible lesson in social distancing from the Spanish flu in 1918.

The difference in deaths and population dynamics between enacting social distancing 2 days after the first case was detected in Saint Louis, versus 2 weeks in Philadelphia, was astounding. Enacting social distancing measures in a timely manner helps spread out the disease peak and avoids overwhelming the healthcare system. If the healthcare system is overwhelmed, this will consequently result in more deaths.

In their own weird way, viruses are like Gremlins. They don’t like sunlight, humidity, and here’s a new one, heat. Our cold, dark, and dry air linear accelerator rooms are perfect to dramatically increase the half-life of COVID-19. Treatment couches, immobilization devices, ... have to be thoroughly cleaned.

Here is a comparison of the symptoms of COVID-19, the flu, common cold, allergies.

One last thought which I hope someone who knows more about pharmacology can answer. If the virus enters the cell through the ACE2 receptor, why can’t antihypertensive medications blocking ACE2 at least help slow down or ameliorate the symptoms?

I agree with @Hiram A. Gay and @Elizabeth M. Nichols: very helpful comments above.

Communication – we have had multiple new protocols rolled out over a very short time period. Clear communication with staff and patients is important to ensure that new infection control protocols are implemented correctly and to also (hopefully) keep everyone comfortable with this rapidly evolving situation.

1. For staff, we have done this through emails, rounding through clinic and hospital-wide virtual town-halls.
2. For patients, this has been done through phone calls, written communications, and direct conversations (covid-19 has become a frequent topic of discussion during OTVs). Many of these changes have been disruptive and with patients, we have tried to emphasize that these heightened measures are being taken for their safety.

Social distancing measures (to slow dissemination of infection and prevent a rapid influx of sick patients that could overwhelm hospitals):

1. We have moved in-person meetings like chart rounds/tumor board, etc to virtual meetings
2. All work-related travel has been cancelled.
3. Our hospital has restricted visitors to 1 per patient for radiation oncology treatments.
4. We have asked physicians to review their clinic schedules to identify routine clinic visits that can be rescheduled.

Staying home: We have emphasized the importance of employees staying home (and away from clinic) when they develop URI symptoms. The hospital has created guidelines re: how long to stay away from work when sick. Fortunately, some radiation oncology work can be completed from home if necessary (treatment planning, contouring, plan checks, etc).

Screening:

1. All visitors are screened upon entry to the hospital and all patients are screened for respiratory symptoms at the clinic entrance.  
2. Any visitors who screen positive for respiratory symptoms are not allowed in the hospital.
3. Any patients who screen positive for respiratory symptoms are placed in a mask and immediately brought to a designated exam room separate from other patients. Treatments are delivered with droplet and contact precautions and all surfaces are disinfected in any room the patient occupied after the patient episode is complete.
4. We have asked patients to call ahead if they develop respiratory symptoms so that we can take appropriate infection control precautions.

Infection control review - Our department chair asked our hospital infection prevention/control team to walk through the clinic along the usual patient pathway to provide feedback on our infection control measures at every step of the treatment process. This was very helpful.

Hand hygiene - Based on recommendations from our infection prevention and control team, we have also started deploying hand sanitizer for patient use before and after entering the treatment vault to reduce the risk of cross contamination from surfaces the patients may come in contact with.

Supplies: Unfortunately, several hospitals in Seattle have encountered rapid depletion of sanitizer/gown/mask/cleaning supplies, suggesting that some of these items were diverted either by patients or staff. If this has not already happened in your institutions, it may be helpful to try to prevent a similar situation by securing supplies ahead of time.

PPE training:

Even though most of our clinic staff are already familiar with PPE, our hospital has set up PPE training classes to ensure everyone is comfortable with appropriate techniques for donning and doffing personal protective equipment. 

Workforce depletion – similar to Maryland above, we have established minimum staffing contingency plans taking into account the following scenarios:

1. Employees who have to stay home from work while they are ruled out for covid-19.
2. Employees who are either diagnosed with covid-19 or have to stay home due to close contact with a confirmed case.    
3. Employees who stay home for child care reasons (in Seattle all the schools are currently closed).

University of Washington's institutional guidance on covid 19 is posted here (and updated frequently).

Thanks for the helpful answers above. I recommend that everyone: patients, staff, and physicians wear masks, and explain it’s for their safety. A single asymptomatic infected technologist can infect every patient. Our patient population is elderly and immunocompromised; it is our duty to protect them. The CDC guidelines were based on SARS, they have NOT been updated to conform to the most recent literature on COVID-19. COVID-19 differs from SARS in that high viral concentrations are present in the upper airways when the patient is asymptomatic or only experiencing mild cold symptoms. Thus, asymptomatic transmission is common. Guidelines that are based on limiting infection by assuming that only people showing obvious symptoms are infective will miss most infectious patients. Masks are effective at decreasing transmission. There is a shortage of masks, but a 2008 study from the Netherlands showed that even homemade cloth masks provide partial protection. Get your volunteers to work sewing masks; there are free patterns on the internet. Masks reduce secondary transmission of the flu within a household, even when mask wearing compliance is poor. The Cochrane review found that surgical mask wearing and hand washing were highly effective at reducing the spread of respiratory viruses, and social distancing was of less benefit.

In theory, the effectiveness of both people wearing masks can be calculated by multiplying the filtration values. The likelihood of a virus being transmitted between two people wearing surgical N85 masks is .15  x .15 = 2.25% of the no mask scenario. If only one person has an N95 mask, the likelihood is 5% of the no mask scenario. If both people are wearing cloth masks, the likelihood is .5 x .5 or 25%. Thus, even cloth masks can be helpful if both people are wearing them. There is a preprint of COVID-19 virus aerosol particle size from Wuhan China. The medical staff office had significant virus aerosol, the size distribution range was 0.1 to over 2.5 microns. The most common particle size was 2.5 microns.

The mechanism of virus removal by filters is by both electrostatic interactions and sized based mechanical entrapment.

The new virus behaves differently from SARS. Whereas SARS is a “chest cold”, COVID-19 is a “head cold” that becomes a “chest cold, based on a German study on the progression of the anatomic sites of infection of COVID-19. This study looked at 14 patients who were found very early by contact tracing of an index case. They followed the patient’s symptoms, their RT-PCR (viral RNA) at multiple anatomic sites, live virus counts as determined by cell culture, and their IgG and IgM antibody levels. The sites they looked at were nasopharyngeal swabs, throat swabs, sputum or lung aspirations, blood, urine, and stool. Nasopharyngeal and throat swabs had similar results. There was a rapid increase in upper airway viral load peaking to 7 x 10⁸ viral copies at five days post symptom onset. This is very different from SARS, where 60% of cases don’t have detectable upper airway viral RNA, and those with upper airway viral DNA have a thousand fold lower peak. COVID-19 virus could readily be cultured from upper airway samples until day 8, after which it couldn’t be cultured. Thus a person late in their disease course with fever and pneumonia is less infectious than they were at early onset. Viral RNA and live virus were both readily isolated from sputum, although the sputum peak lagged slightly behind the upper airway peak. Viral RNA could be isolated from stool in high amounts, but they were unable to culture live virus from stool. There was no virus present in blood or urine. The three most common symptoms at presentation were cough, rhinitis, and sinusitis. Fever was only present in two patients on initial presentation, they also had diarrhea. Patients seroconvert, i.e., develop IgG antibodies on day 6-12 post onset.

The implications of the above study are important. A person with COVID-19 will shed over a thousand fold more virus than SARS. They shed it an earlier stage, and unlike SARS, they can shed it when they are afebrile and when they don’t have pneumonia (yet). Patients are most infective at day five post onset, at a point when the majority is still afebrile, and the most common symptoms are those of a mild cold. Guidelines based on identifying infectious patients by screening for fever, or the severity of their symptoms will miss ¾ of the infected population. There are more viral copies (700 million) on a single throat or nasal swab at day 5 post onset, than the entire population of the US. It would be interesting to measure the viral copies excreted with a single sneeze, it would probably be of a similar magnitude. Yes, masks are very important. If an infected person “touches” their nose or throat early in the course of the illness, then their finger becomes a biohazard. Yes, hand hygiene is very important.

As far as the “keep six foot away” guideline, I think the problem with that is that it is far less effective than wearing a mask, and it leads to a false sense of security. What if someone sneezes? Indoor spread will be affected by the pattern of indoor airflow from the HVAC system, the inverse square law doesn’t necessarily apply. There was a Chinese preprint (since withdrawn) that showed that on a long distance bus, people 15 feet away from a person later diagnosed with COVID-19 became infected. Video cameras monitored the entire trip. People who were closer than 15 feet and wearing masks, didn’t become infected.

Avoiding crowds is a good idea. In the above Wuhan China preprint, Virus aerosol concentrations were higher near a crowd waiting to enter a department store, than they were in the ICU ward of the hospital at peak epidemic. They attributed that to the effectiveness of the air filtration systems, negative pressure ventilation, and high air exchange rate within the ICU. 

In summary, we can help keep our departments safe during this epidemic, if everyone wears masks and practices good hand hygiene. I hope everyone stays healthy.

The NJ Department of Health has issued a very helpful flow chart for risk-stratifying Coronavirus exposure for healthcare providers. It supplements preliminary recommendations from the CDC and is useful for practitioners in any state. 

The key takeaway from the flowchart is that if a patient later tests positive for Coronavirus, it does not take much for rad onc staff who interacted with that patient to have to go into self-quarantine for 14 days, unless precautions are taken. If healthcare providers wear masks (non N95s), gloves, and eye protection AND patients also wear masks (non N95s), healthcare providers will remain in the "low-risk" category and will not have to self-quarantine if the patient later tests positive for Coronavirus. According to the CDC, this is an effective way to reduce risk without the need for widespread use of N95s, which remain in short supply in most rad onc clinics.

Update 3/18/20:

Update: 3/16/20

Below is a list of updates occurring today:

1. Faculty/residents are encouraged to telework on their administrative/research day. 

2. All those performing direct patient care can choose to wear scrubs as opposed to traditional attire (i.e. dry clean only). We typically only wear scrubs if we have procedures.

3. Staffing:

- All photon/proton dosimetry will become remote except for the main hospital site where we will staff one on-site dosimetrist (due to high volume of emergency cases). A second on-site dosimetrist may come due to special procedures.

- Admin staff: beginning 3/17, will work remotely with 2 rotating administrative assistants on-site at main hospital.

4. Due to shortages of supplies, we will attempt to conserve masks for re-use. We do not currently have shortages but we feel this is a best practice given the likely shortage and we will be 'doing our part'. We have also reviewed use of Oxivir wipes vs. Bleach wipes to help conserve.

5. Hosted a town hall session today which was attended by over 100 employees!  We used Zoom and employees typed in questions. This was EXTREMELY WELL RECEIVED. I would highly recommend for those who can.

Thank you all for this wonderful thread. In NC, all major hospital systems are no longer testing outpatients based on updated state recommendations regarding community spread. In rad onc, therefore, we will only know if someone is + if they are an inpatient. We have taken similar precautions as above i.e., limiting follow-ups, delaying appropriate patients, hypofractionation where appropriate, telehealth visits, etc. How else have your practices/recommendations changed now that there is community spread? Airflow in vaults? Therapists wearing surgical masks?

Update 3/25/20:

- Clinical Experience: we have had several patients who were deemed PUIs who we have treated using the algorithms above. Thus far (and fortunately!) all have tested negative. Treating even a PUI has caused significant anxiety for staff. One thing that is clearly critical is reviewing procedures with staff on a routine basis. I'm sure our NY/Seattle colleagues can attest to this! We have implemented telehealth for follow-ups but have not initiated this for consults yet. We have decided not to move forward with OTVs until further CMS clarification is provided. One thing to know is that patients will lie about symptoms to bypass screening questions. All patients are screened daily prior to treatment for symptoms. Any patient with symptoms is masked and removed from waiting room area and isolated to an exam room. We had a patient who lied about symptoms on a day of routine treatment who ended up in the ICU 6 hours later. Be vigilant. As a result of this experience, we are having each doc talk to patients during OTVs to educate the patients that we can continue treatment with symptoms (as long as not in critical condition). Teleworking for appropriate divisions has worked well.  

- ENT Scoping procedures: for all scoping procedures, physicians should wear a mask with face shield for protection. For any suctioning procedures where particles can be aerosolized, N95/PARP should be used.

- GYN procedures: historically, our practice has performed gown/glove/face mask/eye protection for tandem and ring/ovoid or interstitial procedures but for cylinders we have not used the same PPE.  Per reports, viral shedding can occur through stool and possibly vaginal mucosa (possibly accounting for some newborn infections). As a result, we will now move forward with the same PPE with cylinders.

- Contingency plans: contingency planning has also been performed for each clinical division.  Contingency planning for hospital surge capacity is also ongoing and information provided.  Important to think through your minimum number required for each division who could be pulled (nurses, NPs, docs). 

Update 3/26/20:

Clinical practice updates:

- Additional plans for treating PUIs/COVID + patients: If we get in a scenario where we have PUIs and COVID+'s, then PUIs will be treated first with a complete wipe down followed by COVID + pts.  For therapists, you will have 1-2 'dirty' therapists and 1 'clean' therapist. "Dirty therapists" will attend to patient and touch patient. The "clean therapist" will stay outside of room and use treatment console. During actual treatment/imaging, "dirty therapists" will remain gowned/gloved/masked so as to conserve supplies. They will stand outside the treatment area but in a space that will not be contaminated. If any concerns of contamination occur, the area will need to undergo terminal clean. 

- If staff members become COVID+ and develop subsequent immunity, they will preferentially treat PUIs and COVID+ patients once released back to clinic (per HR regulations). This will further limit concerns for additional staff infections.

- Leadership has developed an employee/faculty tracking sheet for those who are out and/or have been tested. This will help assess staffing levels.

Excellent thread and very helpful. We have sectioned off our department of three accelerators into distinct units with specific therapists, entry and exit, such that if one patient tests positive, only specific therapists would have been exposed. We have PPE shortage and all therapists are wearing surgical masks and gloves, all devices wiped down pre and post use, patients wash hands before entering accelerator. We are following the cycling re-use of surgical masks as of today due to short supply, using brown paper bags to cycle use every 72 hours. No use of home-made masks by health care staff because we cannot verify the integrity. MD seeing under treatments virtually from MD office. Harbin is screening every entrant to cancer center with questions and temperature, including employees. We are not treating PUI or positive patients at present because of lack of full PPE required.

We are also not delaying effective definitive anti-cancer therapy in settings where risk of cancer related death is greater than risk of contracting virus and death/long-term morbidity. We have developed specific patient education materials related to staying healthy during this time of crisis and have shifted our supportive care processes (groups, counseling) to phone or online. Most importantly, we keep asking questions and have a permanent slot on our now virtual multidisciplinary conference for discussion of COVID-19 and oncology. 

1. Follow up visits can utilize Telehealth or phone to minimize the risks to patients presenting to busy clinics.

MDs can be allowed to perform the Telehealth or phone visits from home as well to minimize the numbers of personnel and PPE needed.

2. Radiation therapy for small cell lung cancer or for disease control or palliative for cancer pain is not elective and should proceed.

3. Radiation therapy sessions that can be given over shorter duration (less number of days) can be considered.