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The United Kingdom has been severely affected by the coronavirus disease 2019 (COVID-19) pandemic. As the National Health Service (NHS) has urgently prioritized management of this outbreak, the UK clinical oncology community has had to adapt rapidly to maintain cancer services and training. These unprecedented times have altered countless aspects of cancer care, education, and research, providing a legacy that will extend well beyond the pandemic that catalyzed them. This editorial focuses on 3 key themes that distinguish the United Kingdom from many other countries.

Background HDR brachytherapy alone is effective for the treatment of localised prostate cancer when given in 2–4 or more fractions. Single dose treatment has been explored in small cohort studies to date. This paper reports a large patient population with localised prostate cancer treated with single dose HDR brachytherapy delivering 19 Gy providing early outcome data from this approach. Patients and methods Seven centres across the UK collaborated in this national protocol to deliver 19 Gy to the PTV defined by the prostate capsule and a 3 mm expansion with clearly defined planning constraints for the urethra and rectum. Entry criteria allowed all risk groups provided PSA ≤40 µg/L and staging investigations were negative for metastases. The primary end point was biochemical relapse free survival (bRFS) defined using the Phoenix definition. Toxicity was measured using CTCAE v4.0. Results A total of 441 patients were entered with median follow up 26 months (range 2–56). Median age was 73 (range 54–84) and 10% were low risk, 65% intermediate risk and 25% high risk. ADT was received by 37.6% overall and 90% of high risk patients for a median period of 6 months. Three year bRFS was overall 88%: this was 100% in low risk, 86% in intermediate risk and 75% in high risk. Only Gleason score was an independent predictor of bRFS. Relapse in 25 patients was assessed radiologically and occurred in the prostate in 15 of these, 11 of whom had localised prostate relapse only. Acute toxicity was low with no grade 3 or 4 events; there were two cases of late urinary stricture and two grade 3 late rectal events. Conclusion This is the largest cohort of single dose HDR brachytherapy patients treated with a single dose published to date. It shows that with 19 Gy there is 100% bRFS at 3 years in low risk patients but results in intermediate and high risk groups are less encouraging falling to 86% and 75% at 3 years with relapse predominantly in the prostate. Limited by the short follow up period of this study, the long-term outcomes of this single dose HDR approach remains uncertain. It is important to have close ongoing surveillance of this cohort as the data matures.

Introduction Over one million people in the UK identify as LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning). Research has shown that this population experience differing cancer risk factors compared with non-LGBTQ+ patients and persistent inequalities in cancer care. Literature concerning the knowledge of oncologists of this group’s healthcare needs is limited; our study aimed to evaluate knowledge, attitudes and behaviours of UK oncologists about LGBTQ+ patients. Methods A 53-question survey was delivered via a secure online platform. Questions covered respondent demographics, knowledge, attitudes and behaviours with the majority of responses on a Likert scale. Oncologists were recruited via email from professional bodies and social media promotion. Informed consent was sought and responses fully anonymised. Multifactorial ordinal logistic regression and Fisher’s exact test were used to assess for interactions between demographics and responses with Holm-Bonferroni multiple testing correction. Results 258 fully completed responses were received. Respondents had a median age of 43 years (range 28–69); 65% consultants and 35% registrars; 42% medical, and 54% clinical, oncologists. 84% felt comfortable treating LGBTQ+ patients but only 8% agreed that they were confident in their knowledge of specific LGBTQ+ patient healthcare needs. There were low rates of routine enquiry about sexual orientation (5%), gender identity (3%) and preferred pronouns (2%). 68% of oncologists felt LGBTQ+ healthcare needs should be a mandatory component of postgraduate training. Conclusions This survey showed that UK oncologists feel comfortable treating LGBTQ+ patients but may fail to identify these patients in their clinic, making it more difficult to meet LGBTQ+ healthcare needs. There is self-awareness of deficits in knowledge of LGBTQ+ healthcare and a willingness to address this through postgraduate training. Educational resources collated and developed in accordance with this study would potentially improve the confidence of oncologists in treating LGBTQ+ patients and the cancer care these patients receive.

The novel coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had a devastating impact, with the number of deaths worldwide by June 2020 over 400 000. There are currently no proven, effective treatments, so there is an urgent need for clinical trials to test new therapeutic interventions that may be of benefit.

Purpose Whole pelvis radiation therapy (WPRT) may improve clinical outcomes over prostate-only radiation therapy (PORT) in high-risk prostate cancer patients by sterilization of micrometastatic nodal disease, provided there is optimal control of the primary site. Methods and Materials A prospective multicenter cohort study of eligible patients (stage ≥T2c, Gleason score ≥7 or presenting prostate-specific antigen ≥10) treated between 2009 and 2013 were enrolled in a United Kingdom national protocol delivering combined external beam radiation therapy and high-dose-rate brachytherapy. Centers elected to deliver WPRT, 46 Gy in 23 fractions or PORT 37.5 Gy in 15 fractions with 15 Gy single dose high-dose-rate brachytherapy. The primary endpoint was biochemical progression-free survival (bPFS). Secondary endpoints were overall survival, genitourinary, and gastrointestinal toxicity. This was not a randomized comparison and was subject to bias; the findings are therefore hypothesis generating, but not conclusive. Results Eight hundred and twelve patients were entered; 401 received WPRT and 411 received PORT. With a median follow-up of 4.7 years, 5-year bPFS rates for WPRT versus PORT arms were 89% versus 81% (P = .007) for all patients and 84% versus 77% (P = .001) for high-risk patients. Differences in bPFS remained significant after accounting for Gleason score, presenting prostate-specific antigen, T stage, and androgen deprivation therapy duration as covariates. There was no difference in overall survival. The overall post treatment toxicities across both cohorts were low with no greater than 1.5% of ≥grade 3 toxicities at any follow-up time point. WPRT increased both prevalence and cumulative incidence of acute genitourinary toxicity (P = .004) and acute gastrointestinal toxicity (P = .003). No difference in late radiation toxicity was observed. Conclusions A significant improvement in 5-year bPFS was seen in intermediate and high-risk prostate cancer treated with WPRT compared with PORT in a combined external beam radiation therapy and brachytherapy schedule with no increase in late radiation toxicity.

Radical radiotherapy for prostate cancer offers excellent long-term outcomes for patients with high-risk disease. The increased risk of pelvic nodal involvement in this cohort has led to the development of whole-pelvis radiotherapy (WPRT) with a prostate boost. However, the use of WPRT remains controversial. Data are mixed, but advanced radiotherapy techniques enable delivery of increased radiation to pelvic nodes with acceptable levels of toxicity. Contemporary imaging modalities with increased sensitivity for detecting subclinical lymph node disease will facilitate selection of patients most likely to benefit from WPRT. Using such modalities for image guidance of advanced radiotherapy techniques could also permit high-dose delivery to nodes outside the conventional Radiation Therapy Oncology Group volumes, where magnetic resonance lymphography and single-photon-emission CT imaging have mapped a high frequency of microscopic disease. With increased toxicity a concern, an alternative to WPRT would be selective irradiation of target nodal groups most likely to harbour occult disease. New image-based ‘big data’ mining techniques enable the large-scale comparison of incidental dose distributions of thousands of patients treated in the past. By using novel computing methods and artificial intelligence, high-risk regions can be identified and used to optimize WPRT through refined knowledge of the likely location of subclinical disease.

Over 1 million people in the United Kingdom identify as LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning) with increasing literature highlighting inequalities in their cancer care. A recent study of US oncologists revealed 53.1% were confident in their knowledge of health needs of LGB patients and 36.9% of transgender patients. To date, no UK studies have evaluated selfperceived knowledge, attitudes and behaviours of oncologists about LGBTQ+ patients.

Objective: A cohort of high dose-rate (HDR) monotherapy patients was analyzed to (i) establish the frequency of non-malignant urethral stricture; (ii) explore the relation between stricture formation with the dose distribution along the length of the urethra, and MRI radiomics features of the prostate gland. Methods: A retrospective review of treatment records of patients who received 19 Gy single fraction of HDR brachytherapy (BT) was carried out. A matched pair analysis used one control for each stricture case matched with pre-treatment International Prostate Symptom Score (IPSS) score, number of needles used and clinical target volume volume for each stricture case identified. For all data sets, pre-treatment T2 weighted MRI images were used to define regions of interests along the urethra and within the whole prostate gland. MRI textural radiomics features—energy, contrast and homogeneity were selected. Wilcoxon signed-rank test was performed to investigate significant differences in dosimetric parameters and MRI radiomics feature values between cases and controls. Results: From Nov 2010 to July 2017, there were 178 patients treated with HDR BT delivering 19 Gy in a single dose. With a median follow-up of 28.2 months, a total of 5/178 (3%) strictures were identified. 10 patients were included in the matched pair analysis. The urethral dosimetric parameters investigated were not statistically different between cases and controls (p > 0.05). With regards to MRI radiomics feature analysis, significant differences were found in contrast and homogeneity between cases and controls (p < 0.05). However, this did not apply to the energy feature (p = 0.28). Conclusion: In this matched pair analysis, no association between post-treatment stricture and urethral dosimetry was identified. Our study generated a preliminary clinical hypothesis suggesting that the MRI radiomics features of homogeneity and contrast of the prostate gland can potentially identify patients who develop strictures after HDR BT. Although the sample size is small, this warrants further validation in a larger patient cohort. Advances in knowledge: Urethral stricture has been reported as a specific late effect with prostate HDR brachytherapy. Our study reported a relatively low stricture rate of 3% and no association between post-treatment stricture and urethral dosimetry was identified. MRI radiomics features can potentially identify patients who are more prone to develop strictures.

In recent years, rapidly evolving radiation techniques have enabled the precise delivery of very high doses of radiation to local targets with stereotactic ablative body radiotherapy (SABR). In addition to its direct cytotoxicity, radiation and in particular SABR has powerful immunomodulatory effects resulting in immunogenic cell death and potentiation of the anti-tumour immune response. However, due to the immunosuppressive nature of non-irradiated sites of metastases, radiotherapy alone is seldom sufficient to induce the systemic response required for distant tumour rejection. Immune checkpoint inhibitors are a novel class of immunomodulatory agents shown to have robust efficacy against a number of malignancies. These drugs can augment the effects of radiotherapy by helping overcome tumour-induced immunosuppression at local and distant sites. Similarly, radiation may complement immunotherapy by priming tumours in preparation for the adaptive immune response, thereby leading to more prolonged clinical effects. This synergistic relationship has been demonstrated in laboratory models and has been extended to a number of early phase clinical studies.

A 38 year old HIV negative South African man was diagnosed in 2007 with stage IVB Hodgkin’s lymphoma. Conventional chemotherapy and radiotherapy had no effect, so in March 2007 he underwent an autologous stem cell transplant. Relapses in 2009 and 2010 resulted in two allogeneic stem cell transplants, after he was conditioned with fludarabine, cyclophosphamide, and anti-thymocyte globulin. After his second transplant he developed grade four graft versus host disease that affected the liver and gut, and in December 2010 he was started on an immunosuppressive regimen of prednisolone and ciclosporin. In June 2011 he re-presented with a one week history of fever, vomiting, and malaise, followed by severe headache and visual aura. On examination he was cachectic with mild ankle oedema and a fever (39.2°C). The rest of the examination was unremarkable. His peripheral white blood cell count was 0.7×109/L (normal range 4-11), neutrophils were 0.1×109/L (2-7.5), platelets 22×109/L (150-400), and haemoglobin 98 g/L (130-180). Liver function tests showed alanine transaminase 362 U/L (21-72), alkaline phosphatase 960 U/L (30-120), bilirubin 61 μmol/L (3-22; 1 μmol/L=0.06 mg/dL), and albumin 28 g/L (35-50). C reactive protein was raised at 2743 nmol/L (

Abstract 3292 Patients with refractory immune thrombocytopenia (ITP) have limited therapeutic options, with morbidity and mortality as often from infection as from bleeding. Thrombopoietin (TPO) mimetics allow an increase in the platelet count without causing immunosuppression. These agents may be especially useful in patients with secondary forms of ITP. We report three patients treated with TPO agonists for ITP post Allogeneic Stem Cell Transplants (SCT). Patient 1: MC, 37yrs, developed refractory ITP after a myeloablative allogeneic SCT for Accelerated Phase CML. He was unresponsive to standard treatments (figure 1a), requiring platelet transfusions 3x weekly for active bleeding. He started Eltrombopag 50mg/day in July 2009. He had a clinically significant increase in his platelet count (supported count increased to 40) so platelet transfusions were reduced to 2x weekly. Eltrombopag was increased to 75mg in November with a subsequent platelet increase to 90 and by December 2009 he was platelet independent, maintaining a platelet count 90–120 on Eltrombopag alone, 25mg/day, 5 days week. Patient 2: BT, 4yrs(12kg), underwent a myeloablative allogeneic PBSCT in September 2009 for JIA/HLH. She became thrombocytopenic in June 2010, presumed to be ITP. She had no response to prednisolone or rituximab and a only a minimal response to IVIG; requiring platelets 1x weekly. She started Eltrombopag 7mg OD in November 2010, escalated to 12mg by February 2011. This had a synergistic effect with IVIG and she became platelet independent after one month of Eltrombopag and IVIG, maintaining platelet counts 50–200 (figure1b). Patient 3: MG, 62yrs, underwent a reduced intensity allogeneic SCT in March 2010 for stage 3 Sezary syndrome. Post SCT he developed pancytopenia associated with EBV reactivation. He received daily GCSF, regular blood and weekly platelet transfusions. In July he developed GI bleeding from HSV colitis and his platelet transfusion requirements increased to alternate days. In October 2010 he was started on Romiplostim 250mcg, increased to 350mcg weekly, erythropoetin and GCSF. He had a clinically significant rise in his platelet counts and a reduction in his platelet requirements to 1x weekly within weeks of starting romiplostim. By December he was platelet independent, with counts persistently over 50, and romiplostim was stopped (figure1c). All three patients remain in remission at the time of submission of the abstract. Immune cytopenias are well-recognised post myeloablative allografts occurring in 5–37% of SCT recipients. The occurrence of ITP in SCT recipients has been reported, in which GVHD or the production of anti-platelet alloantibodies of recipient origin was considered to play major roles. Although small numbers, these case studies show efficacy of thrombopoietic agents (recently licensed for use in chronic ITP) in patients with thrombocytopenia post SCT refractory to standard therapies, with an early reduction and subsequent cessation in platelet transfusion requirements in all three patients. The lack of immune suppression with these agents may be particularly relevant in patients post SCT, in whom immune reconstitution is vital not only in preventing infections, but also in preventing rejection of the graft and in establishing a graft versus leukaemia effect. Given that TPO receptors are present on haematopoietic stem cells at all stages of development and that TPO provides a growth factor for stem cells, the use of these agents in patients treated for leukaemia requires caution. There was no evidence of progression of disease in these patients and TPO agents were only required for a period of time (patient 3 is off therapy and the others only receive minimal doses). Formal evaluation of these agents in allogeneic SCT is warranted. Disclosures: Cooper: GSK: Honoraria; Amgen: Honoraria.