Radiotherapy and Oncology 193 (2024) 110120

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Radiotherapy and Oncology

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Original Article

Paediatric radiation therapy without anaesthesia – Are the

children moving?
Tatiana Ritchie a, Susan Awrey a, Manjula Maganti b, Rehab Chahin a, Michael Velec a, David
C. Hodgson a, Hitesh Dama a, Sameera Ahmed a, Jeff D. Winter a, Normand Laperriere a, Derek
S. Tsang a, *
a
Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, Toronto, ON, M5G 2M9, Canada
b
Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, 610, University Ave, Toronto, ON, M5G 2M9, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: Children who require radiation therapy (RT) should ideally be treated awake, without anaesthesia, if
Radiotherapy, Image-Guided possible. Audiovisual distraction is a known method to facilitate awake treatment, but its effectiveness at keeping
Radiotherapy Setup Errors children from moving during treatment is not known. The aim of this study was to evaluate intrafraction
Radiotherapy Target Organ Alignment
movement of children receiving RT while awake.
Cone-Beam CT
Methods: In this prospective study, we measured the intrafraction movement of children undergoing treatment
Child
Child, Preschool with fractionated RT, using pre- and post-RT cone beam CT (CBCT) with image matching on bony anatomy.
Study CBCTs were acquired at first fraction, weekly during RT, and at last fraction. The primary endpoint was the
magnitude of vector change between the pre- and post-RT scans. Our hypothesis was that 90 % of CBCT ac­
quisitions would have minimal movement, defined as <3 mm for head-and-neck (HN) treatments and <5 mm for
non-HN treatments.
Results: A total of 65 children were enrolled and had evaluable data across 302 treatments with CBCT acquisi­
tions. Median age was 11 years (range, 2–18; 1st and 3rd quartiles 7 and 14 years, respectively). Minimal
movement was observed in 99.4 % of HN treatments and 97.2 % of non-HN treatments. The study hypothesis of
>90 % of evaluations having minimal movement was met. Children who were age >11 years moved less at initial
evaluation but tended to move more as a course of radiation progressed, as compared to children who were
younger.
Conclusion: Children receiving RT with audiovisual distraction while awake had small magnitudes of observed
intrafraction movement, with minimal movement in >97 % of observed RT fractions. This study validates
methods of anaesthesia avoidance using audiovisual distraction for selected children.

Although generally safe [1], use of anaesthesia in paediatric radia­
tion oncology can be costly [2] and cumbersome, and adds to the burden
of cancer treatment in children and adolescents.[3,4] In many in­
stitutions, a substantial proportion of young children and some adoles­
cents undergo general anaesthesia for radiation treatments [2,5]. At our
institution, a multi-faceted approach has been used to reduce anaes­
thesia utilization as part of standard-of-care radiotherapy (RT): presence
of a dedicated paediatric nurse for procedural preparation, comfort
objects (e.g., stuffed animal), and most importantly, audiovisual
distraction (television) [6]. Using our approach, 72.5 % of children
between ages 3 and 6 can be treated without any anaesthesia [6].
However, this approach and other audio visual distraction systems have
not been systematically evaluated to determine their effectiveness at
immobilizing children receiving RT.
Cone beam CT (CBCT) is used routinely to deliver precision photon-
based image-guided radiotherapy (IGRT), and allows oncologists to
reduce the planning target volume (PTV) expansions used for daily
treatment, as compared to MV planar imaging [7–10]. At our institution,
children routinely receive at least one CBCT scan before each daily ra­
diation treatment to ensure correct and accurate treatment positioning,
consistent with practices at other Children’s Oncology Group in­
stitutions [8]. Post-radiation CBCT acquisitions can also be used to
validate motion mitigation strategies and effectiveness of immobiliza­
tion by assessing patient motion between imaging and beam delivery

* Corresponding author at: 610 University Avenue, Toronto ON M5G 2M9 Canada.
E-mail address: derek.tsang@uhn.ca (D.S. Tsang).

https://doi.org/10.1016/j.radonc.2024.110120
Received 29 November 2023; Received in revised form 16 January 2024; Accepted 24 January 2024
Available online 3 February 2024
0167-8140/© 2024 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-
nc/4.0/).
T. Ritchie et al.
[11–13].
In this study, we prospectively evaluated intrafraction motion of
children receiving fractionated radiotherapy, under our standard clin­
ical practice of delivering awake RT to children including audio visual
distraction. Our hypothesis was that 90 % of CBCT acquisitions would
have minimal movement of bony anatomy, defined as <3 mm for head-
and-neck and brain (HN) treatments and <5 mm for non-HN treatments.
These minimal movement thresholds are within institutional PTV mar­
gins for these body sites.
Materials and methods
This was a prospective study of children receiving fractionated
photon radiotherapy (RT) with a linear accelerator at a single tertiary
care institution. All patients or their substitute decision maker (parent or
caregiver with custody) provided written, informed consent. Eligibility
criteria included children age ≤ 18 who were receiving RT without any
form of gaseous, intravenous, or oral anesthetic, sedative, benzodiaze­
pine or antihistamine. Individuals treated with active breathing coor­
dinator (breath-hold) or receiving total body irradiation were excluded.
Children were accrued to the study prior to, or within the first 2 weeks of
starting RT. The study opened October 29, 2019 and closed to new
enrollment on October 3, 2022 when accrual was complete. The study
was reviewed by two research ethics boards at the cancer centre
(18–5370) and referring children’s hospital (1000060902), and was
registered on ClinicalTrials.gov (NCT03995849).
Study procedures
Our standard paediatric workflow for awake RT treatment has been
previously reported [6]; in brief, a paediatric nurse provided procedural
preparation and children were offered audio visual distraction (televi­
sion during RT) as well as two-way audio communication with their
caregiver. Children immobilized with a thermoplastic frame had their
eyes and mouth cut out for patient comfort (Fig. 1). Standard, institu­
tional PTV margins of 3–5 mm (HN treatment sites) or 5–10 mm (non-
HN treatment sites) were used for all patients. All patients treated with a
linear accelerator routinely received pre-irradiation daily CBCT acqui­
sitions (pre-RT CBCT) as part of standard-of-care. This involved auto­
mated bony anatomy registration and remote translational adjustments
of the couch. Subsequently, study patients underwent another CBCT
acquisition at the end of the treatment session (post-RT CBCT). The
Fig. 1. Examples of thermoplastic masks used to immobilize children. All children had eyes and mouth cutouts to increase patient comfort. (a) Full thermoplastic
frame for head-and-neck treatment. (b) Short thermoplastic frame, for brain-only treatment.
2
Radiotherapy and Oncology 193 (2024) 110120
additional study procedure was applied at the first and last RT session
after study enrollment, and weekly. All patients were treated with daily
fractionation, 5 days per week on weekdays, with the exception of
holidays (4 fractions per week). The post-RT CBCT, similar to the pre-RT
CBCT, was designed to deliver a dose of 1 mGy or less. As an example, a
child prescribed a course of 54 Gy in 30 fractions would have a
maximum additive study dose exposure of 7 mGy to the treatment iso­
centre, which comprises ≤ 0.013 % of the prescription dose. Children
with multiple isocentres treated underwent a post-RT CBCT acquisition
for the last treated isocentre only.
By comparing the pre-RT CBCT and post-RT CBCT, an estimate of the
intrafraction movement of the patient was obtained. Any corrective
couch translations made between pre- and post-RT CBCT were consid­
ered in the vector calculation to consider only bony movement of the
patient. The primary endpoint was the magnitude of vector change be­
tween the two scans (measuring intrafraction movement), which was
calculated based on shifts in craniocaudal (CC), mediolateral (ML) and
anteroposterior (AP) directions using IGRT software (XVI, Elekta,
Stockholm, Sweden).
Sample size
Movement that is <3 mm for HN treatments and <5 mm for non-HN
treatments was deemed clinically acceptable, based on institutional
planning target volume expansions. It was assumed that true intra­
fraction movement was 1 mm for head-and-neck and brain (HN) treat­
ments and 3 mm for non-HN treatments. Thus, we powered the study to
compare the movement of the HN group with 1 mm; therefore, an a
priori difference of 2 mm or less (3 mm–1 mm = 2 mm) was defined as
clinically acceptable. Similarly, we compared the average movement of
the non-HN group to 3 mm, for a difference of 2 mm or less (5 mm–3
mm = 2 mm).
In an equivalence test of means using two one-sided tests on data
from a paired design, a sample size of 58 individuals achieves 80 %
power at a 0.05 significance level when the true difference between the
means is 2 mm for all patients. This assumes that the standard deviation
of the paired differences is 3 mm, and the equivalence limits are 0 mm
and 3 mm. In this design, if the average difference between pre-RT CBCT
and post-RT CBCT is between these two equivalence limits (i.e., <3
mm), the two means are said to be equivalent (which means no motion
was observed). The final sample size, as per study protocol, was 65
patients to account for study attrition.
T. Ritchie et al. Radiotherapy and Oncology 193 (2024) 110120

Statistics Table 1
Characteristics of patients and CBCT evaluations.
Descriptive statistics were used to describe the proportion of patients Characteristic, by patient Value
with adequate immobilization (<3 mm for HN targets, <5 mm for non-
Number of patients N ¼ 65
HN targets), as well as the magnitudes of intrafraction movement. Age at RT, median, years (range) 11 (2–18)
Intrafraction movement was considered using a linear mixed model to Age, 1st and 3rd quartiles, years 7–14
determine if movement changes over study visit number (the nth study Sex
CBCT, acquired at first RT, weekly, and last RT), course of radiotherapy Female 29 (45 %)
Male 36 (55 %)
(1st, 2nd, 3rd, etc.), age, body site of treatment, use of immobilization, Prior courses of RT
patient refusal of audio visual distraction, radiation delivery method None 51
(VMAT vs IMRT vs 3DCRT) and treatment/fraction length (minutes). One 11
Statistically significant variables (defined as p < 0.05), determined by Two 3
Diagnosis
evaluation of the interaction term of the variable of interest and study
Glioma 17 (26 %)
visit number, were included in a multivariable model. Analyses were Ewing sarcoma 9 (12 %)
done using SAS 9.4 and SAS/STAT 14.1 (Cary, USA). Rhabdomyosarcoma 6 (9 %)
Germinoma 5 (8 %)
Non-rhabdomyosarcoma soft tissue sarcoma 5 (8 %)
Results
Neuroblastoma 5 (8 %)
Leukemia 4 (6 %)
A total of 67 patients were enrolled; 65 patients had evaluable data Medulloblastoma 4 (6 %)
over 67 courses of radiotherapy. Supplementary Fig. 1 shows a flow Atypical teratoid rhabdoid tumour 2 (3 %)
diagram of patients through the study. Two study subjects returned for a Hodgkin lymphoma 2 (3 %)
Osteosarcoma 2 (3 %)
subsequent course of RT while enrolled on study and underwent addi­
Ependymoma 1 (2 %)
tional study CBCT evaluations. A total of 302 study post-RT CBCT Meningioma 1 (2 %)
evaluations were included in the final analysis. Baseline characteristics Salivary gland carcinoma 1 (2 %)
by patient and CBCT evaluation are listed in Table 1. The distribution of Schwannoma 1 (2 %)
Wilms tumour 1 (2 %)
post-RT CBCTs across fraction number and study visits for all patients is
Number of CBCT evaluations N ¼ 302
shown in Supplementary Fig. 2 and Supplementary Table 1. All patients Time from 1st CBCT to study CBCT, median, minutes (IQR) 7.3 (5.3–10.7)
were offered the option to watch television during RT. Twenty-two Treated site
fractions (7 %) among five patients, aged 12, 13, 17 (n = 2) and 18, Abdomen 17 (6 %)
were delivered without television because the child declined to watch Brain 143 (47 %)
Chest 40 (13 %)
TV for their treatments; these older children were offered music during
Extremity 15 (5 %)
RT. Head-and-Neck (excluding Brain) 18 (6 %)
The distributions of intrafraction movement across all CBCT evalu­ Orbit 12 (4 %)
ations and stratified by body site are shown in Fig. 2, demonstrating low Pelvis 24 (8 %)
incidence of fractions where intrafraction movement was above usual Spine 7 (2 %)
Craniospinal irradiation* 26 (9 %)
PTV margins of 3 mm (HN treatment sites) or 5 mm (non-HN treatment Treatment technique
sites). In Table 2, the primary endpoint of minimal movement was 3DCRT 12 (4 %)
evaluated, as well as median movement (stratified by body site). The IMRT 52 (17 %)
study hypothesis of >90 % of evaluations having minimal movement VMAT 238 (79 %)
Immobilization
was met. Very few treatments had observed movement above the
Chest board (arms above head) 35 (12 %)
thresholds of 3 mm (for HN treatment sites) or 5 mm (for non-HN Thermoplastic mask, full (head to shoulders) 56 (19 %)
treatment sites). Plots of intrafraction movement for individual pa­ Thermoplastic mask, short (head) 149 (49 %)
tients across their course of RT are displayed in Supplementary Fig. 3a Mattress only 30 (10 %)
(for HN patients) and Supplementary Fig. 3b (for non-HN patients). Vacuum bag 32 (11 %)
Child viewing television 280 (93 %)
Boxplots of intrafraction movement for each patient are shown in Sup­ Boost fraction** 39 (13 %)
plementary Fig. 4. Multi-isocenter treatment 58 (19 %)
Age (with 11 years as a cut point, p = 0.009), method of immobili­
IQR = interquartile range (1st and 3rd quartile).
zation (full thermoplastic mask vs. short thermoplastic mask, p < 0.001; *
For patients receiving craniospinal irradiation (CSI), the last treated site (and
vacuum bag vs. short thermoplastic mask, p = 0.003) and whether the site imaged by post-RT CBCT) was the caudal-most isocenter (in the lumbosacral
study CBCT was acquired during the boost phase of RT (p = 0.005) were spine).
significantly associated with intrafraction movement on univariable **
A boost fraction was defined as a modified phase of daily treatment deliv­
models (Fig. 3). Patient sex, fraction number, course of radiotherapy, ered one working day after an initial RT prescription, using a different RT plan.
site of treatment, method of radiation delivery (VMAT vs IMRT vs
3DCRT), patient refusal of audio visual distraction, and treatment length method, and a child’s tendency to move as a course of radiotherapy
(duration between first CBCT and study CBCT) were not associated with progressed (over time). Children who were older moved less at first
intrafraction movement, and were not considered further. Overall, the evaluation (p = 0.029), but tended to move more over time, as compared
modelled magnitude of movement was low and almost always below 3 to children who were younger (p = 0.012). Patients immobilized with a
mm (Fig. 3). Television use was not statistically significantly associated full thermoplastic mask tended to move less over time, as compared to
with movement because a small number of children who declined TV children immobilized with a short thermoplastic mask (p < 0.001). In
were older, were offered ambient music during treatment, and had contrast, patients immobilized with a vacuum bag tended to move more
assured staff that they would not move (as with all patients treated as a treatment course progressed, as compared to a short thermoplastic
awake). mask (p = 0.027).
Age, immobilization method and boost RT were subsequently eval­
uated in a multivariable linear mixed model, with the variables
considered together (Supplementary Table 2). This analysis found sta­
tistically significant interactions between patient age, immobilization

3
T. Ritchie et al. Radiotherapy and Oncology 193 (2024) 110120

Fig. 2. (a) Histogram of intrafraction movement across all CBCT evaluations. (b) Boxplots of intrafraction movement, by body site. Note, evaluations labelled “Whole
CNS” received CBCT evaluations to the last isocenter treated (in the caudal spine). The width of the box denotes the 1st and 3rd quartiles; the horizontal line in the
box denotes the median value; the diamond denotes mean value, whiskers denote values within 1.5 interquartile range (IQR) of the box, and circles denote outliers.

2.3 mm (awake patients) for patients receiving RT to the HN region;

Table 2
these children did not watch TV during treatment, but did receive child
Median movement and number of fractions adequately immobilized, by body
life specialist support.[14] In the present study with audio visual
site.
distraction offered to all patients, the intrafraction movement was
Group Median Minimal movement numerically lower (median, 0.57 mm).
movement
mm (1st and Threshold Less than Greater than
The multivariable analysis elucidates clinical and technical factors
3rd quartile) threshold, n, % threshold, n, % that affect patient movement dynamics over a course of treatment. We
(95 % CI) found that older patients (age > 11 years) tend to move less at the
Head-and- 0.57 <3 mm 160, 99.4 % 1, 0.6 % beginning of a course of treatment, but this movement increases with
neck (0.35–0.81) (96.2–99.9 %) time (as compared with younger children age ≤ 11 years). This may
(HN) site indicate older children become more “fidgety” with time, whereas
Non-HN 1.3 (0.72–2.2) <5 mm 137, 97.2 % 4, 2.8 % younger kids have more movement earlier (consistent with literature
site (92.3–99.1 %)
findings in diagnostic radiology departments [17]), but then settle into a
routine and become more still with time. We also found that patients
Discussion immobilized with a full thermoplastic mask started out with more
intrafraction movement, which decreased over time (as compared with
In this prospective study of awake children receiving fractionated children immobilized with a short thermoplastic mask). This is domi­
RT, we demonstrate very low magnitudes of intrafraction movement nated by patients receiving craniospinal irradiation, who have longer,
using our previously described methods of audio visual distraction.[6] multi-isocentre treatments. As these patients progress through RT suc­
Almost all patients had movement below 3 mm (for HN treatments) and cessfully, they move less as they become more comfortable with treat­
5 mm (for non-HN treatments). These movement thresholds are within ment. Finally, patients treated with vacuum bag immobilization tended
the PTV guidelines for contemporary Children’s Oncology Group to move more with time; we hypothesize this could be due to patient
studies; for example, ACNS2021 (NCT04684368) suggests a 0.3–0.5 cm discomfort in the device, gradual deflation over time, or loss of con­
PTV expansion for the brain-directed phase of treatment, while formity of the vacuum bag contours to the patient’s body shape.
AREN1921 (NCT04322318) suggests a 0.5–1.0 cm PTV expansion for There has been intense interest in methods that provide audio visual
Wilms tumor. Additionally, we demonstrate effective immobilization distraction for children receiving radiotherapy. Our study is the first
using thermoplastic masks that have eyes and mouth cutouts, which known trial to quantify immobilization effectiveness in the setting of
increase the success of anaesthesia avoidance. Our methods of reducing children receiving fractionated radiotherapy using audio visual
anaesthesia use with audio visual distraction are thus validated, even in distraction, thus validating methods of treating children with anaes­
children as young as 2 years of age. The general principle of minimizing thesia avoidance using television. Audio visual-assisted therapeutic
anaesthesia use significantly reduces the burden of therapy and cost of ambiance in radiation therapy (AVATAR) is the most extensively studied
care [2] for pediatric population, where children as old as age 11 [14], video system, having been initially evaluated at Stanford University
or even age ≥ 12 [15] occasionally require sedation to successfully [18], followed by a large multicenter study across ten institutions in the
complete a course of RT. In the present study, a quarter of children United States [19]. The AVATAR system was able to reduce anaesthesia
enrolled were age 7 or younger. Our data demonstrate very low mag­ usage in young children receiving RT, as compared to historical controls,
nitudes of bony movement during awake RT across the pediatric age resulting in cost savings [20]. Other groups in Australia [21], Canada
spectrum, including both younger children and adolescents. [6], China [16] and the United States [22] have similarly applied
We found very few fractions where more than minimal movement methods using television to distract children and avoid anaesthesia for
(>3 mm for HN, >5 mm for non-HN) was detected. In a study by Liu RT. A video projection system developed at the University of Colorado
et al. [16], where patients were sleep deprived prior to RT, 10 of 253 has been patented (USPTO US-20220217312-A1) with active efforts to
fractions had >5 mm movement (4.0 %), similar to the present study expand implementation more broadly (https://radflix.org).
where 2.8 % of patients receiving treatment to a non-HN site had >5 mm Outside the context of anaesthesia avoidance in paediatric RT, CBCT
movement. In a study by Beltran et al., pre- and post-RT CBCT was used has been successfully used by other investigators to evaluate intra­
to evaluate intrafractional residual uncertainty (movement) [10]; this fraction motion in a small number of patients with Wilms’ tumor (n =
uncertainty ranged from a mean value of 1.5 mm (sedated patients) to 15), though their results are not necessarily generalizable to paediatric

4
T. Ritchie et al. Radiotherapy and Oncology 193 (2024) 110120

Fig. 3. (a) Modelled intrafraction movement (y-axis) by weekly study visit number (x-axis), stratified by age category. (b) Modelled intrafraction movement (y-axis)
by weekly study visit number (x-axis), by immobilization method. Patients treated with craniospinal irradiation were immobilized with a full thermoplastic mask
(fMask). CB = chest board (thoracic treatment); VB = vacuum bag; fMask = full thermoplastic mask; sMask = short thermoplastic mask. (c) Modelled intrafraction
movement (y-axis) by weekly study visit number (x-axis), by phase of treatment (boost or not).

tumors located in other body sites [11]. Huijskens et al retrospectively
evaluated CBCT for 20 patients to study correlations in movement be­
tween intra-abdominal organs during a course of radiotherapy [23]. Pre-
and post-irradiation CBCT has also been used in adult patients with lung
cancer to evaluate patient motion [12,13]. Additionally, interfractional
movement of organs within pediatric patients was evaluated by Meijer
et al., which noted wide variations in the position of the hemi­
diaphragm, spleen, liver and kidneys due to respiration [24]. This study
also found reduced intrafractional and interfractional positional varia­
tion under anesthesia, similar to other work which has observed re­
ductions in liver movement among adults receiving abdominal RT with
concurrent lorazepam sedation [25]. These studies emphasize the need
to consider internal organ motion (in addition to bulk patient move­
ments) using advanced simulation techniques such as 4-dimensional CT
planning to guide ITV (internal target volume) delineation for moving
targets, particularly those tumours with craniocaudal movements from
respiration [26]. A suitable PTV can then be created as an expansion of
the ITV.
Our study did not use a control group to evaluate movement of pa­
tients who were sedated for RT. We considered applying post-RT CBCT
to a group of children treated with general anesthetic as a control, but
this would apply unnecessary radiation to patients who would not
benefit (since sedated patients move less than awake patients [10]) and
would not be ethical. We also did not compare with a control group
treated without audio visual distraction because this approach was not
supported by the radiation therapy or nursing care team, so as to avoid
upsetting children with an TV-free workflow that would not be standard-
of-care at our institution and increasing the risk of children moving
during RT. This study was not able to evaluate internal organ motion or
tumour motion, but does demonstrates that large, bulk body movements
(as evaluated by bony anatomy) were rare; future study of tumour-
specific movement across organ sites in children would be desirable.
We demonstrate that intrafraction patient movement during awake
pediatric RT is within PTV margins, but characterisation of appropriate
PTV margins that accounts for other geometric uncertainty (i.e. respi­
ration) is outside the scope of this study. Also, the study was not pow­
ered to compare movement between subgroups of children receiving RT
to different body sites beyond HN and non-HN tumour sites considered
together.
Another limitation of our study was inability to detect short-interval,
transient movements between initial CBCT (prior to RT fraction de­
livery) and the study CBCT (after the RT fraction delivery is complete),
where the patient moves back to their original position. We considered
using a real-time, non-RT tracking modality using optical reflectors and
a real-time camera tracking system to detect such movement, but prior
use of this system in our department had shown low reliability.
Furthermore, use of an optical tracking system requires line of sight
visibility to the patient, which is more challenging with concomitant
audio visual distraction (television) for paediatric patients. In addition,
avoiding movements that shift the patient to a different static position
and are non-transient are most significant for accurate radiation dose
delivery; fortunately, bulk body shifts remain effectively detected with
our current method of pre- and post-RT CBCT evaluation. Nonetheless,
we look forward to results from the PROMISE trial (NCT05148078),

5
T. Ritchie et al.
which is a prospective study of 30 patients using video and concurrent
real-time video surveillance gating to monitor patient movement.
Conclusions
In this prospective study, we evaluated movement of children before
and after treatment with fractionated radiotherapy and concurrent
audio visual distraction. Almost all treatments had small magnitudes of
observed movement, with minimal movement (defined as <3 mm for
head-and-neck treatments and <5 mm otherwise) in >97 % of observed
RT fractions. Therefore, to answer the titular study question: are the
children moving? The answer is no – paediatric RT patients are not
moving beyond typical PTV margins. This study validates existing
methods of anaesthesia avoidance using audio visual distraction for
selected children.
Conflicts of interest
DST has received travel funding from Mevion Medical Systems and
Elekta AB in 2022, unrelated to the present work. DST has been a
consultant with Need since 2023, unrelated to the present work.
Funding
This work was supported by a Collaborative Academic Practice grant
from University Health Network, received by TR.
Clinical trial information
This prospective study was registered on ClinicalTrials.gov
(NCT03995849).
Data sharing statement
Data are stored in an institutional repository and are available upon
request to the corresponding author.
CRediT authorship contribution statement
Tatiana Ritchie: Conceptualization, Data curation, Funding acqui­
sition, Investigation, Methodology, Resources, Supervision, Visualiza­
tion, Writing – review & editing. Susan Awrey: Investigation,
Methodology, Resources, Writing – review & editing. Manjula Mag­
anti: Conceptualization, Formal analysis, Methodology, Resources,
Visualization, Writing – review & editing. Rehab Chahin: Investigation,
Resources, Writing – review & editing. Michael Velec: Data curation,
Writing – review & Conceputalization, writing – review & editing,
Methdology, Supervision. David C. Hodgson: Funding acquisition,
Project administration, Resources, Writing – review & editing. Hitesh
Dama: Data curation, Writing – review & editing. Sameera Ahmed:
Project administration, Resources, Writing – review & editing. Jeff D.
Winter: Writing – review & editing, Methodology, Data curation. Nor­
mand Laperriere: Resources, Writing – review & editing. Derek S.
Tsang: Conceptualization, Funding acquistion, data curation, Writing –
original draft, Writing – review & editing, Visualization, Investigation,
Validation, Formal ANalysis, Methodology, Supervision, Project
administration.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
6
Radiotherapy and Oncology 193 (2024) 110120
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.radonc.2024.110120.
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