Envisioning a New Landscape of Liver Treatment for Patients With Disabilities

Stereotactic body radiotherapy (SBRT), a type of high-dose, focal radiotherapy, has become a standard approach for precision treatment of patients who present with a tumor in the liver. During the procedure, in order to take into account movement of the liver due to breathing, clinicians instruct patients to perform specific motions—such as holding their breath or taking in a breath—as they deliver high doses of radiation. But how do you offer this effective treatment to a patient who is hearing impaired?

That was a challenge that faced Karyn Goodman, MD, MS, Professor and Vice Chair for Research and Quality in the Department of Radiation Oncology at the Icahn School of Medicine at Mount Sinai and Mount Sinai Health System, in August 2022. A patient, Joshua Sanchez, had been referred to Dr. Goodman following treatment for stage IV colon cancer that included systemic chemotherapy, as well as chemotherapy delivered directly to the liver using a hepatic arterial infusion pump. Although treatment had initially been effective, the cancer had recurred with a single metastatic lesion in the liver.

Dr. Goodman believed the lesion would be amenable to SBRT. The procedure necessitates the use of respiratory gating—a technique in which a high dose of radiation is timed with the patient’s breathing cycle to ensure optimal positioning of the tumor and thus minimizing the risk of damage to surrounding healthy tissue. But Mr. Sanchez, being deaf, would not be able to hear the voice instructions.

Although an American Sign Language (ASL) interpreter could help deliver those instructions to Mr. Sanchez, the interpreter could not be in the same room as the patient during radiation treatment. Dr. Goodman had to find a way to deliver ASL instructions safely and efficiently.

“We have these Cinemizer OLED goggles that we use to deliver visual feedback to patients so they can monitor their breathing,” says Dr. Goodman, who is also Associate Director for Clinical Research at The Tisch Cancer Institute.

“I thought, ‘We could do a Zoom meeting with the ASL interpreter and then project that into the lens of the goggles,’” she says.

This strategy was uncharted territory, as Dr. Goodman was unaware of SBRT being adapted this way. To see if it was possible, she engaged Vishruta Dumane, PhD, Associate Professor of Radiation Oncology at Icahn Mount Sinai.

Dr. Dumane determined they would need to use three Zoom accounts to deliver SBRT—one for the breathing trace, one for the ASL interpreter, and one for Mr. Sanchez so he could receive instructions and monitor his breathing cycle. All this information would be fed to the goggles through an HDMI cable connected to a laptop.

“In many cases, visual feedback of the trace to the patient via these video goggles is beneficial if the patient is not able to effectively follow the breathing instructions,” Dr. Dumane says. “In Mr. Sanchez's case, it's extremely useful for him, and for us, because we were able to look at the imaging and confirm that is exactly what we want.”

During the trial run for the treatment, Dr. Dumane used a dynamic breathing simulator connected to a laptop to represent the patient. With the goggles connected to the laptop, Dr. Dumane opened two Zoom accounts—one representing the ASL interpreter and the other the trace—to confirm she could deliver the beam and engage Mr. Sanchez during the procedure. The trial run provided satisfactory outcomes, but Dr. Dumane knew there were other factors that needed to be addressed.

“For example, Mr. Sanchez’s hearing is essentially his vision, which means we had to situate the ASL interpreter so he would not experience any distractions in his visual field and could concentrate on what he needed to do,” Dr. Dumane says.

It was then time to put the trial into action. Mr. Sanchez underwent a simulation computed tomography (CT) scan to develop a focal radiation plan, and tested the Zoom-powered solution, learning to receive instructions via the goggles, such as holding his breath. The team also performed a four-dimensional CT scan to study the motion of the tumor and the positioning of the fiducial gold seed marker used to guide treatment during Mr. Sanchez’s breathing cycle, to optimize delivery of radiation.

In October 2022, Mr. Sanchez began SBRT treatment, receiving 5,400 centigray of radiation in three fractions of 1,800 centigray. Although setting up the Zoom-powered solution slightly extended the time required to perform the procedure, there were no other challenges to address or changes made in how the team approached treatment. “Incorporating the ASL instruction with the trace through Zoom was the only unique element involved,” Dr. Dumane says. “Once we figured that out, everything went smoothly.”

The adaptation was a simple, affordable, reproducible solution that enables patients with a hearing impairment to benefit from SBRT treatment. Moreover, say Drs. Goodman and Dumane, it can be invaluable for any patient who requires additional assistance in moderating their breathing cycle during the procedure. The goal now is not to refine it, but to enhance it, they say.

“There is the potential to incorporate virtual reality to approximate working with a real patient or to enable an ASL interpreter to join from a remote location,” Dr. Goodman says. “But the most important takeaway for us is we have found a way to provide access to the same quality and options for care for all patients regardless of disabilities.”