• Users Online: 148
  • Print this page
  • Email this page

Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 424-426

Head-and-neck cancer radiotherapy recommendations during the COVID-19 pandemic: Adaptations from the Indian subcontinent

Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Date of Submission14-Aug-2020
Date of Decision16-Aug-2020
Date of Acceptance18-Aug-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Sarbani Ghosh Laskar
Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai - 400 012, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CRST.CRST_277_20

Get Permissions

How to cite this article:
Sinha S, Laskar SG, Mummudi N, Budrukkar A, Swain M, Agarwal JP. Head-and-neck cancer radiotherapy recommendations during the COVID-19 pandemic: Adaptations from the Indian subcontinent. Cancer Res Stat Treat 2020;3:424-6

How to cite this URL:
Sinha S, Laskar SG, Mummudi N, Budrukkar A, Swain M, Agarwal JP. Head-and-neck cancer radiotherapy recommendations during the COVID-19 pandemic: Adaptations from the Indian subcontinent. Cancer Res Stat Treat [serial online] 2020 [cited 2021 May 7];3:424-6. Available from: https://www.crstonline.com/text.asp?2020/3/3/424/295520

Head and neck cancers account for 25%–30% of the patient load in a typical cancer care center in our part of the world.[1] Almost 70%–80% of the patients with head and neck cancer treated with curative intent require radiation therapy (RT) either as a definitive modality or in the adjuvant setting.[2],[3]

The ongoing coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges to cancer care professionals, patients, and the hospital administration. At the Tata Memorial Hospital, in Mumbai, India, in non-COVID times, we routinely register 8000–10,000 new patients with head and neck cancer annually. Under normal circumstances, head and neck cancer RT (±systemic therapy) is associated with severe morbidity and treatment-related mortality rates of approximately 40% and 10%, respectively.[4],[5] Even though the number of new patients registered during this pandemic at our institute was lower than that during the usual times, undertaking head and neck cancer treatment was an arduous task.[6] During the last four months, multiple guidelines and consensus statements have been published from India as well as from across the globe for RT in the times of COVID-19;[7],[8],[9],[10],[11] however, individualization of treatment strategies as per the facilities and resources available were mandated to ensure quality cancer care while minimizing the risk of exposure to patients as well as health-care personnel. Here, we discuss the changes implemented in our head and neck RT practices, the existing evidence to support them, their possible impact on the outcomes, as well as the feasibility of their implementation across low- and middle-income countries (LMICs) such as India.

The majority of the head and neck cancers in the developing countries like India are tobacco-related oral cavity cancers, primarily of the gingivobuccal complex. The incidence of tongue and oropharyngeal cancers is relatively low.[12] Moreover, more than half of these cancers present at a locally advanced stage mandating multimodality treatment (surgery followed by postoperative RT). Although the incidence of margin positivity remains low in experienced surgical hands (< 1% in some large series),[13] in the eventuality of a margin positive resection, patients should be given priority for adjuvant RT. Multiple nodes with perinodal extension are perhaps the single most important prognostic factor (pN3b subset of the American Joint Committee on Cancer 8th edition) for these cancers, and adjuvant RT deserves the highest priority in these patients as well.[14] Nasopharyngeal cancers although relatively uncommon in the west, are endemic to certain regions of Asia and should be given a high priority owing to their superior survival outcomes, especially in young adults and adolescents.

At our center (a tertiary cancer care institute in India), we have now adopted a policy of modest hypofractionation (2.2 Gy per fraction) for most of our patients with head and neck cancers, both in the definitive as well as adjuvant settings for the duration of the pandemic. This has resulted in a modest reduction in the treatment time by one week.

The prevalence of p16-positive oropharyngeal cancers remains low in most LMICs (approximately 20%–25% in India) when compared to the west.[15] There is uniform agreement that these cancers have a better prognosis than their p16-negative counterparts. However, at least two randomized trials have shown that de-escalation of treatment may lead to suboptimal outcomes, and hence, it cannot be recommended as the standard of care.[16] Considering this, it would only be prudent to suggest that p16 testing, the result of which has no bearing on the treatment, should not be considered mandatory in the current resource-constrained situation.

With regard to induction chemotherapy, even though no level 1 evidence exists for its use in non-nasopharyngeal cancers, it may still be of value in primary surgical cases where definitive RT has traditionally yielded a poor response.[17] For instance, patients with tumors in the gingivobuccal complex with mandibular erosion and those with paranasal tumors with skull base involvement and intracranial extension are known to have a suboptimal disease response with RT alone. In these situations, neoadjuvant chemotherapy may help in the biological selection for RT or give enough time for preparing the patient for optimal surgery. Neoadjuvant chemotherapy may also be considered in locally advanced nasopharyngeal and hypopharyngeal cancers for a maximum of 2–3 cycles.[18]

Many institutions are probably experiencing a reduced operating capacity, with only about one-third to half of the operating rooms functioning due to rationing of the workforce.[19] In such scenarios, some of the primary surgical cases, like tumors of the larynx and hypopharynx (with a high propensity to aerosol generation and exposure intraoperatively during laryngectomies or micro-laryngeal surgery) may be referred to the radiation oncologist for definitive RT. In such patients, definitive RT or concurrent chemoradiotherapy (CRT) may be offered, but only after confirming the laryngeal functionality subjectively and objectively (risk of aspiration). Patients should be counseled regarding the exigency under which these treatments are being offered, especially when they do not fulfil the classical criteria for organ preservation.

CRT in both the definitive and the adjuvant settings should be administered whenever indicated as far as possible. However, there may be a case for recommending the omission of CRT in patients aged more than 70 years as per the meta-analysis of chemotherapy in head and neck cancer (MACH NC) published in 2009. Weekly cisplatin schedules at a dose of 30–40 mg/m2 should be preferred over 3-weekly regimens.[20]

A few points have not been addressed in most guidelines which may be relevant in certain countries and scenarios. Approximately 10%–15% of all patients on RT may have a significant treatment gap (>1 week). In our opinion, gap corrections for these patients should not be considered routinely but could be considered in certain special scenarios. Intensity-modulated radiotherapy should remain the preferred technique of delivery for definitive treatments. However, in the adjuvant setting (which forms a major bulk of the caseload in LMICs), with an impending shortage of physical manpower, treatment delivery with relatively simpler techniques (conventional/three-dimensional conformal RT [CRT]) may be considered. To compensate for the decreased machine working hours, changes to the established image-guided RT (IGRT) verification protocols may need to be made. A practical protocol may be a portal image/cone-beam computed tomography (CT) being done on the first three days of treatment and subsequently weekly for most patients (no action level protocol). For patients with tumors near critical structures like the optic apparatus and brainstem, the more stringent IGRT protocols need to be followed.

Telephonic follow-ups should be routinely done for all patients, posttreatment as per the schedule, if they are asymptomatic. In accordance with the positron emission tomography (PET)-NECK study, patients treated with definitive RT should get a PET–CT scan done (or contrast-enhanced CT [CECT] if PET is not available) at 8–12 weeks after the completion of treatment.[21] However, this may not be possible, especially for patients who travel from less urban regions and a simple CECT scan may suffice.

Additional points with regard to auxiliary services to head and neck RT need to be addressed. Pre-RT extraction of the infected teeth directly within the RT portal should still be done. However, routine fluoride applications may be deferred for now, and patients may instead be asked to use fluoride containing toothpastes and follow a stringent oral hygiene protocol. These patients should undergo a complete dental evaluation on subsequent follow-ups.[22] Routine referrals to the speech, language, and swallowing pathologists may be deferred, except in patients where an assessment of functionality is critical for decision making (locally advanced laryngopharyngeal cancers), in which case it should be mandated, but with appropriate care. Noninvasive methods like videofluoroscopy and barium swallow should be preferred over fiberoptic endoscopic evaluation of swallowing. Prophylactic insertion of a feeding tube should be avoided and feeding tube insertion during the RT course should be considered in only those patients with significant dysphagia or at a high risk of aspiration.

Besides the physician, the radiation therapists have the maximum contact with the patients. Their training and education regarding the handling of patients with a high risk of aerosol generation, such as those with a nasogastric tube or a tracheostomy, are of paramount importance. These patients should be treated within a fixed time slot, preferably toward the latter half of the day. Adequate cleaning and sanitization of the couch and machine area should be ensured after every patient's treatment.[23]

In summary, the current COVID-19 pandemic is unprecedented, and mitigation strategies should continue to evolve depending on the prevailing circumstances and the availability of resources. Each country/region needs a pragmatic change in existing practices to ensure adequate personnel safety and reserve workforce on one hand, while minimally compromising cancer-related outcomes on the other.[24]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Poddar A, Aranha R, Royam MM, Gothandam KM, Nachimuthu R, Jayaraj R. Incidence, prevalence, and mortality associated with head and neck cancer in India: Protocol for a systematic review. Indian J Cancer 2019;56:101-6.  Back to cited text no. 1
[PUBMED]  [Full text]  
Chauhan AS, Prinja S, Ghoshal S, Verma R, Oinam AS. Cost of treatment for head and neck cancer in India. PLoS One 2018;13:e0191132.  Back to cited text no. 2
Chandarana MN, Pai PS. Demography and treatment pattern of patients with head and neck carcinoma presenting to a tertiary care center in India: Need for urgent decentralization of cancer care. South Asian J Cancer 2020;9:38-42.  Back to cited text no. 3
[PUBMED]  [Full text]  
Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349:2091-8.  Back to cited text no. 4
Zapata I, Alvarez M, Hidalgo R, Pajares B, Garcia-Anaya MJ, Toledo MD, et al. Causes of death in patients with locally advanced head and neck cancer treated with radiotherapy and systemic therapy. BMC Cancer 2019;19:1241.  Back to cited text no. 5
Patil VM, Srikanth A, Noronha V, Joshi A, Dhumal S, Menon N, et al. The pattern of care in head-and-neck cancer: Comparison between before and during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3 Suppl S1:7-12.  Back to cited text no. 6
Patil V, Noronha V, Chaturvedi P, Talapatra K, Joshi A, Menon N, et al. COVID-19 and head and neck cancer treatment. Cancer Res Stat Treat 2020:3 Suppl S1:15-28.  Back to cited text no. 7
Thomson DJ, Palma D, Guckenberger M, Balermpas P, Beitler JJ, Blanchard P, et al. Practice recommendations for risk-adapted head and neck cancer radiotherapy during the COVID-19 pandemic: An ASTRO-ESTRO consensus statement. Radiother Oncol 2020;107:618-627:S0167-8140(20)30200-0.   Back to cited text no. 8
Vordermark D. Shift in indications for radiotherapy during the COVID-19 pandemic? A review of organ – Specific cancer management recommendations from multidisciplinary and surgical expert groups. Radiat Oncol 2020;15:140.  Back to cited text no. 9
Yuen E, Fote G, Horwich P, Nguyen SA, Patel R, Davies J, et al. Head and neck cancer care in the COVID-19 pandemic: A brief update. Oral Oncol 2020;105:104738.  Back to cited text no. 10
Munshi A, Rastogi K. Management of cancer during the COVID-19 pandemic: Practical suggestions for the radiation oncology departments. Cancer Res Stat Treat 2020;3 Suppl S1:115-8.  Back to cited text no. 11
Kulkarni M. Head and neck cancer burden in India. Int J Head Neck Surg 2013;4:29-35.  Back to cited text no. 12
Laskar SG, Chaukar D, Deshpande M, Chatterjee A, Hawaldar RW, Chakraborty S, et al. Phase III randomized trial of surgery followed by conventional radiotherapy (5 fr/Wk) (Arm A) vs. concurrent chemoradiotherapy (Arm B) vs. accelerated radiotherapy (6fr/Wk) (Arm C) in locally advanced, Stage III and IV, resectable, squamous cell carcinoma of oral cavity- oral cavity adjuvant therapy (OCAT): Final results (NCT00193843). J Clin Oncol 2016;34:6004.  Back to cited text no. 13
Wreesmann VB, Katabi N, Palmer FL, Montero PH, Migliacci JC, Gönen M, et al. Influence of extracapsular nodal spread extent on prognosis of oral squamous cell carcinoma. Head Neck 2016;38 Suppl 1:E1192-9.  Back to cited text no. 14
Murthy V, Swain M, Teni T, Pawar S, Kalkar P, Patil A, et al. Human papillomavirus/p16 positive head and neck cancer in India: Prevalence, clinical impact, and influence of tobacco use. Indian J Cancer 2016;53:387-93.  Back to cited text no. 15
[PUBMED]  [Full text]  
Oosthuizen JC, Doody J. De-intensified treatment in human papillomavirus-positive oropharyngeal cancer. Lancet 2019;393:5-7.  Back to cited text no. 16
Goel A, Singla A, Prabhash K. Neoadjuvant chemotherapy in oral cancer: Current status and future possibilities. Cancer Res Stat Treat 2020;3:51-9.  Back to cited text no. 17
  [Full text]  
Zhang Y, Chen L, Hu GQ, Zhang N, Zhu XD, Yang KY, et al. Gemcitabine and cisplatin induction chemotherapy in nasopharyngeal carcinoma. N Engl J Med 2019;381:1124-35.  Back to cited text no. 18
Prem A, Patel S, Pai E, Pandey D. Surgical management of cancer during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3 Suppl S1:119-22.  Back to cited text no. 19
Pignon JP, le Maître A, Maillard E, Bourhis J; MACH-NC Collaborative Group. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): An update on 93 randomised trials and 17,346 patients. Radiother Oncol 2009;92:4-14.  Back to cited text no. 20
Mehanna H, Wong WL, McConkey CC, Rahman JK, Robinson M, Hartley AG, et al. PET-CT Surveillance versus neck dissection in advanced head and neck cancer. N Engl J Med 2016;374:1444-54.  Back to cited text no. 21
Dholam KP, Sharma MR, Gurav SV, Singh GP, Manjrekar N. Dental measures during the COVID-19 pandemic in cancer patients. Cancer Res Stat Treat. 2020:3;429-33.  Back to cited text no. 22
Kulkarni T, Sharma P, Pande P, Agrawal R, Rane S, Mahajan A. COVID-19: A review of protective measures. Cancer Res Stat Treat 2020;3:244-53.  Back to cited text no. 23
  [Full text]  
Noronha V, Behel V. Catch-22: COVID versus cancer. Cancer Res Stat Treat 2020;3 Suppl S1:1-2.  Back to cited text no. 24


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article

 Article Access Statistics
    PDF Downloaded107    
    Comments [Add]    

Recommend this journal