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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 574-576

Radiotherapy during the COVID-19 pandemic: What we know and what we practice after four months

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

Date of Submission06-Aug-2020
Date of Decision08-Aug-2020
Date of Acceptance14-Aug-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Sarbani Ghosh Laskar
Department of Radiation Oncology and Head and Neck Disease Management Group, Tata Memorial Centre, Homi Bhabha National Institute, Parel, Mumbai - 400 012, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CRST.CRST_270_20

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How to cite this article:
Sinha S, Laskar SG. Radiotherapy during the COVID-19 pandemic: What we know and what we practice after four months. Cancer Res Stat Treat 2020;3:574-6

How to cite this URL:
Sinha S, Laskar SG. Radiotherapy during the COVID-19 pandemic: What we know and what we practice after four months. Cancer Res Stat Treat [serial online] 2020 [cited 2021 May 5];3:574-6. Available from: https://www.crstonline.com/text.asp?2020/3/3/574/295514

The coronavirus disease 2019 (COVID-19) pandemic has turned out to be the gravest health crisis of recent times. As of August 5, 2020, India has reported more than 1,800,000 cases and more than 35,000 deaths due to COVID-19.[1] The nationwide lockdown has been relaxed and re-instated multiple times, depending upon the prevailing local scenario.

Cancer care in itself is an arduous task, both for the patients and their caregivers, requiring multiple investigations and interventions, such as surgery, radiation therapy, and chemotherapy, thus making frequent and regular visits to the hospital necessary. To pursue cancer treatment amid a lockdown while fearing infection, addressing the administrative policies of individual hospitals, and coping with the limited availability of essential goods and services such as groceries and transportation has been a never-before-experienced challenge.[2] On the other hand, oncologists are having to deal with problems such as severely depleted healthcare resources, like operating room capacity, radiotherapy (RT) machine working hours, day-care facility, and workforce, while balancing the risk of COVID-19-related morbidity/mortality with cancer care for the patients.[3],[4]

Out of all the oncological treatment modalities, the most challenging to sustain in terms of availability and quality during the pandemic is perhaps RT.[5] This is because a typical course of RT for curative intent is delivered over a period of 5–7 weeks, requiring daily hospital visits by the patients. In addition, RT requires coordination between several healthcare personnel, viz., radiation oncologists, medical physicists, dosimetrists, and radiation therapists. RT (with or without concurrent chemotherapy) for certain malignancies such as head-and-neck and thoracic tumors is associated with severe treatment-related morbidity and mortality. Therefore, in view of the current pandemic, changes in the existing practices of RT across institutes were warranted to address these problems.[6]

Chauhan et al. in their retrospective observational study conducted at a tertiary cancer center in Eastern India compared the demographic and clinical profile of the patients who received RT before and after the imposition of the lockdown.[7] We wholeheartedly congratulate the authors for reporting this study in such challenging times. We wish to draw attention to certain points about this study that could have significant clinical implications.

The setting in which this study was conducted, a charitable tertiary cancer care hospital in Eastern India, can be considered a representative of the majority of cancer centers in India and other low- and middle-income countries. However, there is a significant variation in the density of RT setups in our country such that the eastern part of India has around 11% of the RT machines but caters to 22% of the total Indian population.[8] Moreover, as correctly pointed out by the authors, the incidence of tobacco-related cancers and cervical cancers (which are generally associated with a relatively low socioeconomic status) is likely to be higher in the given scenario. Hence, the distribution and trends of the cancers reported in this study may vary significantly from those reported in some other studies.

The authors have split the study population into two groups – those who received RT before the COVID-19 lockdown (January 1, 2020, to March 20, 2020) (Group A) and those who received RT during the COVID-19 lockdown (March 21, 2020, to May 31, 2020) (Group B). As experienced by most other centers, the authors reported a sharp decline in the number of patients receiving RT during the nationwide lockdown.[9] Interestingly, the authors also reported a decrease in the proportion of female patients (by 10.46%) and an increase in the proportion of palliative treatments (by approximately 12%) from Group A to Group B. The smaller proportion of female patients may again be reflective of the socioeconomic conditions prevailing in the said geographical region and may not necessarily apply to other settings such as a private center in metropolitan cities. Likewise, the increase in the proportion of patients receiving palliative treatment appears implausible in certain aspects. In our opinion, patients who are well informed about their poor prognosis and limited life expectancy may not be too keen on traveling to a cancer center during a pandemic for symptomatic relief and hence may prefer other forms of treatment such as analgesics instead of palliative RT for painful bone metastasis.[10] Additional information on the overall treatment time (OTT) for RT in head-and-neck and cervical cancer patients which is known to be one of the strongest prognostic factors in both these cancers[11],[12] would have been useful. Further, in the Discussion section, the authors have hypothesized that a proportionate increase (4.7%) in the number of head-and-neck cancer patients could be because of an increase in primary surgical cases being managed with RT. A stronger justification for this argument could have been provided if the proportion of definitive RT versus adjuvant in RT patients of head-and-neck cancers in both the cohorts had been mentioned by the authors. Finally, some studies have reported non-compliance rates as high as 50% for RT during the COVID-19 pandemic.[13] In this study, the authors have reported a non-compliance rate of only 9.2% during the pandemic which is commendable and may possibly be attributed to most patients being from nearby areas during these times. This number (non-compliance) should ideally include the approximately 44% patients who defaulted before starting RT as a 9.2% non-compliance rate (which actually is better than that of non-COVID times of 11.8%) may underestimate the magnitude of the problem.

The authors have also discussed that a hypofractionated schedule was not followed due to a concern regarding the toxicities of high-dose RT with concurrent chemotherapy. For head-and-neck cancers, there is substantial evidence of safety of modest hypofractionated RT schedules with concurrent chemotherapy although robust evidence for cervical cancer may be lacking.[14],[15] Multiple guidelines have advocated an abbreviated hypofractionated schedule for external beam RT across most cancer sites including cervical, breast, and head-and-neck cancers during the COVID-19 pandemic.[16],[17],[18],[19],[20] Such treatment schedules are intended to decrease the number of hospital visits (lowering the risk of infection) by the patients without compromising their oncological outcomes. To the best of our knowledge, many centers in India have adapted these schedules with modification based on the prevailing local situation of COVID-19. Perhaps, the site where it can potentially have a huge impact is breast cancer, where a shortened 1-week (five fractions) course of RT (FAST FORWARD) has been found to be equivalent to the 4–5-week course, in carefully selected patients.[21] It will be interesting to note the impact of these strategies on toxicities as well as survival outcomes, and we hope that the early reports will be published in the next few months. These results can help frame policies and guidelines to be followed once the pandemic is over.

While a change in the fractionation schedule may be considered optional by many centers, certain changes in the existing practices that were imposed upon the oncologists and the patients were inevitable. These include the inability to start RT at the earliest possible time (either due to a shortage of workforce or due to the inability of the patient to commute) and the inability to administer concurrent chemotherapy and RT (with the risk of morbidity/mortality due to COVID-19 infection outweighing the benefit).[22] Decreased OTT and concurrent chemotherapy have been shown to conclusively impact the outcomes in cervical and head-and-neck cancers. As the pandemic evolves, measures to mitigate these issues need to be taken at the level of the treating physician, such as switching to a weekly concurrent cisplatin schedule for head-and-neck cancers (considering their less acute toxicities as compared to the 3-weekly schedule).[23] Similarly, administrative measures need to be taken to curb the logistic issues such as lodging and transportation after triaging patients.[24] Finally, the omission of RT in the adjuvant setting may be considered in certain carefully selected patients, such as those with low- and intermediate-risk endometrial cancers.[25],[26]

In summary, the current COVID-19 pandemic is unprecedented, and strategies should continue to mature depending on the prevailing local circumstances and resource availability. Radiation oncologists should embark on changes that are not only pragmatic for the patients in terms of hospital visits and other logistic issues but also successfully reduce the chance of COVID-19 infection/transmission in the patients as well as medical personnel, with minimal to no compromise in disease-related outcomes.

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