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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 844-846

Caught in the middle: Cancer and COVID-19 risk for patients undergoing radiation therapy during the pandemic

Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA

Date of Submission10-Oct-2020
Date of Acceptance17-Oct-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Sheela Hanasoge
145 Edgewood Ave SE, Atlanta, GA 30303
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CRST.CRST_317_20

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How to cite this article:
Hanasoge S, Stokes WA. Caught in the middle: Cancer and COVID-19 risk for patients undergoing radiation therapy during the pandemic. Cancer Res Stat Treat 2020;3:844-6

How to cite this URL:
Hanasoge S, Stokes WA. Caught in the middle: Cancer and COVID-19 risk for patients undergoing radiation therapy during the pandemic. Cancer Res Stat Treat [serial online] 2020 [cited 2021 Apr 23];3:844-6. Available from: https://www.crstonline.com/text.asp?2020/3/4/844/304987

Radiation oncologists cater to a fragile group of patients whose treatment is often time-sensitive and in whom infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could prove disastrous. Professional societies, collaborative groups, and institutions have published guidelines to help prioritize cancer treatment while mitigating the risk of infection.[1],[2],[3],[4] The applicability of these guidelines in low- and middle-income countries like India must be thoughtfully considered, as scarce resources and local geopolitical circumstances pose unique challenges to their universal implementation. However, the basic tenets of radiation oncology remain unchanged, and every effort must be made to adhere to first principles, with the overarching goals of enhancing cure and symptom relief, and avoiding harm.

From a radiobiological perspective, head-and-neck cancers (HNC) are fast-growing tumors and can lead to significant morbidity and mortality if the treatment is delayed or interrupted.[5] Given the need for multimodality treatment in a majority of cases that present at an advanced stage, their management during the pandemic can be particularly daunting.[6] The coronavirus disease 2019 (COVID-19) pandemic uniquely poses a threat not only to the health of individual patients, but also to the capacity of the entire health-care system, leading many providers to consider treatment approaches that differ from the pre-pandemic standards of care. The recent ASTRO-ESTRO guidelines[1] with some modifications appear to have been adopted by Sinha et al.[7] at the Tata Memorial Hospital in Mumbai, India. It should be noted that fraction sizes of 2.2 Gy to high-risk target volumes are routinely utilized by many institutions, with or without concurrent systemic therapy, and are well-tolerated.[8] This technique has been enabled by the development of highly conformal radiotherapy delivery and image-guidance technologies, which are increasingly available around the world. On the other hand, the implementation of neoadjuvant chemotherapy in disease subsites where no high-level evidence exists for its use must be approached with caution.[9] Doublet and triplet chemotherapy regimens both complicate the completion of definitive therapy and carry the risk of myelosuppression, which in turn could exacerbate the severity of intercurrent SARS-CoV2 infection.[10],[11] In our practice, the preferred approach for locally advanced HNC managed with organ preservation remains the pre-pandemic standard of care, which typically entails concurrent chemoradiotherapy.

In another article in this volume, Chauhan et al. compare the demographics of patients treated at their tertiary cancer center in Eastern India before and during a lockdown imposed in response to the pandemic.[12],[13] As expected, the authors note a drop in the total radiation treatment numbers as well as in the proportion of female patients during the pandemic. As an observational study, this analysis provides useful data that may help operational and logistical planning at institutional and regional levels. However, the true impact of the pandemic on their patient population cannot be expected to be captured with this study design. As expected, HNC and gynecologic cancers constituted the majority of cases treated during the lockdown period. The authors' apparent hesitancy to adopt hypofractionation at a larger scale due to toxicity concerns warrants exploration. The safety and efficacy of modestly hypofractionated regimens across various disease sites have been extensively reported, leading to their growing adoption; however, further implementation at the institutional, regional, and national levels remains contingent on experience, expertise, and technology. With its superior efficiency and throughput, comparable efficacy, and negligible increase in toxicity as compared to conventional fractionation schedules, hypofractionation is ideally suited to the exigencies of the COVID-19 pandemic. This approach both preserves valuable treatment capacity and minimizes potential viral transmission events and therefore warrants particular consideration.[14]

Condensed fractionation schedules hold particular relevance for palliative radiotherapy. Efficacious and minimally toxic treatment for a variety of symptomatic lesions can be provided via a single fraction or hypofractionated course. One silver lining of the pandemic may prove to be the accelerated adoption of single-fraction radiotherapy for bony metastases that already appears to be underway.[15] Indeed, a short course of radiotherapy may be preferable to other palliative measures such as analgesic medications, oral chemotherapy, or supportive care, which are often associated with undesirable side effects or inadequate focal symptom relief. At our institution, patients requiring palliative radiotherapy during the pandemic are prioritized to receive abbreviated treatment courses as soon as possible.

The COVID-19 pandemic continues to pose challenges to health-care systems across the world. The experiences and approaches of Sinha et al. and Chauhan et al. can be instructive for oncologists as we adapt our practice patterns in light of the published data, local viral transmission dynamics, and institutional treatment capacity and technology.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Coles CE, Aristei C, Bliss J, Boersma L, Brunt AM, Chatterjee S, et al. International guidelines on radiation therapy for breast cancer during the COVID-19 pandemic. Clin Oncol (R Coll Radiol) 2020;32:279-81.  Back to cited text no. 2
Elledge CR, Beriwal S, Chargari C, Chopra S, Erickson BA, Gaffney DK, et al. Radiation therapy for gynecologic malignancies during the COVID-19 pandemic: International expert consensus recommendations. Gynecol Oncol 2020;158:244-53.  Back to cited text no. 3
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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. 6
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.  Back to cited text no. 7
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Eisbruch A, Harris J, Garden AS, Chao CK, Straube W, Harari PM, et al. Multi-institutional trial of accelerated hypofractionated intensity-modulated radiation therapy for early-stage oropharyngeal cancer (RTOG 00-22). Int J Radiat Oncol Biol Phys 2010;76:1333-8.  Back to cited text no. 8
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. 9
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Cohen EE, Karrison TG, Kocherginsky M, Mueller J, Egan R, Huang CH, et al. Phase III randomized trial of induction chemotherapy in patients with N2 or N3 locally advanced head and neck cancer. J Clin Oncol 2014;32:2735-43.  Back to cited text no. 10
Haddad R, O'Neill A, Rabinowits G, Tishler R, Khuri F, Adkins D, et al. Induction chemotherapy followed by concurrent chemoradiotherapy (sequential chemoradiotherapy) versus concurrent chemoradiotherapy alone in locally advanced head and neck cancer (PARADIGM): A randomised phase 3 trial. Lancet Oncol 2013;14:257-64.  Back to cited text no. 11
Chauhan R, Trivedi V, Rani R, Singh U, Singh V, Shubham S, et al. The impact of COVID-19 pandemic on the practice of radiotherapy: A retrospective single-institution study. Cancer Res Stat Treat 2020;3:467-74.  Back to cited text no. 12
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Ling DC, Vargo JA, Beriwal S. Breast, prostate, and rectal cancer: Should 5-5-5 be a new standard of care? Int J Radiat Oncol Biol Phys 2020;108:390-3.  Back to cited text no. 14
Rutter CE, Yu JB, Wilson LD, Park HS. Assessment of national practice for palliative radiation therapy for bone metastases suggests marked underutilization of single-fraction regimens in the United States. Int J Radiat Oncol Biol Phys 2015;91:548-55.  Back to cited text no. 15


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