|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 4 | Page : 844-846
Caught in the middle: Cancer and COVID-19 risk for patients undergoing radiation therapy during the pandemic
Sheela Hanasoge, William A Stokes
Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
|Date of Submission||10-Oct-2020|
|Date of Acceptance||17-Oct-2020|
|Date of Web Publication||25-Dec-2020|
145 Edgewood Ave SE, Atlanta, GA 30303
Source of Support: None, Conflict of Interest: None
|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 Jan 20];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.,,, 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. 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. 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 with some modifications appear to have been adopted by Sinha et al. 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. 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. 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., 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., 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.
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. 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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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