David Gierga
Massachusetts General Hospital, Boston, USA

Review of current actions in radiotherapy during COVID-19

The current COVID-19 pandemic has, to date, led to nearly 7 million confirmed infections and over 400,000 deaths¹.  Clearly, all areas of society, including health care systems, have been impacted dramatically.

As a vital component of cancer care, radiotherapy treatments have continued throughout the pandemic, albeit with dramatic changes in order to prioritize care and ensure patient and staff safety.  Many institutions have shared their best practices in the literature, and this short article is intended to provide only a brief overview of a few of these resources.   One of the earliest publications specific to radiation oncology came from the original epicenter of the crisis, where Wei et al.² describe changes to infection control procedures and overall workflow at Hubei Cancer Center in Wuhan, China, and demonstrate how these steps could protect patients and staff during the peak of the outbreak.

Within the USA, the Seattle area was one of the first hard-hit areas, and Rengan and Ford³ from the University of Washington provided helpful guidance for clinics that had yet to deal with the coronavirus in their communities.  In addition to adjustments to workflow practices for increased infection control, fractionation regimens have also been adjusted to minimize on-site clinical visits, while other treatments could be safely postponed.  One example, from a breast cancer population, indicate a dramatic reduction in new patient starts as well as an increase use of hypo-fractionation and higher proportion of advanced disease⁴.

In order to minimize staff exposure, many radiation oncology staff have transitioned to remote work where possible, including virtual physician visits, treatment planning and plan checking, and procedure coverage⁵.  There are also anecdotal reports of the use of imaging to alerting staff to potential infected patients, either with standard chest CT and image-guided radiotherapy (CBCT), as reported by authors from the US, Italy, and China^6-8.  Further resources and guidance are available through professional societies^9-13.  While there are hopeful signs that most areas are past the initial peak of COVID-19 cases, continued vigilance is required as radiation oncology operations slowly and cautiously return to a new normal.

References

1. Johns Hopkins University Coronavirus Resource Center, https://coronavirus.jhu.edu/
2. Wei W, Zhen D, Lei Y, Wu S, Verma V, Liu Y, Wei X, Bi J, Hu D, Han G. Radiotherapy workflow and protection procedures during the Coronavirus Disease 2019 (COVID-19) outbreak: Experience of the Hubei Cancer Hospital in Wuhan, China. Radiother Oncol. 148, 2020.  https://doi.org/10.1016/j.radonc.2020.03.029
3. Report from COVID-19 Ground Zero, University of Washington, Seattle. https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/Report-From-Coronavirus-Presentation
4. Koch CA, Lee G, Liu ZA, Liu FF, Fyles A, Han K, Barry A, Croke J, Rodin D, Helou J, Hahn E, Isfahanian N, DeRocchis J, Lofgren S, Purdie TG. Rapid Adaptation of Breast Radiotherapy Utilization during the COVID-19 Pandemic at a Large Academic Cancer Centre in Canada. Advances in Radiation Oncology, 2020.  https://www.astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/COVID-Koch-et-al(ADRO).pdf
5. Price A, Kim H, Henke LE, Knutson NC, Spraker MB, Michalski J, Hugo GD, Robinson CB, Green O. Implementing a Novel Remote Physician Treatment Coverage Practice for Adaptive Radiotherapy During the Coronavirus Pandemic. Advances in Radiation Oncology, 2020.  https://doi.org/10.1016/j.adro.2020.05.007.
6. Li Y, Xia L. Coronavirus Disease 2019 (COVID-19): Role of Chest CT in Diagnosis and Management. American J of Roentgenology 214, 2020.  org/10.2214/AJR.20.22954
7. Boldrini L, Dinapoli N, Valentini V. Radiotherapy imaging: An unexpected ally in fighting COVID 19 pandemic.  Radiother Oncol. 148, 2020.  https://doi.org/10.1016/j.radonc.2020.04.036
8. Youssef I, Donahue B, Flyer M, Thompson S, Huang A, Gallant F, Covert Covid-19: CBCT Lung Changes in An Asymptomatic Patient Receiving Radiotherapy. Advances in Radiation Oncology, 2020.  https://doi.org/10.1016/j.adro.2020.04.029
9. AAPM COVID-19 Information for Medical Physicists. https://w3.aapm.org/covid19/
10. ASTRO COVID-19 Recommendations and Information: https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information
11. ESTRO COVID-19 Resources: https://www.estro.org/About/Newsroom/COVID-19-and-Radiotherapy
12. IAEA COVID-19: Webinars. https://www.iaea.org/topics/health/infectious-diseases/covid-19/webinars
13. IOMP COVID-19 Information Resource: https://www.iomp.org/covid-19-information-resource/