|Year : 2020 | Volume
| Issue : 4 | Page : 135-139
An approach to cancer amid COVID-19 pandemic – Radiation oncologists perspective
Shaqul Qamar Wani1, Talib Khan2, Fir Afroz3
1 Department of Radiation, Oncology and State Cancer Institute, Srinagar, Jammu and Kashmir, India
2 Division of Cardiovascular and Thoracic Anaesthesia and Cardiac Surgical Intensive Care; Department of Anaesthesiology, Pain and Critical Care, Sher -IKashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, India
3 Departments of Radiation, Oncology and State Cancer Institute, Srinagar, Jammu and Kashmir, India
|Date of Submission||03-Nov-2020|
|Date of Acceptance||03-Dec-2020|
|Date of Web Publication||30-Dec-2020|
Dr. Shaqul Qamar Wani
Department of Radiation, Oncology and State Cancer Institute, Srinagar, Jammu and Kashmir, India
Source of Support: None, Conflict of Interest: None
The background of this article is to provide a general information regarding the safety of the patients and health-care workers besides providing management guidelines for cancer patients in the current context of COVID 19 (SARS CoV-2) crisis. The treatment recommendations are prioritized as per the risk stratification till the current crisis is mitigated. The recommendations not only provides information in dealing with different malignancies treated either with curative or palliative intent but also ascertains the role of electronic media as an effective source of communication with patients whether on active or pending treatment or on follow-up, so that their anxiety levels and mental fears regarding their disease and future management plans amid COVID-19 pandemic are minimised.
Keywords: COVID-19 pandemic, curative intent, palliative care, practice guidelines, radiation oncology, SARS CoV-2
|How to cite this article:|
Wani SQ, Khan T, Afroz F. An approach to cancer amid COVID-19 pandemic – Radiation oncologists perspective. J Radiat Cancer Res 2020;11:135-9
| Introduction|| |
The COVID-19 pandemic has created major dilemmas for providers in all areas of health care sector, including cancer centers. Lack of sufficient health-care infrastructure and human resources, serious supply-chain disruptions, and widespread fear among patients and health care workers (HCW) have resulted in patient care and safety being compromised. Several cancer centers have drastically scaled back their services after preliminary reports from China showed that COVID-19 outcomes are significantly worse among patients with cancer.
Radiation oncologists treat a mixed malignant population including relatively fit patients receiving curative treatment and also patients treated with palliative intent. COVID-19 is already affecting providers of health care due to shrinking oncology force, because of cautionary isolation, and sometimes unfortunately, contracted (COVID-19) infection and providers are pulled to other services also affecting cancer patients directly. Radiation oncologists have to support their patients and teams so we need to prepare, communicate, operate, and compensate during this crisis. Older adults and patients with preexisting comorbidities (such as diabetes and cardiovascular disease) are facing the most severe and critical consequences of the COVID-19 outbreak. Furthermore, patients with cancer are more susceptible to infections as compared to healthy controls due to general immunosuppression secondary to both the malignancy and anticancer treatments.
| Focused Management and Review of Guidelines|| |
There has been three suggested measures for reducing the burden of COVID-19 in oncology in endemic areas, first to postpone treatments or elective surgeries for stable cancers in endemic areas, second to provide stronger personal protection provisions to patients and finally, to offer more intensive surveillance or treatment for patients infected with SARS-CoV-2. In this situation of emergency for health-care systems, the inability to receive needed medical services is an additional concern. There are various recently suggested modules from various organizations and major institutions to deal with the malignant patients during this time of crisis.
| Practical Suggestions on How to Implement Cancer Care during the COVID-19 Outbreak|| |
Oncologists should consider, on a case by case basis, the possibility of a delay in treatment administration. The decision of confirming the scheduled administration or delaying treatment should be based on the biological features of the tumor, the clinical condition of the patient, treatment outcome in the form of expected benefit and adverse events including myelosuppression, disease response to the current anticancer therapy, and the potential risks for an infection with SARS-CoV-2. However, it should be recognized that an evidence-based estimation of the impact of treatment delay or interruption on the risk benefit balance for each individual patient is currently lacking. For patients who are currently on follow-up, oncologists should consider to avoid disease-free patients coming to the hospital for routine follow-up visits. A phone call or online exchange of clinical documentation can be useful to reassure patients, and refrain them from consultation at the hospital except for the emergence of new symptoms or new clinical or radiological signs of disease progression. Regarding admission to the hospital, outpatients scheduled for treatment should come alone and avoid the assistance by a caregiver except for documented need of continuous assistance. Triage of patients with fever or respiratory symptoms is essential to prevent exposure to other patients and healthcare providers. The overall goal of all these recommendations is an attempt to maintain cancer care as safe as possible for both patients and health-care providers during this crisis period.
This difficult moment serves as the basis to implement telemedicine whenever possible and feasible. Massive efforts should be put into monitoring of patients at home with regular contacts by telephone, E-mail or smartphone apps. Although telehealth cannot be the only strategy of medicine considering the relevance of patient–doctor interactions which are of special relevance in the field of oncology, the current crisis of the health-care system necessitates the use of electronic communication as a valid tool to further optimize cancer care in such difficult circumstances.
In brief one can put the protection guidelines in three simple steps:
- Protect yourself, at work, with constant focus and attention on personal protective equipment
- Oncological care of our patients, by delaying what can be delayed, and trying as much as possible to minimize the impact of the emergency on the usual standard of care
- Protect patients' from getting infected, by making every possible effort to minimize the risks and giving continuous direction and appropriate information.
Reduce the number of clinic visits and the inherent risks by providing shorter radiotherapy (RT) protocols and when ever possible either stop or reduce the frequency of maintenance treatments. For example moving from 2-weekly to 4-weekly administration of durvalumab as consolidation therapy for patients with nonsmall-cell lung cancer, and recommending the consideration of treatment breaks for those receiving maintenance pemetrexed, or even withholding maintenance pemetrexed entirely. On the basis of the urgency of treatment required, the malignant tumors are prioritized as.
| Higher Priority Tumors|| |
- Those with imminent risk of early mortality such as Acute leukemias, aggressive lymphomas, metastatic germ cell tumors.
- Having high chances of morbidity and impaired quality of life, for example, spinal cord compression or opioid-refractory pain crisis owing to bone metastases.
- Definitive curative treatments like concurrent chemoradiotherapy for head and neck, cervical, or anal cancers.
- Neoadjuvant or adjuvant indications with substantial benefit, for example, adjuvant chemotherapy for stage III colon cancer, chemotherapy, and RT for high-risk breast cancer.
- Neoadjuvant or adjuvant indications with modest survival benefit for example, neoadjuvant or adjuvant chemotherapy for bladder cancer, or adjuvant chemotherapy for NSCLC.
| Lower Priority Tumors|| |
- Tumors with substantial survival benefit like immunotherapy for melanoma, systemic therapy for metastatic breast cancer, or metastatic colorectal cancer.
- Tumors with palliative indications, modest survival benefit and major symptom control for example palliative chemotherapy for upper gastrointestinal cancers, RT for bone metastasis unresponsive to other treatments.
- Tumors where alternative treatments exist or delay does not affect outcomes for example bone metastases manageable with medications, prostate cancer appropriate for active surveillance.
- Tumors with palliative indications and without benefits in terms of overall survival or major symptom control, for example, second and third-line palliative chemotherapy for many solid tumors.
The COVID-19 pandemic has the potential to overwhelm current health-system capacity. Postponing cancer treatments might be associated with some risk, although these risks will need to be considered in light of the magnitude of potential benefits. Throughout the pandemic, supporting our patients' emotional wellbeing and ensuring that adequate psychosocial support systems are in place will be more important than ever. Treatment decisions during the COVID-19 pandemic will rely on the precautionary principle, transparent and evidence-based prioritization of cases for triage, and fluidity in recognizing that local contexts can change very rapidly.
In the current crisis the management recommendations for some of the common malignancies are.
| Prostate Cancer|| |
A framework called RADS standing for Remote visits Avoid, Delay, and Shorten RT has been elaborated over the past few months as COVID infections rose globally.
Under RADS, the recommendations include:
- Remote visits should be used in place of in-person visits when patients don't need to be seen physically to determine a course of treatment. The added value of a physical exam is usually outweighed by the risk of COVID-19 exposure.
- Avoid radiation when evidence suggests it would be of little or no benefit to a patient. Multiple clinical trials have shown favorable outcomes with a watchful approach to monitoring patients with low-to intermediate-risk cancers.
- Delay treatment for as long as possible, depending on patient's clinical condition. If a patient's disease is progressing rapidly, the benefits of treatment must be weighed against COVID-19 exposure and other potential risk factors, like other chronic conditions the patient may already have.
- Shorten RT treatments to the shortest number has been shown to be safe and effective. This can help limit the number of visits each patient will need to make.,
| Breast Cancer|| |
Given that breast RT accounts for 30% of delivered RT fractions, the following recommendations require particularly urgent consideration. By adopting these recommendations RT treatment is minimized and targeted to those with the highest risk of breast recurrence.
- Omit RT for patients 65 years and over (or younger with relevant comorbidities) with invasive breast cancer that are up to 30 mm with clear margins, Grade 1 to 2, estrogen receptor (ER) positive, human epidermal growth factor receptor 2 (HER2) negative and node negative.
- Deliver RT in 5 fractions only for patients requiring RT with node negative tumors that do not require a boost. Options include 28 to30 Gy in once weekly fractions over 5 weeks or 26 Gy in 5 daily fractions over 1 week as per the FAST and FAST Forward trials respectively.
- Boost RT should be omitted to reduce fractions and complexity in the vast majority of patients unless patient is 40 years old or less, or more than 40 years with significant risk factors for local relapse.
- Nodal RT can be omitted in post-menopausal women requiring whole breast RT following sentinel lymph node biopsy and primary surgery for T1, ER positive, HER2 negative G1-2 tumors.
- Moderate hypofractionation should be used for all breast or chest wall and nodal RT, for example, 40 Gy in 15 fractions over 3 weeks.
| Cervical Cancer|| |
Early stage disease
Assuring that disease is localized by imaging studies, consideration of postponing procedures that may be considered high-risk because of prolonged operative time, or potential intraoperative and or postoperative complications (like radical trachelectomy or radical hysterectomy) for 6-8 weeks, or until crisis resolves. In the setting of microscopic disease or low-risk disease (<2 cm, low-risk histology), consideration for conization or simple trachelectomy ± sentinel lymph nodes, if feasible. In the setting of gross visible tumor, consideration of neoadjuvant chemotherapy should be given.
Consider hypofractionation to reduce the total number of fractionation followed by brachytherapy procedures in a stipulated time, unless contraindicated.
| Endometrial Cancer|| |
- Low-risk patients: Patients with grade 1 disease can be considered for conservative management with nonsurgical options, including systemic hormonal therapy.
- High-risk patients: Patients with higher-risk disease (grade 2 or 3 or high-risk histology) should be considered for simple hysterectomy and bilateral salpingo-oophorectomy alone ± sentinel lymph nodes, if feasible, and postoperative management based on uterine risk factors.
- Advanced disease: Patients with advanced disease should be considered for tissue biopsy to confirm diagnosis and proceeding with systemic therapy.
| Rectal Cancer|| |
- Early subgroup: Depending on stage, feasibility and expertise surgical procedure preferred which may be in the form of transanal excision, low anterior resection (LAR), total mesorectal excision (TME), etc.,
- Advanced subgroup: Two options can be considered in the current pandemic.
- Preoperative long course concurrent chemoradiotherapy (LCCRT)– this is the most established standard of care and the duration of concurrent capecitabine chemotherapy is limited to 5–5.5 weeks. It involves the use of long course of RT.
- Short course RT (SCRT) ± neoadjuvant chemotherapy– here the duration of RT is substantially less and the advantages of this approach when compared to CRT are reported similar.
SCRT and a delay to surgery has advantages that may be beneficial in both routine clinical practice and in the COVID-19 setting. In elderly patients, patients with poorer performance status, or patients not fit for chemotherapy or standard CRT, SCRT with a delay is strongly recommended. SCRT has been shown to be a noninferior alternative to LCCRT, with multiple randomized trials demonstrating no difference in locoregional recurrence, distant recurrence, or overall survival.,,
| Head and Neck Cancer|| |
For head and neck cancer, there is evidence that a 16% increased risk of death exists for every month of delay of RT. A risk-benefit analysis is warranted if RT is offered as an adjunct to prior surgery, also in patients where we expect only modest benefit in terms of long-term survival RT may be delayed by few weeks during the pandemic. For patients receiving treatment for palliation, the recommendation is to exhaust all other options, such as maximizing analgesia, before planning for RT. Furthermore, most patients who have recently completed RT may have their follow-up appointments safely delayed by two or more months, with telemedicine if feasible.
| Primary Mucosal Squamous Cell Carcinomas Eligible for Surgery or Definitive Nonsurgical Therapy|| |
Primary surgery with or without adjuvant therapy and primary radiation with or without chemotherapy are long-standing first-line treatment options for the majority of mucosal squamous cell carcinomas. These therapies often exhibit equivalent oncologic outcomes. Many of these cases will present high-risks of COVID-19 transmission during and after surgery. Therefore, for most of these patients, having, multilevel risks of surgery during this pandemic, we temporarily favor selection of nonsurgical treatment over surgery wherein nonsurgical therapy is a first-line option, especially when a prolonged postoperative admission would be anticipated. Nonsurgical therapy will facilitate primarily outpatient management of these patients. There may be exceptions to this general rule, particularly when adjuvant therapy is not predicted.
Radiation oncology services should attempt to anticipate staffing and other capacity constraints, which will be difficult in a rapidly changing situation. Consider the use of shorter fractionation schedules wherever an option, deferral of therapy, or omission of RT if the clinical benefit is low and the risk high. Radiation oncology services should screen patients for symptoms suggestive of COVID-19 disease, and adopt infection control measures simultaneously.
| Palliative Care|| |
Palliative care will play a critical role during the COVID-19 pandemic, and will be a responsibility for all health care professionals. Cancer services should collaborate with specialist palliative care services when developing COVID-19 contingency plans. Palliative care will involve managing symptoms of cancers, including the end of life. Other roles include rapid reassessment of an individual patient's goals if treatment plans are changed, helping patients and families navigate end of life care decisions during societal and economic disruption, supporting care in the community to avoid unnecessary hospitalizations, and delivering care in a culturally safe and responsive manner.
COVID-19 disease presents a threat to specialist palliative care service staffing and capacity and the delivery of palliative care will frequently need to be undertaken by primary treating teams, under the guidance of specialist palliative care services.
Issues of trust, isolation, disconnectedness, and worries about abandonment should be proactively addressed. In particular, the impact of restriction or banning of hospital visits by family and friends at life's end needs to be addressed with compassion and humanity.
The COVID-19 pandemic has the potential to overwhelm current health-system capacity. Postponing cancer treatments might be associated with some risk, although these risks will need to be considered in light of the magnitude of potential benefits. Throughout the pandemic, supporting our patients emotional wellbeing and ensuring that adequate psychosocial support systems are in place will be more important than ever.
| Conclusion|| |
COVID-19 pandemic represents a global health challenge, triaging becomes essential component for managing the cancer patients in a best possible way, while at the same time reducing the COVID-19 risk of exposure to patients and health care providers is of paramount importance. Standard and safety practices needs to be followed by the HCWs while managing cancer patients amid the current pandemic besides, proper education needs to be disseminated to patients regarding prevention, protection, and safety against COVID-19.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pramesh CS, Badwe RA. Cancer management in India during COVID-19. N Engl J Med 2020;382:e61.
Simcock R, Thomas TV, Estes C, Filippi AR, Katz MA, Pereira IJ, et al.
COVID-19: Global radiation oncology's targeted response for pandemic preparedness. Clin Transl Radiat Oncol 2020;22:55-68.
Lambertini M, Toss A, Passaro A, Criscitiello C, Cremolini C, Cardone C, et al
. Cancer care during the spread of coronavirus disease 2019 (COVID-19) in Italy: young oncologists' perspective. ESMO Open 2020;5:e000759.
Hanna TP, Evans GA, Booth CM. Cancer. COVID-19 and the precautionary principle: Prioritizing treatment during a global pandemic. Nat Rev Clin Oncol 2020;17:268-70.
Demsky I. How Should Radiation Oncologists Manage Prostate Cancer Patients During the COVID-19 Pandemic? Available from:
https://labblog.uofmhealth.org/rounds/how-should-radiation-oncologists-manage-prostate-cancer-patients-during-covid-19-pandemic. [Last accessed on 2020 Apr 17].
Zaorsky NG, Yu JB, McBride SM, Dess RT, Jackson WC, Mahal BA, et al
. Prostate cancer radiotherapy recommendations in response to COVID-19. Adv Radiat Oncol 2020;5:659-65.
Coles CE, Aristeiyz C, Blissx J, Boersma L, Brunt AM, Chatterjee S, et al.
International guidelines on radiation therapy for breast cancer during the COVID-19 pandemic. Clin Oncol 2020;32:279-81.
Ramirez PT, Chiva L, Eriksson AGZ, Frumovitz M, Fagotti A, Martin AG, et al
. COVID-19 global pandemic: Options for management of gynecologic cancers. Int J Gynecol Cancer 2020;30:1-3.
Marijnen CA, Peters FP, Rödel C, Bujko K, Haustermans K, Fokas E, et al
. International expert consensus statement regarding radiotherapy treatment options for rectal cancer during the COVID-19 pandemic. Radiother Oncol 2020;148:213-5.
Romesser PB, Wu AJ, Cercek A, Smith JJ, Weiser M, Saltz L et al
., Management of locally advanced rectal cancer during the COVID-19 pandemic: A necessary paradigm change at memorial sloan kettering cancer center. Adv Radiat Oncol 2020;5:687-9.
Siavashpour Z, Hesary FZ, Rakhsha A. Recommendations on management of locally advanced rectal cancer during the COVID-19 pandemic: an Iranian consensus. J Gastrointest Cancer 2020;51:1-5.
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.
Day AT, Sher DJ, Lee RC, Truelson JM, Myers LL, Sumer BD, et al
. Head and neck oncology during the COVID-19 pandemic: Reconsidering traditional treatment paradigms in light of new surgical and other multilevel risks. Oral Oncol 2020;105:104684.