"Radiotherapy in a time of crisis", ESTRO Presidents' statement

Many radiotherapy centers throughout the world are confronted with the Covid-19 pandemic. This leads to unforeseen situations and stringent measures. Some of these are hospital specific and/or applicable to all patients or employees in the hospital. A number of additional questions for radiotherapy patients are discussed below, keeping in mind our role as radiation oncologists, but also the World Health Organization (WHO) statement, that our aim and obligation is “to stop, contain, control, delay and reduce the impact of this virus at every opportunity”. As Presidents of ESTRO, we would like to provide some considerations on this situation.

Should all new patients still start their treatment, or should it be delayed?

For a patient with a prostate tumor or basal cell carcinoma, the answer may be simple, but how about patients with stage III lung cancer or with head and neck cancer?

Once a patient has started radiotherapy, we always avoid interruptions and an increase of overall treatment time.  We eventually compensate for it by scheduling additional days (eg in case of machine breakdown) or adapt the regimen to make sure the patient receives the required dose within an acceptable time frame.

In the current situation of Covid19 outbreak we carry the risk that:

  • a patient gets infected during treatment and has to stop treatment;
  • radiotherapy personnel gets infected, is not able to work and treatments for larger groups of patients have to be cancelled;
  • part of the radiotherapy personnel may be requested to work in other areas of the hospital (eg. RTTs in radiology departments, doctors in other departments)
     

What to do if a patient under treatment becomes infected?

Should treatment be stopped/interrupted, the patient be treated in isolation, or should radiotherapy be completed asap? First of all, local health authorities’ regulations should be considered. There is a significant risk of infection for other patients and personnel. Therefore, treatment on a dedicated machine, with a separate entrance, and a dedicated team using full protection and not involved in treatment of other patients may be needed, but not easily achievable. Consider also the complexity for an already overwhelmed hospital organization in moving in bed a patient from a Covid ward to the Radiation Oncology department.

An asymptomatic infected patient is required to stay at home, with no social contacts; it is difficult to imagine outpatients coming to radiotherapy centers when infected, even if asymptomatic.

Moreover, which are the risks of continuing a radiotherapy program in a patient becoming infected during treatment? No scientific information is currently available of course. Especially in immunocompromised patients, Covid infection might be linked to higher risk of mortality. Probably special considerations are needed for patients with intrathoracic tumors.

In case radiotherapy has been interrupted and the patient can restart, how should the dose be adjusted? These will be highly individualized decisions. The paper by Gay et al. evaluating the impact of hurricane Maria in Puerto Rico in 2017, provides some guidelines on how to handle treatment interruptions for common disease sites (Practical Radiation Oncology (2019) 9, 305-321).

What to do when the staffing in the radiotherapy department becomes critical?

Before this happens, attempts should be made to reduce the chance of infection or spread of the virus, taking into account local authorities’ disposals/rules. All personnel who can work from home without impacting quality of the treatments should work at home. A minimum number of staff members should be present to reduce the risk of infection and to have another group ready at home. With the reduction of surgical activities due to limitations in intensive care beds, participation in multidisciplinary tumor boards is very important. To reduce risk of infection, number of participants should of course be limited, and telemedicine solution should be used whenever possible.

Departments should consider to develop scenarios in advance on how to deal with shortage of staff. What happens if 10% is sick, or even one third or half of the work force? Departments may have to refrain from the most complex treatments and accept more standard techniques. It might become necessary to deliver more hypofractionated schemes in larger groups of patients.

On a regional and national level, departments should inform each other on developments. Although attempt should be made to avoid transfer of personnel between hospitals to reduce the risk of virus spread, it might eventually even be necessary to share or exchange personnel to treat all patients safely and timely.

Although the phases of the Covid outbreak may differ and situations are specific for various countries, and scientific evidence is lacking, some general advice might be that

  • in this time of crisis, in patients who are expected not to suffer from delays, radiotherapy should be postponed;
  • if a patient is COVID-19 positive or suspected, seriously consider interrupting treatment immediately to reduce the risk of infecting others and to reduce the risk of making evolution of infection even more risky;
  • have as few people as reasonably possible present in the department at any given time;
  • collaborate between regional departments with personnel exchanges if needed. 

Finally, we would like to stress that this is not intended as a scientific document, given the absence of evidence on the argument. Other, more specific and evidence-based documents will probably become available from experts on different disease sites. All different contributions may certainly be very useful to the whole radiotherapy community facing this very difficult and unusual scenario.

We wish all workers in our field strength and wisdom to conquer this crisis.

 

Ben Slotman,                     Umberto Ricardi,                        Yolande Lievens,
President-Elect                     President                                     Past-President