Radiation therapy
Radiation therapy may help avoid high-aerosol generating surgery and an
inpatient admission, particularly in patients with early stage laryngeal
or oropharyngeal cancers. However, radiation treatment may increase
exposure risk to both patients and healthcare workers because of the
requirement for daily travel to hospital-based facilities for 6-7 weeks.
Additionally, HNC patients may have tracheotomies, open stomas after
laryngectomy, or require manipulation of the oral cavity for dental
stents that increase staff exposure risk.
With these considerations in mind, an American Society for Radiation
Oncology (ASTRO)/European Society for Radiotherapy and Oncology (ESTRO)
consensus statement has been developed to give treatment recommendations
for RT in HNC 34. Based on responses from an
international panel of experts, there is agreement that radical RT is of
high priority while adjuvant RT for minor risk factors is of lower
priority. Depending on the scenario (early risk mitigation versus late
pandemic where there are severely reduced RT resources),
hypofractionated RT schedules that reduce those courses by 1-2 weeks,
can be used if necessary.
Beyond being prepared for a COVID-19 surge with altered fractionation
schedules, our radiation oncology team has made other anticipatory
moves. Anecdotal reports from radiation treatment centers with earlier
COVID-19 surges/peaks suggest that up to about 35% of radiation
oncology staff could be off work due to quarantine or illness. We
reduced the number of patients under treatment in the main campus, so as
to be able to maintain treatment continuity even with manpower
shortages. The department achieved this by transferring daily radiation
therapy to satellites healthcare facilities while monitoring their
progress by telemedicine, and encouraging out-of-state patients that
comprise a significant portion of our practice to seek radiation
treatment locally. Current institutional guidelines require out-of-state
patients to self-quarantine for 14 days and have a negative COVID-19
test before being seen here, so select patients or those with complex
cancers may continue RT treatment at MDACC. The ability to treat
patients at a local satellite facility also helps to reduce traffic to
the main hospital that cares for an often immunocompromised, at-risk
patient population.
Lastly, potential for treatment breaks could occur if a patient is under
investigation for COVID-19 (PUI) or develops COVID-19 during multi-week
radiation therapy. It is well known that treatment time factors are
important for local control and survival in RT for head and neck
cancers35. Some guidelines recommend that RT be
stopped for PUI until they achieve a negative COVID-19 test. This may be
compensated for by giving second daily fractions to catch up. In the
recent ASTRO/ESTRO consensus guidelines, there is agreement not to
interrupt RT after week 2 for mild COVID-19 related symptoms in test
positive patients, but there is strong agreement to interrupt RT for
severe symptoms 34. These patients are at highest risk
for prolonged, detrimental treatment interruptions.