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.