Breast Radiation Therapy Under COVID-19 Pandemic Resource Constraints—Approaches to Defer or Shorten Treatment From a Comprehensive Cancer Center in the United States

Abstract

Breast radiation therapy accounts for a significant proportion of patient volume in contemporary radiation oncology practice. In the setting of anticipated resource constraints and widespread community infection with SARS-CoV-2 during the COVID-19 pandemic, measures for balancing both infectious and oncologic risk among patients and providers must be carefully considered. Here, we present evidence-based guidelines for omitting or abbreviating breast cancer radiation therapy, where appropriate, in an effort to mitigate risk to patients and optimize resource utilization. Methods and Materials: Multidisciplinary breast cancer experts at a high-volume comprehensive cancer center convened contingency planning meetings over the early days of the COVID-19 pandemic to review the relevant literature and establish recommendations for the application of hypofractionated and abbreviated breast radiation regimens. Results: Substantial evidence exists to support omitting radiation among certain favorable risk subgroups of patients with breast cancer and for abbreviating or accelerating regimens among others. For those who require either whole-breast or postmastectomy radiation, with or without coverage of the regional lymph nodes, a growing body of literature supports various hypofractionated approaches that appear safe and effective. Conclusions: In the setting of a public health emergency with the potential to strain critical healthcare resources and place patients at risk of infection, the parsimonious application of breast radiation therapy may alleviate a significant clinical burden without compromising long-term oncologic outcomes. The judicious and personalized use of immature study data may be warranted in the setting of a competing mortality risk from this widespread pandemic.

Quantifying the Impact of COVID-19 on Cancer Patients: A Technical Report of Patient Experience During the COVID-19 Pandemic at a High-volume Radiation Oncology Proton Center in New York City

“…Similar to the UW, we instituted policies to minimize risks to patients, including providing patient education materials; completing daily symptom screenings of patients and close contacts; implementing rigorous sanitization measures; deferring treatment of indolent diseases; instituting telemedicine appointments, virtual meetings, restricting visitors, spacingout treatment times, and closing patient waiting rooms. Patients in subacute care or nursing facilities were no longer eligible for treatment until discharged and we utilized hypofractionation to shorten treatment schedules per expert-consensus, when feasible [2][3][4][5]. Lastly, we began prospectively monitoring each patient on treatment and those expected to initiate treatment for new symptoms, date of onset, possible sick contacts, and COVID-19 test results.…”

Radiation therapy considerations during the COVID‐19 Pandemic: Literature review and expert opinions

“…Similar experiences were demonstrated during the Severe Acute Respiratory Syndrome epidemics 27 . As such, in response to the current pandemic, a number of guidelines are now published providing recommendations for practice changes to optimize use of resources and maximizing patient and personnel safety in radiation oncology clinics 28–32 . Major institutions have released operational guidance regarding practice of RT during the pandemic 33–39 .…”

Development and execution of a pandemic preparedness plan: Therapeutic medical physics and radiation dosimetry during the COVID‐19 crisis

“…Zaorsky et al . recommend the “RADS” framework, which stands for “Remote visits, Avoid radiation, Defer radiation, Shorten radiation.” 15 Several site‐specific recommendations have been published to aid physicians in decisions of avoiding or deferring radiation and toward specific fractionation regimens to shorten radiation 16–19 . Many of these works, however, were accepted for publication and made available online after the coronavirus began to spread exponentially in the greater New York area.…”