[NEWS] Covid19 - What impact on radiotherapy services and patient care?


The direct health and socio-economic consequences of covid19 are now well known. Nevertheless, with 10 million deaths a year according to the WHO, cancer is the second leading cause of death worldwide, and the indirect impact of the epidemic on cancer management has yet to be quantified.
Containment measures and the saturation of hospital wards had a major impact on diagnosis, care and treatment times for cancer patients, while surgical activity decreased to make room for covid19 patients, encouraging the use of radiotherapy as a treatment option, with often short sessions and minimal physical contact with the patient.

Right from the start of the epidemic, groups of international experts issued recommendations on treatment management, depending on the type of cancer and the therapeutic strategy envisaged. This note provides a brief overview of the impact of covid19 on radiotherapy departments and the measures taken to maintain their activity during this unprecedented health crisis.
We’ll be focusing on the most common cancers, for which there are more data in the literature: breast, prostate, ENT and lung cancers. As the literature on this subject is more extensive in Europe and North America, the data presented in this document will mainly concern these geographical areas.

Expert group recommendations

In April 2020, at a time when a state of health emergency had just been declared in most European and North American countries, ESTRO and ASTRO joined forces to issue recommendations for the treatment of certain cancers1,2.

Two scenarios are taken into account in these recommendations: early (significant alteration in the benefit-risk balance due to potential covid19 contamination during treatment) and late (significant reduction in radiotherapy resources). These recommendations clarify when treatments should be prioritized, modified, postponed or cancelled, depending on the patient’s overall condition (covid19-positive patient, risk of cancer progression, chances of successful treatment, etc.) and the treatment strategy envisaged in the first place.

Among these recommendations, it is advisable to interrupt or postpone treatment in the case of a covid 19-positive patient, whatever the grade of cancer. Another example: hypofractionation (reducing the number of sessions by increasing the dose delivered at each session) should be considered as soon as possible as an alternative to normal fractionation, except in the case of concomitant chemotherapy.

The situation in Europe
At the same time, an initial Europe-wide study showed that just under half of all radiotherapy treatments for breast cancer were affected by COVID 19: 23.4% received hypofractionation treatment, 22.6% had their sessions postponed, and 2.1% had to move their treatment sessions to another facility.3.

In Switzerland, a national study revealed that in April 2020, almost half of radiotherapy departments (43%) had to deal with patients suffering from covid-19, and 73% saw their daily activity decrease4. One of the consequences was an increase in hypofractionated treatments for breast cancer (from 64% in 2019 to 82% during the epidemic), a postponement of prostate cancer treatments for low-grade, intermediate-grade and intermediate-favorable patients in 90.9% of services.

In the UK, radiotherapy activity fell drastically in 2020 compared with 2019 (-19.9% in April, -6.2% in May and -11.6% in June), with the main decline being in patients aged over 70.5 and a 77% reduction in radiotherapy treatments for prostate cancer observed in April. Conversely, radiotherapy sessions for esophageal and bladder cancers increase by 41.2% and 64.2% respectively, and the use of ultra-hypofractionated treatments rises from 0.2% to 60.6% between 2019 and 2025.

A survey published by ESTRO in September shows that, out of 139 radiotherapy centers in Europe, 58% have had to delay the start of treatment for new patients, and 78% have used telemedicine for clinical assessment or post-treatment follow-up of patients6. A 25% decline in patient volume was observed in 60% of centers, mainly due to treatment postponements or reduced staffing levels (caused by childcare or sick/cas-contact staff). As advised by ESTRO and ASTRO, the most frequently reported treatments were prostate, non-malignant indications, low-grade breast cancer and non-emergent palliative cancers.
The situation in North America
Across the Atlantic, at the University Hospital of Montreal, the trend has been the same since March 2020: compared to 2019, the workload in the radiotherapy department has decreased by 12%, a reduction in the number of sessions of 11% on average (the cancers most marked by the reduction in sessions are prostate, breast, gastrointestinal cancers and palliative cases).7. Patients are categorized according to the grade of their disease and the clinical benefit of radiotherapy, in line with ASTRO recommendations.

In the USA, the consequences are the same: a sharp increase in telemedicine consultations, postponements of treatment for low- and intermediate-risk prostate cancers, early-stage breast cancer, palliative treatments and benign diseases8.
At the same time, 70% of radiotherapy centers have seen their staff reduced either because of suspected covid19 (covid19 positive or case-contacts) or to reinforce services directly affected by covid198.
In conclusion
Despite the global covid19 pandemic, healthcare professionals were quick to find solutions to keep cancer patients on treatment. The democratization of hypofractionation and the prioritization, triage and creation of “covid-free” zones in hospitals enabled a large proportion of European and American hospitals to maintain effective clinical activity during this unprecedented health crisis. Although our focus here is primarily on developed countries, the IAEA held a roundtable discussion on February 4, 2021 to examine the impact of the pandemic on cancer management worldwide.
According to a recent IAEA study, diagnostic procedures have been cut by an average of more than half in the 72 countries concerned9. Underlining once again the wide gap in access to diagnosis and treatment between developed and developing countries.

Of course, the full impact of delayed diagnosis, postponements and changes in treatment on the management and evolution of the disease will only become apparent several years from now. Further studies are needed to assess the medium- and long-term impact of the covid19 epidemic on cancer treatment.

1. Guckenberger M, Belka C, Bezjak A, et al. Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement. Radiotherapy and Oncology. 2020;146:223-229. doi:10.1016/j.radonc.2020.04.001

2. Thomson DJ, Palma D, Guckenberger M, et al. Practice Recommendations for Risk-Adapted Head and Neck Cancer Radiation Therapy During the COVID-19 Pandemic: An ASTRO-ESTRO Consensus Statement. International Journal of Radiation Oncology Biology Physics. 2020;107(4):618-627. doi:10.1016/j.ijrobp.2020.04.016

3. Gasparri ML, Gentilini OD, Lueftner D, Kuehn T, Kaidar-Person O, Poortmans P. Changes in breast cancer management during the Corona Virus Disease 19 pandemic: An international survey of the European Breast Cancer Research Association of Surgical Trialists (EUBREAST). Breast. 2020;52:110-115. doi:10.1016/j.breast.2020.05.006

4. Beer KT, Betz M, Breuneval T, et al. A national survey on radiation oncology patterns of practice inSwitzerland during the COVID-19 pandemic: Present changes and futureperspectives. 2020;(January).

5. Spencer K, Jones CM, Girdler R, et al. The impact of the COVID-19 pandemic on radiotherapy services in England, UK: a population-based study. The Lancet Oncology. 2021;22(3):309-320. doi:10.1016/s1470-2045(20)30743-9

6. Slotman BJ, Lievens Y, Poortmans P, et al. Effect of COVID-19 pandemic on practice in European radiation oncology centers. Radiotherapy and Oncology. 2020;150:40-42. doi:10.1016/j.radonc.2020.06.007

7. Roberge D, Delouya G, Bohigas A, Michalowski S. Catching the wave: Quantifying the impact of COVID on radiotherapy delivery. Current Oncology. 2021;28(1):152-158. doi:10.3390/curroncol28010018

8. Wakefield D v., Sanders T, Wilson E, et al. Initial Impact and Operational Responses to the COVID-19 Pandemic by American Radiation Oncology Practices. International Journal of Radiation Oncology Biology Physics. 2020;108(2):356-361. doi:10.1016/j.ijrobp.2020.06.060

9. Michael Amdi Madsen I. World Cancer Day: The impact of COVID-19 on cancer control. Accessed May 20, 2021. https://www.iaea.org/fr/newscenter/news/journee-mondiale-du-cancer-lincidence-de-la-covid-19-sur-la-lutte-contre-le-cancer

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