Hi Everyone,

I agree with all the comments—this is certainly a fluid situation. We have not had a confirmed COVID-19 case, but we have developed a plan. If it is deemed a known COVID-19 patient, and it is elected to continue treatment by the treating physician, the treatment will happen at the end of the day with minimal staff in full protection and a deep clean after. We have no specific chemo/RT recommendations—but will probably take it as a case by case basis.

I suggest we track our patients that we treat with COVID-19 and look at the outcomes with a hope to combine data—if interested—please reach out to me (wmsmall@lumc.edu).

Be safe everyone,

Bill

Agree with @Karen L. Reckamp, however wanted to clarify 'symptomatic'. If a patient is symptomatic (in the ICU, on high flow O2 or CPAP or BiPAP) we would hold treatment. If, however, the patient is symptomatic but 'mild - moderate' you could continue to treat the patient on a case-by-case basis based on patient symptoms, cancer type/stage. We have elected (thus far) that we will not hold treatment for someone who has 'mild-moderate' symptoms but would take all the precautions previously posted.  

Lehigh Valley Health Network is an Academic Community Hospital with a main facility in Allentown, PA (4 linacs, GK, HDR) and two smaller facilities in Bethlehem, PA (2 linacs) and East Stroudsburg, PA (2 linacs, HDR). I was asked to draft guidelines for our facility, which I will post below for others to consider. They are by no means authoritative, nor even final yet. I post them only to stimulate discussion and help others struggling to navigate these complex medical and ethical decisions in the face of limited and rapidly evolving data. While the ASTRO guidelines/FAQ published online to date are helpful, they do not offer guidance on the most difficult question of all: namely, what do we do when a patient already under treatment tests positive for COVID-19? The most thoughtful answer to this question that I could find is a statement that has been published by ESTRO President Dr. Umberto Richardi, Chairmen of the Department of Radiation Oncology at the University of Turin, which I highly recommend you read: 

https://www.estro.org/About/Newsroom/News/Radiotherapy-in-a-time-of-crisis

He makes some arguments for putting patients on break until they have recovered completely that I found compelling. Although the avoidance of radiotherapy treatment breaks is generally desirable from a cancer control standpoint, we have to consider the risk of infecting the staff and the risk of infecting other patients (some of whom may be immunocompromised). If a substantial proportion of the staff is exposed and requires quarantine, the radiotherapy department may not even be able to operate at all, jeopardizing outcomes for the presumably much larger group of non-infected patients. Despite following strict infection control procedures, an alarming number of health care workers caring for COVID-19 patients are themselves becoming infected.

Furthermore, we have no idea if continuing radiotherapy before the SARS-CoV-2 infection has resolved will increase the risk of radiotherapy treatment-related complications or whether doing so would hinder recovery from COVID-19. Given these substantial concerns I would argue we should mandate treatment breaks for all SARS-CoV-2 infected patients until they have fully recovered which, following CDC guidelines for quarantine, we have defined as SEVEN days after resolution of all symptoms. Since the exact period of contagiousness following recovery from COVID-19 is unknown, patients who recover and resume radiotherapy should still be treated at the end of the day by a limited staff (COVID team), using strict infection control procedures designed by your hospital's infection control department.

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RADIATION ONCOLOGY COVID-19 TRIAGE ALGORITHM (DRAFT)

COVID-19 NEGATIVE PATIENTS:

1. Level 1: The following patients should proceed with RT without delays:
   1. CURATIVE, DEFINITIVE: Lung, Locally advanced H&N, Esophagus, Pancreas, Gall bladder/bile duct, Anus, unresectable GBM, unresectable sarcomas, inoperable bladder, cervix
   2. CURATIVE, PREOP: GI cases, Lung, Sarcoma
   3. CURATIVE, ADJUVANT: GBM, inflammatory breast cancer, head and neck cancer
   4. PALLIATIVE: Cord Compression, SVC Syndrome, symptomatic brain metastases , patients with acute hemorrhage for primary or metastatic disease, patients with severe pain from metastases
   5. BENIGN: heterotopic bone
2. Level 2: A delay of 2-4 weeks is appropriate for the following:
   1. CURATIVE, DEFINITIVE: T1-2N0 lung cases getting SBRT, low grade lymphomas, low-grade glioma, T1-2N0 H&N
   2. CURATIVE, ADJUVANT: most curative adjuvant cases
   3. PALLIATIVE: most cases including asymptomatic brain metastases
3. Level 3: A delay of 2-4 months is reasonable for the following:
   1. CURATIVE, DEFINITIVE: small slow growing skin cancers, low-risk and favorable intermediate-risk prostate cancer, unfavorable intermediate-risk prostate and high-risk prostate cancer on ADT
   2. CURATIVE, ADJUVANT: favorable invasive breast cancer, DCIS
   3. BENIGN: trigeminal neuralgia
4. Level 4: A delay of 4-6 months is acceptable for the following:
   1. BENIGN: grade 1 meningioma, schwannoma, keloids, essential tremor

COVID-19 PRESUMPTIVE POSITIVE:

1. Patients with spinal cord compression with potentially reversible neurologic impairment, SVC syndrome, active moderate to severe hemorrhage and not appropriate for embolization who are deemed by their physician to have a life expectancy of at least 3-6 months: treat immediately.
2. All other patients: treatment will be held until a negative test result is available.  

COVID-19 POSITIVE PATIENTS:

1. Patients with spinal cord compression with neurologic impairment, SVC syndrome, active moderate to severe hemorrhage and not appropriate for embolization who are deemed by their physician to have a life expectancy of at least 3-6 months and are not acutely ill from COVID-19: treat immediately.
2. All other patients: patient on break until 7 days after resolution of all COVID-related symptoms.

Patients who are COVID-19 presumptive positive or COVID-19 confirmed positive who are under treatment for the emergency indications as noted above will be treated at the end of the day on a single LINAC with a reduced staff following procedures approved by infection control to reduce infection risk for both staff and other patients in the Radiation Oncology Department. Given that the duration of contagiousness of patients who have recovered from COVID-19 illness is unknown at this time, patients who resume treatment after a break necessitated by COVID-19 infection will also be treated at the end of the day on a single LINAC.

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As stated above these guidelines are by no means authoritative. I welcome feedback and comments from the larger Radiation Oncology community. Good luck to everyone as we struggle to deliver the best care we can during this very challenging time. 

Robert Prosnitz, MD, MPH

A patient with confirmed COVID-19 would be tested at this time due to symptoms, and exposure.  While the patients is symptomatic, I would recommend interrupting chemotherapy and radiation as we would do with any other serious infection. Once symptoms subside and pulmonary function is stable, I would resume with caution, monitoring symptoms and oxygen saturation closely throughout the course. 

Overall, cancer patients are not at a higher risk for contracting COVID-19; however, some cancer patients with weakened immune systems may develop more serious symptoms from any viral illness. Remaining at home with limited social contact during a community outbreak, washing hands frequently, and limiting close contact with others are useful precautions. 

Continuing on treatment and discussing concerns can help to develop a plan that works for each patient on therapy. The CDC, local health officials, and treating hospitals are continually monitoring updated information and adapting plans as needed.

Here is the Yale guideline mentioned above. This effort has been led by @James B. Yu, @Lynn D. Wilson, and @Ranjit S. Bindra with contributions from the entire faculty for each specific cancer site:

Yale Radiation Oncology COVID-19 Guidelines Version 6.0 (3/20/2020 12pm)

Like most centers, we have a plan in place for treating these patients but don't have a patient yet with confirmed COVID-19 infection. The plan includes a special team completely protected, end of the day treatment, special entrance and exit and terminal clean of the area.

I would say for patients with intact gynecological cancers undergoing definitive treatment (if only minor symptoms) it would be best to continue radiation.

We have not come up with a plan on chemotherapy yet, but that decision may need to be discussed with the treating medical oncologist.

I have attached ASTRO recommendations below.

Kevin Albuquerque

https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/Summary

There is a lot to consider. There is a similar algorithm floating around from Yale to Dr Prosnitz, with which I agree. We have been triaging patients for the last two weeks to minimize volume on our linacs in the coming weeks through delaying judiciously and expediting patients that could finish within the 2 weeks. 

There are other things to consider as well in the coming days. Availability of protective equipment, without which I would not recommend treating anyone positive or suspected if the risk is exposing staff, and availability of a clean linac vault. Immunocompromised patients (chemo-RT) are at an increased risk of getting it, but likely an increased risk of dying from a serious infection. 

Vaults are not known for their airflow, so throughput will be reduced. We estimated one patient an hour to sanitize and allow for air to exchange. Patients will not be in negative ventilation and waiting areas need to have limited access and set up for social distancing with frequent cleaning (we are doing this every 1-2 hrs). 

Of note, the recommendation is for self-isolation for those with an infection for 7 days AND 3 days of no symptoms. It is closer to a 2-week break if you decide to not treat any patient who tests positive.