Are you employing more or less primary chemoRT v. surgery for some cancers? Are you dose de-escalating? What are issues radiation oncologists should be considering at this time?
I am speaking for myself and not my institution. I’ve been slow to respond because I’m conflicted. On the one hand, I dislike split course RT, particularly for head and neck. On the other hand, if you don’t split a covid positive patient, you risk infecting fellow patients and staff and possibly shutting down your facility, not to mention additionally burdening an overwhelmed health care system and increasing the number of deaths. Planned split course RT was popular in the late 60s and early 70s. I’m told that Dr. Gilbert Fletcher warned us not to do it but we did. I was in high school at the time and my opinion was not sought. Dr. Jim Parsons published very nice papers on the outcomes (Parsons et al. IJROBP 1980: p. 1645 and p. 175). Split course was worse, particularly for rapidly proliferating cancers like head and neck, but not horrible, which is why it took a few years to figure it out. Not so bad for prostate. Sadly, splitting covid positive patients until they are no longer contagious is the least of two evils. Covid is not a windmill with which we should tilt.
I agree. There has been excellent discussion of management of COVID+ patients in the rad onc community. One thing we don’t have is the level of PPE that allowed Wuhan rad onc to treat through the outbreak. As you note, keeping the department up during these times is of the utmost concern. Unfortunately in a mass cass situations, the needs of the many is by definition the priority.
How are people managing contact precaution duration for COVID+ patients receiving head neck chemo/RT, considering that they will have prolonged and excess pharyngeal/oral secretions?
Our infectious disease team decided to prolong contact precautions throughout radiation treatment. They decided to be safe, because to their knowledge this had not been studied.
I agree...there is no data on this subject and it's probably better to err on the side of safety.
All answers to these questions are evolving daily.
It is incumbent on us to free up beds, free machine time where possible, and protect patients, ourselves, and staff (if we go down we are no longer a force multiplier).
I agree that curative head and neck cancer treatment should go on and that is our intention. My personal thoughts are below:
Reduce interventions with borderline/uncertain benefits: induction chemo, chemo over age 70, soft indications for adjuvant RT, postop thyroid RT
Palliative RT: Unfortunately palliative RT will fall to the bottom of the priority list and it is essential to optimize medical management for these patients. They may need to delay or forgo RT. If treating, consider hypofractionation such as quad shot or 24Gy/3 # ("0-7-21).
Curative RT: Lean towards RT instead of surgery for borderline cases. No upfront surgery for oropharynx cancer curable with chemoRT or RT alone. We are not de-escalating p16+ yet off trial, and all trials are on hold at our institution.
Scopes: Aerosolizing. Do not perform unless absolutely necessary for treatment planning or symptom investigation. N95 etc.
Treatment: Bigger question addressed in other answers, considering waiting spaces, patient flow, "hot unit" for patients with the virus. limit visitors, screen staff and patients, etc.
EDIT: Practice recommendations for risk-adapted head and neck cancer radiotherapy during
the COVID-19 pandemic: an ASTRO-ESTRO consensus statement, Thomson et al
https://www.astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/COVID-Thomson-et-al(ROB).pdf
https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/Journal-Articles
Scopes: Aerosolizing. Do not perform unless absolutely necessary for treatment planning or symptom investigation. N95 etc.
Completely agree and this point bears repeating. Some of the early reports indicate a very high risk for viral transmission with endoscopic procedures.
For asymptomatic patients in which a scope exam is going to be critical for their care plan, we are closely coordinating with our ENT colleagues to keep all interventions to a minimum to reduce potential exposure to staff and other patients at my institution. I would absolutely not electively scope any symptomatic or known positive patient.
Yes totally agree with this, data supports staying away from endoscopic procedures.
How about an early stage glottic cancer? Would you be more likely to send to surgeon for voice sparing surgery rather than treat with definitive RT?
If VSS is equivalent to RT for that patient, sure. But if RT offers better voice preservation, either due to extent of the cancer or ant commissure involvement, I would still opt for RT.
Our group does not believe we can use an OR, bed, and potentially expose a patient to tracheostomy in the current environment and are recommending radiotherapy for these patients currently.
From a public health and resources perspective that makes sense. OR suites and surgical unit beds need to be freed up depending on where you are. In NYC today, this operation would probably be cancelled. We would either not operate on this patient at all, and go RT route, or would delay operation.
I agree with most of the comments, but would differ on the following points.
For patients who would be eligible for curative organ-sparing approaches, that should be considered before any surgical approaches (minimally invasive, TORS or otherwise) (no change in protocol because of COVID). I am not sure about dental clearance, but imagine that sometimes, this might have to be omitted.
For patients with advanced stage IVB/IVC disease, palliative chemo with immuno or immuno alone would be appropriate (no change in protocol because of COVID).
The problem lies with anterior tumors oral cancers specifically, in whom surgery would be the best option. For very early tumors, waiting till this pandemic ends (hoping it is weeks and not months) would be appropriate, but for any deep, LN pos tumor- approaching with neoadjuvant might be considered. However, the typical neoadjuvant TPF regimen would be a mistake (in my opinion) given high risk for neutropenia (despite GCSF support), AKI, and other complications. Off label regimens like carboplatin/paclitaxel alone or with pembrolizumab or cetuximab off-label might have to be considered. Multidisciplinary discussion is a must for all these cases.
I generally agree with my colleagues above.
Here at our institution, our head & neck surgeons do not generally perform elective surgeries on these patients. Right now the OR is a high risk site, and only absolutely necessary operations are performed. With regards to lung cancer, surgeons are urged to take resectable cases to the OR for surgery. Patients that can wait are encouraged to wait to minimize exposure to COVID-19. In these situations, our head & neck surgeons ask us to give them induction chemotherapy to buy time.
Related Questions
Short answer:
Most head and neck cancer radiation is as necessary as it gets. At this point, my management won't change very much. That may change as the pandemic evolves.
Use all the appropriate precautions to stop the spread of COVID-19 and other viruses (we are using masks for every staff member, stopping visitors, keeping patients separated, wiping down surfaces).
Long-answer:
*There are a few situations where I might deviate from usual care:
1) Induction chemo given to inpatients. If the case is borderline for induction chemo, I might move away from induction and start chemoRT right away. Better to keep patients out of the hospital inpatient units.
2) Palliative RT—try quad-shot, or 5 fractions. use IGRT/SBRT to reduce toxicity.
3) Elderly patients or patients with multiple co-morbidities who have borderline indications for RT—delay or offer no RT.
4) Thyroid—can probably delay many.
*I would carry on with:
*Regarding Dose for Curative cases: I don't advise dose de-escalating unless it's based on level I evidence or on a clinical trial.
How have you dealt with dentists considering dental evaluations “elective” and not wanting or shutting down their facilities?
Great question, it has not come up for me this week. Last dental patient I had cleared was on 3/10 before the mass shutdowns. I would try to find a dentist associated with a cancer center who would proceed with clearance. If you can’t find that, oh boy. I suggest waiting 1-2 weeks until you find an office that opens up. If you can’t, I guess you start treatment. Tough situation!
Update! The last 2 HNC patients I have seen have been able to undergo dental evaluations. Their dentists were still seeing patients for "emergencies" and we were lucky enough that they thought pre-RT clearance fell into this category. I got on the phone with one dentist myself who understood the need and got the patient in right away. A personal phone call to the dentist might do the trick.
We continue to treat our community HNC patients without significant change compared to pre-Covid times. Dental evals at this point (October 2020) do not seem to be an issue. The only change I have seen in our practice is a small increase in patients presenting for "quad shot" palliative therapy. Perhaps likely due to delay in evaluation/management earlier in the pandemic.