Treatment Interruptions

The pandemic has forced “a few obvious and less obvious changes” in radiotherapy practice, said ASTRO Board Chair Theodore L. DeWeese, MD [email communication, April 2020]. “We continue to provide high quality care while also minimizing the time patients have to spend in the clinic. This has required juggling schedules and treatment protocols, and it is likely to continue for some weeks to come.”

It is a “virtual certainty” that some patients have experienced unplanned disruptions in their care for any number of reasons, Dr Eichler acknowledged. COVID-19 positive patients are usually treated on a separate linear accelerator when that is possible, with thorough disinfection between patients. 


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“The greatest risk for treatment interruption exists in small practices with a single radiation oncologist and two radiation therapy technologists,” Dr Eichler noted. “If any member of the team tests positive or is forced to go into quarantine as a person under investigation (PUI), the practice could grind to a halt with patients either being referred to another facility (if practical) or delaying their radiation therapy until their team is back at full strength.”

Some clinics have staggered clinical team scheduling to keep at least one treatment team, including radiation therapy techs and clinicians, away from the clinic each day to prevent the SARS-CoV-2 virus that causes COVID-19 from sweeping through a center’s clinical staff, Dr Eichler said.

At larger multifacility cancer centers, such as the University of California San Francisco (USCF), a “team in place” strategy aims at a similar goal.

“You try to keep your teams at their location and not circulating (between locations),” explained UCSF Professor Sue S. Yom, MD, PhD, Departments of Radiation Oncology and Otolaryngology-Head and Neck Surgery [email communication, April 2020].

“Within different areas of the department, we try to keep people within their areas and not circulating,” she added. “We also try to minimize the number of people in close proximity on-site. We have a lot of our employees working from home. We set them up with virtual private network access and phone lines, and the ability to do remote appointments and scheduling.”

Those policies have allowed most administrative and scheduling staff to work from home.

Because the City of San Francisco, California state officials, and the University of California responded relatively early to the threats posed by COVID-19, they remain in a “risk mitigation” phase response rather than the crisis response that would become necessary were COVID-19 patient loads to overwhelm hospitals or clinical teams to be incapacitated by infections.

“It is difficult to know how this will play out in the weeks to come but the predictive models would suggest that certain parts of the country may have some very challenging days ahead,” Dr Eichler acknowledged.

Population centers in New York, New Jersey, Massachusetts, Illinois, California, Pennsylvania, and Michigan have seen high numbers of COVID-19 hospitalizations.

Changing Treatment Schedules

“ASTRO has also strongly advocated for shorter treatment courses for patients using hypofractionation — larger daily fractions of radiation over a shorter overall time span with equivalent radiobiologic efficacy,” Dr Eichler said.

This isn’t the first time a natural disaster has forced radiation oncology centers to reckon with missed appointments and interruptions in care.

“The most common solution for a missed day here or there is to simply add those treatments on at the end of the therapy course,” Dr Eichler noted. “Historically, longer interruptions have been more problematic in terms of how to recalculate the radiation dose to account for these delays. In 2017, hurricanes in Houston (Harvey) and Puerto Rico (Maria) caused widespread destruction as well as interrupting cancer treatment for hundreds of patients.”

ASTRO convened an expert panel to draft recommendations regarding how to restart radiation therapy after a 2 to 3 week pause in treatment for lung, head and neck, cervical, breast, and prostate cancers.4 Those recommendations “offer clear guidance that is applicable today,” Dr Eichler said.

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Tumor boards and research conferences are being held virtually, via video conferences, during the COVID-19 pandemic, Dr Eichler and others noted.

Changed interactions with patients during the COVID-19 pandemic have represented a subtle but important issue, Dr DeWeese said. “We are no longer able to have the close, personal contact that is often so helpful to patients as they navigate a course of cancer care,” he explained. “The handshake, the compassionate touch on the shoulder, or the warm hug we share with our patients is now on hold, and I believe that is making the experience for our patients less than ideal.”

References

1. COVID-19 Clinical Guidance. ASTRO. Last updated April 30, 2020. Accessed May 1, 2020. https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/Clinical-Guidance

2. Simcock R, Thomas TV, Estes C, et al. COVID-19: global radiation oncology’s targeted response for pandemic preparedness. Clin Transl Radiat Oncol. 2020;22:55-68.

3. Rivera A, Ohri N, Thomas E, Miller R, Knoll MA. The impact of COVID-19 on radiation oncology clinics and cancer patients in the United States [published online March 27, 2020]. Adv Radiat Oncol. doi: 10.1016/j.adro.2020.03.006

4. Gay HA, Santiago R, Gil B, et al. Lessons learned from Hurricane Maria in Puerto Rico: practical measures to mitigate the impact of a catastrophic natural disaster on radiation oncology patients. Pract Radiat Oncol. 2019;9(5):305-321.