What has the impact of COVID-19 been on radiotherapy activity in Belgium regarding the amount of treatments? Can you indicate for which cancers the decrease of treatment has been the most significant?
“In a national survey we saw that radiotherapy activity in Belgian hospitals dropped to 87% at its lowest point. In the UZ Brussel, we remained at full capacity. We adapted to the pandemic situation early on. We achieved this by aggressively introducing working remotely from home as much as possible and we managed to implement this within a week. We introduced teleconsultations. We tested all patients in the UZ Brussel with fever or signs of respiratory infection for COVID. Initially we did this by CT, until RT-PCR testing became widely available. We executed group radiating of all COVID-patients at the end of the day, optimizing organization and limiting waiting time to a minimum. In addition, we organized our staff into rotating teams, in order to avoid a possible outbreak within the staff. We decided to start using PPE before Belgian virologists recommended this. Lastly, we put great effort into vaccinating our staff and later on our patients. A survey among our patients confirmed that they felt safe in our hospital despite the pandemic, and were highly satisfied with their treatment.”
Has the use of hypofractionated regimens (requiring fewer visits to the hospital) increased and do you think the use of these hypofractionated regimens should continue after the pandemic?
“Yes, with the introduction of stereotactic radiotherapy and especially MRI-guided radiotherapy, historical fractionation (25 to 40 fractions of 1,8 to 2 Gy) is not necessary anymore, in order to limit toxicity. Besides that, new radiobiological insights and clinical trials favor the use of hypofractionation (eg. 1 to 5 fractions of 5 to 20 Gy) with regards to tumour control and anti-tumour immunity. The pandemic facilitated the introduction of these existing concepts, and I believe that they will remain in place after the pandemic. The RIZIV (Belgian Health insurance) has changed their reimbursement criteria. In Belgium radiotherapy is reimbursed in four categories. In order to receive a category 4 reimbursement, patients had to be treated with a minimum of 15 fractions of radiotherapy. That discouraged some centres to use hypofractioned schemes. With the new reimbursement rules a category 4 reimbursement can be obtained for hypofractionated schemes and Stereotactic Body Radiotherapy. This will encourage the investments in high-tech radiation machines in Belgium.”
Has radiotherapy been used in UZ Brussels as a means of replacing or postponing surgery due to COVID-19?
“In the UZ Brussel optimal cancer care remained a top priority during the pandemic. As such, we did not alter our treatment strategy or fractionation schemes because of COVID. For years, we were already gradually implementing hypofractionation. A shorter treatment means a better quality of life, it’s a win-win scenario. The pandemic merely sped the process up and further triggering hypofractionation. Studies on this subject merely confirmed what we already believed. During the first wave of the pandemic I remained in close contact with colleagues in other countries, like Italy and Canada. They witnessed a significant shift from surgery to radiotherapy in for instance non-small cell lung cancer (NSCLC), prostate cancer and oesophageal cancers. In the treatment of these tumour types radiotherapy results are equal or better than surgery. Radiotherapy furthermore has the added advantage not to compete for in demand resources, such as respirators or ICU beds. However, in Belgium we chose to prioritize maintaining cancer care, and we did not need to implement these practices. Aside from switching to more hypofractionation, oncological treatments remained as they were, providing the best possible care following evidence-based medicine.”
Were there any delays in radiotherapeutic treatments in UZ Brussels due to the pandemic? Treatment delay is associated with especially worse survival outcomes in head and neck cancers (oesophageal cancer for instance), can you elaborate on this?
“In the UZ Brussel we focused our organization with the absolute priority of assuring the continuity of radiotherapy for all cancer patients, irrespective of their COVID status. As such, we had no delays in radiotherapy or extensions in overall treatment time. We know from many studies that these two factors are associated with a worse outcome. This is the case for types of cancer for which radiation is applied in an adjuvant setting as part of the therapy, as well as in cancers for which radiation is the entire treatment. For example, the findings of a systematic review demonstrates that delaying initiation of adjuvant radiotherapy more than 8 weeks after surgery doubles the risk of local recurrence in patients with breast cancer3.”
“An increase in overall treatment time has also shown to negatively affect the overall survival in patients treated by primary (chemo)radiation, for instance patients with head-and-neck cancer and NSCLC. Our main concern were patients that developed COVID during chemoradiation. In these patients, chemotherapy had to be stopped, with should result in a worse outcome. It’s a Catch-22 situation. Chemotherapy has an immunosuppressive effect, so an eventual COVID-19 infection becomes worse, resulting in a higher risk of death. In effect, COVID-19 is considered a counter-indication for chemotherapy, and this is still the consensus.”
A recent comparative effectiveness study, published in JAMA4, indicates that radiation fractionation was not associated with outcomes in low COVID-19–risk scenarios. In higher-risk scenarios, aggressive hypofractionation was associated with a survival benefit, whereas moderate hypofractionation was not.
How can you explain these results? And how do these outcomes guide treatment decision-making and characterizing of infection risks for Covid-19 associated with the radiotherapeutic treatment of cancer patients?
“Hypofractionation has the same or sometimes a better outcome than normofractionation.
On the other hand, the risk of getting infected and dying from COVID-19 increases in high-COVID-19 scenarios This explains why hypofractionation is an attractive treatment option during a pandemic. It decreases the risk of dying from COVID-19, without decreasing cancer survival.”
1: 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. Lancet Oncol. 2021 Mar;22(3):309-320. doi: 10.1016/S1470-2045(20)30743-9.
2: Nagar H, Formenti SC. Cancer and COVID-19 – potentially deleterious effects of delaying radiotherapy. Nat Rev Clin Oncol. 2020 Jun;17(6):332-334. doi: 10.1038/s41571-020-0375-1.
3: Hanna TP, King WD, Thibodeau S, et al. Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ. 2020 Nov 4;371:m4087. doi: 10.1136/bmj.m4087
4: Tabrizi S, Trippa L, Cagney D, et al. Assessment of Simulated SARS-CoV-2 Infection and Mortality Risk Associated With Radiation Therapy Among Patients in 8 Randomized Clinical Trials. JAMA Netw Open. 2021 Mar 1;4(3):e213304. doi: 10.1001/jamanetworkopen.2021.3304.
Further reading suggested by Mark de Ridder
Achard V, Aebersold DM, Allal AS, et al. A national survey on radiation oncology patterns of practice in Switzerland during the COVID-19 pandemic: Present changes and future perspectives. Radiother Oncol. 2020 Sep;150:1-3. Epub 2020 Jun 6. doi: 10.1016/j.radonc.2020.05.047.
Buckstein M, Skubish S, Smith K, et al. Experiencing the Surge: Report From a Large New York Radiation Oncology Department During the COVID-19 Pandemic. Adv Radiat Oncol. 2020 May 5;5(4):610-616. doi: 10.1016/j.adro.2020.04.014.
Combs, S.E., Belka, C., Niyazi, M. et al. First statement on preparation for the COVID-19 pandemic in large German Speaking University-based radiation oncology departments. Radiat Oncol 15, 74 (2020). doi: 10.1186/s13014-020-01527-1
Vordermark D. Shift in indications for radiotherapy during the COVID-19 pandemic? A review of organ-specific cancer management recommendations from multidisciplinary and surgical expert groups. Radiat Oncol. 2020 Jun 3;15(1):140. doi: 10.1186/s13014-020-01579-3.
Beddok A, Calugaru V, Minsat M, et al. Post-lockdown management of oncological priorities and postponed radiation therapy following the COVID-19 pandemic: Experience of the Institut Curie. Radiother Oncol. 2020 Sep;150:12-14. Epub 2020 Jun 5. doi: 10.1016/j.radonc.2020.05.043.