A rapid review of evidence and recommendations from the SIOPE radiation oncology working group to help mitigate for reduced paediatric radiotherapy capacity during the COVID-19 pandemic or other crises

Impact of COVID-19 pandemic on delivery of pediatric radiotherapy: A critical review

The COVID-19 pandemic has prevented the timely diagnosis and treatment of many diseases, including pediatric cancer. Its impact on pediatric oncologic treatments warrants investigation. As radiotherapy is an integral component of cancer care, we reviewed the published data regarding the impact of COVID-19 on the delivery of pediatric radiotherapy to inform actions for future global events. We found that disruptions in radiotherapy were reported amongst interruptions in other therapies. Disruptions were more common in low-income countries (78%) and low middle-income countries (68%) compared with upper middle-income countries (46%) and high-income countries (10%). Several papers included recommendations for mitigation strategies. Altered treatment regimens were common, including increasing the use of active surveillance and systemic therapy to delay local therapies, and accelerated/hypofractionated dose delivery. Our findings suggest that COVID-19 has impacted radiotherapy delivery in the pediatric population globally. Countries with limited resources may be more affected. Various mitigation strategies have been developed. The efficacy of mitigation measures warrants further investigation.

Nursing Care for Metastatic Bone Cancer: Trends for the Future

To effectively treat patients and minimize viral exposure, oncology nurses and radiology departments during COVID-19 had to re-examine the ability to offer palliative radiation treatments to people with metastatic bone cancer. Decreasing potential exposure to the virus resulted in extra measures to keep patients and personnel safe. Limiting radiotherapy treatments, social distancing, and limiting caregivers were a few of the ways that oncology patients were impacted by the pandemic. Hypofractionated radiation therapy (HFRT), or the delivery of fewer higher-dose treatments, was a method of providing care but also limiting exposure to infection for immunocompromised patients as well as healthcare staff. As oncology radiation centers measure the impact of patient care during the pandemic, a trend toward HFRT may occur in treating the painful symptoms of bone cancer. In anticipation that HFRT may be increasingly used in patient treatment plans, oncology nurses should consider patient perspectives and outcomes from the pandemic to further determine how to manage future trends in giving personalized care, and supportive care.

Telemedicine in Care of Sarcoma Patients beyond the COVID-19 Pandemic: Challenges and Opportunities

BACKGROUND

The COVID-19 pandemic has created a challenging environment for sarcoma patients. Most oncology societies published guidelines or recommendations prioritizing sarcoma patients and established telehealth as an efficient method of approaching them. The aim of this review is the assessment of current evidence regarding the utilization of telemedicine in diagnosis, treatment modalities, telerehabilitation and satisfaction among sarcoma patients and healthcare providers (HP).

METHODS

This systematic review was carried out using the databases PubMed and Ovid MEDLINE according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

The application of telemedicine to the management of sarcoma has yielded improved clinical and psychological outcomes. Specifically, significant progress has been demonstrated in the areas of tele-oncology and telerehabilitation during the last decade, and the COVID-19 outbreak has accelerated this transition toward them. Telehealth has been proven efficient in a wide spectrum of applications from consultations on physical therapy and psychological support to virtual care symptom management. Both HP and patients reported satisfaction with telehealth services at levels comparable to in-person visits.

CONCLUSIONS

Telehealth has already unveiled many opportunities in tailoring individualized care, and its role in the management of sarcoma patients has been established in the post-COVID-19 era, as well.

Covid-19 and radiotherapy: a systematic review after 2 years of pandemic

Introduction

Following the Covid-19 pandemic spread, changes in clinical practice were necessary to limit the pandemic diffusion. Also, oncological practice has undergone changes with radiotherapy (RT) treatments playing a key role.Although several experiences have been published, the aim of this review is to summarize the current evidence after 2 years of pandemic to provide useful conclusions for clinicians.

Methods

A Pubmed/MEDLINE and Embase systematic review was conducted. The search strategy was "Covid AND Radiotherapy" and only original articles in the English language were considered.

Results

A total of 2.733 papers were obtained using the mentioned search strategy. After the complete selection process, a total of 281 papers were considered eligible for the analysis of the results.

Discussion

RT has played a key role in Covid-19 pandemic as it has proved more resilient than surgery and chemotherapy. The impact of the accelerated use of hypofractionated RT and telemedicine will make these strategies central also in the post-pandemic period.

Clinical outcomes and efficacy of stereotactic body radiation therapy in children, adolescents, and young adults with metastatic solid tumors

OBJECTIVE

The objective of this study is to report disease outcomes and toxicity with the use of stereotactic body radiation therapy (SBRT) in the treatment of pediatric metastatic disease.

METHODS

All pediatric and adolescent young adult (AYA) patients' who received SBRT were included between the years 2000 and 2020. Study endpoints included local control (LC), progression-free survival (PFS), overall survival (OS), cumulative incidence (CI) of death or local failure and toxicity. The end points with respect to survival and LC were calculated using the Kaplan-Meier estimate. The cumulative incidence of local failure was calculated using death as a competing risk.

RESULTS

16 patients with 36 lesions irradiated met inclusion criteria and formed the study cohort. The median OS and PFS for the entire cohort were 17 months and 15.7 months, respectively. The 1 year OS for the entire cohort was 75%. The 6- and 12 month local control was 85 and 78%, respectively. There were no local failures in irradiated lesions for patients who received a BED10≥100 Gy. Patients who were treated with SBRT who had ≤5 metastatic lesions at first recurrence had a superior 1 year OS of 100 vs 50% for those with >5 lesions. One patient (6.3%) experienced a Grade 3 central nervous system toxicity.

CONCLUSION

LC was excellent with SBRT delivered to metastatic disease, particularly for lesions receiving a BED10≥100 Gy. High-grade toxicity was rare in our patient population. Patients with five or fewer metastatic sites have a significantly better OS compared to >5 sites.

ADVANCES IN KNOWLEDGE

This study demonstrates that SBRT is safe and efficacious in the treatment of pediatric oligometastatic disease.

General Anesthesia for Pediatric Radiotherapy in the Era of COVID-19

Purpose

Managing pediatric patients requiring daily general anesthesia (GA) for radiation therapy (RT) in the setting of COVID-19 is complex, owing to the aerosolizing nature of GA procedures, the risk of cardiopulmonary complications for infected patients, and the treatment of immunocompromised oncology patients in a busy, densely populated radiation oncology clinic.

Methods and Materials

We developed an institutional protocol to define procedures for COVID-19 testing and protection of patients, caregivers, and staff, hypothesizing that this protocol would allow patients requiring GA to be safely treated, minimizing COVID-19 transmission risk to both patients and staff, and at the same time maintaining pre–COVID-19 patient volumes. All patients underwent COVID-19 testing before their first treatment and thrice weekly during treatment. For patients who tested positive for COVID-19, RT was delivered in the last end-of-day treatment appointment. A negative pressure room was used for GA induction and recovery, and separate physician/nurse teams were designated for in-room versus out-of-room patient management.

Results

Seventy-eight pediatric patients received RT under GA, versus 69 over the same prior year timeframe, and 2 patients received 2 courses of RT under GA, for a total of 80 courses. The mean age was 4.9 years (range, 0.5-19.0 years) and 41 of 78 (52.6%) were male. Two patients (2.6%) received 2 courses of RT under GA, establishing a total of 80 courses. The mean number of treatment fractions was 22.2 (range, 1-40). Two of 78 patients (2.6%) tested positive for COVID-19; both were asymptomatic. Both patients completed treatment as prescribed. Neither patient developed cardiopulmonary symptoms complicating anesthesia, and neither patient experienced grade 3+ acute radiation toxicity.

Conclusions

With careful multidisciplinary planning to mitigate COVID-19 risk, pediatric RT with GA was carried out for a large patient volume without widespread infection and without increased toxic effects from either GA or RT.

SARS-CoV-2 in children with cancer or after haematopoietic stem cell transplant: An analysis of 131 patients

PURPOSE

There are limited data on SARS-CoV-2 (COVID-19) infection in children with cancer or after haematopoietic stem cell transplant (HSCT). We describe the severity and outcomes of SARS-COV-2 in these patients and identify factors associated with severe disease.

METHODS

This was a multinational, observational study of children (aged <19 years) with cancer or HSCT and SARS-CoV-2 confirmed by polymerase chain reaction. COVID-19 was classified as asymptomatic, mild, moderate, severe or critical (≥1 organ support). Exact polytomous regression was used to determine the relationship between clinical variables and disease severity.

RESULTS

One hundred and thirty-one patients with COVID-19 across 10 countries were identified (median age 8 years). Seventy-eight (60%) had leukaemia/lymphoma, 48 (37%) had solid tumour and five had primary immunodeficiency and HSCT. Fever (71%), cough (47%) and coryza (29%) were the most frequent symptoms. The median duration of detectable virus was 16 days (range, 1-79 days). Forty-nine patients (37%) were hospitalised for COVID-19 symptoms, and 15 (11%) required intensive care unit-level care. Chemotherapy was delayed/modified in 35% of patients. COVID-19 was asymptomatic in 32% of patients, mild in 47%, moderate in 8%, severe in 4% and critical in 9%. In 124 patients (95%), a full recovery was documented, and four (3%) died due to COVID-19. Any comorbidity (odds ratio, 2.94; 95% confidence interval [CI], 1.81-5.21), any coinfection (1.74; 95% CI 1.03-3.03) and severe baseline neutropenia (1.82; 95% CI 1.13-3.09) were independently and significantly associated with increasing disease severity.

CONCLUSION

Although most children with cancer had asymptomatic/mild disease, 13% had severe COVID-19 and 3% died. Comorbidity, coinfection and neutropenia may increase the risk of severe disease. Our data may help management decisions in this vulnerable population.

The impact of the COVID-19 pandemic on pediatric cancer care

This editorial contextualizes the work by Sharma et al on the effects of the COVID‐19 pandemic on pediatric cancer care in India.

Radiotherapy based management during Covid-19 pandemic - A systematic review of presented consensus and guidelines

Treatment management of cancer patients in the radiation oncology departments during the current COVID-19 pandemic is challenging. A systematic review of published consensus/guidelines on the role of radiotherapy prioritization, suggested treatment protocols, and set up management was undertaken based on the PRISMA protocol and through PubMed/PMC, Scopus, Google Scholar, Web of Science databases until 01/20/2021. One hundred and sixty-eight publications or regional consensus were included. Summary of recommendations contained: (1) using hypo-fractionated (Hypo-F) regimens for therapeutic/palliative indications, (2) delaying radiotherapy for several weeks or until pandemic over, (3) omitting radiotherapy by replacement of alternative therapies or active surveillance, (4) applying safer patients' setup and preparation protocols, (5) developing telemedicine/telehealth service. To conclude, it is essential to carefully weigh the risk of exposure to COVID-19 infection and the benefit of treating cancer patients during the pandemic. Trying to have a global guideline facing this or any other probable crisis is crucial for health care service.

The Global COVID-19 Observatory and Resource Center for Childhood Cancer: A response for the pediatric oncology community by SIOP and St. Jude Global

The COVID-19 pandemic quickly led to an abundance of publications and recommendations, despite a paucity of information on how COVID-19 affects children with cancer. This created a dire need for a trusted resource with curated information and a space for the pediatric oncology community to share experiences. The Global COVID-19 Observatory and Resource Center for Childhood Cancer was developed, launched, and maintained by the International Society of Pediatric Oncology and St. Jude Children's Research Hospital. The three components (Resource Library, Global Registry, and Collaboration Space) complement each other, establishing a mechanism to generate and transfer knowledge rapidly throughout the community.

The Care of Children With Cancer During the COVID-19 Pandemic

The COVID-19 pandemic has considerably changed health services for children with cancer worldwide by creating barriers throughout the care continuum. Reports available at this time suggest that asymptomatic and mild upper and lower respiratory tract syndromes are the most common presentation of COVID-19 in children with cancer. Nonetheless, severe cases of COVID-19 and deaths secondary to the infection have been reported. In addition to the direct effects of the severe acute respiratory syndrome coronavirus 2, children with cancer have suffered from the collateral consequences of the pandemic, including decreased access to diagnosis and cancer-directed therapy. The COVID-19 pandemic has presented unprecedented challenges to safe and effective care of children with cancer, including their enrollment in therapeutic clinical trials. Data from the Children's Oncology Group and Cancer Research U.K. Clinical Trials Unit show variability in the enrollment of children with cancer in clinical trials during the COVID-19 pandemic. However, the overall effects on outcomes for children with cancer undergoing care during the pandemic remain largely unknown. In this article, we review the current knowledge about the direct and collateral effects of the COVID-19 pandemic, including on clinical trial enrollment and operations.

Teleoncology: The Youngest Pillar of Oncology

The core pillars of multimodal care of patients with cancer are surgical, radiation, and medical oncology. The global pandemic of coronavirus disease 2019 (COVID-19) has suddenly resurrected a new pillar in oncology care: teleoncology. With oncologists reaching out to patients through telemedicine, it is possible to evaluate and fulfill patients’ needs; triage patients for elective procedures; screen them for influenza-like illness; provide them with guidance for hospital visits, if needed; and bridge oral medications and treatments when a hospital visit is not desirable because of any high risk-benefit ratio. Teleoncology can bring great reassurance to patients at times when reaching an oncology center is challenging, and more so in resource-constrained countries. Evidence-based treatment protocols, dispensable by teleoncology, already exist for many sites of cancer and they can provide a bridge to treatment when patients are unable to reach cancer centers for their standard treatment. The young pillar of teleoncology is going to remain much longer than COVID-19.

Radiation Fractionation Schedules Published During the COVID-19 Pandemic: A Systematic Review of the Quality of Evidence and Recommendations for Future Development

PURPOSE

Numerous publications during the COVID-19 pandemic recommended the use of hypofractionated radiation therapy. This project assessed aggregate changes in the quality of the evidence supporting these schedules to establish a comprehensive evidence base for future reference and highlight aspects for future study.

METHODS AND MATERIALS

Based on a systematic review of published recommendations related to dose fractionation during the COVID-19 pandemic, 20 expert panelists assigned to 14 disease groups named and graded the highest quality of evidence schedule(s) used routinely for each condition and also graded all COVID-era recommended schedules. The American Society for Radiation Oncology quality of evidence criteria were used to rank the schedules. Process-related statistics and changes in distributions of quality ratings of the highest-rated versus recommended COVID-19 era schedules were described by disease groups and for specific clinical scenarios.

RESULTS

From January to May 2020 there were 54 relevant publications, including 233 recommended COVID-19-adapted dose fractionations. For site-specific curative and site-specific palliative schedules, there was a significant shift from established higher-quality evidence to lower-quality evidence and expert opinions for the recommended schedules (P = .022 and P < .001, respectively). For curative-intent schedules, the distribution of quality scores was essentially reversed (highest levels of evidence "pre-COVID" vs "in-COVID": high quality, 51.4% vs 4.8%; expert opinion, 5.6% vs 49.3%), although there was variation in the magnitude of shifts between disease sites and among specific indications.

CONCLUSIONS

A large number of publications recommended hypofractionated radiation therapy schedules across numerous major disease sites during the COVID-19 pandemic, which were supported by a lower quality of evidence than the highest-quality routinely used dose fractionation schedules. This work provides an evidence-based assessment of these potentially practice-changing recommendations and informs individualized decision-making and counseling of patients. These data could also be used to support radiation therapy practices in the event of second waves or surges of the pandemic in new regions of the world.

Radiation oncology during COVID-19: Strategies to avoid compromised care

The COVID-19 pandemic will present a range of challenges to radiation oncology departments. Early data suggest that cancer patients carry a higher than average, but still low absolute risk of hospitalization from COVID-19. The risk of severe events for those who are hospitalized however, is high. Resources for usual cancer care will likely be limited. Decisions to alter, delay or omit treatment during this period should consider both the risk of the cancer and of COVID-19 to the patient, as well as resource constraints. There is a need for departments to adapt with goals of maintaining an uninterrupted, high quality service and of minimizing compromise to oncologic care.

Radiotherapy after the easing of public restrictions during COVID-19 epidemic

The daily new confirmed Coronavirus disease 2019 (COVID-19) cases have decreased in some European and Asian countries. Many countries and areas have started to ease public restrictions. Here, we share our experiences and recommendations on how to conduct radiotherapy after public restrictions have eased or upon reopening. Firstly, COVID-19 nucleic acid test screening should be performed for all new admitted patients in areas with enough test capability. Secondly, radiotherapy can be conducted reference to consensus or recommendations on radiotherapy during COVID-19. Thirdly, it is not the time to consider compromising the guidance and the guidance on radiotherapy workflow and protection procedures still should be strictly followed.

Evolution of clinical radiotherapy physics practice under COVID-19 constraints

As the COVID-19 spread continues to challenge the societal and professional norms, radiotherapy around the globe is pushed into an unprecedented transformation. We will discuss how clinical physics has transformed to ascertain safety and quality standards across four facilities around the world through diversity of action, innovation, and scientific flexibility.