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APRIL 08, 2020 -- A major comprehensive cancer center at the epicenter of the New York City COVID-19 storm is preparing to scale back palliative radiation therapy (RT), anticipating to focus on only oncologic emergencies.
"We're not there yet, but we're anticipating when the time comes in the next few weeks that we will have a system in place so we are able to handle it," Jonathan Yang, MD, PhD, from the Memorial Sloan Kettering Cancer Center (MSKCC) in New York City, told Medscape Medical News.
Yang and an expert panel of colleagues reviewed high-impact evidence, prior systematic reviews, and national guidelines to compile a set of recommendations for triage and shortened palliative rRT at their center, should the need arise.
The recommendations on palliative radiotherapy for oncologic emergencies in the setting of COVID-19 appear in a preprint version in Advances in Radiation Oncology, released by the American Society of Radiation Oncology.
Yang says the recommendations are a careful balance between the risk of COVID-19 exposure of staff and patients with the potential morbidity of delaying treatment.
"Everyone is conscious of decisions about whether patients need treatment now or can wait," he told Medscape Medical News. "It's a juggling act every single day, but by having this guideline in place, when we face the situation where we do have to make decisions, is helpful."
The document aims to enable swift decisions based on best practice, including a three-tiered system prioritizing only "clinically urgent cases, in which delaying treatment would result in compromised outcomes or serious morbidity."
"It's brutal, that's the only word for it. Not that I disagree with it," commented Padraig Warde, MB BCh, professor, Department of Radiation Oncology, University of Toronto, and radiation oncologist, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
Like many places, Toronto is not yet experiencing the COVID-19 burden of New York City, but Warde says the MSKCC guideline is useful for everyone. "Other centers should review it and see how they could deal with resource limitations," he said. "It's sobering and sad, but if you don't have the staff to treat all patients, which particular patients do you choose to treat?"
In a nutshell, the MSKCC recommendations defines Tier 1 patients as having oncologic emergencies that require palliative RT, including "cord compression, symptomatic brain metastases requiring whole-brain radiotherapy, life-threatening tumor bleeding, and malignant airway obstruction."According to the decision-making guideline, patients in Tiers 2 and 3 would have their palliative RT delayed. This would include Tier 2 patients whose needs are not classified as emergencies, but who have either symptomatic disease for which RT is usually the standard of care or asymptomatic disease for which RT is recommended "to prevent imminent functional deficits." Tier 3 would be symptomatic or asymptomatic patients for whom RT is "one of the effective treatment options."
"Rationing is always very difficult because as physicians you always want to do everything you can for your patients but we really have to strike the balance on when to do what, said Yang. The plan that he authored anticipates both reduced availability of radiation therapists as well as aggressive attempts to limit patients' infection exposure.
"If a patient's radiation is being considered for delay due to COVID-19, other means are utilized to achieve the goal of palliation in the interim, and in addition to the tier system, this decision is also made on a case-by-case basis with departmental discussion on the risks and benefits," he explained.
"There are layers of checks and balances for these decisions...Obviously for oncologic emergencies, radiation will be implemented. However for less urgent situations, bringing them into the hospital when there are other ways to achieve the same goal, potential risk of exposure to COVID-19 is higher than the benefit we would be able to provide."
The document also recommends shorter courses of RT when radiation is deemed appropriate.
"We have good evidence showing shorter courses of radiation can effectively treat the goal of palliation compared to longer courses of radiation," he explained. "Going through this pandemic actually forces radiation oncologists in the United States to put that evidence into practice. It's not suboptimal care in the sense that we are achieving the same goal — palliation. This paper is to remind people there are equally effective courses of palliation we can be using."
"[There's] nothing like a crisis to get people to do the right thing," commented Louis Potters, MD, professor and chair of radiation medicine at The Feinstein Institutes, the research arm of Northwell Health, New York's largest healthcare provider.
Northwell Health has been at the epicenter of the New York outbreak of COVID-19. Potters writes on an ASTRO blog that, as of March 26, Northwell Health "has diagnosed 4399 positive COVID-19 patients, which is about 20% of New York state and 1.2% of all cases in the world. All cancer surgery was discontinued as of March 20 and all of our 23 hospitals are seeing COVID-19 admissions, and ICU care became the primary focus of the entire system. As of today, we have reserved one floor in two hospitals for non-COVID care such as trauma. That's it."
Before the crisis, radiation medicine at Northwell consisted of eight separate locations treating on average 280 EBRT cases a day, not including SBRT/SRS and brachytherapy cases. "That of course was 3 weeks ago," he notes.
Commenting on the recommendations from the MSKCC group, Potters told Medscape Medical News that the primary goal "was to document what are acceptable alternatives for accelerated care."
"Ironically, these guidelines represent best practices with evidence that — in a non-COVID-19 world — make sense for the majority of patients requiring palliative radiotherapy," he said.
Potters said there has been hesitance to transition to shorter radiation treatments for several reasons.
"Historically, palliative radiotherapy has been delivered over 2 to 4 weeks with good results. And, as is typical in medicine, the transition to shorter course care is slowed by financial incentives to protract care," he explained.
"In a value-based future where payment is based on outcomes, this transition to shorter care will evolve very quickly. But given the current COVID-19 crisis, and the risk to patients and staff, the incentive for shorter treatment courses has been thrust upon us and the MSKCC outline helps to define how to do this safely and with evidence-based expected efficacy."
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