Source: Practice recommendations for lung cancer radiotherapy during COVID-19 pandemic: An ESTRO-ASTRO Consensus Statement
View or Download Full Statement (PDF)

 

These are your patients. Experts respond below who should get postponed treatment.
What do you think?

Case 1:
Stage I NSCLC
New diagnosis of stage I, inoperable, peripherally located NSCLC
Institutional standard fractionation of SBRT according to NCCN: 3–4 Fx total dose 45–54 Gy
Case 2:
Stage III NSCLC
Locally advanced stage IIIA (bulky N2) NSCLC
Standard fractionation of radiochemotherapy: 30–33 Fx over 6–6.5 weeks, total dose 60–66 Gy
Case 3: P
ORT NSCLC
Resected N2 (multi-station and extra nodal spread) NSCLC
Standard fractionation of radiotherapy: 27 Fx over 5.5 weeks, total dose 54 Gy
Case 4:
LS SCLC
SCLC, limited stage
Standard fractionation of radiochemotherapy: 30 Fx over 3 weeks, BID, total dose 45 Gy, OR 33 Fx over 6.5 weeks, total dose 66 Gy
Case 5:
PCI LS SCLC
PCI for SCLC limited stage after good response to radiochemotherapy
Standard fractionation of radiotherapy: 10 Fx over 2 weeks, total dose 25 Gy
Case 6:
palliative NSCLC
Palliative metastatic NSCLC with failure after first-line chemo-IO combination and symptoms due to mediastinal/hilar disease progression and severe cough and moderate dyspnea.

 

Would you recommend postponing the initiation of treatment by 4–6 weeks?
CaseResponse
Case 1: stage I NSCLCYes: 43%
No: 57%
Case 2: stage III NSCLCYes: 4%
No: 96% (strong consensus)
Case 3: PORT NSCLCYes: 82% (strong consensus)
No: 18%
Case 4: LS SCLCYes: 11%
No: 89% (strong consensus)
Case 5: PCI SCLCYes: 70% (consensus)
No: 30%
Case 6: Palliative NSCLCYes: 4%
No: 96% (strong consensus)

 

Table 2 Questions in the first round of the Delphi process.
Early pandemic scenario 1 – risk mitigation
All casesDo you recommend that physicians change their radiotherapy practice to address the challenges in this early phase of the COVID-19 pandemic? (i.e. risks due to multiple visits, susceptibility of lung cancer patients to COVID-19 morbidity/mortality)
All casesWould you recommend postponing the initiation of treatment by 4–6 weeks?
All casesWould you recommend hypofractionating beyond your usual fractionation?
Case 1–3Would your answers to questions #2 and #3 above change if the tumor was mutation positive (EGFR or ALK) or PD-L1 positive (i.e. >50%)?
Case 2Would you recommend induction therapy in this case?
All casesIf you recommended hypofractionation, what would be the maximum degree of hypofractionation you would propose to a patient in your clinical service?
Specify the total dose, number of fractions, total treatment time, and provide any pertinent references if available.
All casesIf this patient was COVID-19 positive before starting treatment, would you postpone RT until the patient becomes asymptomatic and the test for COVID-19 negative?
All casesIf this patient became COVID-19 positive after starting treatment, would you recommend interrupting RT until the patient becomes asymptomatic and the test for COVID-19 negative?
Case 1Case 1B: An operable patient with stage I NSCLC is referred to you by a thoracic surgeon because timely access to surgery is not available due to surgical capacity issues. Would you treat with SABR/SBRT?
Case 2Would you recommend starting with induction chemotherapy to postpone the start of radiation?
Later pandemic scenario 2 – reduced radiotherapy resources
All casesHow highly would you prioritize this patient’s treatment compared to all other cancer patients in your centre?
All casesIf there was a critical shortage of RT capacity, would you recommend further hypofractionation beyond what you have described above?
All casesIf you answered yes to the question above, what would be the maximum degree of hypofractionation you would propose to a patient in your clinical service?
Specify the total dose, number of fractions, total treatment time, and provide any pertinent references if available
All casesIn the setting of reduced RT capacity, if this patient was COVID-19 positive before the start of treatment, what would be the maximum duration to postpone the initiation of radiotherapy (in weeks)?
All casesIn the setting of reduced RT capacity, if this patient became COVID-19 positive after starting treatment, would you recommend interrupting RT until the patient becomes asymptomatic and the test for COVID-19 negative?
OverallPlease rank the six cases in order of priority, starting with the highest-priority case, in the setting of reduced resources
OverallIf you were to triage patients for treatment, in the setting of reduced RT resources, please provide up to 5 factors that you would use to decide who gets treatment, in order of importance

 

Would you recommend hypofractionating beyond your usual fractionation?
CaseStandard fractionationsResponseMaximum degree of hypofractionation supported
Case 1: stage I NSCLCSBRT: 45–54 Gy in 3 Fx, 48 Gy in 4 fractionsYes: 50%
No: 50%
30–34 in 1 Fx [17]: 90% support if choosing hypofractionation (strong consensus)
Case 2: stage III NSCLCRadiochemotherapy: 60–66 Gy in 30–33 Fx over 6–6.5 weeksYes: 46%
No: 54%
Case 3: PORT NSCLCPORT: 50–60 Gy over 5–6 weeksYes: 29%
No: 71%
(consensus)
Case 4: LS SCLCRadiochemotherapy: 60–66 Gy in 30–33 Fx over 6–6.5 weeks, or 45 Gy in 30 Fx over 3 weeks using BID fractions of 1.5 GyYes: 33%
No: 67%
(consensus)
Case 5: PCI SCLCPCI: 25 Gy in 10 Fx over 2 weeksYes: 7%
No: 93% (strong consensus)
Case 6: Palliative NSCLC30 Gy in 10 Fx over 2 weeksYes: 89% (strong consensus)
No: 11%
Favored fractionations:
20 Gy in 5 Fx (30%) [18]
17 Gy in 2 Fx (37%) [19]
8–10 Gy in 1Fx (33%) [20]

View all responses.

M. Guckenberger, C. Belka, A. Bezjak et al., Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic:
An ESTRO-ASTRO consensus statement, Radiotherapy and Oncology, https://doi.org/10.1016/j.radonc.2020.04.001