Source: Practice recommendations for lung cancer radiotherapy during COVID-19 pandemic: An ESTRO-ASTRO Consensus Statement
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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? | |
| Case | Response |
| Case 1: stage I NSCLC | Yes: 43% No: 57% |
| Case 2: stage III NSCLC | Yes: 4% No: 96% (strong consensus) |
| Case 3: PORT NSCLC | Yes: 82% (strong consensus) No: 18% |
| Case 4: LS SCLC | Yes: 11% No: 89% (strong consensus) |
| Case 5: PCI SCLC | Yes: 70% (consensus) No: 30% |
| Case 6: Palliative NSCLC | Yes: 4% No: 96% (strong consensus) |
Table 2 Questions in the first round of the Delphi process.
| Early pandemic scenario 1 – risk mitigation | |
| All cases | Do 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 cases | Would you recommend postponing the initiation of treatment by 4–6 weeks? |
| All cases | Would you recommend hypofractionating beyond your usual fractionation? |
| Case 1–3 | Would 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 2 | Would you recommend induction therapy in this case? |
| All cases | If 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 cases | If 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 cases | 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? |
| Case 1 | Case 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 2 | Would you recommend starting with induction chemotherapy to postpone the start of radiation? |
| Later pandemic scenario 2 – reduced radiotherapy resources | |
| All cases | How highly would you prioritize this patient’s treatment compared to all other cancer patients in your centre? |
| All cases | If there was a critical shortage of RT capacity, would you recommend further hypofractionation beyond what you have described above? |
| All cases | If 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 cases | In 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 cases | In 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? |
| Overall | Please rank the six cases in order of priority, starting with the highest-priority case, in the setting of reduced resources |
| Overall | If 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? | |||
|---|---|---|---|
| Case | Standard fractionations | Response | Maximum degree of hypofractionation supported |
| Case 1: stage I NSCLC | SBRT: 45–54 Gy in 3 Fx, 48 Gy in 4 fractions | Yes: 50% No: 50% |
30–34 in 1 Fx [17]: 90% support if choosing hypofractionation (strong consensus) |
| Case 2: stage III NSCLC | Radiochemotherapy: 60–66 Gy in 30–33 Fx over 6–6.5 weeks | Yes: 46% No: 54% |
|
| Case 3: PORT NSCLC | PORT: 50–60 Gy over 5–6 weeks | Yes: 29% No: 71% (consensus) |
|
| Case 4: LS SCLC | Radiochemotherapy: 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 Gy | Yes: 33% No: 67% (consensus) |
|
| Case 5: PCI SCLC | PCI: 25 Gy in 10 Fx over 2 weeks | Yes: 7% No: 93% (strong consensus) |
|
| Case 6: Palliative NSCLC | 30 Gy in 10 Fx over 2 weeks | Yes: 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] | |||
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
