This document discusses recommendations for using hypofractionated radiotherapy schedules during the COVID-19 pandemic for various cancer types. It recommends omitting or shortening radiotherapy treatment for breast and other cancers to reduce patient visits and exposure. For breast cancer, it suggests 5 fraction schedules or omitting radiotherapy for some low risk patients. For head and neck cancers it recommends simultaneous integrated boost techniques. For lung cancer it discusses hypofractionated IMRT schedules. For prostate cancer it recommends the shortest safe 5-7 fraction EBRT regimen.

1. Hypofractionated Radiotherapy
During COVID-19 Pandemic
Prof Amin E AAmin
Dean of the Higher Institute of Optics Technology
&
Prof of Medical Physics
Radiation Oncology Department
Faculty of Medicine
Ain Shams University

2. Introduction
❖ During COVID-19 Pandemic, it is needed to suppress coronavirus
spread by minimizing travelling of patients for daily treatments and
the exposure of hospital and radiotherapy staff.
❖ And because of shortage in radiotherapy resources due to staff
sickness or leave for family care entailing allocation of resources
and triage of patients.
❖ The use of hypofractionated radiotherapy (radiation schedules that
are shorter in overall treatment time, lower number of fractions
with larger fraction size) could help address the latter two concerns.

3. Prioritizing Radiotherapy Treatments
• In March 2020 The National Institute for Health and Care Excellence
published a “COVID-19 rapid guideline: delivery of radiotherapy”.
This guideline showed the principles of prioritizing radiotherapy.
In case radiotherapy treatment got to be prioritized, take into
consideration the following:
❖ balancing the chance of cancer not being treated optimally with the hazard of
the patient getting to be genuinely sick from COVID-19.
❖ patient-specific risk factors, including comorbidities and any risk of them
being immunosuppressed.
❖ service capacity issues, such as limited resources (workforce, facilities,
anesthetics, equipment).

4. Prioritizing Radiotherapy Treatments
• Use the following priority classification to assist make these
decisions.

5. 1st Periority
❖Radical radiotherapy or chemoradiotherapy with curative intent, if:
➢the patient has a category 1 (rapidly proliferating) tumor and
➢treatment has already started and
➢there is little or no possibility of compensating for treatment gaps.
❖External beam radiotherapy with subsequent brachytherapy, if:
➢the patient has a category 1 (rapidly proliferating) tumour and
➢external beam radiotherapy has already started.
❖Radiotherapy that has not started yet, if:
➢ the patient has a category 1 (rapidly proliferating) tumour and
➢ they would normally start treatment, based on clinical need or current
cancer treatment waiting times.

6. 2nd Priority
• Urgent palliative radiotherapy, for patients with malignant
spinal cord compression who have salvageable neurological
function.

7. 3rd Priority
❖Radical radiotherapy for a category 2 (less aggressive)
tumour, if radiotherapy is the first treatment with curative
intent.
❖Post-operative radiotherapy, if:
➢the patient has a tumour with aggressive biology or
➢they have had surgery, but there is known residual disease.

8. 4th Priority
• Palliative radiotherapy, where improving symptoms would
reduce the need for other interventions.

9. 5th Priority
❖Adjuvant radiotherapy, if:
➢the disease has been completely resected and
➢there is a less than 20% risk of local recurrence at 10 years.
❖Radical radiotherapy for prostate cancer, in patients having
neoadjuvant hormone therapy.

10. Essential Considerations
• Do not treat benign conditions with radiotherapy unless there is an
immediate threat to life or function.
• Make prioritization decisions as part of a multidisciplinary team
and ensure each patient is considered on an individual basis.
Ensure the reasoning behind each decision is recorded.
• Clearly communicate, with written documentation if possible,
what prioritization is and the reason for the decision to patients,
their families and careers.

11. Hypofractionated Radiotherapy
for Breast Cancer During COVID-
19 Pandemic

12. Cole et al (2020)
• Cole et al (2020) issued International Guidelines on Radiation
Therapy for Breast Cancer During the COVID-19 Pandemic.
In this guidelines they suggested the following
recommendations.

13. 1st Recommendation
• Omit RT for patients 65 years and over (or younger with relevant
co-morbidities) with invasive breast cancer that are up to 30mm
with clear margins, grade 1e2, oestrogen receptor (ER) positive,
human epidermal growth factor receptor 2 (HER2) negative and
node negative who are planned for treatment with endocrine
therapy.
• Trials investigating safe omission of RT can be considered if they
do not impact on patients visits and resources are available.
Centres may also consider omitting RT for ductal carcinoma in-situ
(DCIS) depending on individual risk and benefit.

14. 2nd Recommendation
• Deliver RT in 5 fractions only for all patients requiring RT with
node negative tumors that do not require a boost. Options include
28-30Gy in once weekly fractions over 5 weeks or 26Gy in 5 daily
fractions over 1 week as per the FAST and FAST Forward trials
respectively.
• Partial breast RT using 28.5-6Gy in 5 fractions over 1-2 weeks can
also be considered for selected patients if resources are available for
increased complexity and/or to avoid deep inspiration breath hold
(DIBH) for leftsided tumours in the upper half of the breast (if
DIBH impacts on treatment time). N.B. IMPORT Low has the same
fractionation schedule in the control group as FAST Forward so
26Gy in 5 fractions over 1 week could also be proposed in the
partial breast irradiation setting.

15. 3rd Recommendation
• Boost RT should be omitted to reduce fractions and/or complexity
in the vast majority of patients unless they 40 years old and under,
or over 40 years with significant risk factors for local relapse.
• Boost RT has no proven survival advantage so risks and benefits
during the COVID-19 pandemic need to be reevaluated. An
example of a significant risk factor is the presence of involved
resection margins where further surgery is not possible. Any boost
should be either simultaneous and integrated to minimise fractions
if resource permits or hypofractionated sequential, e.g. 12Gy in 4
fraction over 4 days.

16. 4th Recommendation
• Nodal RT can be omitted in post-menopausal women requiring
whole breast RT following sentinel lymph node biopsy and
primary surgery for T1, ER positive, HER2 negative G1-2 tumors
with 1e2 macrometastases.
• This approach gives this group of patients the option of 5
fractions of RT, and may reduce complexity of
planning/treatment.

17. 5th Recommendation
• Moderate hypofractionation should be used for all breast/chest
wall and nodal RT, e.g. 40Gy in 15 fractions over 3 weeks.
• The use of moderate hypofractionation is already the standard of
care inmany countries and in the altered risk benefit context of a
pandemic should be strongly considered in patients with breast
reconstruction. However, many centres will halt immediate
reconstruction during the pandemic as this is not essential cancer
surgery.

18. Head & Neck Cancer

19. De Felice et al (2020)
• De Felice et al (2020) recommended to shorten overall treatment
time in radiotherapy for head and neck during COVID-19 Pandemic.
• Definitive radiotherapy should be limited to simultaneous integrated
boost (SIB) techniques in the standard (5 fractions per week) or
accelerated schedule (6 fractions per week), in order to achieve a 1-
week reduction compared to sequential technique.
• SIB technique represents an optimum balance between tumor control
and prevention of late toxicity excess.
• Delay post-operative RT in patients with salivary gland tumors until
12 weeks after surgery. Time factor is not strictly linked to adverse
effect in these cases.

20. Radiotherapy For Locally Advanced
Non-small Cell Lung Cancer During
The COVID-19 Pandemic

21. Kumar et al (2020)
Kumar et al recommended the following in radiotherapy for
Locally Advanced Non-small Cell Lung Cancer During The
COVID-19 Pandemic;
• Utilize IMRT with a hypofractionated schedule.
• Elective nodal coverage is not needed and may increase toxicity
• In the absence of pathological hilar or mediastinal staging treat
all hypermetabolic lymph nodes as if they are positive for
disease. If CT with contrast was used alone, consider treatment
of all lymph nodes > 1 cm in short axis

22. Hypofractionated Radiation Therapy
Schedules For LA-NSCLC
• They summarized some commonly used hypofractionated
radiotherapy schedules for LA-NSCLC. These schedules are
shown in the following tables.
Total Dose
(Gy)
Number
of
Fractions
Dose per
Fraction
(Gy)
Biologically Effective
Dose in Gy (BED) for a/b
= 10 Gy
60 15 4 84
60 20 3 78
55 20 2.75 70

23. Management Of Prostate Cancer
During The Covid-19 Pandemic

24. Recommendations Of The NCCN
• According to the recommendations of the National
Comprehinsive Cancer Network (NCCN); If it is deemed safe
for patients to receive radiotherapy, the shortest safe external
beam radiotherapy (EBRT) regimen should be used. This can
consist of 5 to 7 fractions, consistent with current NCCN
Guidelines.