DISCUSSION
Radiation treatment management of HNC patients in the COVID-19 era is challenging. As Lombardy was the first European area affected form COVID-19 pandemic, guidelines and recommendation for RT in HNC patients were very limited at that time. Therefore, our Department approved extra-caution measurements to maintain adequate safety standards for both patients and healthcare personnel to minimize the risk of transmission. Our experience has shown that the designation as an oncological hub, together with internal procedures, allowed to preserve our standard of care while protecting health professionals treating HNC patients.
As COVID-19 likely binds to epithelial cells in the nasal cavities and the oropharynx20, aerosolized droplets from infected patients determine a high risk of transmission during the whole HNC clinical workflow, from diagnosis (i.e. physical examination, trans-oral endoscopy) to treatment delivery (i.e. surgery, RT± systemic therapy)5. During the emergency, it was difficult to identify a clear cut between our duty to provide optimal care and the one to protect healthcare professional and their families from infection5. Specifically, contamination reduction had to be balanced with the need of guaranteeing access to the best treatment options, as per national and international guidelines6. If an absolute solution to this ethical question is probably impossible to be found, the issue has been debated by some authors. Shuman et al advocate for a deliberate effort towards balancing exposure and maintaining moral and professional integrity in patient care21.
An additional concern for HNC patients who undergo RT is the counterbalance between the benefit of a timely delivered treatment and the risk of contracting COVID-19 infection during the 7 weeks of an average curative-intent irradiation. In this regard, Bhattacharjee et al developed a multistate and hazard model to simulate the risk of death from disease progression vs the risk of death from COVID-19 infection in patients diagnosed with stage IV cancer of the oral cavity22. Given the risks of hospital admission, the authors suggest to defer treatment in this subset of HNC patients and to make efforts to minimize the chance of infection. While statistical models can provide reasonable solution to practical and ethical problems in the COVID-19 era, there was an unmet need for practice recommendations encompassing different clinical scenarios (i.e. curative vs adjuvant treatments, high-risk vs low-risk adjuvant settings). To this aim, a joint effort by the ASTRO and ESTRO has produced an expert consensus statement for five common cases of HN carcinoma7. While the reader is invited to refer to the full recommendations, we would like to focus on the need of adequately prioritizing treatment at the time of limited resources. Of note, as the authors claim, all measurements and recommendations need to be weighted according to the extent and duration of the pandemic across nations and regions, which are hardly predictable and constantly evolving7. As hospitals represent critical areas in the epidemiology of the disease: it is therefore straightforward to understand how critical it is to keep transmission rates as low as possible in all healthcare facilities. The rationale of oncological hubs instituted in March 2020 is to provide the best treatment options to the highest number of safely eligible patients, in order to preserve oncological outcomes of these populations. Our experience shows that these measures were effective in limiting cross infections for candidates to curative-intent RT for HNC. Overall, we did not experience a significant reduction in the number of treated patients, while maintaining high quality standards for delivered treatments.
In the context of HNCs, IMRT has proven to be superior to 3-dimensional conformal radiotherapy in reducing both acute and long-term treatment-related side effects (i.e. xerostomia, dysphagia) without jeopardizing oncological outcomes23–25. Coherent with these results, we decided not to modify our planning strategies and to prioritize the maintenance of high-quality treatment standards for our patients. To this aim, set-up accuracy is an essential condition to ensure a safe and effective treatment delivery. Therefore, in order to assure an accurate set-up, our immobilization device is provided with a mouthpiece-assisted bite for every curative-intent treatment. A previous study from our Department showed that using this device maintain the set-up error within 5 mm in all directions26. As we did not test the outcomes of patients’ positioning without a mouthpiece-assisted bite, we favored to maintain our standard immobilization procedures despite they could not allow patients to wear surgical masks. Accordingly, all Radiation Therapists managing HNC patients were considered at high risk of COVID-19 infection and equipped with personnel protection accordingly. Therefore, they were instructed to safely use PPE, as well as to adequately sanitize treatment rooms and any equipment in contact with patients. Results of our report highlight that to maintain a high quality standard of care, RT for HNC patients requires adequate personal protection as well as a department re-organization to optimize the room sanitization.
Considering that a percentage of individuals ranging from 13% to 30% were found to be COVID-19 asymptomatic, all HNC patients were considered as potentially COVID-19 carriers6,27. One of the limitations in our management was the impossibility to perform a swabs-based screening to all patients prior to the beginning of RT. A Chinese respective cohort study has underlined that the correct use of PPE prevented all 41 healthcare workers included in the analysis from being infected following the contact with COVID-19-positive patients28,29. Despite higher probability of contact with COVID-19 infected patients, Lombardy centers received, less PPE than the Italian average, most probably due to insufficient supply at the beginning of the outbreak. As an example, FFP2 and FFP3 provisions to the healthcare personnel were approximately 2 and 3 times lower in Lombardy than other regions, respectively1. Therefore, at our Department during the first weeks of the outbreak, priority for PPE assignment was given to those managing HNC patients. Arguably, this strategy probably contributed to reduce cross-infections between potentially COVID-19 positive HNC patients and health care providers. The relatively limited number of COVID-19 cases among health professionals in our Department could therefore be explained by contacts with asymptomatic carriers before rigorous self-protection measurements were introduced. Encouragingly, no other cases were diagnosed among our Colleagues recently. This might suggest that the high risk of cross-infection of HNC patients management was mitigated by the use of adequate PPE.
We are well aware that further protective measurements could have been taken. Possibly, the risk of viral dissemination could have been further reduced by defining two separate working shifts for health care professionals, as well as by creating separate areas for patients at higher risk for COVID-19 infection. Serological screenings for the whole staff have been executed only in a minority of swab-proven cases, while a systematic testing is programmed for the upcoming weeks. However, at the time of the outbreak available guidelines and/or recommendation were scares and admittedly, the pandemic urged us to quickly address unprecedented issues and to balance patients’ and personnel’s safety and oncological indications.
Overall, the peculiarities of our experience derive from our designation as an oncological hub in an area of severe COVID-19 outbreak, from the patients’ volume and from the need (especially in the early phases of the emergency) of optimizing the use PPE. However, our aim is far from being either educational or didactic. The current work should in fact be considered as an early report of our management for HNC patients at the time of an unprecedented global health crisis. Nevertheless, we believe that it could be useful to provide our Fellow Radiation Oncologists with a set of indication covering Department organization in providing patients’ and health professionals protection.
Conclusion: We presented the first report analyzing the beginning of COVID-19 pandemic in Europe with a dedicated focus on HNC patients candidate to curative radiation treatments. Results of the present work show that an adequate and well-timed organization (both in terms of national/regional and Institutional rules) permitted us to maintain a high quality radiation therapy standards of care, balancing the best clinical practice with healthcare personnel’s safety.