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.