Thread by @cpeedell

THREAD for cancer patients: Why we need to change radiotherapy practice during #COVID19 pandemic.
Radiotherapy is the practice of treating cancer with high energy Xrays. 1 in 2 cancer patients will need radiotherapy at some point which may be with curative or palliative intent #1

Patients having curative radiotherapy generally receive 20-30 daily treatments lasting a few minutes, over a period of 4-6 weeks. Palliative treatments are much shorter eg typically 1-5 visits #COVID19 #coronavirus #radonc #2

The pandemic is going to cause serious issues with cancer treatment, including radiotherapy. The biggest issue will be staffing problems, as many staff will have to self-isolate if they get a fever or cough. It’s happening right now. This will reduce the capacity of the system #3

Another key issue is that cancer is generally a disease of older age, which is the at risk population that needs to minimise exposure to the virus. Since most Radiotherapy Depts are attached to large hospitals, where patients with the virus are being treated, this is a problem #4

We are therefore going to need to find innovative ways to keep the system going and minimise visits to the hospital. The key principles will be to treat those in most need and with the most to gain, and reduce the number of radiotherapy visits without compromising care #5

Luckily, over the last few yrs there have been major advances in radiotherapy that have increased accuracy of treatment. We can now give higher doses in fewer treatments, to achieve increased cure rates with lower toxicity. This is exactly what we need now to reduce visits #6

If we reduce the number of radiotherapy visits (fractions) to our departments throughout the UK, then we will able to deliver the service with fewer machines and staff. In other words, we can potentially cope with the upcoming crisis #7

The key is to focus on the common cancers which have the greatest demand on radiotherapy services, which are breast cancer, prostate cancer and lung cancer (accounting for 2/3 of all radiotherapy). Fortunately, we can safely reduce the number of treatments in all these cancers #8

For example, some radiotherapy treatments are of marginal benefit, providing no increase in survival rate, so in a crisis it is completely reasonable to omit these treatments. An example would be radiotherapy to the breast after surgical removal of a low grade small cancer #9

Other radiotherapy treatments can be safely delayed. Early stage prostate cancer is an example. We can keep an eye on the lowest risk patients by monitoring a blood test (PSA), and higher risk patients can be safely treated with hormones prior to radiotherapy for many months #10

In other situations we can safely reduce the number of fractions, by increasing dose per fraction. In breast cancer we can give 5 fractions instead of 15. This is based on a big UK trial (about to be published), but breast community is rightly going with it before publication #11

Lung cancer is another example where we can increase the cure rate by using a technique called Stereotactic Ablative Body Radiotherapy (SABR or SBRT). This means that we can treat early stage lung cancers with 1-5 treatments instead of 20-35. #12

Moreover, if the pandemic forces closure of thoracic surgery theatres to transform into temporary ITUs, then we can use SBRT instead of thoracic surgery to cure early lung cancers. The cure rate may be very close to that of surgery (trials ongoing to confirm). #13

My dept has estimated that if we adopt the above measures, we can do the work of 6 radiotherapy machines with only 4 machines, without harming patient outcomes. We may then have enough staff to run a “hot Linac” to treat patients who have COVID19 infection and curable cancer #14

Finally, I would like to mention the value of @Twitter that has allowed the UK #radonc community to communicate with experts in the field all over the world to plan for the dark days ahead. Let’s continue on with hope, collaboration, innovation, pragmatism & hard work! #15

PS I should also mention just a few of the social media #radonc community that are trailblazing the way
@subatomicdoc @DrAndrewLoblaw @drdavidpalma @gerryhanna @_ShankarSiva @DrSpratticus @DrewMoghanaki @fifimcdrmh @achoud72 @finn_corinne @BreastDocUK @Rad_Nation @RCRadiologists