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Covid-19 HSE Clinical Guidance and Evidence

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NCCP advice for medical professionals on the management of patients undergoing lung cancer radiotherapy in response to the current novel coronavirus COVID 19 pandemic

NCCP advice for medical professionals on the management of patients undergoing lung cancer radiotherapy in response to the current novel coronavirus COVID 19 pandemic (CD 19-186/18.06.20)


  • This document relates to patients who do not have COVID-19 or are not suspected of having COVID-19.
  • Current events surrounding the COVID-19 pandemic are challenging and all public health bodies are placing the safety of patients, staff and communities first in all decisions.
  • This is an evolving situation. This advice is based on current information, it is additional to the advice of the NPHET, the HSE and the DoH, and will be updated as necessary.
  • The NCCP acknowledges that each hospital is working under individual constraints, including staff and infrastructure, and as a result will implement this advice based on their own unique circumstances.
  • The purpose of this advice is to maximise the safety of patients and make the best use of HSE resources, while protecting staff from infection. It will also enable services to match the capacity for cancer care to patient needs if services become limited due to the COVID-19 pandemic.
  • Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment.

NPHET, HSE and DoH advice

Hospitals will operate under the overarching advice of the National Public Health Emergency Team (NPHET), the HSE and the DoH. Information is available at:


Purpose
  • The purpose of this document is to provide guidance to medical professionals on the management of patients undergoing lung cancer radiotherapy during the COVID-19 pandemic.
  • In general, lung cancers are at high risk of progression and delaying treatment has been demonstrated to have a detrimental effect on outcome (1-4).
     
Scope
  • The scope of this guidance document is the radical and palliative management of lung cancer.
  • It does not include recommendations on the management of brain metastasis treated with intracranial stereotactic radiosurgery (SRS).

Pathological subtype and staging

The present document refers to:

  • 2015 WHO classification for lung cancer pathology
  • Lung Cancer TNM 8th classification
     

Recommendations for lung cancer radiotherapy during the COVID-19 pandemic

  • These recommendations are in line with international guidelines for the COVID-19 pandemic (5).


Alternative Treatment indications

In the context of the COVID-19 crisis, three alternative therapeutic options are considered:

  • Standard = indication and timing as per standard (but radiotherapy schedule can be modified)
  • Delay = indication confirmed, but a delay in initiation of treatment is acceptable (e.g. a limited delay including a period of observation)
  • Omit = consider no treatment in light of an unfavourable risk/benefit ratio.

 

Proposed Implementation according to capacity

Please refer to ‘NCCP advice on radiation therapy capacity escalation plan in response to the current COVID-19 pandemic’ for further information

186
 

Radical Radiotherapy/SABR (Non-metastatic NSCLC & Limited Stage SCLC)

186_2

186_3


Palliative Radiotherapy

186emergency

nonemergency186
 

Consolidation Radiotherapy for Extensive Stage Small Cell Lung Cancer
extensice186
 
Radiotherapy Schedules Recommendations

Taking into consideration the department workforce availability and the individual patient risk benefit of multiple attendances in the radiotherapy benefit, alternative hypofractionated radiation schedule can be considered when applicable.

Radical Radiotherapy

sabr186

2tables
 

Palliative Radiotherapy

bone186
 

Consolidation Radiotherapy

consolidation186
 

Guidance Development Group

This guidance was developed in conjunction with St. Luke’s Radiation Oncology Network.

  • Dr Carol McGibney, Consultant Radiation Oncologist
  • Dr Pierre Thirion, Consultant Radiation Oncologist
  • Dr Cormac Small, Consultant Radiation Oncologist
  • Dr David Fitzpatrick, Consultant Radiation Oncologist
  • Dr Eve O’Toole, Guideline Lead, NCCP
  • Ms Ruth Ryan, Programme Manager, NCCP
  • Ms Louise Murphy, Research Officer, NCCP

 

References
  1. Mohammed, N., Kestin, L.L., Grills, I.S., Battu, M., Fitch, D.L., Wong, C.Y.O., Margolis, J.H., Chmielewski, G.W. and Welsh, R.J., 2011. Rapid disease progression with delay in treatment of non–small-cell lung cancer. International Journal of Radiation Oncology* Biology* Physics, 79(2), pp.466-472.
  2. Bullard, J.T., Eberth, J.M., Arrington, A.K., Adams, S.A., Cheng, X. and Salloum, R.G., 2017. Timeliness of Treatment Initiation and Associated Survival Following Diagnosis of Non–Small-Cell Lung Cancer in South Carolina. Southern medical journal, 110(2), p.107.
  3. Olsson, J.K., Schultz, E.M. and Gould, M.K., 2009. Timeliness of care in patients with lung cancer: a systematic review. Thorax, 64(9), pp.749-756.
  4. Chen, C.P., Weinberg, V.K., Jahan, T.M., Jablons, D.M. and Yom, S.S., 2011. Implications of delayed initiation of radiotherapy: accelerated repopulation after induction chemotherapy for stage III non-small cell lung cancer. Journal of Thoracic Oncology, 6(11), pp.1857-1864.
  5. Guckenberger, M., Belka, C., Bezjak, A., Bradley, J., Daly, M.E., DeRuysscher, D., Dziadziuszko, R., Faivre-Finn, C., Flentje, M., Gore, E. and Higgins, K.A., 2020. Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement. Radiotherapy and Oncology.
  6. Seto, T., Takahashi, T., Yamanaka, T., Harada, H., Nokihara, H., Saka, H., Nishio, M., Nakagawa, K., Takayama, K., Ishimoto, O. and Takeda, K., 2014. Prophylactic cranial irradiation (PCI) has a detrimental effect on the overall survival (OS) of patients (pts) with extensive disease small cell lung cancer (ED-SCLC): Results of a Japanese randomized phase III trial.
  7. Slotman, B.J. and van Tinteren, H., 2015. Which patients with extensive stage small-cell lung cancer should and should not receive thoracic radiotherapy? Translational lung cancer research, 4(3), p.292.
  8. Royal College of Radiologists, 2020. Reduced fractionation in lung cancer patients treated with curative-intent radiotherapy during COVID-19 pandemic Guideline document by collaboration of Clinical Oncologists for Lung Cancer published on website of Royal College of Radiologists
  9. Maguire, J., Khan, I., McMenemin, R., O’Rourke, N., McNee, S., Kelly, V., Peedell, C. and Snee, M.S.O.C.C.A.R., 2014. SOCCAR: A randomised phase II trial comparing sequential versus concurrent chemotherapy and radical hypofractionated radiotherapy in patients with inoperable stage III Non-Small Cell Lung Cancer and good performance status. European journal of cancer, 50(17), pp.2939-2949.
  10. Xia, B., Hong, L.Z., Cai, X.W., Zhu, Z.F., Liu, Q., Zhao, K.L., Fan, M., Mao, J.F., Yang, H.J., Wu, K.L. and Fu, X.L., 2015. Phase 2 study of accelerated hypofractionated thoracic radiation therapy and concurrent chemotherapy in patients with limited-stage small-cell lung cancer. International Journal of Radiation Oncology* Biology* Physics, 91(3), pp.517-523.
  11. Grønberg, B.H., Halvorsen, T.O., Fløtten, Ø., Brustugun, O.T., Brunsvig, P.F., Aasebø, U., Bremnes, R.M., Tollåli,

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