The document reviews advisories and contingency plans for radiotherapy facilities during the COVID-19 pandemic. It summarizes guidelines from various radiation oncology societies on risk stratification of cancer patients, prioritization of treatments, and treatment modifications. It also discusses specific recommendations for tumor sites like head and neck, breast, and gynecological cancers. Screening of patients and staff, treatment scheduling and coordination between departments is emphasized. Treatment principles of remote, avoid, defer, and shorten treatments are recommended to balance cancer and COVID-19 risks.

1. Review of Advisories and Contingency Plan
for COVID 19 Pandemic in Radiotherapy
Facilities
DR ANIL GUPTA
DR RASHMI SARAWAGI
PROF D N SHARMA
DR BRA IRCH- AIIMS

2. Introduction
 The Coronavirus diseases 2019 (COVID 19) is caused by the novel severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2)
 First identified in Wuhan, Hubei, China in December 2019
 The WHO declared it as a public health emergency of international concern on 30 January
2020
 Subsequently, the outbreak was recognized as a pandemic on 11 March 2020
 In India, the first case was reported on 30 January 2020.
 The Epidemic Diseases Act, 1897 has been invoked in many states and union territories

3. Chinese Data of COVID 19 in Cancer patients
 18 (1%) of 1590 cases had a history of cancer, higher than national data (0.29)%
 12 (75%) patients were cancer survivors in routine follow up
 Higher risk of severe events (ICU, requiring invasive ventilation, or death)
 Were older (63.1 vs 48.7), more smoker (22% vs 7%)
https://doi.org/10.1016/S1470-2045(20)30096-6LANCET, February 14, 2020

4. Risk in admitted cancer patients
 Reviewed the medical records, of 1524 patients with cancer admitted to RT and
Medical Oncology facility in Wuhan (dec-19 to feb-20)
 Infection rate of SARS-CoV-2 in patients with cancer 0.79% (12/1524 pt) higher
than cumulative incidence of all diagnosed cases in Wuhan over the same time
period (0.37%; 41,152/1,10,81,000 pt)
 3 deaths (25.0%) were recorded
 Findings imply that hospital admission and recurrent hospital visits are potential
risk factors for SARS-CoV-2 infection
Data cutoff on Feb 17, 2020 March 25, 2020. doi:10.1001/jamaoncol.2020.0980

5. Epidemiology in India- 4th April 2020
https://www.covid19india.org/ The COV-IND-19 Study Group- Michigan University

6. COVID 19 future prediction models pertaining to
India
 ICMR study. Only one to follow SIER ( ‘susceptible’, ‘exposed’, ‘infected’ and
‘recovered’ (S, I and R, for short)
 Michigan study - In the absence of any interventions, there will be about 16 cases per 10,000
people
 Princeton study- https://cddep.org/covid-19/- provides state-level information for the number
of infected people as a function of time. Total number of people with COVID-19 in India
could peak at 1 crore to 2.5 crore
 Cambridge study - https://arxiv.org/abs/2003.12055 Single lockdown of 21 days has little
effect. Instead, it recommends a single 48-day lockdown for a more long-lasting
effect

7. Timeline of COVID-19 interventions in India
14-hour voluntary public curfew on 22 March
21 day lockdown- 25 March 2020 to expire on
14 April 2020

8. ADVISORIES & CONTINGENCY PLAN FROM VARIOUS RADIATION ONCOLOGY SOCIETIES

9. ASTRO
 Gave a 13 page 20 Frequently
asked Questions

13. ESTRO
 “RADIOTHERAPY IN TIME OF CRISIS” ESTRO President statement

14. NICE COVID-19 rapid guideline:
delivery of radiotherapy

15. 5 Grouping and separating patients to reduce risk
5.1 To minimise cross infection, set up and review facilities and treatment schedules so that patients
can be scheduled for treatment based on their COVID-19 status. Options include:
 scheduling treatment for patients with known or suspected COVID-19 at a specific time of day
 scheduling treatment for patients who are at particularly increased risk of severe illness from
COVID-19 (such as patients with lung cancer) at a different time from patients with COVID-19.
5.2 If possible, have separate entrances and facilities for patients who do not have COVID-19 and for
patients known or suspected to have COVID-19.
5.3 Ensure treatment schedules can properly accommodate the cleaning needs for any areas used
by patients with COVID-19.

16. 7 Prioritising radiotherapy treatments
7.1 If radiotherapy treatments need to be prioritised, use table 1 to help
make these decisions. Take into account:
 balancing the risk of cancer not being treated optimally with the risk of
the patient becoming seriously ill 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,
anaesthetics, equipment).

19. 8 Modifications to usual care
8.1 Think about how to modify usual care to reduce patient exposure to COVID-19 and make best use
of resources (workforce, facilities, anaesthetics, equipment).
8.2 Centres should discuss changes to standard cancer treatment pathways within their operational
delivery networks. This may include discussing alternative dose fractionation schedules
8.4 Make policy decisions about modifying usual care at an organisational level.
8.5 When modifying individual patients' treatment plans:
 take their clinical circumstances into account
 involve all relevant members of the multidisciplinary team in the decision
 record the reasoning behind each decision.
8.6 When treatment has to be interrupted because of COVID-19, use the Royal College of Radiologists'
guidance on the management of unscheduled treatment interruptions to help make decisions.
8.7 Use the RADS (Remote, Avoid, Defer, Shorten) principle to help plan individual patient treatment:

20. Royal College of Radiologist
 Most detailed guidelines
 Explained individually about different sub sites- Breast, CNS, H&N,
Gynae, Lung, Upper & Lower GI, Lymphoma, Pediatric, Prostate,
Sarcoma, Melanoma & Non Melanoma Skin cancer, Bladder, Acute
emergencies, SRS, Thyroid, NET
 Given guidelines about hypofractionated shorter treatments
 Given guidelines about unscheduled interrupted treatments

21. The most vulnerable cancer patients
Some people with cancer are more at risk of becoming seriously ill if they contract the coronavirus infection:
• People having radical radiotherapy for lung cancer
• People with cancer who are undergoing active chemotherapy
• People with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage
of treatment
• People having immunotherapy or other continuing antibody treatments for cancer
• People having other targeted cancer treatments which can affect the immune system, such as protein kinase
inhibitors or PARP inhibitors.
• People who have had bone marrow or stem cell transplants in the last 6 months, or who are
Co-morbidities are likely to be linked with a poorer prognosis with coronavirus
 age over 60
 pre-existing cardiovascular disease
 pre-existing respiratory disease.

22. Head & Neck Cancer in COVID 19
Palliative Treatment
 Do not deliver unless benefit clearly outweigh current risk
 Shorter Treatment 20Gy/5# or 8 Gy/1#
Curative Treatment
 Consider 65 Gy/30# or 55 Gy/20# over 70 GY/35# - evidence based
 Limit concurrent chemo over 60 yr age
Adjuvant
 If benefit is limited (low/intermediate risk of recurrence) consider omitting/postpone
 Strongly consider omitting concurrent chemo

23. Breast Cancer in COVID 19
 Omit RT for patient age >65 yr upto 30 mm size, clear margins, low
grade, ER +ve, Her 2 –ve
 Deliver 26 Gy in 5# in 5 day (FAST Forward Trial) who require RT in node
negative
 Boost RT should be omitted, unless < 40 yr age

24. Gynaecological Cancer in COVID 19
Cervical Cancer
 With the possibility of Onco Surgeries suspension, definitive RT will play
a role in early stage cervical cancer
 Consider using 45 Gy/25# with conc cisplatin, if bulkier or node positive
use 50.5 Gy28#
 Consider omitting conc chemo case by case and age > 70 yr
Endometrial Cancer
 Adjuvant treatment may be delayed upto 3 months from surgery in
residual disease, positive margins or aggressive histology
 In intermediate risk consider no RT, as no OS benefit and good salvage

25. Radiotherapy care during a major
outbreak of COVID-19 in Wuhan
Over 100 radiotherapy
patients, with no
incidence of on-site
COVID-19 transmission
between patients and
health care workers in the
duration
https://doi.org/10.1016/j.adro.2020.03.004

26. India is no China

27. Dr BRA IRCH- AIIMS
 State of art Radiotherapy, chemotherapy,
immunotherapy, targeted therapy, Stem Cell
Transplants, Onco-surgery, palliative care,
Mammography, CT scans, interventional
Radiology, Lab Oncology under one roof
 Caters to more than 1.5 lakhs OPD visits,
more than 10 thousand new registration,
more than 40 thousand admission and more
than 12 thousand procedures in a year*
AIIMS Annual report 2018-19

28. CONCLUSION
 Screening of Patients and Healthcare Personnel
 Proper Travel History? India going towards community transmission
 Coordinate with other department
 Rotation of Healthcare Personnel
 Treatment- Remote, avoid, defer, shorten & schedule (RADS) treatment
 Trust No One (regarding infection)

29. THANK YOU
“…and there are no more surgeons, urologists, orthopaedician, we are only doctors
who suddenly become part of a single team to face this tsunami that has
overwhelmed us…” Dr Daniele Macchine, Bergamo, Italy. 9 March 2020