ABSTRACT
Purpose or Objective During the COVID-19 pandemic, health insurance providers permitted to treat esophageal cancer (EC) patients with proton therapy (PT) when treated in the neo-adjuvant setting. This decision was based on the results of the MD Anderson randomized study showing significantly lower rates of the Total Toxicity Burden (TTB), especially of postoperative toxicity and consequently decreased hospital and intensive care unit (ICU) stay. The TTB combines a large range of toxicities with different incidence rates and severities into a single sum score. For patient selection, we used a model-based approach (MBA) using a model for TTB (>60). The aim of this study was to investigate if the post-operative TTB decreased with PT. Materials and Methods In accordance with the MBA, a plan comparison (photon vs proton radiotherapy (RT)) was performed in all EC patients that were to be treated with neo-adjuvant chemoradiotherapy (nCRT) according to the CROSS regimen. For patient selection, we developed a normal tissue complication probability (NTCP)-model for a TTB > 60, which corresponds to at least one grade > III or 2 grade > II complications. Patients, who were eligible for PT in terms of target motion (<15 mm), and with a ANCTP >5%, were selected and treated with PT. Postoperative TTB and hospital and ICU stay were compared with a prospective dataset of patients that were treated with photon RT between 2014 and 2018 (n=224). Results Since March 2020, 26 out of 32 patients were selected for PT. The average reduction in mean lung dose was 5.2 Gy with PT compared to VMAT, with a corresponding average NTCP-reduction for TTB of 9.7%. Mean heart, spleen and liver dose were reduced by 7.9, 7.4 and 7.1 Gy, respectively. At the time of analyses, 14 out of 19 patients underwent esophagectomy. Three patients developed intercurrent metastases, in one a wait and see policy was applied and one switched to definitive CRT. In the resected PT patients, the expected proportion of patients with a TTB>60 was 29.7% for photon and 20.8% for proton RT. After resection, only one out of 14 patients (7.1%) had an TTB>60 ((p=0.051), compared to the expected proportion based on the photon plans). On average, the observed post-operative TTB was 15 (SEM: 6) after PT, compared to the historical photon cohort in which the observed post-operative TTB was 45 (SEM: 5). Hospital and ICU stay were also reduced by PT compared to the photon cohort;12.7 (SEM 1.4) vs. 20.0 (SEM 1.2) and 1.9 days (SEM 0.4) vs. 4.9 (SEM 0.6), resulting in an average cost reduction of about 10,000 euro per patient. Follow up will continuously be updated in our dynamic database. Conclusion In the neo-adjuvant setting, the first results indicate that proton-based nCRT reduces the post-operative TTB compared to historic photon-based nCRT. Moreover, there seems to be a trend towards reduced hospital and ICU stay.
ABSTRACT
PURPOSE: Because of the unprecedented disruption of health care services caused by the COVID-19 pandemic, the American Society of Radiation Oncology (ASTRO) and the European Society for Radiotherapy and Oncology (ESTRO) identified an urgent need to issue practice recommendations for radiation oncologists treating head and neck cancer (HNC) in a time of limited resources and heightened risk for patients and staff. METHODS AND MATERIALS: A panel of international experts from ASTRO, ESTRO, and select Asia-Pacific countries completed a modified rapid Delphi process. Topics and questions were presented to the group, and subsequent questions were developed from iterative feedback. Each survey was open online for 24 hours, and successive rounds started within 24 hours of the previous round. The chosen cutoffs for strong agreement (≥80%) and agreement (≥66%) were extrapolated from the RAND methodology. Two pandemic scenarios, early (risk mitigation) and late (severely reduced radiation therapy resources), were evaluated. The panel developed treatment recommendations for 5 HNC cases. RESULTS: In total, 29 of 31 of those invited (94%) accepted, and after a replacement 30 of 30 completed all 3 surveys (100% response rate). There was agreement or strong agreement across a number of practice areas, including treatment prioritization, whether to delay initiation or interrupt radiation therapy for intercurrent SARS-CoV-2 infection, approaches to treatment (radiation dose-fractionation schedules and use of chemotherapy in each pandemic scenario), management of surgical cases in event of operating room closures, and recommended adjustments to outpatient clinic appointments and supportive care. CONCLUSIONS: This urgent practice recommendation was issued in the knowledge of the very difficult circumstances in which our patients find themselves at present, navigating strained health care systems functioning with limited resources and at heightened risk to their health during the COVID-19 pandemic. The aim of this consensus statement is to ensure high-quality HNC treatments continue, to save lives and for symptomatic benefit.
ABSTRACT
PURPOSE: Because of the unprecedented disruption of health care services caused by the COVID-19 pandemic, the American Society of Radiation Oncology (ASTRO) and the European Society for Radiotherapy and Oncology (ESTRO) identified an urgent need to issue practice recommendations for radiation oncologists treating head and neck cancer (HNC) in a time of limited resources and heightened risk for patients and staff. METHODS AND MATERIALS: A panel of international experts from ASTRO, ESTRO, and select Asia-Pacific countries completed a modified rapid Delphi process. Topics and questions were presented to the group, and subsequent questions were developed from iterative feedback. Each survey was open online for 24 hours, and successive rounds started within 24 hours of the previous round. The chosen cutoffs for strong agreement (≥80%) and agreement (≥66%) were extrapolated from the RAND methodology. Two pandemic scenarios, early (risk mitigation) and late (severely reduced radiation therapy resources), were evaluated. The panel developed treatment recommendations for 5 HNC cases. RESULTS: In total, 29 of 31 of those invited (94%) accepted, and after a replacement 30 of 30 completed all 3 surveys (100% response rate). There was agreement or strong agreement across a number of practice areas, including treatment prioritization, whether to delay initiation or interrupt radiation therapy for intercurrent SARS-CoV-2 infection, approaches to treatment (radiation dose-fractionation schedules and use of chemotherapy in each pandemic scenario), management of surgical cases in event of operating room closures, and recommended adjustments to outpatient clinic appointments and supportive care. CONCLUSIONS: This urgent practice recommendation was issued in the knowledge of the very difficult circumstances in which our patients find themselves at present, navigating strained health care systems functioning with limited resources and at heightened risk to their health during the COVID-19 pandemic. The aim of this consensus statement is to ensure high-quality HNC treatments continue, to save lives and for symptomatic benefit.