Changes in Rectal Radiotherapy practice at a London Teaching hospital during the COVID-19 pandemic

Introduction: Strategies for radiotherapy in rectal cancer have changed significantly in the past year, with the publication of the RAPIDO trial and the COVID-19 pandemic. As part of our COVID-19 response we audited and compared our radiotherapy treatments during the first COVID-19 peak with the equivalent period in 2019. Methods: All neoadjuvant rectal radiotherapy patients between 01/03/2019-30/ 06/2019 and 01/03/2020-30/ 06/2020 were identified. Patient demographics, tumour characteristics, radiotherapy treatment and outcome data were collected from electronic hospital records and radiotherapy planning software. Results: Eighteen patients underwent neoadjuvant (chemo-) radiotherapy in 2020 compared to 8 during 2019, >100% increase. 'Ugly' disease was present in 83% (15/18) in 2020 and 88% (7/8) in 2019. More patients received short course radiotherapy (SCRT) (56%, 10/18) and total neoadjuvant therapy (TNT) (72%, 13/18) in 2020 compared to 2019, 12% (1/8) and 50% (4/8) respectively. Surgery was performed in 56% (10/18) with 7 complete resections in 2020, 4 patients await exenteration, 3 declined surgery and 1 progressed. Local control rates were 78% (14/18). Whilst in 2019 surgery was performed in 75% (6/8) with 3 complete resections, 1 patient opted for watch and wait and 1 patient progressed. Local control rates were 75% (6/8). Radiological and pathological response will be presented. Conclusion: Radiotherapy practice has changed significantly in the last 12 months with increased volume of patients, more SCRT and more TNT. This pragmatic response to external pressures shows early indicators of equivalent outcomes. Longer follow up is needed to fully assess the benefit of TNT on reducing distant recurrence.

Why is there a paucity of clinical trials in Africa?

Disproportionately few clinical trials are undertaken on the African continent, in part due to lingering neocolonial attitudes in the Global North which keep research activity primarily in developing countries, while being skeptical of the abilities of those in the Global South to undertake organized clinical studies. In the era of the COVID-19 pandemic, applicable research and clinical trials should be undertaken in relevant populations in order to extrapolate to a population level. This is all the more important in Africa, which has a rich genetic diversity. We suggest that a lack of organized research ethics committees across the continent and a deficiency of appropriate training are responsible in part for the reluctance of clinical trial organizers in the developed countries of the Global North to engage with medical leadership in Africa. We consider ways of alleviating this problem, including suggesting a pan-continental surveillance of ethics committee agendas and of training, either through the auspices of the African Union or the World Health Organization. In addition, medical leadership in African nations must be encouraged to take ownership of their medical ethics agendas to facilitate decent international clinical trial participation for the good of the continent as a whole.

The COVID-19 era: the view from Nigeria.

If we were told that one day the entire world would take its guidance for managing a health crisis from empirical thought, nobody would have believed it. However, with the December 2019 arrival of COVID-19 in China, the world subsequently went into a frenzied state that resulted in the widespread adoption of untested strategies or potential cures; circumstantial evidence provided without randomized control trials (RCTs) was published rapidly and widely considered the gold standard in medical research and therapeutics. Nigeria and much of the rest of the world blindly adopted treatments like chloroquine or hydroxychloroquine and various prevention strategies, often without monitoring the efficacy of these treatment and social control strategies. COVID-19 provided Nigeria a critical opportunity to create or strengthen its national laboratory system by building up its Level 3 laboratories in all parts of the country with the capability to perform PCR tests and viral isolation. There was also an opportunity to establish hospitals in every region of a sufficient standard to reduce the numbers of Nigerians travelling abroad to seek medical treatment; to invest in building capacity to develop antiviral medications and vaccines in Nigeria, and to ensure better international health policies. Rather, Nigerian leaders, government and health managers decided (like most other nations of the world) to shut down the society using isolationist policies that were not necessarily tailored to local needs. Despite adopting these methods, COVID-19 cases continued to skyrocket in Nigeria. In the future, before adopting such broad sweeping policies, there should be local tailoring to assess their effectiveness in different communities. Given that the country has much experience in controlling Lassa and Marburg Fever outbreaks, Nigeria should lead by developing new strategies, new protocols and new local guidelines, based on validated and reproducible studies to ensure that the public health authorities are not caught unaware by any new outbreaks of emerging or remerging diseases.