What Did the Pandemic Teach Us About Palliative Radiation in Head and Neck Cancer?

Objective: To assess the feasibility and efficacy of palliative radiotherapy dose regimens for patients with locally advanced head and neck cancer. Methods: Fifty patients of previously untreated, inoperable, stage IVA and IVB squamous cell carcinoma of the head and neck, deemed unfit for radical treatment, were included in the study from May 2020 to June 2020. Two palliative radiotherapy regimens were used. First was a single fraction radiation with 8 Gy for patients with limited life expectancy and poor performance status, which was repeated after 4 weeks in case of good symptom relief. The second regimen was used for patients with good performance status and consisted of fractionated radiation with 30 Gy in 10 fractions over 2 weeks, which was followed by supplementary radiation with 25 Gy in 10 fractions over 2 weeks in patients with good symptomatic response at 2 weeks. Symptoms were assessed at baseline and at the end of 4 weeks after treatment completion using the numerical rating score. Patients were followed up for a median of 4.5 months and assessed for symptom control and overall survival. Results: Forty-eight patients completed treatment and were included for analysis. Of the 24 patients who received single fraction radiation, 13 (54.2%) were given the second dose. Improvement in pain and dysphagia were reported in 57.9% and 60% patients, respectively. A total of 55.5% noted decrease in size of the neck node. Twenty-four patients received fractionated radiation and 15 (62.5%) were given the second course after 2 weeks. Relief in pain and dysphagia was reported in 68.2% and 63.6% patients, respectively. There were no grade 3/4 toxicities. Symptom control lasted for at least 3 months in 30% of the patients who received single fraction radiation and 54.2% of the patients who received fractionated radiation. The estimated 6-month overall survival of the entire cohort was 51.4%. Conclusion: Judicious use of palliative radiation in advanced incurable head and neck cancers provides effective and durable symptom relief and should be used after careful consideration of patient prognosis, logistics of treatment, and goals of care.

Patient and practitioner perspectives on the design of a simulated affective touch device to reduce procedural anxiety associated with radiotherapy: a qualitative study.

OBJECTIVE: The aim of this study was to elicit the views of relevant stakeholders on the design of a device using simulated affective touch to reduce procedural anxiety surrounding radiotherapy and imaging. DESIGN: This qualitative study collected data from focus groups which were then analysed using inductive thematic analysis in line with Braun and Clarke's methods. PARTICIPANTS AND SETTING: Twenty patients and carers were recruited, as well as 10 healthcare practitioners involved in either delivering radiotherapy or imaging procedures. RESULTS: Patients, carers and healthcare practitioners agreed on some aspects of the device design, such as ensuring the device is warm and flexible in where it can be used on the body. However, patient and healthcare practitioner cohorts had at times differing viewpoints. For example, healthcare practitioners provided professional perspectives and required easy cleaning of the device. Meanwhile patients focused on anxiety-relieving factors, such as the tactile sensation of the device being either a vibration or pulsation. There was no consensus on who should control the device. CONCLUSIONS: The desired features of a simulated affective touch device have been investigated. Different priorities of patients and their carers and healthcare practitioners were evident. Any design must incorporate such features as to appease both groups. Areas where no consensus was reached could be further explored, alongside including further patient and public involvement in the form of a project advisory group.

Gynecologic radiation therapy in low and middle income countries during the COVID-19 pandemic.

The COVID-19 pandemic has forever affected healthcare and posed an incredible challenge to our society to care for our sick. Patients with cancer were found early on to have higher rates of complications with COVID-19. Radiation therapy is an integral part of treatment for many types of gynecologic cancer and adaptation on its utilization during the pandemic varied across the globe. In this review, we detail certain guidelines for the use of radiation in gynecologic cancers during the pandemic as well as real world accounts of how different countries adapted to these guidelines or created their own based on individualized resources, staffing, government restrictions, and societal norms. Critically, this review demonstrates the breadth of fractionation schemes and technologies used when resources were limited but highlights the importance of long term follow-up for many of our patients during this time.

Low-Dose Lung Radiation Therapy for COVID-19 Lung Disease: A Preclinical Efficacy Study in a Bleomycin Model of Pneumonitis.

PURPOSE: Low-dose whole lung radiation therapy (LDLR) has been proposed as a treatment for patients with acute respiratory distress syndrome associated with SARS-CoV-2 infection, and clinical trials are underway. There is an urgent need for preclinical evidence to justify this approach and inform dose, scheduling, and mechanisms of action. METHODS AND MATERIALS: Female C57BL/6 mice were treated with intranasal bleomycin sulfate (7.5 or 11.25 units/kg, day 0) and then exposed to whole lung radiation therapy (0.5, 1.0, or 1.5 Gy, or sham; day 3). Bodyweight was measured daily, and lung tissue was harvested for histology and flow cytometry on day 10. Computed tomography lung imaging was performed before radiation (day 3) and pre-endpoint (day 10). RESULTS: Bleomycin caused pneumonitis of variable severity, which correlated with weight loss. LDLR at 1.0 Gy was associated with a significant increase in the proportion of mice recovering to 98% of initial bodyweight, and a proportion of these mice exhibited less severe histopathologic lung changes. Mice experiencing moderate initial weight loss were more likely to respond to LDLR than those experiencing severe initial weight loss. In addition, LDLR (1.0 Gy) significantly reduced bleomycin-induced increases in interstitial macrophages, CD103+ dendritic cells (DCs), and neutrophil-DC hybrids. Overall, bleomycin-treated mice exhibited significantly higher percentages of nonaerated lung in left than right lungs, and LDLR (1.0 Gy) limited further reductions in aerated lung volume in right but not left lungs. LDLR at 0.5 and 1.5 Gy did not improve bodyweight, flow cytometric, or radiologic readouts of bleomycin-induced pneumonitis. CONCLUSIONS: Our data support the concept that LDLR can ameliorate acute inflammatory lung injury, identify 1.0 Gy as the most effective dose, and provide evidence that it is more effective in the context of moderate than severe pneumonitis. Mechanistically, LDLR at 1.0 Gy significantly suppressed bleomycin-induced accumulation of pulmonary interstitial macrophages, CD103+ DCs, and neutrophil-DC hybrids.

Active matrix metalloproteinase-8 (aMMP-8) point-of-care test (POCT) in the COVID-19 pandemic.

INTRODUCTION: Active matrix metalloproteinase (aMMP)-8 utilized in point-of-care testing (POCT) is regarded as a potential biomarker for periodontal and peri-implant diseases. Various host and microbial factors eventually influence the expression, degranulation, levels and activation of aMMP-8. The type of oral fluids (saliva, mouthrinse, gingival crevicular, and peri-implant sulcular fluids [GCF/PISF], respectively) affect the analysis. AREAS COVERED: With this background, we aimed to review here the recent studies on practical, inexpensive, noninvasive and quantitative mouthrinse and GCF/PISF chair-side POCT lateral flow aMMP-8 immunoassays (PerioSafe and ImplantSafe/ORALyzer) and how they help to detect, predict, monitor the course, treatment and prevention of periodontitis and peri-implantitis. The correlations of aMMP-8 POCT to other independent and catalytic activity assays of MMP-8 are also addressed. EXPERT OPINION: The mouthrinse aMMP-8 POCT can also detect prediabetes/diabetes and tissue destructive oral side-effects due to the head and neck cancers' radiotherapy. Chlorhexidine and doxycycline can inhibit collagenolytic human neutrophil and GCF aMMP-8. Furthermore, by a set of case-series we demonstrate the potential of mouthrinse aMMP-8 POCT to real-time/online detect periodontitis as a potential risk disease for coronavirus disease 2019 (COVID-19). The clinical interdisciplinary utilization of aMMP-8 POCT requires additional oral, medical, and interdisciplinary studies.

Durable tracking anti-SARS-CoV-2 antibodies in cancer patients recovered from COVID-19.

Cancer patients are more susceptible to SARS-CoV-2 infection and generally have higher mortality rate. Anti-SARS-CoV-2 IgG is an important consideration for the patients in this COVID-19 pandemic. Recent researches suggested the rapid decay of anti-SARS-CoV-2 antibodies in the general population, but the decline rate of the antibodies in cancer patients was unknown. In this observational study, we reported the clinical features of the 53 cancer patients infected by SARS-CoV-2 from Wuhan, China and tracked the presence of anti-SARS-CoV-2 antibodies in the patients for more than 12 months. We found the duration (days) of anti-SARS-CoV-2 IgG in the patients was significant longer in chemotherapy (mean: 175; range: 75 to 315) and radiotherapy groups (mean: 168; range: 85 to 265) than in non-chemo- or radio-therapy group (mean: 58; range: 21 to 123) after their recovery from COVID-19. We also used single-cell RNA sequencing to track the immunologic changes in a representative patient recovered  from COVID-19 and found that CD8 + effective T cells, memory B cells and plasma cells were persistently activated in the patient undergoing chemotherapy. Together, our findings show that chemotherapy and radiotherapy might be beneficial to extend the duration of anti-SARS-CoV-2 IgG.

COVID-19: The Disease, the Immunological Challenges, the Treatment with Pharmaceuticals and Low-Dose Ionizing Radiation.

The year 2020 will be carved in the history books-with the proliferation of COVID-19 over the globe and with frontline health workers and basic scientists worldwide diligently fighting to alleviate life-threatening symptoms and curb the spread of the disease. Behind the shocking prevalence of death are countless families who lost loved ones. To these families and to humanity as a whole, the tallies are not irrelevant digits, but a motivation to develop effective strategies to save lives. However, at the onset of the pandemic, not many therapeutic choices were available besides supportive oxygen, anti-inflammatory dexamethasone, and antiviral remdesivir. Low-dose radiation (LDR), at a much lower dosage than applied in cancer treatment, re-emerged after a 75-year silence in its use in unresolved pneumonia, as a scientific interest with surprising effects in soothing the cytokine storm and other symptoms in severe COVID-19 patients. Here, we review the epidemiology, symptoms, immunological alterations, mutations, pharmaceuticals, and vaccine development of COVID-19, summarizing the history of X-ray irradiation in non-COVID diseases (especially pneumonia) and the currently registered clinical trials that apply LDR in treating COVID-19 patients. We discuss concerns, advantages, and disadvantages of LDR treatment and potential avenues that may provide empirical evidence supporting its potential use in defending against the pandemic.

Low dose lung radiotherapy for COVID-19 pneumonia: A potential treatment.

The covid-19 pandemic has been affecting many countries across the world and lost precious lives. Most patients suffer from respiratory disease which progresses to the severe acute respiratory syndrome, termed as SARS-CoV-2 pneumonia. A systemic inflammatory response occurs in SARS-CoV-2 pneumonia severely ill patients, The inflammation process if uncontrolled has a detrimental effect, and the release of cytokines play an important role leading to lung fibrosis. Radiation therapy used in low doses has an anti-inflammatory and immunomodulatory effect. Its low cost, wider availability, and decreased risk of acute side effects can reduce the burden on the health care system.

Effectiveness of low-dose radiation therapy to improve mortality of COVID-19.

INTRODUCTION: Performing low-dose radiation therapy (LDRT) is a new approach to treat pneumonia resulting from COVID-19 disease. This paper aims to evaluate the effectiveness of LDRT in treating COVID-19 patients. METHODS: Medline was searched for "low-dose" and "radiation therapy" and "COVID-19" and "pneumonia" and "inflammation", to retrieve papers that published on low-dose radiation therapy to improve mortality of COVID-19 patients. Only clinical investigations that included original and case report papers were selected for this paper. RESULTS: The completed clinical trials that have performed LDRT to treat COVID-19 showed that the effectiveness of LDRT in treating COVID-19 was up to 90%. CONCLUSION: The vast majority of primary and secondary outcomes of clinical trial investigations regarding LDRT in treating COVID-19 found that LDRT can be considered a feasible treatment to improve mortality of COVID-19 patients.

[COVID-19 Vaccination for Cancer Patients: Progress and Preliminary Recommendations].

The pandemic of coronavirus disease 2019 (COVID-19) has had a serious impact on global health. COVID-19 vaccines may be one of the most effective measure to end the pandemic. High infection risk and higher serious incident and mortality rates have been shown in cancer patients with COVID-19. Therefore, cancer patients should be the priority group for COVID-19 prevention. Until now, data of COVID-19 vaccination for cancer patients is lacking. We review the interim data of safety and immune-efficacy of COVID-19 vaccination in cancer patients based on the latest studies. Due to the complicated immune systems of cancer patients caused by the malignancy and anticancer treatments, we proposed preliminary specific COVID-19 vaccination recommendations for cancer patients with different anticancer treatments and at different stages of the disease. Preventing COVID-19 with vaccinations for cancer patients is crucial, and we call for more large-scale clinical trials and real-world studies, for further COVID-19 vaccination recommendations development.
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Prostate cancer diagnosis, staging, and treatment in Sweden during the first phase of the COVID-19 pandemic.

INTRODUCTION: The first case of COVID-19 in Sweden was diagnosed in late January 2020, the first recommendations against the spread of the virus were released in mid-March, and the peak of the first wave of the pandemic was reached in March-June. The aim of this cross-sectional study was to assess the short-term effects of the first wave of the COVID-19 pandemic on prostate cancer (PCa) diagnosis, staging, and treatment. MATERIALS AND METHODS: Data in the National Prostate Cancer Register (NPCR) of Sweden on newly diagnosed PCa cases and on the number of diagnostic and therapeutic procedures performed between 18 March 2020 and 2 June 2020 were compared with those in the corresponding time periods in 2017-2019, as reported until January 31 of the year after each study period. RESULTS: During the study period in 2020, 36% fewer PCa cases were registered in NPCR compared with the corresponding time period in previous years: 1458 cases in 2020 vs a mean of 2285 cases in 2017-2019. The decrease in new PCa registrations was more pronounced in men above age 75 years, down 51%, than in men aged 70-75, down 37%, and in men below age 70, down 28%. There was no decrease in the number of radical prostatectomies and number of radical radiotherapy courses increased by 32%. CONCLUSIONS: During the peak of the first phase of the COVID-19 pandemic, the number of men diagnosed with PCa in Sweden decreased by one third compared with previous years, whereas there was no decrease in the number of curative treatments.

[Impact of COVID-19 on Nuclear Medicine Procedures in Germany 2020 - Results of a National Survey]. / Auswirkungen von COVID-19 auf nuklearmedizinische Untersuchungen und Therapien im Verlauf von 2020 ­ Ergebnisse einer nationalen Umfrage.

INTRODUCTION: The COVID-19 pandemic imposed an unimaginable challenge to the healthcare systems worldwide. This online survey captured the impact of the COVID-19 pandemic on nuclear medicine services in Germany comparing 2020 to 2019. MATERIALS AND METHODS: A web-based questionnaire was developed to record the 2020 numbers of nuclear medicine procedures and, in particular, the change compared with 2019. The changes in nuclear medicine diagnostics and therapy were queried, as well as the extent to which "Coronavirus SARS-CoV-2" recommendations provided by the DGN were implemented. RESULTS: 91 complete responses were recorded and evaluated. This corresponds to about 20 % of all German nuclear medicine facilities. Nuclear medicine diagnostic tests showed a decrease in scintigraphies for thyroid (15.9 %), bone (8.8 %), lung (7.6 %), sentinel lymph nodes (5.5 %), and myocardium (1.4 %) with small increases in PET/CT examinations (1.2 %) compared with 2019. Among nuclear medicine therapies, reductions were highest for benign indications (benign thyroid 13.3 %, RSO 7.7 %), while changes from 2019 were less pronounced for malignant indications (PRRT: + 2.2 %, PSMA: + 7.4 %, SIRT: -5.9 %, and RJT for thyroid carcinoma -2.4 %). The DGN recommendations for action were fully or partially applied in 90 %. CONCLUSIONS: The initial significant reduction in nuclear medicine procedures in the first three weeks of the COVID-19 pandemic did not continue, but there was no compensation of the previously not performed services. The decrease in diagnostics and therapy procedures of benign diseases was particularly severe.

Severity of COVID-19 in patients with lung cancer: evidence and challenges.

Cancer patients are highly vulnerable to SARS-CoV-2 infections due to frequent contacts with the healthcare system, immunocompromised state from cancer or its therapies, supportive medications such as steroids and most importantly their advanced age and comorbidities. Patients with lung cancer have consistently been reported to suffer from an increased risk of death compared with other cancers. This is possibly due to the combination of specific pathophysiological aspects, including underlying pulmonary compromise due to smoking history and the increased specific pressures on respiratory healthcare services caused by the related pandemic. Rationally and safely treating patients with lung cancer during the pandemic has become a continuous challenge over the last year. Deciding whether to offer, modify, postpone or even cancel treatments for this particular patient's population has become the crucial recurrent dilemma for lung cancer professionals. Chemotherapy, immunotherapy and targeted agents represent distinct risks factors in the context of COVID-19 that should be balanced with the short-term and long-term consequences of delaying cancer care. Despite the rapid and persistent trend of the pandemic, declared by WHO on March 11, 2020, and still ongoing at the time of writing (January 2021), various efforts were made by oncologists worldwide to understand the impact of COVID-19 on patients with cancer. Adapted recommendations of our evidence-based practice guidelines have been developed for all stakeholders. Different small and large-scale registries, such as the COVID-19 and Cancer Consortium (CCC19) and Thoracic Cancers International COVID-19 Collaboration quickly collected data, supporting cancer care decisions under the challenging circumstance created by the COVID-19 pandemic. Several recommendations were developed as guidance for prioritizing the various aspects of lung cancer care in order to mitigate the adverse effects of the COVID-19 healthcare crisis, potentially reducing the morbidity and mortality of our patients from COVID-19 and from cancer. These recommendations helped inform decisions about treatment of established disease, continuation of clinical research and lung cancer screening. In this review, we summarize available evidence regarding the direct and indirect impact of the COVID-19 pandemic on lung cancer care and patients.

Managing breast gangrene during the COVID-19 pandemic.

At the onset of the COVID-19 crisis, a 63-year-old woman with multiple life-limiting comorbidities was referred with a necrotic infected left breast mass on a background of breast cancer treated with conservation surgery and radiotherapy 22 years previously. The clinical diagnosis was locally advanced breast cancer, but four separate biopsies were non-diagnostic. Deteriorating renal function and incipient sepsis and endocarditis resulted in urgent salvage mastectomy during the peak of the COVID19 pandemic. The final diagnosis was infected ischaemic/infarcted breast (wet gangrene) secondary to vascular insufficiency related to diabetes, cardiac revascularisation surgery and breast radiotherapy.

Impact of COVID-19 on workload burden of a complex radiotherapy facility.

BACKGROUND AND PURPOSE: COVID-19 constitutes a worldwide threat, prompting Italian Government to implement specific measures on March 8, 2020, to protect patients and health workers from disease transmission. The impact of preventive measures on daily activity of a radiotherapy facility may hamper the ability to fulfill normal workload burden. Thus, we assessed the number of delivered treatments in a specific observation period after the adoption of preventive measures (since March 11 to April 24, 2020) and compared it with the corresponding period of the year 2019. MATERIALS AND METHODS: Overall number of delivered fractions was related to actual time of platform daily activity and reported as a ratio between number of delivered fractions and activity hours (Fr/Hrs). Fr/Hrs were calculated and compared for two different periods of time, March 11-April 24, 2019 (Fr/Hrs1), and March 11-April 24, 2020 (Fr/Hrs2). RESULTS: Fr/Hrs1 and Fr/Hrs2 were 2.66 and 2.54 for year 2019 and 2020, respectively, for a Fr/Hrsratio of 1.07 (95% CI 1.03-1.12, p = 0.0005). Fr/Hrs1 was significantly higher than Fr/Hrs2 for SliR and PreciseR, with Fr/Hrsratio of 1.92 (95% CI 1.66-2.23, p < 0.0001) and 1.11 (95% CI 1.03-1.2, p = 0.003), respectively. No significant difference was reported for SynergyR and CyberknifeR with Fr/Hrsratio of 0.99 (95% CI 0.91-1.08, p = 0.8) and 0.9 (95% CI 0.77-1.06, p = 0.2), respectively. Fr/Hrs1 was significantly lower than Fr/Hrs2 for TomotherapyR, with Fr/Hrsratio of 0.88 (95% CI 0.8-0.96, p = 0.007). CONCLUSION: Preventive measures did not influence workload burden performed. Automation in treatment delivery seems to compensate effectively for health workers number reduction.

Major impact of COVID-19 national containment on activities in the French northern comprehensive cancer center.

The SARS-CoV-2 pandemic has significantly impacted cancer patient management. National and local recommendations to reduce SARS-CoV-2 transmission have been applied in a comprehensive cancer center located in Northern France. We prospectively measured key indicators for three successive eight-week periods: directly before, during, and right after the containment (from 16 March to 10 May 2020). Overall, the number of newly diagnosed and referred cancer patients in our hospital steadily increased (1027; 1135 and then 1704; +11% during containment and +50% just after). To reduce patient transportation, teleconsultations were implemented. Teleconsulting activity steadily increased during the three periods (5, 2025, and 2351). However, a marked decrease in the number of surgical procedures was observed (448; 330 and 288; -26% during containment and -13% just after). We observed a slight decrease in the number of radiation therapy sessions (7761; 7328 and 7075; -6% during containment and -3% just after) and in day-hospital cycles of IV systemic treatment (2891; 2736 and 2717; -5% during containment and -1% just after). We observed an increase in the number of patients admitted to palliative care and a dramatic reduction in clinical trial enrollment. During this 24-week period, organizational changes were mainly characterized by an increase in newly diagnosed cancer patient referral and the implementation of protective measures, such as teleconsultations. Activities in cancer surgery have decreased while radiotherapy and chemotherapy activities were stable.

COVID-19 pneumonia treated with ultra-low doses of radiotherapy (ULTRA-COVID study): a single institution report of two cases.

INTRODUCTION: Since the outbreak of coronavirus disease 2019 (COVID-19) pandemic, healthcare systems have focused their efforts into finding a treatment to avoid the fatal outcomes of severe acute respiratory syndrome due to coronavirus­2 (SARS-CoV-2). Benefits and risks of systemic treatments remain unclear, with multiple clinical trials still ongoing. Radiotherapy could play a role in reducing the inflammatory response in the lungs and relieve life-threatening symptoms. METHODS: We designed a prospective study of Ultra-Low Doses of Therapy with Radiation Applied to COVID-19 (ULTRA-COVID) for patients who suffer pneumonia, are not candidates for invasive mechanical ventilation and show no improvement with medical therapy. RESULTS: We present the preliminary results of two patients diagnosed with COVID-19 pneumonia treated with ULTRA-COVID. After one radiotherapy session, significant clinical response and a good radiological response was observed in both cases, resulting in both patients being discharged from hospital in less than 2 weeks after radiation treatment. CONCLUSION: Preliminary clinical and radiological results suggest a potential benefit of treating COVID-19 pneumonia with ULTRA-COVID. ClinicalTrials.gov Identifier: NCT04394182.