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Category: Volume 09 Issue 02 February 2021
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Title: Hypofraction... Revisited: The emerging role of shorter treatment schedules for locally advanced cancers during the COVID-19 pandemic

Authors: Dr Bindhu Joseph, Dr Nithin Bhaskar V, Dr Nikhila K R, Dr Sanjay R, Dr Lokesh V

 DOI: https://dx.doi.org/10.18535/jmscr/v9i2.09

Abstract

Introduction: The COVID-19 pandemic is now imposing an immense strain on the oncology health care system, both in terms of optimal cancer care and safe delivery and execution of treatment. The period of lockdown has also created additional concerns over completion of interrupted treatments, progression of disease, the delay and increasing waiting list in the backdrop of limited health care resources and personnel.

In Asian countries, a large bulk of patients present with locally advanced cancers of the head and neck, breast and cervix. However other cancers involving esophagus, lung and brain also impose a problem during the pandemic because of the morbidity and mortality associated with postponed treatment.

Purpose and Objectives: In the midst of the COVID-19 pandemic, priority to minimise the risk of exposure of infection to patients and health care personnel is critical in ensuring the sustenance and completeness of treatment. The authors would like to provide optional hypofractionated protocols supported by scientific data that may be used as an interval expedient during this crisis.

Materials and Methods: A systematic literature research was done using Pubmed and other search engines. The focus was on scientific rationale, clinical adaptability, manageable toxicity and with comparable treatment outcomes with the standards of care.

Conclusions: The authors propose shorter, hypofractionated protocols with the option of selective concurrent chemotherapy in the management of head and neck cancer as well as the potential of shorter treatment options for esophageal and lung cancers and high grade gliomas. A few alternatives for an integrated boost to counter the reduced availability of brachytherapy have also been elaborated on.

Keywords: COVID-19, locally advanced cancers, hypofractionation.

References

  1. Nguyen N-TA, Doerwald-Munoz L, Zhang H, Kim D-H, Sagar S, Wright JR, et al. 0-7-21 hypofractionated palliative radiotherapy: an effective treatment for advanced head and neck cancers. Br J Radiol. 2015 May 19;88(1049):20140646.
  2. Paliwal R, Kumar-Patidar A, Walke R, Hirapara P, Jain S, Raj-Bardia M. Palliative Hypo-fractionated Radiotherapy in Locally Advanced Head and Neck Cancer with Fixed Neck Nodes. Vol. 5, Iranian journal of cancer prevention. Cancer Research Center, Shahid Beheshti University of Medical Sciences; 2012. p. 178–82.
  3. Howard A, Banks S, Owens R, Ward L, Warner N, Mukherjee S. The role of active nutritional intervention in patients receiving chemoradiation (CRT) for oesophageal cancer. Vol. 30, Annals of Oncology. Elsevier; 2019. p. iv78.
  4. Franzese C, Fogliata A, Franceschini D, Navarria P, Cozzi L, Tomatis S, et al. Impact of hypofractionated schemes in radiotherapy for locally advanced head and neck cancer patients. Laryngoscope. 2020;130(4):E163–70.
  5. Tandon S, Gairola M, Ahlawat P, Rawat S, Aggarwal A, Sharma K, et al. Randomized controlled study comparing simultaneous modulated accelerated radiotherapy versus simultaneous integrated boost intensity modulated radiotherapy in the treatment of locally advanced head and neck cancer. Vol. 30, Journal of the Egyptian National Cancer Institute. 2018. p. 107–15.
  6. Grewal AS, Jones J, Lin A. Palliative Radiation Therapy for Head and Neck Cancers. Int J Radiat Oncol Biol Phys. 2019 May 22;
  7. Zhang L, Zhu F, Xie L, Wang C, Wang J, Chen R, et al. Clinical characteristics of COVID-19-infected cancer patients: a retrospective case study in three hospitals within Wuhan, China. Annals of Oncology. Elsevier;
  8. Guckenberger M, Belka C, Bezjak A, Bradley J, Daly ME, DeRuysscher D, et al. Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement. undefined(undefined).
  9. Nguyen LN, Komaki R, Allen P, Schea RA, Milas L. Effectiveness of accelerated radiotherapy for patients with inoperable non-small cell lung cancer (NSCLC) and borderline prognostic factors without distant metastasis: a retrospective review. Vol. 44, International Journal of Radiation Oncology • Biology • Physics. Elsevier; 1999. p. 1053–6.
  10. Amini A, Lin SH, Wei C, Allen P, Cox JD, Komaki R. Accelerated hypofractionated radiation therapy compared to conventionally fractionated radiation therapy for the treatment of inoperable non-small cell lung cancer. Vol. 7, Radiation oncology (London, England). BioMed Central; 2012. p. 33–33.
  11. Maguire J, Khan I, McMenemin R, O’Rourke N, McNee S, Kelly V, et al. 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. Vol. 50, European Journal of Cancer. Elsevier; 2014. p. 2939–49.
  12. Din OS, Harden SV, Hudson E, Mohammed N, Pemberton LS, Lester JF, et al. Accelerated hypo-fractionated radiotherapy for non small cell lung cancer: Results from 4 UK centres. Vol. 109, Radiotherapy and Oncology. Elsevier; 2013. p. 8–12.
  13. Shrivastava S, Mahantshetty U, Engineer R, Chopra S, Hawaldar R, Hande V, et al. Cisplatin Chemoradiotherapy vs Radiotherapy in FIGO Stage IIIB Squamous Cell Carcinoma of the Uterine Cervix.
  14. Mishra Subhasis, Niharika Panda. A Comparative Study to Evaluate the Role of Hypofractionated Radiotherapy With Concurrent Weekly Cisplatin Vs Conventional Radiotherapy with Concurrent Weekly Cisplatin in Advanced Carcinoma Cervix. Vol. 5, Sch. J. App. Med. Sci. 2017. p. 2809–16.
  15. Mahobia Vijay Kumar, Rewadhkar Mahesh. Study of comparison of outcome between conventional versus hypofractionated radical radiotherapy alongwith Cisplatin as a Radiosensitizer in Stage IIIB cancer cervix. Vol. 5, indian journal of basic and applied medical research. p. 112–21.
  16. Muckaden MA, Budrukkar AN, Tongaonkar HB, Dinshaw KA. Hypofractionated radiotherapy in carcinoma cervix IIIB: Tata Memorial Hospital experience. Indian J Cancer. 39(4):127–34.
  17. Boulware RJ, Caderao JB, Delclos L, Wharton JT, Peters LJ. Whole pelvis megavoltage irradiation with single doses of 1000 rad to palliate advanced gynecologic cancers. Int J Radiat Oncol Biol Phys. 5(3):333–8.
  18. Hodson DI, Krepart GV. Once-monthly radiotherapy for the palliation of pelvic gynecological malignancy. Gynecol Oncol. 16(1):112–6.
  19. Halle JS, Rosenman JG, Varia MA, Fowler WC, Walton LA, Currie JL. 1000 cGy single dose palliation for advanced carcinoma of the cervix or endometrium. Int J Radiat Oncol Biol Phys. 12(11):1947–50.
  20. Onsrud M, Hagen B, Strickert T. 10-Gy single-fraction pelvic irradiation for palliation and life prolongation in patients with cancer of the cervix and corpus uteri. Gynecol Oncol. 82(1):167–71.
  21. Mishra SK, Laskar S, Muckaden MA, Mohindra P, Shrivastava SK, Dinshaw KA. Monthly palliative pelvic radiotherapy in advanced carcinoma of uterine cervix. J Cancer Res Ther. 1(4):208–12.
  22. Yan J, Milosevic M, Fyles A, Manchul L, Kelly V, Levin W. A Hypofractionated Radiotherapy Regimen (0-7-21) for Advanced Gynaecological Cancer Patients. Clin Oncol. 2011 Sep 1;23(7):476–81.
  23. Guerrero M, Li XA, Ma L, Linder J, Deyoung C, Erickson B. Simultaneous integrated intensity-modulated radiotherapy boost for locally advanced gynecological cancer: Radiobiological and dosimetric considerations. Vol. 62, International Journal of Radiation Oncology • Biology • Physics. Elsevier; 2005. p. 933–9.
  24. Mazzola R, Ricchetti F, Fiorentino A, Levra NG, Fersino S, Di Paola G, et al. Weekly Cisplatin and Volumetric-Modulated Arc Therapy With Simultaneous Integrated Boost for Radical Treatment of Advanced Cervical Cancer in Elderly Patients: Feasibility and Clinical Preliminary Results. 2016/07/08. Vol. 16, Technology in cancer research & treatment. SAGE Publications; 2017. p. 310–5.
  25. Vandecasteele K, Makar A, Van den Broecke R, Delrue L, Denys H, Lambein K, et al. Intensity-modulated arc therapy with cisplatin as neo-adjuvant treatment for primary irresectable cervical cancer. Vol. 188, Strahlentherapie und Onkologie. 2012. p. 576–81.
  26. Haas JA, Witten MR, Clancey O, Episcopia K, Accordino D, Chalas E. CyberKnife Boost for Patients with Cervical Cancer Unable to Undergo Brachytherapy. Vol. 2, Frontiers in oncology. Frontiers Research Foundation; 2012. p. 25–25.
  27. Marnitz S, Köhler C, Budach V, Neumann O, Kluge A, Wlodarczyk W, et al. Brachytherapy-emulating robotic radiosurgery in patients with cervical carcinoma. Vol. 8, Radiation Oncology. 2013. p. 109.
  28. Kubicek GJ, Xue J, Xu Q, Asbell SO, Hughes L, Kramer N, et al. Stereotactic Body Radiotherapy as an Alternative to Brachytherapy in Gynecologic Cancer. Vol. 2013, BioMed Research International. Hindawi Publishing Corporation; 2013. p. 898953.
  29. Hsieh C-H, Tien H-J, Hsiao S-M, Wei M-C, Wu W-Y, Sun H-D, et al. Stereotactic body radiation therapy via helical tomotherapy to replace brachytherapy for brachytherapy-unsuitable cervical cancer patients - a preliminary result. 2013/02/04. Vol. 6, OncoTargets and therapy. Dove Medical Press; 2013. p. 59–66.
  30. Mantz CA. Stereotactic Body Radiation Therapy as a Boost Alternative for Nonmetastatic Cancer of the Cervix and Endometrium: Disease Control and Quality of Life Outcomes From a Phase 2 Trial at 3 Years’ Minimum Follow-up. Vol. 96, International Journal of Radiation Oncology • Biology • Physics. Elsevier; 2016. p. E286.
  31. Park HC, Shimizu S, Yonesaka A, Tsuchiya K, Ebina Y, Taguchi H, et al. High dose three-dimensional conformal boost using the real-time tumor tracking radiotherapy system in cervical cancer patients unable to receive intracavitary brachytherapy. 2009/12/29. Vol. 51, Yonsei medical journal. Yonsei University College of Medicine; 2010. p. 93–9.
  32. Chan P, Yeo I, Perkins G, Fyles A, Milosevic M. Dosimetric comparison of intensity-modulated, conformal, and four-field pelvic radiotherapy boost plans for gynecologic cancer: a retrospective planning study. Vol. 1, Radiation oncology (London, England). BioMed Central; 2006. p. 13–13.
  33. Barraclough LH, Swindell R, Livsey JE, Hunter RD, Davidson SE. External Beam Boost for Cancer of the Cervix Uteri When Intracavitary Therapy Cannot Be Performed. Vol. 71, International Journal of Radiation Oncology • Biology • Physics. Elsevier; 2008. p. 772–8.
  34. Stupp R, Mason WP, van den Bent MJ, Weller M, Fisher B, Taphoorn MJB, et al. Radiotherapy plus Concomitant and Adjuvant Temozolomide for Glioblastoma. New Engl J Med. 2005 Mar 10;352(10):987–96.
  35. Malmström A, Grønberg BH, Marosi C, Stupp R, Frappaz D, Schultz H, et al. Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: the Nordic randomised, phase 3 trial. Lancet Oncol. 2012 Sep 8;13(9):916–26.
  36. Bauman GS, Gaspar LE, Fisher BJ, Halperin EC, Macdonald DR, GRegory Cairncross J. A prospective study of short-course radiotherapy in poor prognosis glioblastoma multiforme. Vol. 29, International Journal of Radiation Oncology • Biology • Physics. Elsevier; 1994. p. 835–9.
  37. Perry JR, Laperriere N, O’Callaghan CJ, Brandes AA, Menten J, Phillips C, et al. Short-Course Radiation plus Temozolomide in Elderly Patients with Glioblastoma. Vol. 376, New England Journal of Medicine. Massachusetts Medical Society; 2017. p. 1027–37.
  38. Roa W, Brasher PMA, Bauman G, Anthes M, Bruera E, Chan A, et al. Abbreviated Course of Radiation Therapy in Older Patients With Glioblastoma Multiforme: A Prospective Randomized Clinical Trial. Vol. 22, Journal of Clinical Oncology. American Society of Clinical Oncology; 2004. p. 1583–8.
  39. Mallick S, Kunhiparambath H, Gupta S, Benson R, Sharma S, Laviraj MA, et al. Hypofractionated accelerated radiotherapy (HART) with concurrent and adjuvant temozolomide in newly diagnosed glioblastoma: a phase II randomized trial (HART-GBM trial). Vol. 140, Journal of Neuro-Oncology. 2018. p. 75–82.
  40. Rackley T, Leong T, Foo M, Crosby T. Definitive chemoradiotherapy for oesophageal cancer -- a promising start on an exciting journey. Vol. 26, Clinical Oncology (Royal College of Radiologists (Great Britain). 2014. p. 533–40.
  41. Jones CM, Spencer K, Hitchen C, Pelly T, Wood B, Hatfield P, et al. Hypofractionated Radiotherapy in Oesophageal Cancer for Patients Unfit for Systemic Therapy: A Retrospective Single-Centre Analysis. Vol. 31, Clinical Oncology. Elsevier; 2019. p. 356–64.
  42. Lyu J, Liu T, Li T, Li F, Wang Q, Wang J, et al. Comparison of efficacy, safety, and costs between neoadjuvant hypofractionated radiotherapy and conventionally fractionated radiotherapy for esophageal carcinoma. 2019/05/22. Vol. 8, Cancer medicine. John Wiley and Sons Inc.; 2019. p. 3710–8.
  43. Li N, Wang X, Tang Y, Zhao D, Chi Y, Yang L, et al. A prospective phase I study of hypo-fractionated neoadjuvant radiotherapy for locally advanced gastric cancer. Vol. 18, BMC cancer. BioMed Central; 2018. p. 803–803.
  44. Ma J-B, Wei L, Chen E-C, Qin G, Song Y-P, Chen X-M, et al. Moderately hypofractionated conformal radiation treatment of thoracic esophageal carcinoma. Asian Pac J Cancer Prev APJCP. 2012;13(8):4163–7.

Corresponding Author

Dr Bindhu Joseph

Associate Professor, Department of Radiation Oncology, Kidwai Memorial Institute of Oncology