Brachytherapy practice during the COVID-19 pandemic: a review on the practice changes

Abstract

The COVID-19 pandemic has caused a havoc across the globe, and has significantly affected oncology services, especially radiation therapy due to the need of social distancing as a measure for the pandemic mitigation. Brachytherapy, being an integral part of radiation therapy, posts a dilemma related to the practice of evidence-based oncology. It requires a significant amount of resources and personnel, thereby increasing the risk of exposure to the virus. There has been a significant amount of papers published providing the best available alternatives to external radiation; however, there is a lack of literature on the practice of brachytherapy. In times of the pandemic, deploying brachytherapy as a treatment modality can act as a double-edged sword and therefore, judicious use is warranted in such times of crisis. In this article, we provide a comprehensive review of the role of brachytherapy in various forms and different malignancy sites.

Radiotherapy based management during Covid-19 pandemic – A systematic review of presented consensus and guidelines

“… Adding approx. 5 Gy per week for each week of BT delay beyond seven weeks, respecting (OARs) tolerance doses ( Barthwal et al, 2020 ) - Reducing the number of applications by delivering multiple fractions with each application - Using higher dose/fr (fewer fraction number) considering the indications (e.g., 3 × 8 Gy or 4 × 7 Gy) ( Miriyala and Mahantshetty, 2020 ; ElMajjaoui et al, 2020 ; Kumar and Dey, 2020 ; Ismaili and Elmajjaoui, 2020 ) Adjuvant treatment: 9 Gy / 2 frs over 2 weeks, over conventional 7 Gy / 3–4 frs or 6 Gy / 5 frs ( Upadhyay and Shankar, 2020 ) 9 Gy × 2 frs weekly (in patients with low volume disease post-RT and in whom inferior local control) ( Kumar and Dey, 2020 ) Stages IB3, IIA2-IIIC2, and early IVA: Intracavitary HDR brachytherapy 3 frs Stages IA1, IA2, IB1, IB2, IIA1: Vault brachytherapy 12 Gy/2 frs ( Hinduja et al, 2020 ) For centers with single brachytherapy operating: postpone at least 24 days or until the infection is resolved Reduced number of fractions: 24 Gy/3 frs or 28 Gy/4 frs HDR ICBT: 7 Gy/4 frs at 1 week apart or 2 frs per day separated by a 6 h interval For patients >70 yrs, significant comorbidities, small tumors, or responding well to RT: -Shortened schedule (9 Gy /2 frs at 1 week apart) -Brachytherapy for cervical cancer (stage IB1, IIIB) ( ElMajjaoui et al, 2020 ) Advanced cervical cancer: temporarily defer interstitial brachytherapy ( Kwek et al, 2021 ) Uterine - Postpone BT but no more than 12 weeks after surgery ( Williams et al, 2020 ) Endometrial - Standard treatment (preferably three frs) ( Aghili et al, 0 ) Inoperable definitive positive COVID-19 symptomatic patients: - Hold on RT for 10-14 days - Start BT after recovery ( …”

“…Using SBRT or frameless SRS was also suggested for these patients where these radiotherapy techniques are feasible. Avoiding palliative BT was proposed to minimize coronavirus infection risk ( Barthwal et al, 2020 ).…”

High Dose Rate Brachytherapy for Inoperable Endometrial Cancer: a Case Series and Systematic Review of the Literature

“…There are studies using EBRT alone without brachytherapy [55,56]; however, the outcomes seem to be much lower, with disease-free survival of 58e63%. Even though EBRT alone is seemingly inferior to brachytherapy with or without pelvic EBRT, it is important to consider this option if needing to reduce exposure of staff, as needed through the COVID-19 global pandemic [57].…”

A two-center experience: The impact of COVID-19 on two brachytherapy programs in Ontario - virtual care, service suspension and radiation therapy workflow

“…In radiotherapy, patients were prioritized by disease site and treatment risk benefit. Furthermore, where possible, the number of radiation fractions were reduced [2] and mitigation strategies designed [3] to minimize the risk of exposure to staff and patients. To date, only one medical physics group shared their physics work during COVID-19 pandemic [30] , specifically in BT, the group recorded the same adaptation of working remotely for BT planning and plan checks.…”

“…Many brachytherapy (BT) procedures require the support of general anesthesia (GA) in an operating room setting and are considered aerosol generating medical procedures (AGMPs). In the COVID-19 era, AGMPs require additional infection control precautions when delivering these treatments [2] .…”