What is our threshold: Departmental planning for radiation oncology's future in the time of COVID-19.

The outbreak of novel coronavirus disease 2019 (COVID-2019) is of significant concern. As of this writing, the slope of the upward portion of the logarithmic curve of cases and deaths in the US is unclear and much is unknown about the virology and epidemiology of the disease. Furthermore, the short- and long-term impact of this pandemic on the medical community and society, at-large, is yet to be understood. Nevertheless, it is becoming clearer, however, that we are settling into a new and dynamic reality as a medical specialty. If leveraged well, the operational efficiencies realized in response to current challenges will be an asset. However, we must be mindful of taking steps that don’t inadvertently lead us all towards a less optimal future.

Current uncertainties

The impact of COVID-19 on cancer patients is not well understood. In the March 2020 issue of Lancet Oncology, Liang et al. [1] described the clinical experience of 18 (out of 1590 COVID-19 cases) patients with a history of cancer in China, disclosing an increased cumulative probability of severe events (HR 3.65, 95% CI: 1.65–7.69) compared to non-cancer patients. Of these 18 patients, four had received systemic therapy within the past month and the other 12 were in follow-up. The authors conclude that cancer patients are at higher risk – perhaps not surprising – and that greater attention should be paid to intentional postponing of care and constructive exploitation of disease surveillance as a partial mitigation strategy to flatten the curve via the protection patients and health care workers alike [2]. In time, more information may become available as to specific factors associated with risk.

There is also excess risk to staff, and ourselves, during this time. Certainly there is a risk of infection that can impact departmental workforce and the ability to care for patients [2]. This risk may be amongst staff or between staff and patients. As oncologists, we also worry about transmission to our frail patients. And beyond this, the social disruption of this time has created other headwinds for our field: additional responsibilities at home caring for sick or out of school family members, trainees and students in a time of uncertainty, additional clinical responsibilities within institutions that may only worsen as the influx of patients increases.

The coming weeks and months will be instructive as to how the virus, social response measures, and local institutional directives impact our ability to care for our patients, and how we are forced to adapt. We will likely be asked to do more with less; it is therefore incumbent that we prepare now for this new reality, however long it may be.

New opportunities

Departments are presently responding by decreasing on site work force wherever possible, and in many cases deferring or altering patient treatments to minimize their physical time within the departments. As a result, many institutions, including our own, are rolling out telemedicine and remote care strategies on short order. The rollout of such platforms can be immensely useful, both in the short run for permitting physicians to continue to care for their own patients, but perhaps in the future in helping institutions broaden their catchment, especially in rural areas. What if much of the E&M portions of care could be transitioned to a telemedicine platform, especially for patients living at distance from the hospital? When coupled with increasing utilization of hypofractionation, such technologies could allow our facilities to reach even more patients than ever before. Other new second opinion and remote care opportunities may also develop.

At the same time, departments are realizing internal efficiencies, such as remote work for physics, dosimetry, and other technical operations. As networks of radiation oncology facilities become larger and more complex, the ability to work together over cyberspace – rather than “at the elbow” will be tremendously useful. However, as will be discussed below, we must be mindful of maintaining the value of these team members over the long run such that members of the team work near the top of their license and skill set.

Another critical opportunity involves new technology development, particularly in the patient care realm. As the “tech nerds” of the cancer world, we radiation oncologists have the opportunity to innovate and invent new ways to care for patients when they are with us. The current shortages of personal protective equipment (PPE) is already forcing departments to get creative with infection control equipment and person flow. How can we further improve patient flow, setup, and on treatment care to minimize their risk for infection, and ours? Virtual visits in department, texting appointment updates, and other creative all are being tested. We must share best practices well through formalized, sharable electronic means (e.g. ASTRO or ESTRO board) that are accessible to all. One thing is clear, the status quo from just a few short weeks ago will not return after the COVID-19 crisis abates.

Looking ahead: recommendations

At the present writing, current attention is being paid to the concept of social distancing, as a mitigation strategy to minimize direct physical interactions between patients and us, so as to limit virus transmission. This cannot persist, however, especially if the COVID-19 societal measures continue beyond the next few weeks if we wish to maximize patient outcomes and the future stability of our departments and practices. We must think carefully now about levels of risk, and defining thresholds for care.

As oncologists we are used to thinking about competing risks, and the risk/benefit ratios for our interventions. We unfortunately won’t be able to truly quantify the excess risk for each patient for COVID exposure, at least for some time while observational data mature. But we do have much better data for the risks delaying individual patients might have on local control and survival. “Do no harm” is not as simple as minimizing COVID exposure risk, as some recent commentaries have suggested [3]. Each team of physicians locally needs to start developing triage paradigms [4], similar to the surgical world, for which patients are high, medium, or low risk from a cancer perspective, and develop workflows to get them in for treatment promptly, and safely. Indeed this has begun. One strategy is outlined in Table 1 . We suggest considering high risk patients as those with intact tumors (e.g. CNS, head and neck, lung, cervical, some pediatric, palliative) or those with aggressive histology (e.g. whereby a delay in treatment is likely to comprise outcomes). Perhaps counterintuitively, patients receiving chemotherapy should be prioritized; though risks of COVID disease may be higher, so too is the risk of treatment delay. Medium risk patients could be those where an objective local control benefit is risked by delay, but there is no known survival decrement (e.g. many GI sites, sarcoma, some GU cancers). Lower risk are those were outcome risk is lower and there is more room for pragmatism (e.g. most early breast, low or favorable intermediate risk prostate, T1 non-small cell lung cancer, and/or indolent lymphoma).

Table 1

Example risk-adapted triage strategy for radiotherapy patients during COVID-19.

Risk Level	Example Diseases	Possible Strategy
High	Symptomatic CNS, intact Head & Neck tumors, locally advanced NSCLC or SCLC, cervical, high risk pediatric, palliative (cord, CNS, SVC, bleeding, dyspnea)	Prioritize treatments promptly, with maximal precautions
Medium	Definitive esophagus, pancreas, rectal, node positive breast, sarcoma, unfavorable intermediate or high risk prostate cancer, bladder cancer, vulvar or higher risk uterine, palliative pain	Delay start no more than 2–3 weeks, pursue normal treatment paradigms
Low	Early stage NSCLC, post-op CNS, low risk breast cancer, indoldent lymphoma, low or favorable intermediate risk prostate, very high infectious risk patients (e.g. TBI, pediatric with low urgency)	Consider longer delay for start or do not treat; more liberal use of newer/evolving hypofractionation paradigms, more “neoadjuvant” systemic or hormonal therapy

Attention should be paid to how we fractionate and how our staffs are utilized. While this certainly is a time to be pragmatic about fractionation, we would caution authors not to step out too far ahead of data, and mindful of not adopting paradigms that will be difficult to undo in the future. Certainly the risks and benefits should be part of a shared decision making conversation between doctor and patient. As well, the ability to function well with less (fewer onsite staff, more distributed/remote resources) might mean future job challenges for much of our technical staff as administrators could question their future cost, necessity, and value, especially in a future bundled care era. We must keep all departmental enterprises functioning at a high level of output, in some cases creatively repurposing personnel for special projects. Departments must develop robust staffing plans, but also be pragmatic about testing, minimizing quarantine restrictions, and maintaining a viable workforce to continue uninterrupted operations. Our services are essential, and in most cases not elective, and our plans must reflect this.

Above all, we must remember we are physicians first, and radiation oncologists second. While the prospect of intubating and managing ventilator settings might be a scary prospect for some – as demonstrated by a recent rad onc trainee’s quote in The New York Times – we want to be a demonstrable part of the conversation and solution, rather than outside of it. Now is a time to show that we are real doctors and always have been. If we are called to help, let’s help, and let’s establish our value within the hospital. We may suffer personal harm, but this is our responsibility. New and innovative opportunities for our future work and partnerships may emerge as a result. The entrepreneurs amongst us must develop new tools, both physical and electronic, during this time to care for patients. Though there is much fear amongst our patients and staff, and perhaps even ourselves, we must let equanimity under duress prevail [5] and provide much-needed tangible leadership that will benefit our current and future patients.

Conflict of interest

The authors have no COIs or funding to disclose relevant to this work.