Effect of radiotherapy interruption due to COVID-19 outbreak.

To the Editor

The impact of the COVID-19 pandemic on cancer death was reported recently [1]. Wuhan where COVID-19 broke out has been critically hit [2], [3]. The emergence has affected every aspect of health care, including the delivery of standard radiotherapy to patients with cancer. Those patients was facing disruption because of concerns about their susceptibility to the serious risks of COVID-19, travel restrictions, and the shortage of personnel, beds and personal protective equipment, and it has been reported that many cancer patients in hospitals of Wuhan got into such difficulties, so the number of patients receiving radiotherapy significantly decreased during the pandemic [4], [5].

The radiotherapy center of Renmin Hospital of Wuhan University (RHWU) was shut down on January 24, and reopened until March 9, 2020. Thus, many patients were unplanned interrupted of radiotherapy during this period. Our survey of 140 consecutive patients in RHWU from March 9 to June 30, 2020, summarizes the clinical characteristics and outcome of these patients whose radiotherapy interrupted for 45 days or longer.

The median age at diagnosis was 57 (range 27–83) years, 70 patients (50%) were men, and 70 (50%) were women. Including lung (n = 26 [18.6%]), breast (n = 21 [15%]), head and neck cancer (n = 24 [17.1%]), or gastrointestinal (n = 25[17.9%]) or gynecological cancer (n = 17 [12.1%]). During the pandemic, 76 patients stayed at home without any cancer treatments. Twenty-six patients took traditional Chinese medicine, 12 took oral chemotherapy or molecular targeted therapy medications, 10 continued radiotherapy in other hospitals. 87 (62.1%) patients have returned to our center. The result indicated that stage IV was associated with poor prognosis compared with stage I-III. But the delivered radiation dose was not associated with disease prognosis (Table1 ). After 5 months of follow-up, 16 patients including nine females and seven males were died (11.4%), age from 40 to 77 years old. 11 were diagnosed with stage IV cancer and five with stage III cancer. 14 (10.0%) died of cancer and 2 (1.4%) died of COVID-19.

Table 1

Characteristics of patients with interrupted radiotherapy.*

	No.
Tumor TNM stage	PD	SD	PR	P
IV	17	13	1	0.000**
III	6	14	4
II	1	20	3
I	0	7	1
Radiation dose delivered/prescribed (radical radiotherapy)
>=50%	4	12	5	0.153
<50%	6	10	2
Aim of radiotherapy
Palliative	9	4	0	/#
Radical	10	22	7
Postoperative	5	28	1
Preoperative	0	0	1
Site of primary cancer
Intracranial	4	6	1	/#
Head and neck	4	11	4
Chest	11	23	3
Abdomen	1	1	0
Pelvic cavity	2	9	1
Others	2	4	0

List of abbreviations: PD: progressive disease; SD: stable disease; PR: partial response.

Only including the 87 patients who came back to our hospital to continue therapy.

Stage I, II, III were compared as a whole group with stage IV.

P value was not calculated as sample size is too small for statistical analyze.

Suboptimal delivery of radiotherapy (including delays, interruptions or omissions) has been demonstrated to compromise both local control and survival, especially for stage IV cancer patients. Other anti-tumor therapies (oral chemotherapy, endocrinotherapy or molecular targeted therapy) maybe improve the situation. Salvage radiotherapy was practicable, such as weekend treatments or increased number of daily fractions; increased dose per fraction; delivering extra fractions [6]. Balancing the risks of infection and subsequent mortality with the increased risks of cancer mortality derived from delaying treatment is of utmost importance, to date, many cancer centers have shared their strategies and experiences, which were effective in protecting the patient and staff from infection [7], [8], [9]. Further follow-up may clearly demonstrate the consequence of treatment interruption on local control and survival of cancer patients.

Author contributions

Drs Li and Song had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. They are co-senior authors. Drs Yu and Hu are co-first authors who contributed equally to this work.