Table 4.
Priority categories for radiation oncology
| Priority | Patient Description | COVID-19 Treatment Considerations |
|---|---|---|
| Priority A | ||
| A |
Bleeding/painful inoperable local–regional disease, Symptomatic metastatic disease |
Consider palliative HF regimens |
| A | Progression of disease during NAC | Consider definitive HF regimens |
| Priority B | ||
| B1 | Inflammatory BC s/p mastectomy | Consider PMRT HF regimens |
| B1 | Node positive: TNBC or HER2 + disease s/p BCT or mastectomy | Consider WBRT or PMRT HF regimens |
| B1 | Postmastectomy with 4 or more tumor-positive nodes | Consider PMRT HF regimens |
| B1 | Residual node-positive disease after NAC | Consider WBRT or PMRT regimens |
| B2 | PMRT with 1–3 tumor-positive nodes | Consider PMRT HF regimens |
| B2 | Node negative: TNBC or HER2 + s/p BCT | Consider WBRT HF regimens |
| B2 | If tumor-positive margin after BCT for invasive BC with no alternative therapy options* | Consider WBRT HF regimens |
| B3 | If tumor-positive margin after BCT for invasive BC with alternative therapy options | Consider WBRT HF regimens |
| B3 | Young age (≤ 40 years) s/p BCT, node negative with ≥ 1 additional high-risk features (LVI + , PNI +) | Consider HF regimens |
| B3 | ER- DCIS with a positive margin | Consider HF WBRT regimens |
| Priority C | ||
| C | DCIS** | Initiate endocrine therapy if ER + Defer radiation therapy until pandemic is over |
| C | > 65 years early-stage, nodenegative ER + / HER2- taking adjuvant endocrine therapy s/p BCT | Omit radiation therapy or defer until pandemic is over |
| Hypofractionated Regimens: | ||
| Palliative Radiation | ||
| 4 Gy × 5 total 20 Gy | Meta-analysis [43] | |
| 8 Gy × 1 total 8 Gy | RTOG 97–14 [42] | |
| Whole breast radiation therapy: | ||
| 2.67 Gy daily × 15 total 40.05 Gy | START B [45] | |
| 2.66 Gy daily × 16 total 42.56 Gy | Canadian [46] | |
| 5.7 Gy once per week × 5 total 28.5 Gy | FAST [52] | |
| 5.2–5.4 Gy daily × 5 total 26–27 Gy | FAST Forward [53] | |
| Postmastectomy radiation therapy: | ||
| 2.5 Gy daily × 15 to chest wall total 37.50 Gy; 2.5 Gy daily × 14 to regional nodes (including IMN) total 35 Gy | British Columbia PMRT trial [49] | |
|
2.90 Gy × 15 daily to chest wall, SC & Level III axilla total 43.5 Gy No IMN or reconstruction |
China PMRT Trial [50] | |
| 2.66 Gy daily × 16 to chest wall + regional nodes (with IMN) total 42.56 Gy | NCT03414970 | |
| 2.67 Gy daily × 15 to chest wall total 40.05 Gy, 2.67 × 14 to RNI total 37.38 Gy | NCT03422003 | |
| Boost | ||
| 2.5 Gy × 4 total 10 Gy, consider additional 2.5 Gy fraction for positive margin | ||
| Considerations for treatment interruptions | ||
|
No change to WBRT, PMRT dose. Adjust boost as follows: No boost in original treatment plan: Add boost 2.5 Gy × 4 Boost in original treatment plan: consider additional 2.5 Gy fraction to boost PTV total 12.5 Gy*** | ||
BC breast cancer, TNBC triple negative breast cancer, HF hypofractionated, NAC neoadjuvant chemotherapy, PMRT postmastectomy radiation therapy, WBRT whole breast radiation therapy, BCT breast conserving therapy, LVI lymphovascular invasion, PNI peri-neural invasion, ER estrogen receptor, HER2 human epidermal growth factor receptor 2, IMN internal mammary node; RNI regional-nodal irradiation
*TNBC with tumor positive margins should be given priority over TNBC with negative margins
**Exception to DCIS in Priority C is ER-negative DCIS with positive margin
***Adapted from Gay HA, et al. [57]