Prioritization on palliative radiotherapy during the COVID-19 pandemic (and beyond)

To the Editor

The Covid-19 pandemic imposes reflections on the priorities of oncological treatments, and particularly on the balance between benefits by receiving radiotherapy (RT) and the increased infective risk. A shared perspective is discriminating (by prioritization) the treatments not to be delayed or omitted from the ones suitable for such an option [1], [2]. van deHaar et al. provided a priority list for RT and addressed the issue of available resources to deliver RT in each Department along different phases of the infective spread, due to possible personnel limitation [3]. Nevertheless, in their excellent overview the proposed priority order for RT indications is not adapted through the proposed grades of available resources. Moreover still no validated tool to exactly predict the risk of infection by accesses to Hospital is available, often limiting choices to clinician’s judgment. That makes harder to take decision on when provide RT, and palliative RT (PRT) in particular. Some Authors provided separated indication to PRT for early and later infection spread phases, depending of RT personnel resources availability [4], [5]. Still the priority for PRT remains an issue. Some proposed solutions widely range from limiting palliative RT to emergencies [6], or even considering it for “Covid positive” patients [7]. A shared perspective is to delay or omit PRT if an efficient alternative can be offered [8], [9]. Considering that issue by a general perspective, we do not agree with the assumption that curative intent is more prior than the palliative one by itself (in presence of full availability for RT administration). For the 2 major oncological aims (cure and palliation) the pursued outcomes, measured by the most proper endpoint (i.e.: overall Survival -OS- for cure and quality of life -QoL- for palliation, respectively) are equivalent by patient’s perspective. Until we will not be forced by infective spread to restrict the RT administrable to our patients, palliative and curative settings should meet the same priority. A consequent question is the grade of improvement gained for each endpoint by a certain treatment option (e.g.: how much the optimal endpoint is improved by RT for a certain palliative treatment) and if that could be similarly obtained by alternative approaches. Supposing pain as example (one of the most frequent issues in palliative settings), the main alternative optimization to PRT is represented by analgesic drug administration. Of note, pain control in itself is not the best endpoint to base the selection of an “alternative optimization” on: QoL should be instead. RT has been clearly shown of high pain control rates [10], also if analgesic drug modification is accounted, and significantly improves QoL for palliative pain management [11], [12]. If PRT is not administered when indicated, the possibly needed dose escalation of medical analgesic therapy can determine side effects affecting QoL although controlling the pain level (beside the cost-effective impact on Health Services by missed drug medication’s reduction). Separately administering either PRT or medical analgesic therapy should not be considered equivalent by radiation oncologists: the concomitant integration of both, and modulation over time represents the gold standard. In conclusion, we highlight the need for radiation oncologists to do not set palliative indications at priority level different from any other presentation until the current resources will permit it. We stress the need for careful evaluation of alternative options to PRT through case personalization and routine use of prognostic scores. We recommend considering off-line preliminary evaluations for all palliative request (not only emergency) and we recommend providing fast track PRT administration when possible.