Management of gynecologic cancer: Choosing radiotherapy wisely by 3 Southern Ontario academic centers during the COVID-19 pandemic

Dear Editor:

The COVID-19 pandemic has dramatically impacted surgical capacity, radiotherapy and chemotherapy delivery worldwide. Contributing factors include the importance of social distancing to reduce viral transmission, the recognition that cancer patients have a higher risk of severe events compared to non-cancer patients [1], and resource limitations of the cancer centre with limited personal protective equipment (PPE), staffing shortages due to illness and redeployment. Recommendations have been made by national bodies and individual institutions to defer adjuvant RT, and to hypofractionate adjuvant and definitive treatment where appropriate [2], [3], [4].

Radiotherapy has an important and established role in the primary and adjuvant management of gynecologic cancers. It is the definitive treatment modality for locally advanced cervical, vaginal, and vulvar cancers. Adjuvant radiotherapy may be recommended for endometrial, cervical, vaginal and vulvar cancers. While the volume of patients referred for adjuvant radiotherapy may have decreased during the pandemic with reduction in operation room hours, there conversely may be an increased demand for radiotherapy for cancers traditionally managed with upfront surgery, or progressed during the pandemic.

We would like to share our approaches earlier on during the pandemic with the broader community. As radiation oncologists specializing in gynecological cancer management at three large academic cancer centers in Southern Ontario, Canada, we participated in separate multi-disciplinary (with gynecologic and/or medical oncologists) at our institutions and cross-institutional meetings with each other between March – early April 2020 for COVID-19 pandemic planning. The radiation oncology group searched the literature on hypofractionated, abbreviated and alternative radiotherapy regimens, as well as impact on the delay of radiation treatment using National Library of Medicine (PubMed/MEDLINE). We established potential strategies based on the existing literature, prioritizing prospective data and randomized controlled trial where available (Supplementary material). Where multiple modalities are employed, the relative and/or incremental benefit of each modality was considered. We employed evidence-based strategies where possible for radiation treatment of gynecologic cancers during the COVID-19 pandemic, with a view towards treatment deferral and/or reduced number of fractions whenever feasible and appropriate. In general, we prioritized newly diagnosed or isolated loco(regional) recurrent, curable gynecological cancer where radiotherapy is the primary curative modality, such as locally advanced cervical, vaginal and vulvar cancer, and isolated vaginal recurrence of endometrial cancer. Every effort was made to minimize the overall treatment time of locally advanced cervical cancer, including the use of simultaneous integrated nodal boost and not delaying 3D image-guided brachytherapy during the pandemic. While the numbers of COVID-19 cases have been declining in several countries (including Canada), they continue to surge in others where our approaches may be of interest.

Appendix A. Supplementary data

The following are the Supplementary data to this article: