Radiation in the Time of Covid-19

A panel of top radiation oncologists in the US and UK addressed the question of putting off or shortening various kinds of radiation treatments for prostate cancer at a time when it is best to maintain distance from institutions that treat patients.

Their recommendations depended on the disease setting. For detailed recommendations, see this table. They recommend:

• Consultations and return visits post-RT should be handled by telephone or online if possible.
• The preferred therapy for all favorable risk prostate cancers (very low, low, favorable intermediate risk) is active surveillance during the pandemic.
• 4-6 month depot injections of a GnRH agonist (e.g., Lupron, Eligard, Zoladex, etc.) should be used prior to primary RT for all unfavorable-risk patients (unfavorable intermediate risk, high risk, and lymph node positive). If there must be treatment during the pandemic, a shortened course of external beam RT using moderate (20 treatments) or extreme hypofractionation (5 treatments) is recommended.
• Brachytherapy should be avoided during the pandemic, and delayed until afterwards if desired,  due to high exposure of anesthesiological medical staff.
• Adjuvant/Salvage RT should be delayed. 4-6 month depot injections of a GnRH agonist (e.g., Lupron, Eligard, Zoladex, etc.) may be used during the delay.
• De-bulking the prostate with RT in patients with low volume metastases can be delayed with 4-6 month depot injections of a GnRH agonist (e.g., Lupron, Eligard, Zoladex, etc.).
• Treatment of oligometastases with one to three RT treatments may be delayed with 4-6 month depot injections of a GnRH agonist (e.g., Lupron, Eligard, Zoladex, etc.).

I only take issue with the recommendation for non-palliative oligometastatic RT. (They specifically excluded palliative RT from their guidelines.) They state that they recommend delaying treatments that fall into the category of "non-essential procedures that do not have evidence to support their impact on overall survival rates." Treatment of oligometastases is definitely in that category. Yet they state that RT±ADT is the preferred treatment during the pandemic. Anyone with metastases  (any number) should be on ADT or advanced ADT anyway. Painful metastases and those at danger of spinal compression should receive SBRT+ADT.