Advances in Radiation Oncology
In Regard to Yerramilli et al’s “Palliative Radiotherapy for Oncologic Emergencies in the Setting of COVID-19: Approaches to Balancing Risks and Benefits”
Volume: 5, Issue: 4
DOI 10.1016/j.adro.2020.04.017
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Hahn, Livergant, Millar, Ringash, Wong, Dawson, Warde, Cummings, and Barry: In Regard to Yerramilli et al’s “Palliative Radiotherapy for Oncologic Emergencies in the Setting of COVID-19: Approaches to Balancing Risks and Benefits”

To the Editor:

This timely paper provides guidance on short course palliative radiation therapy (RT) for common indications (eg, brain metastases, cord compression, tumor bleeding, airway obstruction, and bone metastases) during the coronavirus disease 2019 (COVID-19) pandemic.1 The increased risk of patients with cancer contracting COVID-19 infection and their higher risk of morbidity and mortality are strong motivators for using the shortest, most effective palliative RT regimens.1,2

We recommend 8 Gy single fraction RT as the first choice to palliate tumor bleeding during COVID-19. Yerramilli et al1 recommend against 10 Gy in 1 fraction owing to late gastrointestinal (GI) toxicity and recommend 4 Gy × 5 or 3.7 Gy × 4 twice daily. Onsrud et al3 observed late GI toxicity in patients with bleeding gynecologic malignancies treated with 2 or 3 10 Gy fractions; however, no late GI toxicity was observed after a single 10 Gy fraction.3 Other studies have reported bleeding control rates approaching 90% in multiple disease sites including GI, gynecologic, genitourinary, head and neck, extremity, and lung cancer after a single fraction of 8 Gy.4, 5, 6 A single 8 Gy is also widely used in some countries, including Canada and the Netherlands, and was the preferred approach to palliate bleeding tumors in the pre-COVID-19 era.7

Another versatile palliative RT schedule is the 0 to 7-21 regimen, in which a single fraction of 6 or 8 Gy is delivered on day 0, day 7, and a third time 2 weeks later if needed, while ensuring the final fraction is off-cord and off the brain stem to reduce toxicity risk. This protocol has been studied in multiple contexts and is effective for both symptom palliation and local tumor control.8, 9, 10 In head and neck cancers, Ngyuen et al8 found symptom response in over 80% of patients with 31% having a complete clinical response. Similar responses were reported in gynecologic cancers and nodular melanoma.9,10 A frequent strategy when using 0 to 7-21 is to reassess the patient before each fraction; symptoms are often adequately palliated after 1 or 2 8 Gy fractions. A regimen of 0 to 7-21 allows for shared decision-making with the patient, assessment of response to guide decision making, reduced visits, and a chance for sustained local control, as long as tolerances to organs at risk are respected. In the COVID-19 era, this schedule also allows flexibility regarding treatment days, and ensures that a higher biologically effective dose has been delivered if the course needs to be stopped early (compared with 1 or 2 fractions of other palliative regimens).



    Yerramilli D., Xu A., Gillespie E.. Palliative radiotherapy for oncologic emergencies in the setting of COVID-19: Approaches to balancing risks and benefits. Adv Radiat Oncol 5: 2020. , pp.589-594


    Liang W., Guan W., Chen R.. Cancer patients in SARS-CoV-2 infection: A nationwide analysis in China. Lancet Oncol 21: 2020. , pp.335-337


    Onsrud M., Hagen B., Strickert T.. 10-Gy single-fraction pelvic irradiation for palliation and life prolongation in patients with cancer of the cervix and corpus uteri. Gynecol Oncol 82: 2001. , pp.167-171


    Chaw C.L., Niblock P.G., Chaw C.S., Adamson D.J.. The role of palliative radiotherapy for haemostasis in unresectable gastric cancer: A single-institution experience. Ecancermedicalscience 8: 2014. , pp.384


    Tey J., Soon Y.Y., Cheo T.. Efficacy of palliative bladder radiotherapy for hematuria in advanced bladder cancer using contemporary radiotherapy techniques. In Vivo 33: 2019. , pp.2161-2167


    Sapienza L.G., Ning M.S., Jhingran A.. Short-course palliative radiation therapy leads to excellent bleeding control: A single centre retrospective study. Clin Transl Radiat Oncol 14: 2018. , pp.40-46


    Strijbos J., van der Linden Y.M., Vos-Westerman H., van Baardwijk A.. Dutch Platform Palliation, Radiotherapy. Patterns of practice in palliative radiotherapy for bleeding tumours in the Netherlands; a survey study among radiation oncologists. Clin Transl Radiat Oncol 15: 2019. , pp.70-75


    Nguyen N.T., Doerwald-Munoz L., Zhang H.. 0-7-21 hypofractionated palliative radiotherapy: An effective treatment for advanced head and neck cancers. Br J Radiol 88: 2015. 20140646


    Yan J., Milosevic M., Fyles A., Manchul L., Kelly V., Levin W.. A hypofractionated radiotherapy regimen (0-7-21) for advanced gynaecological cancer patients. Clin Oncol (R Coll Radiol) 23: 2011. , pp.476-481


    Johanson C.R., Harwood A.R., Cummings B.J., Quirt I.. 0-7-21 radiotherapy in nodular melanoma. Cancer 51: 1983. , pp.226-232


Allan and Ruth Kerbel Palliative Radiation Oncology Program


Sources of support: This work had no specific funding.
Disclosures: L.A.D. has a licensing agreement with Raystation that is unrelated to this work. Regard to Yerramilli et al’s “Palliative Radiotherapy for Oncologic Emergencies in the Setting of COVID-19: Approaches to Balancing Risks and Benefits”&author=Ezra Hahn,Jonathan Livergant,Barbara-Ann Millar,Jolie Ringash,Rebecca Wong,Laura A. Dawson,Padraig Warde,Bernard Cummings,Aisling Barry,&keyword=&subject=Recommendations for clinic operations and treatment during COVID19,