International expert consensus statement regarding radiotherapy treatment options for rectal cancer during the COVID 19 pandemic
Open accessAbstract
The rapid spread of COVID19 infection across the globe is causing a health care emergency. Our aim is to assist discussion about the risks and benefits to facilitate decision-making regarding radiotherapy for rectal cancer patients. In our roles as clinicians and as experts who have conducted clinical trials evaluating the role of radiotherapy in rectal cancer, we present our assessment of treatment options that should be considered by health care professionals in the setting of the COVID 19 pandemic. We want to minimize the risks to our patients whilst aiming to maintain cancer outcomes. We have used the European Society for Medical Oncology (ESMO) rectal cancer guidelines as a framework to describe our recommendations [[1]Glynne-Jones R. Wyrwicz L. Tiret E. et al.Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.Ann Oncol. 2017; 28 (iv22-iv40)Abstract Full Text Full Text PDF Scopus (1109) Google Scholar] (Fig. 1). ESMO Guideline: TME without pre-operative radiotherapy is recommended in most cases. Recommendation: We strongly support the use of TME without pre-operative radiotherapy. ESMO Guideline: TME alone or SCRT/CRT if good quality mesorectal excision cannot be assured. Recommendation: In countries where high quality surgery is performed, we strongly recommend TME alone. Careful discussion of the use of radiotherapy in this group is needed in the COVID 19 setting where the benefits of preoperative radiotherapy are likely to be small. If radiotherapy is to be used, SCRT should be the preferred option rather than CRT (see below). ESMO Guideline: Pre-operative SCRT or CRT is recommended. Recommendation: We strongly recommend the use of SCRT. Two phase III trials have compared SCRT and CRT and demonstrate comparable outcomes for local recurrence, disease free survival (DFS), overall survival (OS) and late toxicity [2Ngan S.Y. Burmeister B. Fisher R.J. et al.Randomized trial of short-course radiotherapy versus long-course chemoradiation comparing rates of local recurrence in patients with T3 rectal cancer: Trans-Tasman Radiation Oncology Group trial 01.04.J Clin Oncol. 2012; 30: 3827-3833Crossref PubMed Scopus (657) Google Scholar, 3Bujko K. Nowacki M.P. Nasierowska-Guttmejer A. Michalski W. Bebenek M. Kryj M. Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer.Br J Surg. 2006; 93: 1215-1223Crossref PubMed Scopus (1004) Google Scholar]. Both approaches are widely used. In the COVID 19 setting there are some important factors to consider. When the use of SCRT is compared with CRT there are many advantages of SCRT:- less acute toxicity; fewer radiotherapy treatment attendances; substantial reduction in travel and contact with other patients and staff; avoidance of any detrimental effect of concurrent chemotherapy on immune function; and thus significantly reduced risk of COVID 19 infection during treatment. The greater social distancing achieved with SCRT is a major advantage. An additional benefit is that the use of SCRT instead of CRT in this setting will have a substantial reduction in linear accelerator usage, will help avoid waiting time to start treatment and increase the ability of departments to treat all their patients in the setting of reduced staffing levels. ESMO Guideline: Not stated as the Stockholm III trial was published post guideline. Recommendation: SCRT and a delay to surgery has advantages that may be beneficial in both routine clinical practice and in the COVID 19 setting. The Dutch TME and MRC CR07 trials as well as the previous Swedish trials recommended that surgery should be performed within three to seven days of completion of SCRT [4van Gijn W. Marijnen C.A. Nagtegaal I.D. et al.Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial.Lancet Oncol. 2011; 12: 575-582Abstract Full Text Full Text PDF PubMed Scopus (1372) Google Scholar, 5Sebag-Montefiore D. Stephens R.J. Steele R. et al.Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial.Lancet. 2009; 373: 811-820Abstract Full Text Full Text PDF PubMed Scopus (1246) Google Scholar, 6Folkesson J. Birgisson H. Pahlman L. Cedermark B. Glimelius B. Gunnarsson U. Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate.J Clin Oncol. 2005; 23: 5644-5650Crossref PubMed Scopus (687) Google Scholar]. The recently reported Stockholm III trial compared surgery performed within one week with 4–8 weeks after SCRT [[7]Erlandsson J. Holm T. Pettersson D. et al.Optimal fractionation of preoperative radiotherapy and timing to surgery for rectal cancer (Stockholm III): a multicentre, randomised, non-blinded, phase 3, non-inferiori
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In a single-center retrospective analysis, postponing surgery by 60 days for stage I-II breast cancer did not worsen outcomes.
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Wang, W., Hu, K., Qiu, J., & Zhang, F. (2020) · Radiation Oncology · doi:10.1186/s13014-020-01612-5 · Cited by 2 · see citing works
Montero‐Oleas, N., Puente-Vallejo, R., León-Micheli, B., Cabrera, A. I., Silva, M., Gamarra, E., Rodas, B. F. A., Segovia, N., Roldán, P. R. A., Silva, C. N., et al. (2020) · Medwave · doi:10.5867/medwave.2020.08.8012 · Cited by 2 · see citing works
The Economic Impact of the COVID-19 Pandemic on Radiation Oncology Practice
Oliveira, C., Wilson, B. E., Aggarwal, A. K., Lievens, Y. N., & Rodin, D. L. (2021) · Applied Radiation Oncology · doi:10.37549/aro1295 · Cited by 2 · see citing works
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RetractedImplementation of Radiotherapy and Overcoming the Treatment Breaks in COVID-19 Crisis
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Radiotherapy and Systemic Anti-Cancer Treatment in Older Adults with Cancer and Frailty
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Management of Non metastatic Colo-Rectal Cancers During the COVID-19 Pandemic: Viewpoint
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Review Paper_Ethical Issues in Patient Care in the current COVID-19 Pandemic
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Insights into the management of anorectal disease in the coronavirus 2019 disease era
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- Authors
- Marijnen, C. A. M., Peters, F. P., Rödel, C., Bujko, K., Haustermans, K., Fokas, E., Glynne-Jones, R., Valentini, V., Spindler, K.-L. G., Guren, M. G., Maingon, P., Calvo, F. A., Pares, O., Glimelius, B., & Sebag-Montefiore, D.
- Affiliations
- Leiden University Medical Center (NL)
- Goethe University Frankfurt (DE)
- The Maria Sklodowska-Curie National Research Institute of Oncology (PL)
- Universitair Ziekenhuis Leuven (BE)
- Università Cattolica del Sacro Cuore (IT)
- Aarhus University Hospital (DK)
- Oslo University Hospital (NO)
- Sorbonne Université (FR)
- Uppsala University (SE)
- ORCID
- Venue
- Radiotherapy and Oncology
- Publisher
- Elsevier BV
- Published
- 2020-07
- Volume
- 148
- Pages
- 213-215
- ISSN
- 0167-8140 (ISSN-L)
- PMC
- PMC7194592
- OpenAlex
- W3013670950
- Cited by
- 78
- References
- 10
- Citations by year
- 2026: 2 · 2025: 3 · 2024: 3 · 2023: 5 · 2022: 11 · 2021: 16 · 2020: 38
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Radiotherapy and Oncology (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- Lirias (submittedVersion, other-oa)
- Funders
- Cancer Research UK (28832, 25447)
- Topics
- Health Sciences › Medicine › Oncology › Colorectal Cancer Surgical Treatments
- Health Sciences › Medicine › Oncology › COVID-19 and healthcare impacts
- Health Sciences › Medicine › Surgery › Colorectal and Anal Carcinomas
- Keywords
- rectal cancer, radiotherapy, COVID-19 pandemic, treatment options, total mesorectal excision, short-course radiotherapy, chemoradiotherapy, preoperative radiotherapy, local recurrence, treatment prioritization, patient safety, ESMO guidelines, clinical guidelines, late toxicity, disease-free survival, overall survival
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