Lucy Wood BMedRad(RadTh)_¹
1. Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia

This piece is based on the scoping review: Proton radiation therapy patient selection and impacts of COVID-19 by Wood et al.

Proton therapy patient selection and prioritisation during covid-19

The process of patient selection is crucial in proton therapy (PT) due to resource constraints, with costs reportedly around four times higher than traditional radiation therapy (Wood et al.) Therefore, it is vital to prioritise and allocate resources to those patients who would gain the greatest benefit. This process of prioritisation and selection became even more important during the pandemic, as appointments were more limited due to additional safety requirements.

What happened to proton therapy during the pandemic?

Each PT centre was impacted in various ways by the pandemic, and to different extremes depending on multiple factors including geographical location, implementation of health restrictions and prevalence of the virus. By the time the first recommendations from experts and PT centres were published in late 2020, each clinic would have already implemented their own precautions to prevent the spread of the virus (McGovern et al., 2020; Mishra et al., 2020). Overall, reduction in patient visitors, screening procedures, remote work, rigorous cleaning protocols and telehealth consults were recommended and reported to be implemented. Some screening protocols required negative COVID-19 tests prior to each treatment, whereas others followed a checklist to declare any symptoms.

In some cases, proton therapy was preferred over other interventions such as surgery, as PT is non-invasive and could take place with appropriate personal protective equipment. But for others, the length of PT treatment courses and the risk of exposure due to the frequency of appointments was enough to suggest quicker treatment options. Continuation of some aspects of patient care was aided by the transfer of consultations and appointments to tele-health.

Which patients were prioritised?

As could be expected, from the published literature it was most commonly reported that patients with benign or low risk conditions were frequently deferred. It was also reported patients with head and neck cancer, paediatric patients or patients for re-irradiation would often proceed or be recommended to complete PT. Patients that tested positive to COVID-19 during their course of treatment received various responses. The reported responses to infectious patients ranged between deferral of treatment until patient recovery or negative test result, continue treatment, and defer if possible, but to treat if urgent PT was required. Patient decision not to attend treatment due to risk of travel or exposure to COVID-19 also contributed to deferrals and cancellations.

It was ultimately up to each centre to decide how to prioritise their patient base, potentially being guided by the risk and staging systems already utilised for patients.

What happened to those without local access to proton therapy?

In an effort to contain COVID-19, travel between countries was limited and borders were closed to minimise spreading the virus. Patients referred for PT that did not have access to treatment locally were now much more restricted in where they could access treatment, if at all. Alternatively, these patients were offered other treatment such as conventional radiation therapy or surgery.

Referrals declined for PT during the pandemic, and it can be assumed countries without local access to PT centres contributed to this decrease as travel was restricted globally.

Considering the pandemic had varying impacts across the world, it can be said that each centre had a potentially unique response to managing treatment of patients whilst maintaining expert recommendations to prevent the spread of the virus. This response may also be guided by promptness and level of government action in implementing health restrictions. During the COVID-19 pandemic, implementing workflows to triage patients and for managing staff prior to experiencing big waves of infections was key in upholding treatment centres.

References:

McGovern, S. L., Wages, C., Dimmitt, A., Sanders, C., Martin, D., Ning, M. S., Manning, R., Amin, M., Zhu, X. R., Frank, S. J., & Gunn, G. B. (2020). Proton Therapy in a Pandemic: An Operational Response to the COVID-19 Crisis. International Journal of Particle Therapy, 7(1), 54-57. https://doi.org/https://dx.doi.org/10.14338/IJPT-20-00027
Mishra, K. K., Afshar, A., Thariat, J., Shih, H. A., Scholey, J. E., Daftari, I. K., Kacperek, A., Pica, A., Hrbacek, J., Dendale, R., Mazal, A., Heufelder, J., Char, D. H., Sauerwein, W. A. G., Weber, D. C., & Damato, B. E. (2020). Practice Considerations for Proton Beam Radiation Therapy of Uveal Melanoma During the Coronavirus Disease Pandemic: Particle Therapy Co-Operative Group Ocular Experience. Advances in radiation oncology, 5(4), 682-686. https://doi.org/https://dx.doi.org/10.1016/j.adro.2020.04.010
Wood, L., Giles, E., Cunningham, L., Le, H., Zientara, N., & Short, M. Proton radiation therapy patient selection and impacts of COVID-19: A scoping review. Journal of Medical Radiation Sciences, n/a(n/a). https://doi.org/https://doi.org/10.1002/jmrs.706

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