Kevin Brown

Precision radiation medicine and Covid-19: Providing optimal outcomes during extraordinary times

June 18, 2020
By Kevin Brown

Precision radiation medicine is a twenty-first century approach to fundamental cancer therapy. Approximately 50-60 percent of cancer patients will receive radiation therapy at some point during their cancer journey, as it is used for curative regimens and palliative care. Radiation therapy has been a pillar of cancer treatment for most of the past century, yet far from being an old or unsophisticated technology, recent advances in radiation delivery technology and software automation have enabled a new era of personalized precision radiation medicine.

The ability to develop personalized radiation therapy regimens is a direct result of the increased precision and accuracy with which cutting-edge systems deliver radiation doses. These systems enable delivery of higher doses of radiation to tumors, which increases efficacy, while reducing exposure of normal tissue, which is essential for improving safety, tolerability and long-term toxicity. The improved targeting to tumors allows more radiation to be delivered during each treatment session, which results in fewer sessions, reduces patients’ treatment burden, and allows more patients to be treated on each delivery system. Importantly, improved targeting is also opening the door to the use of radiation therapy in hard-to-treat cancers that are not amenable to traditional radiation therapy approaches.

Based on advances that allow the safe delivery of increased radiation doses, there is a growing trend toward the clinical use of hypofractionated regimens in which a total radiation dose is delivered over fewer treatment sessions. In addition to providing excellent outcomes, hypofractionated regimens may also have an important role to play in value-based approaches to cancer care because they reduce the total number of treatment sessions while providing excellent results.

The challenges of cancer care during the Covid-19 pandemic
The Covid-19 pandemic presents unique and diverse challenges to the safe and effective delivery of cancer care. A key challenge is that many cancer therapies, including chemotherapy and some targeted therapies, are immunosuppressive. Patients treated with these therapies have an increased risk of infection in routine treatment, and these regimens put patients at high risk of infection with SARS-CoV-2, the virus that causes Covid-19. The curtailing of non-emergency surgeries at most hospitals and cancer care centers is also upending standard of care cancer regimens that include surgery.

Beyond the challenges related to specific modes of cancer therapy, pandemic-related lockdown guidelines and travel restrictions make it difficult for patients to travel to cancer care centers. And even those patients willing and able to travel, or those who typically receive treatment close to home, may have difficulty receiving treatment as hospitals and cancer centers strive to reduce access to their facilities. Decreased access for non-essential staff, vendors and repair technicians may slow or limit the care that can be delivered. Finally, physician burnout, which is a significant challenge in oncology during normal times, is a growing concern as physicians work in increasingly high-stress environments with less support staff and while trying to ensure the survival of their practices.

Radiation medicine and healthcare informatics are power solutions
Precision radiation medicine and robust healthcare informatics enable effective and timely care that meets the Covid-19-related needs of patients, physicians and care centers. A key advantage of cutting-edge radiation medicine regimens is that they can be designed to avoid bone marrow, reducing immunosuppression and patients’ infection risk. While reduced infection risk is beneficial for any cancer patient any time treatment is delivered, it is particularly critical during a viral pandemic. Additionally, the use of hypofractionated regimens reduces the number of treatment sessions required for effective dosing. This offers a triple benefit of reducing the number of times a patient needs to leave home for cancer therapy, decreasing traffic through care centers, and alleviating workload for overburdened staff.

Another advantage to using precision radiation medicine approaches during the Covid-19 pandemic is its integration into multi-modal therapy. In response to the challenges of immunosuppressive chemotherapy or the limited ability to perform surgery, oncologists are, in some instances, restructuring how combination therapy is delivered. Some patients may receive radiation before chemotherapy or surgery rather than after these other modalities in order to delay immunosuppression and to enable some form of treatment to be delivered while operating rooms are closed to all but the most emergent procedures.

Robust informatics and automated systems also have a critical role to play in delivering timely and effective cancer therapy during the Covid-19 pandemic. This is because they enable significant operational and workflow efficiencies that minimize patients’ wait times once they arrive for treatment and allow high-quality care to be delivered even when on-site staffing levels may be below normal.

Software tools with a demonstrated history of enabling safe and efficient care while reducing hands-on time – which are increasingly important in routine care – become critical when radiation oncology departments are likely to face significant personnel constraints due to staff illness and the drive toward reducing the number of onsite personnel. Innovative patient management systems can help to ensure that required steps are taken in a timely fashion to allow patients to receive treatment on time and with minimal waiting once they are on site. Remote access and cloud-based systems can allow much of the radiation therapy workflow to happen remotely and in a distributed fashion, ensuring treatment is delivered safely, effectively and on schedule.

While streamlining workflows is essential for optimizing how patients, physicians and clinical personnel move through the care delivery pathway, keeping radiation delivery systems functioning safely and effectively is also critical. Travel and hospital access restrictions may make it difficult for technicians to perform onsite maintenance, upgrades or repairs. Remote and automated equipment monitoring systems that can predict potential failure of radiation delivery equipment allows vendors and care centers to work proactively to minimize system downtime without the need for onsite activity. Online customer technical support options may minimize the need for onsite repair/maintenance visits and allow systems implementation and training to continue even when in-person training is not an option. Thus, informatics should be considered an essential component for optimizing all aspects of radiation oncology during the current pandemic.

Learning from today to enable better care tomorrow
Much of what Covid-19 is demanding from cancer care providers today is relevant to providing value-based care on a day-to-day basis. Hypofractionated regimens reduce patient treatment burdens as well as demands on care center resources and, while this is critical during the pandemic, it also provides significant benefits during routine care delivery. Similarly, the ability for precision radiation medicine to provide oncologists and patients with potential alternative regimens that may have reduced immunosuppression helps to reduce the risk of contracting Covid-19 – but it also reduces the risk of infection with many common pathogens that pose serious danger to cancer care. These approaches may now be more widely adapted as a response to the pandemic, but the benefits they provide warrant adopting them in day-to-day cancer care.

Similarly, cloud-based and remote systems allow effective care to be delivered with fewer on-site personnel requirements and reduced space requirements, while giving staff improved flexibility and work-life balance. They can also be used to reduce system downtime and ensure that care is delivered in a timely manner. These are objectives that cancer care centers strive for every day – yet it has taken a global pandemic to bring the tools that enable this vision into clear focus. Necessity is said to be the mother of invention. In the case of cancer care during the Covid-19 pandemic, the technology we need is already here. The challenge is to re-invent our approach to using it.

About the author: Kevin Brown is a distinguished scientist with Elekta.