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      Rapid Adaptation of Breast Radiotherapy Utilization during the COVID-19 Pandemic at a Large Academic Cancer Centre in Canada

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          Abstract

          Background

          Mitigation strategies to balance the risk of COVID-19 infection against oncologic risk in breast cancer patients undergoing radiotherapy have been deployed. To this end, shorter hypofractionated regimens have been recommended where appropriate, with prioritization of radiotherapy by oncologic risk and omission or deferral of radiotherapy for lower risk cases. Timely adoption of these measures reduces COVID-19 risk to both patients and health care workers, and preserves resources. Herein we present our early response and adaptation of breast radiotherapy utilization during the COVID-19 pandemic at a large academic cancer centre in Canada.

          Methods

          A state of emergency was announced in Ontario on March 17, 2020 due to the COVID-19 pandemic. Emergency guidelines were instituted. To examine our response, the number of weekly breast RT starts, type of breast RT, and patient age were compared from March 1 to April 30, 2020 to the same period in 2019.

          Results

          Following the declaration of emergency in Ontario, there was a decrease of 39% in radiotherapy starts in 2020 compared to 2019 (79 vs. 129, p<0.001). There was a relative increase in the proportion of patients receiving regional nodal irradiation (RNI) in 2020 compared to 2019 (46% vs. 29%, respectively), with the introduction of hypofractionated RNI in 2020 (27 of 54 cases, 50%). A smaller proportion of patients starting radiotherapy were aged > 50 years in 2020, 66% (78/118) vs. 83% (132/160) in 2019, p=0.0027.

          Conclusions

          A significant reduction in breast radiotherapy starts was noted during the early response to the COVID-19 pandemic, with prioritization of radiotherapy to patients associated with higher oncologic risk requiring RNI. A quick response to a health care crisis is critical, and is of particular importance for higher volume cancer sites where the potential impact on resources is greater.

          Abstract

          The adaptation of breast radiotherapy utilization during the COVID-19 pandemic at a large academic cancer centre was evaluated. A significant reduction in breast radiotherapy starts was noted during the early response to the pandemic, with prioritization of radiotherapy to patients associated with higher oncologic risk. A rapid response to a health care crisis is critical, and is of particular importance for higher volume cancer sites where the potential impact on resources is greater.

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          Most cited references15

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          Clinical Characteristics of Coronavirus Disease 2019 in China

          Abstract Background Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan city and rapidly spread throughout China, data have been needed on the clinical characteristics of the affected patients. Methods We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death. Results The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission. Conclusions During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.)
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            Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

            Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.
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              Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China

              In December 2019, novel coronavirus (2019-nCoV)-infected pneumonia (NCIP) occurred in Wuhan, China. The number of cases has increased rapidly but information on the clinical characteristics of affected patients is limited.
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                Author and article information

                Contributors
                Journal
                Adv Radiat Oncol
                Adv Radiat Oncol
                Advances in Radiation Oncology
                The Author(s). Published by Elsevier Inc. on behalf of American Society for Radiation Oncology.
                2452-1094
                19 June 2020
                19 June 2020
                Affiliations
                [1 ]Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 700 University Avenue, Toronto, Ontario, Canada M5G 1Z5
                [2 ]Department Radiation Oncology, University of Toronto, Ontario, Canada
                [3 ]Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
                [4 ]Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
                Author notes
                []Corresponding author: Dr. C. Anne Koch, MD, PhD, FRCPC Princess Margaret Cancer Centre, University Health Network Radiation Medicine Program 700 University Avenue, 7W-311 Toronto, Ontario, Canada M5G 1Z5 T 416-946-2122 F 416-946-4586 E anne.koch@ 123456rmp.uhn.ca
                Article
                S2452-1094(20)30149-4
                10.1016/j.adro.2020.06.002
                7303606
                32775788
                5f95ea8d-bf01-4b19-b5f6-14d5a1f58c3d
                © 2020 The Author(s)

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 28 May 2020
                : 2 June 2020
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