key: cord-260995-ji8aifck authors: Mohindra, Pranshu; Beriwal, Sushil; Kamrava, Mitchell title: Proposed brachytherapy recommendations (practical implementation, indications, and dose fractionation) during COVID-19 pandemic date: 2020-05-01 journal: Brachytherapy DOI: 10.1016/j.brachy.2020.04.009 sha: doc_id: 260995 cord_uid: ji8aifck nan Proposed brachytherapy recommendations (practical implementation, indications, and dose fractionation) during COVID-19 pandemic The ongoing COVID-19 pandemic has impacted the availability of health care resources (personnel and material) for all patients (1e4). This has especially impacted patients with cancer who are at a higher risk of contracting and suffering serious complications from COVID-19 infection (5e9). Nationwide, there have also been limitations placed on procedures including biopsies and cancer surgeries (10) . Given the unclear duration for the resource limitations might last, it is imperative to promote clinical efficiencies while maintaining optimal efficacy and safety. Brachytherapy is an integral part of radiotherapeutic management for a variety of clinical indications. Many brachytherapy procedures are carried out with anesthesia support and with utilization of operating room resources. As such, there is considerable pressure on providers to judiciously select patients in need of brachytherapy. After applicator/catheter placement, there is also substantial variability in planning (CT vs. MRI simulation), isotope selection for low-dose-rate brachytherapy, and dose and fractionation for high-dose-rate brachytherapy. To maximize resources, there is an urgent need to propose efficient dose/fractionation recommendations that are supported by evidence-based medicine. Guidance is additionally needed regarding brachytherapy utilization in patients who develop influenza-like illness, persons under investigation, or those who test positive for COVID-19 (COVID-19 þ). A number of guidelines are now published providing external beam radiation recommendations, but none have focused specifically on brachytherapy (11e13). We fully appreciate that access to brachytherapy is contingent on the impact of COVID-19þ patients on each specific hospital system and that clinical judgment needs to be used when considering the appropriateness of a treatment plan. Because of the critical role of brachytherapy in the management of a variety of cancers, it is important for institutions to consider offering brachytherapy if appropriate staff and personal protective equipment are available for the protection of patients and staff. Institutions are encouraged to follow guidelines set by their local policy with regard to personal protective equipment use during different surgical procedures. Through data shown in the table as follows, we suggest practical implementation considerations when using brachytherapy for a variety of clinical indications (Table 1) . We also summarize available data supporting the use of higher doseper-fraction high-dose-rate regimens to allow treatment completion in a shorter course thereby limiting resource utilization and exposure risk. It is strongly recommended that for all modified fractionations being considered, strict respect for normal tissue dosimetric constraints be met using available published data. We also recognize that our understanding of COVID-19 infections is rapidly evolving and that suggestions regarding appropriate time to wait for re-initiating therapy after a patient recovers from COVID-19 could change and may be institution specific. These suggestions are not meant to replace appropriate clinical judgment. Conflicts of Interest: None of the authors have any conflicts of interest to disclose. Funding: No funding was received for this article. HDR 5 high-dose-rate; LDR 5 low-dose-rate; BRT 5 brachytherapy; EBRT 5 external beam radiotherapy; PMID 5 Pubmed identifier; SRS/SRT 5 stereotactic radiosurgery/stereotactic radiotherapy; COVID-19 þ/PUI/ILI 5 influenza-like illness (ILI), persons under investigations (PUI) for COVID-19 with test results pending, and patients who may have tested positive for COVID-19 (COVID-19 þ). 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