key: cord-0992325-qi43vfit authors: Noticewala, Sonal S.; Ludmir, Ethan B.; Bishop, Andrew J.; Chung, Caroline; Ghia, Amol J.; Grosshans, David; McGovern, Susan; Paulino, Arnold de la Cruz; Wang, Chenyang; Woodhouse, Kristina D.; Yeboa, Debra N.; Prabhu, Sujit S.; Weathers, Shiao-Pei; Das, Prajnan; Koong, Albert C.; McAleer, Mary Frances; Li, Jing title: Radiation for Glioblastoma in the Era of COVID-19: Patient Selection and Hypofractionation to Maximize Benefit and Minimize Risk date: 2020-05-27 journal: Adv Radiat Oncol DOI: 10.1016/j.adro.2020.04.040 sha: e4419399a21312f903819302aff35f6b3681554a doc_id: 992325 cord_uid: qi43vfit We describe the institutional guidelines of a major tertiary cancer center with regard to using hypofractionated radiation regimens to treat glioblastoma as a measure to minimize exposure to coronavirus disease 2019 (COVID-19) while not sacrificing clinical outcomes. Our guidelines review level one evidence of various hypofractionated regimens, and recommend a multidisciplinary approach while balancing the risk of morbidity and mortality among individuals at high risk for severe illness from COVID-19 infection. We also briefly outline strategies our department is taking in mitigating risk among our cancer patients undergoing radiation. In the midst of the COVID-19 pandemic, minimizing risk of exposure for both patients and healthcare personnel is critical. Early data suggest that cancer patients are particularly susceptible to severe illness due to COVID-19 1 . Delivering a course of radiation therapy (RT) involves multiple personto-person interactions at the individual level over many weeks, including between patients, physicians, nurses, radiation therapists, physicists, and more. Thus, many radiation oncology facilities are identifying measures to reduce exposure of patients and providers to COVID-19. Radiation oncologists are therefore revisiting the role of hypofractionated RT regimens to decrease treatment time and exposure for all involved. To that end, our central nervous system working group at a large tertiary cancer care center has drafted guidance for selecting glioblastoma (GBM) patients who would benefit from hypofractionated RT in the era of COVID-19 ( Figure 1 ). According to the Center for Disease Control and Prevention (CDC), patients aged ≥65 years and those with uncontrolled comorbidities (primarily cardiopulmonary conditions; Figure 1 ) are considered at risk for severe illness from COVID-19 2 . Based on these risk factors, we recommend patients with GBM presenting for first-course RT aged ≥65 years should strongly be considered for hypofractionated RT regimens, in particular 40 Gy in 15 fractions, as supported by phase 3 data (Figure 1 being considered for first-course RT. Alternatively, best supportive care or TMZ with omission of RT is reasonable (Figure 1 ). For patients with recurrent GBM, we do not generally recommend re-irradiation, and instead favor consideration of systemic therapies if considered reasonable (Figure 1) . These therapies may include, but are not limited to temozolomide, bevacizumab, lomustine, and others. Within our department, a daily multidisciplinary group provides guidance to radiation oncologists on decision-making given the rapidly-changing evidence and protocols in response to the COVID-19 pandemic. This group assesses the appropriateness of safely delaying consultations or treatment, referring patients to local providers as indicated, utilization of telemedicine, and handling of COVID-19 positive patients requiring RT. Given the aggressive nature of GBM, we recommend patients who are asymptomatic, COVID-19-negative, and do not meet criteria for self-quarantine should receive RT in a manner that decreases exposure without compromising clinical outcomes as outlined (Figure 1) . For In conclusion, the COVID-19 pandemic is likely to impact oncologic management in a lasting way, and the recommendations provided here may evolve over time. Other institutions should consider implementing these guidelines in accordance with local institutional, state, and federal regulations and with multidisciplinary discussions with radiation oncology, neuro-oncology, and neurosurgery. Collectively, we believe these recommendations allow safe, effective, and expedient RT for GBM patients in the era of COVID-19. *: Healthcare guidelines during COVID-19 pandemic are dynamic and application of the guidelines outlined should be in accordance with local institutional, state, and federal guidelines. Consider travel restrictions for new patients and use of a telemedicine platform to monitor patients for side-effects while on treatment. #: recommend multidisciplinary discussion with radiation oncology, neuro-oncology regarding systemic therapy, and neurosurgery ╪: In patients who have tested COVID-19 negative, we recommend re-testing if the index of suspicion for COVID-19 infection is high. If a patient becomes COVID-19 positive during RT, we recommend holding RT until the patient self-quarantines for 14 days after positive test date. The patient is then screened for symptoms after completion of self-quarantine and the patient's case undergoes multidisciplinary review to determine if he/she can resume RT. ¥: consider 60 Gy in 30 fractions with excellent performance status and without high risk CDC identified COVID-19 comorbidities. π: consider risk/benefits of hypofractionated RT if patient has the following uncontrolled comorbidities as identified by the CDC: chronic lung disease, moderate to severe asthma, serious heart conditions, immunocompromised, severe obesity, diabetes, chronic kidney disease undergoing dialysis, liver disease Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China Abbreviated course of radiation therapy in older patients with glioblastoma multiforme: A prospective randomized clinical trial Short-Course Radiation plus Temozolomide in Elderly Patients with Glioblastoma Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: The Nordic randomised International Atomic Energy Agency Randomized Phase III Study of Radiation Therapy in Elderly and/or Frail Patients With Newly Diagnosed Glioblastoma Multiforme Effects of radiotherapy with concomitant and adjuvant temozolomide versus radiotherapy alone on survival in glioblastoma in a randomised phase III study: 5-year analysis of the EORTC-NCIC trial Abbreviated course of radiation therapy in older patients with glioblastoma multiforme: A prospective randomized clinical trial Short-Course Radiation plus Temozolomide in Elderly Patients with Glioblastoma Temozolomide versus standard 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: The Nordic randomised International Atomic Energy Agency Randomized Phase III Study of Radiation Therapy in Elderly and/or Frail Patients With Newly Diagnosed Glioblastoma Multiforme