Radiation Fractionation Schedules Recommended During the COVID-19 Pandemic: A Systematic Review of the Quality of Evidence and Considerations for Future Development

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Introduction Numerous publications during the COVID-19 pandemic recommended the use of hypofractionated radiotherapy. This project assessed aggregate changes in the quality of the evidence supporting these schedules, to establish a comprehensive evidence base for future reference and highlight aspects for future study. Methods and Materials Based on a systematic review of published recommendations related to dose-fractionation during the COVID-19 pandemic, twenty expert panellists assigned to fourteen disease groups named and graded the highest-quality of evidence schedule(s) used routinely for each condition and also graded all COVID-era recommended schedules. The ASTRO quality of evidence criteria were used to rank the schedules. Process-related statistics and changes in distributions of quality ratings of the highest-rated versus recommended COVID-19-era schedules were described by disease groups and for specific clinical scenarios. Results From January to May 2020 there were 54 relevant publications, including a total of 233 recommended COVID-19-adapted dose-fractionations. For site-specific curative and palliative schedules, there was a significant shift in the publishing record from established higher-quality evidence to lower-quality evidence and expert opinions for the recommended schedules (p = 0.022 and p < 0.001, respectively). For curative-intent schedules, the distribution of quality scores was essentially reversed (51.4% high-quality ‘pre-COVID’ versus 49.3% supported only by expert opinion ‘in-COVID), although there was variation in the magnitude of shifts between disease sites and among specific indications. Conclusions A large number of publications recommended hypofractionated radiotherapy schedules across all major disease sites during the COVID-19 pandemic, which were supported by a lower quality of evidence than the highest-quality routinely used dose-fractionation schedules. This work provides an evidence-based assessment of these potentially practice-changing recommendations and informs individualized decision-making and counselling of patients. These data would also support radiotherapy practices in the event of second waves or surges of the pandemic in new regions of the world.

Bibliographical metadata

Original languageEnglish
JournalInternational Journal of Radiation: Oncology - Biology - Physics
Publication statusAccepted/In press - 21 Jun 2020