Hypofractionation in COVID-19 radiotherapy: A mix of evidence based medicine and of opportunities
Hypofractionation in COVID-19 radiotherapy: A mix of evidence based medicine and of opportunities
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DOI：
10.1016/j.radonc.2020.06.036
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发表时间：
2020-09-01
影响因子：
5.7
通讯作者：
Bambace, S.
中科院分区：
文献类型：
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作者：
Portaluri, M.;Barba, M. C.;Bambace, S.
自二零二零年一月起，COVID-19疫情在中国蔓延，并于未来数周在意大利蔓延，继而蔓延至欧洲其他地区及世界各地，对放射肿瘤科医生的组织、安全程序及处方行为产生巨大影响。在过去三个月内发表的大量评论、信件和论文中表达的主要关注问题是：（a）如何确保放射治疗的正常供应;（B）如何保持医护人员的人数不变;（c）如何识别接受放射治疗的病人是否对SARS-CoV-2呈阳性;（d）如何保护医护人员免受病毒感染;（e）如何保护病人免受感染;（f）如何保护病人免受病毒感染。（f）如何减少RT启动的推迟和延迟。在以前的通信中，在宣布大流行后不久，描述了意大利南部（感染发生率相对较低的地区）放射治疗部门临床活动的初步修改[1]，并针对国家政府和科学机构的安全建议提出了一些批评，因为它们是矛盾的，可以说不足以确保病人和医务人员的安全[2]。已经发表了许多论文，目的是恢复大分割（HF）计划，这被认为更适合避免多次前往医院中心，尊重手术和RT之间的时间，从而降低感染风险。去年4月29日，在Pubmed（www.青春期的gov）基于放射疗法+ covid-19的查询给出了53篇论文。其中，我们选择了那些关于分馏方案。表1总结了不同国家在本次大流行期间提出的HF计划[3-14]。它们是众所周知的时间表，已经出于不同的动机而使用：（a）预期寿命短或一般状况差;（B）到达RT医院的高龄和后勤问题;（c）肿瘤中的放射生物学证据具有比常规部分剂量更高的灵敏度（d）需要减少姑息治疗的住院时间;（e）在普遍获得医疗服务的国家，对RT的需求不断增加，导致机器相对短缺，等待时间增加。基于证据的决策也是医学科学的基石，至少在理论上是如此;然而，在实践中，有时很难发现其匹配性。例如，在意大利，很难在私人环境中找到开具HF计划的动机中的e）点（当私人结构代表卫生公共服务（HPS）提供放射治疗时也是如此），因为报销是基于每日会话的。最近，在动态构象技术的时代，HF时间表的使用变得更加分散，在私人结构中也是如此，因为它们在某些区域获得了更好的补偿-HPS是意大利的区域性。在大流行期间，可能会发生医学断层线的出现。其中之一是临床医生愿意放弃医学的主要格言，不做伤害，并急于进行不仅可能无用而且很可能是危险的治疗。[15]事实是，大多数医生没有接受过识别科学好坏的训练。他们也没有时间分析每一项研究，当恐惧开始时，太多人愿意忽视对可靠证据的需求。我们要去他的陷阱吗？
Since January 2020, the spread of the COVID-19 pandemic in China and, in the next weeks, in Italy and then in the rest of Europe and the world, has had an enormous impact on the organization, safety procedures and prescription behavior of the physicians in radiation oncology. The main concerns expressed in the numerous comments, letters and papers published in the last three months are (a) how to assure the normal supply of the radiotherapy treatments;(b) how to keep constant the number of Healthcare Workers (HCW);(c) how to identify radiotherapy (RT) patients SARS-CoV-2 positive;(d) how to protect HCW from the viral infection;(e) how to protect the patients from the infections;(f) how to reduce the postponing and the delay of RT start. In previous communications, the initial modifications of the clinical activity in a radiotherapy department in Southern Italy–an area with a relative of low incidence of infections–were described soon after the declaration of the pandemic [1] and some criticism were addressed towards the safety recommendations of the national governmental and the scientific institutions, as they were contradictory and arguably inadequate to ensure patients’ and HCWs’ safety [2]. Many papers have been published with the aim to resume the Hypofractionated (HF) schedules which are considered more suitable for avoiding many visits to the hospital centre, for respecting the time between surgery and RT and thus reducing the risk of infection. Last 29 April, a search on Pubmed (www. pubmed. gov) based on the query radiotherapy+ covid-19 gave 53 papers. Among these, we selected those regarding fractionation scenario. In Table 1, the HF schedules proposed in this pandemic period, from different countries, are summarized [3–14]. They are well known schedules, already used with different motivations:(a) short life expectancy or poor general conditions;(b) advanced age and logistic problems in reaching the RT hospital;(c) radiobiological evidence in tumors with higher sensitivity than conventional fraction dose (breast, prostate);(d) the need to reduce inpatient stay for palliative treatments;(e) the increasing demand of> RT, in countries with universal access to health services, produced a relative shortage of machines and an increasing of waiting times.Evidence-based decisions are a cornerstone also in medical sciences, at least at theoretical; its matching in the practices is however, sometimes, difficult to detect. For instance, point e) of the motivations for prescribing HF schedules, in Italy it is difficult to find it in a private setting (also when the private structure supplies radiotherapy on behalf of Health Public Service (HPS)) because reimbursement is on daily session basis. Recently, in the era of dynamic conformational techniques, the use of HF schedule has become more diffuse, also in the private structures, because they obtain in some region–the HPS is regional in Italy–a better reimbursement. During a pandemic, it may happen the occurrence of fault lines in medicine. One of these is the ‘‘willingness on the part of clinicians to abandon the prime dictum of medicine, to do no harm, and rush into treatments that not only may be useless but may well be dangerous.[15] The fact is, most physician are not trained to recognize good science from bad. Nor do they have the time to analyze every study, and too many are willing to ignore the need for reliable evidence when fear sets in”[16]. Are we going to his pitfall?