Monthly Archives: August 2020

Differences between 5-Minute and 15-Minute Measurement Time Intervals of the CGM Sensor Glucose Device Using GH-Method: Math-Physical Medicine (No. 281)

DOI: 10.31038/IMROJ.2020532

Introduction

This paper describes the research results by comparing the glucose data from a Continuous Glucose Monitor (CGM) sensor device collecting glucose at 5-minute (5-min) and 15-minute (15-min) intervals during a period of 125 days, from 2/19/2020 to 6/23/2020, using the GH-Method: math-physical medicine approach. The purposes of this study are to compare the measurement differences and to uncover any possible useful information due to the different time intervals of the glucose collection.

Methods

Since 1/1/2012, the author measured his glucose values using the finger-piercing method: once for FPG and three times for PPG each day. On 5/5/2018, he applied a CGM sensor device (brand name: Libre) on his upper arm and checked his glucose measurements every 15 minutes, a total of ~80 times each day. After the first bite of his meal, he measured his Postprandial Plasma Glucose (PPG) level every 15 minutes for a total of 3-hours or 180 minutes. He maintained the same measurement pattern during all of his waking hours. However, during his sleeping hours (00:00-07:00), he measured his Fasting Plasma Glucose (FPG) in one-hour intervals.

With his academic background in mathematics, physics, computer science, and engineering including his working experience in the semiconductor high-tech industry, he was intrigued with the existence of “high frequency glucose component” which is defined as those lower glucose values (i.e. lower amplitude) but occurring frequently (i.e.. higher frequency). In addition, he was interested in identifying those energies associated with higher frequency glucose components such as the various diabetes complications that would contribute to the damage of human organs and to what degree of impact. For example, there are 13 data-points for the 15-minute PPG waveforms, while there are 37 data-points for the 5-minute PPG waveforms. These 24 additional data points would provide more information about the higher frequency PPG components.

Starting from 2/19/2020, he utilized a hardware device based on Bluetooth technology and embedded with customized application software to automatically transmit all of his CGM collected glucose data from the Libre sensor directly into his customized research program known as the eclaireMD system, but in a shorter time period for each data transfer. On the same day, he made a decision to transmit his glucose data at 5-minute time intervals continuously throughout the day; therefore, he is able to collect ~240 glucose data within 24 hours.

He chose the past 4-months from 2/19/2020 to 6/19/2020, as his investigation period for analyzing the glucose situation. The comparison study included the average glucose, high glucose, low glucose, waveforms (i.e. curves), correlation coefficients (similarity of curve patterns), and ADA-defined TAR/TIR/TBR analyses. This is his secondresearch report on the 5-minute glucose data. His first paper focused on the most rudimentary comparisons [1].

References 2 through 4 explained some example research using his developed GH-Method: math-physical medicine approach [2,3].

Results

The top diagram of Figure 1 shows that, for 125 days from 2/19/2020 – 6/23/2020, he has an average of 259 glucose measurements per day using 5-minute intervals and an average of 85 measurements per day using 15-minute intervals. Due to the signal stability of using Bluetooth technology, for the 5-min, it actually has 259 data instead of the 240 data per day.

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Figure 1. Daily glucose, 30-days & 90-days moving average glucose of both 15-minutes and 5-minutes.

The middle diagram of Figure 1 illustrates the 30-days moving average of the same dataset as the “daily” glucose curve. Therefore, after ignoring the curves during the first 30 days, we focus on the remaining three months and can detect the trend of glucose movement easier than “daily” glucose data chart. There are two facts that can be observed from this middle diagram. First, the gap between 5-min and 15-min is wider in the second month, while the gap becomes smaller during the third and fourth month. This means that the 5-min results are converging with the 15-min results.Secondly, both curves of 5-min and 15-min are much higher than the finger glucose (blue line). This indicates that the Libre sensor provides a higher glucose reading than the finger glucose. From the listed data below, the CGM sensor daily average glucoses are about 8% to 10% higher than the finger glucose.

5-min sensor: 118 mg/dL (108%)

15-min sensor: 120 mg/dL (110%)

Finger glucose: 109 mg/dL (100%).

The bottom diagram of Figure 1 is the 90-days moving average glucose. Unfortunately, his present dataset only covers 4 months due to late start of collecting his 5-min data; however, the data trend of the last month, from 5/19-6/23/2020, can still provide a meaningful trend indication. As time goes by, additional data will continue to be collected, his 5-min glucose’s 90-days moving trend will be seen more clearly.

Figure 2 shows the synthesized views of his daily glucose, PPG, and FPG.Here, “synthesized” is defined as the average data of 125 days.For example, the PPG curve is calculated based on his 125×3=375 meals. Listed below is a summary of his primary glucose data (mg/dL) in the format of “average glucose/extreme glucose”. Extreme means either maximum or minimum, where the maximum for both daily glucose and PPG due to his concerns of hyperglycemic situation, and the minimum for FPG due to his concerns of insulin shock. The percentage number in prentice is the correlation coefficients between the curves of 15-min and 5-min.

Daily (24 hours):15-min vs. 5-min

117/143vs. 119/144(99%)

PPG (3 hours):15-min vs. 5-min

126/135vs. 125/134(98%)

FPG (7 hours):15-min vs. 5-min

102/95 vs. 105/99 (89%).

Those primary glucose values between 15-min and 5-min are close to each other in the glucose categories. It is evident that the author’s diabetes conditions are under well control for these 4 months. However, by looking at Figure 2 and three correlation coefficients %, we can see that daily glucose and PPG have higher similarity of curve patterns (high correlation coefficients of 98% and 99%) between 15-min and 5-min, but FPG curves have a higher degree of mismatch in patterns (lower correlation coefficient of 89%). This signifies that his FPG values during sleeping hours have a bigger difference between 15-min and 5-min.

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Figure 2. Synthesized daily glucose, PPG, and FPG of both 15-minutes and 5-minutes.

Figure 3 are the results using candlestick model [4,5]. The top diagram is the 15-min candlestick chart and the bottom diagram is the 5-min candlestick chart. Candlestick chart, also known as the K-Line chart, includes five primary values of glucoses during a particular time period; “day” is used in this study. These five primary glucose data are:

Start: beginning of the day.

Close: end of the day.

Minimum: lowest glucose.

Maximum: highest glucose.

Average: average for the day.

Listed below are five primary glucose values of both 15-min and 5-min.

15-min: 108/116/86/170/120.

5-min: 111/116/84/173/118.

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Figure 3. Candlestick charts of both 15-minutes and 5-minutes.

By ignoring the first two glucoses, start and close, let us focus on the last three glucoses: minimum, maximum, and average. The 5-min method has a lower minimum and a higher maximum than the 15-min method. This is due to the 5-min method capturing more glucose data; therefore, it is easier to catch the lowest and highest glucoses during the day. The difference of 2mg/dL between 15-min’s average 120 mg/dL and 5-min’s average 118 mg/dL is only a negligible 1.7%.

Again, it is also obvious from these candlestick charts that the author’s diabetes conditions are under well control for these 4 months.

Conclusion

In summary, the glucose differences between 5-min and 15-min based on simple arithmetic and statistical calculations are not significant enough to draw any conclusion or make any suggestion on which are the “suitable” or better measurement time intervals. However, the author will continue his research to pursue this investigation of energy associated with higher-frequency glucose components in order to determine the glucose energy’s impact or damage on human organs (i.e. diabetes complications).

The author has read many medical papers about diabetes. The majority of them are related to the medication effects on glucose symptoms control, not so much on investigating and understanding “glucose” itself. This situation is similar to taming and training a horse without a good understanding of the temperament and behaviors of the animal. Medication is like giving the horse a tranquilizer to calm it down. Without a deep understanding of glucose behaviors, how can we truly control the root cause of diabetes disease by only managing the symptoms of hyperglycemia?

References

  1. Hsu, Gerald C. eclaireMD Foundation, USA (2020) Analyzing CGM sensor glucoses at 5-minute intervals using GH-Method: math-physical medicine (No. 278).
  2. Hsu, Gerald C. eclaireMD Foundation, USA(2020) Predicting Finger PPG by using Sensor PPG waveform and data via regression analysis with three different methods using GH-Method: math-physical medicine (No. 249).
  3. Hsu, Gerald C. eclaireMD Foundation, USA (2019) Applying segmentation pattern analysis to investigate postprandial plasma glucose characteristics and behaviors of the carbs/sugar intake amounts in different eating places using GH Method: math-physical medicine (No. 150).
  4. Hsu, Gerald C. eclaireMD Foundation, USA (2019) A case study of the impact on glucose, particularly postprandial plasma glucose based on the 14-day sensor device reliability using GH-Method: math-physical medicine (No. 124).
  5. Hsu, Gerald C. eclaireMD Foundation, USA. Comparison study of PPG characteristics from candlestick model using GH-Method: Math-Physical Medicine (No. 261).

Management of Cancer Patients Undergoing Radiation Therapy during the Novel Coronavirus Disease 2019 (COVID-19) Pandemic: A Review of the Literature

DOI: 10.31038/CST.2020531

Abstract

Cancer patients are more vulnerable to acquiring COVID 19 infection and may also experience higher morbidity and mortality. In the context of COVID-19, cancer patients may be affected through delayed diagnosis and have significant impact on management in resource strained settings. Cancer treatment typically involves a possible combination of surgical resection, chemotherapy and radiation therapy (RT). RT delivery requires often daily attendance to a cancer center, is complex and poses potentially additional risks for infection as well as treatment related complications. Optimization of infection control measures and RT treatment schedules is paramount to minimize the impact of the pandemic on patients and optimize outcomes. This review aims to summarize the existing limited literature surrounding RT administration and optimization in the context of COVID-19.

Introduction

Since the recognition of the COVID-19 pandemic, evidence has become available that a cancer diagnosis is considered one of the comorbid conditions that increase the risk of COVID 19 infection [1- 3]. Meanwhile COVID-19 infection in cancer patients is associated with higher morbidity and mortality [4]. Data is still preliminary, but it is likely that both the increased risk of acquiring COVID-19 and more severe consequences thereof in cancer patients are multifactorial in nature likely involving complex relationships between the type of cancer site and extent or location of the disease as well as more nuanced patient and treatment related factors. While a number of publications have delved into the presentation and management of COVID-19, and its relationship to comorbid conditions including malignancy, and yet others into the implications of systemic management (chemotherapy, targeted agents), fewer publications specifically discuss the implications for patients who undergo radiation therapy (RT) and the operational considerations of radiation therapy (RT) departments. RT is administered mostly on a daily basis in cancer centers or facilities with complex logistics, unique organizational demands, high possibility of interaction between vulnerable patients and risk of exposure to multiple patients and staff. The lack of evidence surrounding best practices has left radiation oncology providers and patients with many questions still unanswered.

These questions include the level of vulnerability of cancer patients, who for example may undergo radiation but may not be undergoing systemic management and may therefore not necessarily be immune- compromised, as well as the implication for daily attendance to a RT facility and the associated infection risk and how to best mitigate it. Other questions involve the ability to and safety of delaying or altering RT treatment schedules to minimize risk of infection. Important additional considerations abound in particular settings such a RT emergencies and treatment of the COVID-19 positive patient as well as the administration of radioactive isotopes such as radioactive iodine in thyroid patients who then need to self-isolate at home or as inpatients for several days. Since the COVID-19 pandemic has raised unprecedented challenges and questions, with ongoing lack of robust data, periodic review of the available evidence is important to help guide providers and patients in order to enable evidence-based care hence prompting this scoping review.

Materials and Methods

To carry out the scoping review, publications that specifically addressed the impact and management of cancer patients undergoing radiation therapy in the context of the COVID 19 pandemic were identified in PubMed using the following mesh terms: ((“risk”[MeSH Terms] OR “risk”[All Fields]) OR “risk of”[All Fields]) AND (((((((“covid 19”[All Fields] OR “covid 2019”[All Fields]) OR “severe acute respiratory syndrome coronavirus 2”[Supplementary Concept]) OR “severe acute respiratory syndrome coronavirus 2”[All Fields]) OR “2019 ncov”[All Fields]) OR “sars cov 2”[All Fields]) OR “2019ncov”[All Fields]) OR ((“wuhan”[All Fields] AND (“coronavirus”[MeSH Terms] OR “coronavirus”[All Fields])) AND (2019/12/1:2019/12/31[Date – Publication] OR 2020/1/1:2020/12/31[Date – Publication]))) AND ((((“patient s”[All Fields] OR “patients”[MeSH Terms]) OR “patients”[All Fields]) OR “patient”[All Fields]) OR “patients s”[All Fields]) AND (((((((((“cancer s”[All Fields] OR “cancerated”[All Fields]) OR “canceration”[All Fields]) OR “cancerization”[All Fields]) OR “cancerized”[All Fields]) OR “cancerous”[All Fields]) OR “neoplasms”[MeSH Terms]) OR “neoplasms”[All Fields]) OR “cancer”[All Fields]) OR “cancers”[All Fields]) AND ((((((((((((“radiate”[All Fields] OR “radiated”[All Fields]) OR “radiates”[All Fields]) OR “radiating”[All Fields]) OR “radiation”[MeSH Terms]) OR “radiation”[All Fields]) OR “electromagnetic radiation”[MeSH Terms]) OR (“electromagnetic”[All Fields] AND “radiation”[All Fields])) OR “electromagnetic radiation”[All Fields]) OR “radiations”[All Fields]) OR “radiation s”[All Fields]) OR “radiator”[All Fields]) OR “radiators”[All Fields]). 87 abstracts were identified.

Results

As of July 10, 2020: 1706 papers were published on the topic of COVID 19 and oncology in 2020 to date of which 457 (27%) of these discussed cancer as a risk factor for the development of the COVID 19 infection. The MeSH term was generated to capture papers specific to the context of the cancer patient undergoing radiation therapy during the COVID 19 pandemic. 87 papers were identified using the above MeSH term. Of these 5 (6%) were literature reviews or broad guideline recommendation papers, 12 (14%) dealt related to oncology but were not RT specific (eg. systemic management of hematological malignancies), 63 (72%) were oncology and RT specific and 7 (8%) were not directly relevant to either oncology or radiation but were relevant to COVID 19 more broadly. All of the abstracts were published between March and July, with 75% of the abstracts between the end of April and beginning of July 2020.

Types of Publications Identified

Four types of publications were broadly identified: 1) Literature reviews and operational/planning guidelines which did not contain patient data but rather represent institutional or expert opinion (Table 1); 2) consensus guidelines generated by governing bodies and site- specific groups for specific cancer histologies (Table 2); 3) retrospective single or multiple institution papers (Table 3) and 4) more context focused papers eg. management of the elderly with cancer during COVID-19 and palliative management (Table 4).

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Literature reviews involving COVID-19 and oncology identified with ** were made available by Al-Shamsi et al., Shankar et al. and Anderson et al. (Table 1 ** denotes encompassing reviews), * smaller important reviews) [1-3]. These broader reviews (**) were not necessarily RT specific but contained some information regarding RT. Discussion of RT departmental planning, logistics and operational considerations were available in other reviews (Table 1). Site specific consensus guideline papers with recommendations (organ or histology specific) were also identified specifically for head and neck, lung, genitourinary and hematological malignancies and to a lesser extent in other sites (Table 2). Some papers dealt more generally with single center experiences which also provided some guidelines while others reported on testing for COVID 19 in cancer patients undergoing or about to undergo radiation therapy (Table 1). Finally, there were also papers that were more specifically targeting the elderly patient with cancer, palliative management and other smaller topics (Table 4).

Logistical and Operational Focused Publications

Logistics and Operational Considerations – Limit the Risk of Infection

From a practical day to day perspective the ability to effectively manage new logistical and operational challenges in order to mitigate risk of infection to patients and staff with need of frequent adaptation, poses one of the greatest challenges to RT in the context of COVID-19 [5-7]. In the absence of both data and homogenous higher-level guidelines, cancer therapy centers and individual radiation therapy departments have created their own guidelines and this is reflected in the publications uncovered in this review. Important insights originate in virus epicenters like Italy [8], New York in the US [9,10]. According to a survey by Opperman et al., who conducted an online survey among medical physicists in Germany, Austria and Switzerland from March 23rd to 26th 2020, 72.4% of the respondents stated that their processes were affected due to COVID-19, with longer processing times (54.2%), patient no-shows (42.5%) and staff reduction (36.7%). 75.8% expected further unavailability of their personnel in the upcoming weeks [11].

COVID-19 Testing in Cancer Patients Undergoing RT – Address Testing Practices

Another challenge is that of the selection, timing and actions taken with respect to patient and staff testing for COVID-19. As noted with respect to other aspects of the management of the pandemic, guidelines are lacking and complex standard of care practices had to be rapidly adapted to include patient (and staff) testing when appropriate [12]. This is particularly complex when patients may need to undergo brachytherapy or radioactive iodine and carry significant risk on infecting other staff if they themselves are infected and/or pose significant logistical challenges eg. Isolation as in or outpatient in the case of radioactive iodine administration. We now understand that testing negative for COVID carries a not in-insignificant possibility that the patient may have a false negative test and that the timing of the test is also impacting on its usefulness and accuracy. Testing itself is not readily available in many jurisdictions and may take some time to obtain results. Patients have to be pre-screened and directed to undergo testing, which may be difficult or impossible. However, data does support the notion that a positive result may render cancer patients more vulnerable to COVID-19 [4,13]. Bajaj et al. report on the salivary detection of SARS-CoV-2 (COVID-19) and implications for oral health-care providers summarizing guidelines for oral care specialists [14]. This literature review notes that salivary specimens have a higher than 90% concordance rate with nasopharyngeal specimens which while enabling PCR testing of salivary samples also reveals that saliva poses additional risk to health care providers. Since there is currently no data available to assess the risk of transmission of COVID-19 in dental practices, and since cancer patients in particular with head and neck primaries require dental interventions, this is an area where further data is required to optimize management and outcomes. Madriaga et al. reviewed the literature for COVID-19 testing in cancer patients and describe the approach to COVID-19 testing adopted in a large cancer center in Toronto [15].

Indications for/Modification of RT – Modify RT When Possible to Mitigate Risk

Parashar et al. from a tertiary cancer center in New York provides a general set of robust guidelines for curative RT in the context of the pandemic echoing other site-specific papers and setting some “ground rules” for this approach while summarizing alternative dose and fractionation options for each tumor site that may be employed in the context of COVID-19 to minimize risk to patients and staff [16]. They discuss the scenarios of RT as an alternative to surgery when immediate surgery is not possible, RT as a ‘bridge’ to surgery and radiation options as an alternative to chemotherapy given the risk of hospitalization with high-dose chemotherapy. It should be noted that while enrollment of patients on clinical trials is considered in this paper and would be preferable when fractionation schemes with lesser evidence are employed or patients are documented COVID-19 positive, in practical terms this is often curtailed as clinical trials are on hold in many centers due to the pandemic. Vordermark also provides a review of organ-specific cancer management [17]. In this publication the author searched for multidisciplinary and expert recommendations to guide potential shift in RT indications and found limited data as of April 2020 when it was published however provides a good summary of the available data at that point. Chen et al. and Franco et al. provide broader frameworks for prioritization of patients [6,18]. Franco et al. also provides guidelines for the management of patients with COVID-19 [18].

Brachytherapy

Williams et al. provide a thorough review of the impact of delaying or prolonging brachytherapy treatment courses in multiple disease sites including gynecological sites, prostate and breast [19]. While the timing and duration of brachytherapy is highly sensitive in sites like cervix and vaginal cancer, breast and in particular prostate may allow for some postponement of brachytherapy. Additional alternative fractionation schemes are also discussed for each cancer site. Aghili et al. review brachytherapy guidelines in the context of COVID-19 highlighting the need to consider the best regimens as opposed to discontinuation or postponement of brachytherapy [20].

Oncology Site Specific Publications and Consensus Guidelines

Head and Neck Cancers

Head and neck cancer patients are vulnerable to COVID-19 because in addition to the cancer diagnosis they may also share other risk factors (smoking, nutritional depletion, swallowing and/ or breathing dysfunction) [21,22]. In addition, many head and neck primaries are rapidly progressive causing significant clinical deterioration and often requiring hospital admission for nutritional support and refeeding syndrome. Delay in diagnosis is particularly detrimental [23] and in the case of nasopharyngeal cancer additional chemotherapy could be employed to counteract the delay in diagnosis [23]. Head and neck cancers also require significant PPE due to the diagnoses requiring examination under anesthesia or direct laryngoscopy with biopsy [24]. Thomson et al. provide the ASTRO-ESTRO consensus to risk adapted head and neck cancer RT [25]. Two pandemic scenarios: early (risk mitigation) and late (severely reduced radiation therapy resources), were evaluated and a panel of experts developed treatment recommendations for 5 HNC cases. They evaluated potential symptomatic benefit with the risk of active COVID-19 infection balancing potential for cure and risk of progression as well as patient fitness to recommended rational patient triage. With respect to interventions in the upper aerodigestive tract region (eg. rhinoscopy or flexible laryngoscopy in the outpatient setting and tracheostomy or rigid endoscopy under anesthesia), it is recommended that all health care personnel wear personal protective equipment such as N95, gown, cap, eye protection, and gloves [26]. Additional guidelines are provided by Werner et al. and Mehanna et al. [24,27].

Breast Cancer

Breast cancer patients make up a large proportion of the patients on treatment and follow-up in most cancer treatment centers and therefore a robust approach to risk stratification is crucial to ensure adequate access to care and diminish the risk of adverse outcomes while minimizing risk of COVID-19 infection. Curigliano et al. creates a framework on how to approach these using scenarios often encountered in clinical practice [28]. The use of primary systemic therapy is also discussed as an alternative to upfront surgery in the context of COVID-19. RT is prioritized according to the risk categorization of the cancer and whether the patient is already on treatment. Palliative treatments and acute spinal cord compression are considered urgent, followed by high risk patients while postoperative RT for low risk patients and post treatment visits are of lower priority. Additional recommendations include the omission of boost RT and accelerated partial breast RT for low risk patients. It is recognized that patients receiving chemotherapy regimens with intermediate/ high risk of immunosuppression, such as anthracyclines, 3-weekly docetaxel or 3 weekly platinum are at intermediate or high risk of immunosuppression. Vuagnat et al. set up a prospective registry for 15600 patients actively treated for early or metastatic breast cancer in the last 4 months [29]. They found that the COVID-19 mortality rate depended more on the comorbidities prior to RT that the treatment itself. Other recommendations are also provided by Chan et al. and Braunstein et al. but patient outcome data is still lacking [30,31].

Lung Cancer

Lung cancer patients pose a uniquely challenging scenario in the context of COVID-19 in part because they are already vulnerable to lung infections and in the context of RT because they are at risk for radiation pneumonitis which can be challenging to distinguish clinically and radiographically [32] but is also treated with high dose steroids which may worsen COVID-19 related lung injury. Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic are provided in an ESTRO-ASTRO consensus statement by Guckenberger et al. Singh et al. and Dingemans et al. also make recommendations on standardizing the care of lung cancer patients during COVID-19 while recommending that general standard principles of practice be followed [33-35]. Wu et al. provide guidelines for thoracic radiation therapy specifically while Kumar et al. discusses alternative management options [36,37].

Genito-Urinary

Delaying treatment in genito-urinary cancers is potentially of significant detriment [38]. In penile cancer, surgery should proceed when possible due to the aggressive nature of the disease, with RT as an organ preserving approach [39]. Zaorsky et al. provide RT recommendations for prostate cancer [40]. However, since prostate cancer is a more indolent malignancy in early stages, treatment can be avoided or delayed for very low, low, and favorable intermediate- risk disease For unfavorable intermediate-risk, high-risk, clinical node positive, recurrence post-surgery, oligometastatic, and low- volume M1 disease neoadjuvant hormone therapy for 4-6 months was recommended [40]. Ultrahypofractionation may be preferred for localized, oligometastatic, and low volume M1, and moderate hypofractionation may be preferred for post-prostatectomy and clinical node positive disease. Postoperatively, salvage RT is preferred to adjuvant radiation [40]. Short fractionation RT for early prostate cancer is at the forefront of the field and is discussed in the context of COVID-19 by Barra et al. [41].

Central Nervous System Cancers

In the context of central nervous system cancers, the unique aspects include the often older age of the patients and co-existing neurological symptoms requiring ongoing steroid use to decrease increased intracranial pressure. In addition to these, the prognosis is often guarded, and advanced care planning will be more important than ever to address upon diagnosis and initiation of management. Guidelines are provided by Mohile et al. [42]. These include mitigating risk through social distancing and discussions of goals of care (considering that ventilator use may unfortunately be denied to some of these patients considering that high grade glioma such as glioblastoma will be considered a terminal diagnosis particularly in the elderly). Nonetheless maximal safe resection is recommended both to decrease intracranial pressure but also to improve longevity and diminish steroid use. In lower grade glioma prognosis may be far superior and thus some interventions may be deferred. Tabrizi et al. extracted patient level data from 1321 elderly glioblastoma patients to provide a quantitative framework for modelling COVID-19 risk using published randomised trials in the elderly with glioblastoma [43]. They support hypofractionated RT and increased utilization of temozolomide alone in patients with MGMT methylation when the risk of COVID-19 infection is high. With respect to WHO grade III and IV gliomas Bernhardt et al. combined the opinion of 6 international experts in a consensus-based practice recommendation including neuro-oncologists, neurosurgeons, radiation -oncologists and a medical physicist [44]. Overall agreement was had that treatment cannot be significantly delayed and initiating therapy should not be outweighed by COVID-19.

Hematological  Cancers

Patients with hematological cancers are vulnerable to COVID-19 as they may suffer for cytopenias and may be immunosuppressed. Yahalom et al. offer guidelines to potentially omit RT in order to decrease the risk of exposure as a result of daily attendance to the cancer center [45]. They recommend possible omission of RT in: palliative settings where alternatives can be offered, for completely excised localized low-grade lymphomas and localized nodular lymphocyte- predominant Hodgkin lymphoma and for consolidation RT for diffuse large B-cell lymphoma/aggressive non-Hodgkin lymphoma (NHL) in patients who have completed a full chemotherapy course and achieved a complete remission [45]. Some lymphomas can safely delay RT (eg. asymptomatic localized low-grade lymphomas, localized nodular lymphocyte-predominant Hodgkin lymphoma, patients who develop COVID-19 infection prior to commencing RT), while others can benefit from shortened RT courses (eg. 20 Gy in 10 fractions or 30.6 Gy in 17 fractions). A consensus statement is available from Di Ciaccio et al. and Kirova et al. [46,47].

Other Cancer Subtypes

Guidelines have been published for pancreatic cancer [48], representing the UK consensus position. Endoscopy is recommended to continue for malignant biliary obstruction, however as it is an aerosol-generating procedure it is recommended that all elective and non-essential endoscopic procedures not be performed. Chemotherapy is suggested when surgery is not possible in the context of COVID-19 as are hypofractionated RT approaches (eg. 5-15 fraction regimens). Skin cancer management and triage was discussed by Baumann et al. and Tagliaferri et al. [49,50]. For patients with Merkel cell carcinoma, the authors recommend prioritizing treatment, unless favorable T1 disease. For patients with melanoma, the authors recommend delaying the treatment of patients with T0 to T1 disease for 3 months if there is no macroscopic residual disease at the time of biopsy. Treatment of tumors ≥T2 can be delayed for 3 months if the biopsy margins are negative. For squamous cell carcinoma, early disease can have treatment delayed for 2 to 3 months unless there is rapid growth, symptomatic lesions, or the patient is immunocompromised. The treatment of tumors ≥T2b should be prioritized, but a 1-month to 2-month delay is considered acceptable. For squamous cell carcinoma in situ and basal cell carcinoma, treatment can be deferred for 3 months unless symptomatic [49]. With respect to gynecological cancers Martinelli et al. carried out a survey showing that responders prioritized treatment of early stage high-risk uterine cancers (45%), newly diagnosed epithelial ovarian cancer (41%), and locally advanced cervical cancer (41%) [51]. 77% of respondents reported no changes in surgical treatment for early stage cervical cancer in COVID-19- negative patients, but treatment was postponed by 54% if the patient tested COVID-19-positive. Responders also considered neoadjuvant chemotherapy for advanced ovarian cancers and hypofractionation of RT for locally advanced cervical cancers. A similar survey was carried out by Nakayama et al. Rossi et al. report on their early experience in the management of sarcoma with priority given to bone and soft tissue sarcomas, metastases and aggressive benign tumors at risk of impending or pathologic fracture. For these and other sites further publications are as yet lacking [52,53].

Single Center Experiences

Single center experiences provide an “on the ground” perspective of the transformative experience COVID-19 has had on radiation oncology practice and health care resources and can provide an avenue for practical guidelines. Several papers exemplify this in particular in areas that were/are epicenters for the disease. Tey et al. provides a workflow for the COVID-19 positive patient on RT [54]. Chen et al. reports from a multicenter New York area institution with experience- based guidelines for disease sites that require concurrent chemo- irradiation and thus were more likely to result in patient presentation to the emergency room or in hospital admission [6]. The priority framework in this publication implemented as of April 13, 2020 is extremely practical in that it addresses efficiency from a systemic standpoint to optimize care for all patients within a RT department. Three priority levels are described; the first for cases where delay may result in loss of life, progression of disease or permanent loss of neurologic or other function (oncologic emergencies, advanced head and neck, gastrointestinal, gynecologic and lung cancers); priority 2 for cases that may be delayed for up to 4 weeks (early stage head and neck, lung and lymphoma, benign central nervous system cases) and priority 3 for cases that may be delayed for 30 days or more (early prostate, breast or prostate already on androgen deprivation therapy). This publication also presents patient data and addresses approaches to toxicity management in the context of COVID-19. Press et al. also described a single institution experience from a proton center in Manhattan quantifying the impact of treatment delays and interruptions [9]. Chhabra et al. also provide recommendations for prioritization of proton patient in the New York Proton Center [55]. Additional radiation oncology center experiences are published by Tan et al. (Singapore), Montesi et al. (Italy), Wu et al. (Wuhan), Handoko et al. (Indonesia), Mishra et al. (New York) [8,56-59].

Specific Considerations

The Elderly: Desideri et al. provides a very good summary of the data surrounding COVID-19 and the elderly [60]. Freedman et al. report specifically on managing older adults with breast cancer noting appropriately that considerations for management are highly relevant “within the new normal” considering that 30% of breast cancer patients are 70 years old or older [61]. They provide options for the most commonly encountered scenarios within the framework of existing evidence. Interestingly they also recommend deferral of routine follow-up and routine breast imaging and anticipate that this postponement will prompt discussion of the limited utility of these measures beyond the pandemic, as will no doubt be the case for other low value interventions. Asokan et al. provide a review of the impact of COVID-19 on the cardio-oncology population [62]. This is a population that also includes elderly patients with pre- existing cardiac comorbidities and possibly additional cardiotoxic insults such as chemotherapy and/or radiation or systemic treatment such as androgen deprivation therapy. Data surrounding the risk of COVID-19 infection and outcomes in this population is currently lacking.

Palliative RT: Yerramilli et al. provide a review of palliative RT for oncologic emergencies with emphasis on balancing risk and benefit [63]. Palliative treatments make up a large proportion of the workload of the RT department and the patients who require palliative RT often require it within days if not hours. This patient population is particularly vulnerable to the impact of the pandemic in a resource strained environment. Yerramilli et al. provides a framework for the triaging a patient with an oncologic emergency which is not dissimilar from frameworks already employed in resources strained environments [63]. Patients who are symptomatic and/or have an oncologic emergency and a more prolonged life expectancy are recommended to receive short course palliative RT, delay of RT or best supportive in the case of limited life expectancy is otherwise recommended. Thureau et al. in their GEMO (the European Study Group of Bone Metastases) position paper, astutely note that the indications and treatment modalities for palliative bone metastases must be re-discussed in the context of COVID-19 [64-67]. Palliative treatments often require the most clinical judgement and can benefit the most from available evidence surrounding reduction in the number of treatments and the complexity thereof in a resource strained setting. Their recommendations to carry out simulation planning and treatment at the same time as the consult, carry out tele- consults when appropriate, and use existing criteria to assess bone instability to allow for optimization of decision making enabling the least invasive technique. They also provide guidelines for retreatment of bone metastasis, spinal cord compression and SBRT (Stereotactic Body Radiation Therapy) for which they consider the level of evidence too low to be considered in the current situation.

Conclusions

Although multiple attempts at guideline and consensus generation have been made with respect to RT administration in the context of the COVID-19 pandemic in several tumor sites, evidence for the effectiveness or adequacy of these is lacking and some cancer sites have as yet very little or no guidelines. This is equally so the case with respect to the utilization of altered fractionation schemes being potentially proposed to diminish patient visits to cancer centers which should likely be approached with some caution and emphasis on following standard of care practice whenever possible. Several frameworks have been published for the optimization of logistics and operational planning that may be employed in radiation therapy centers and departments. Over time it is likely that more data will become available with respect to patient management and outcome, however as of July 2020, very few small retrospective data sets are available with respect to the outcomes of COVID-19 positive cancer patients undergoing RT. It is as yet unclear to what extent adverse outcomes in cancer patients may be related to preexisting comorbidities, the cancer diagnosis and its implications or the treatment of the cancer itself. Additional areas where evidence is lacking include:

1) The impact on of COVID-19 on older patients with cancer

2) The impact of treatment delay in patients currently considered intermediate or low risk for tumor progression

3) The impact of altered fractionation schedules

4) The long and short-term psychological impact of COVID-19 and altered cancer management on patients and staff.

Declarations

Ethics approval and consent to participate: This study is a literature review and does not report on data collected from humans and is exempt from ethics approval.

Consent for publication: Not applicable.

Availability of data and material: The data supporting the conclusions of this article are included within the article as references.

Competing Interests: The author declares that they have no competing interests.

Authors’ contributions: AVK conceived the idea for the review, reviewed the literature, created the accompanying material, and wrote the manuscript.

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Aspirin Use for Enhanced Primary Cardiovascular Prevention during the Coronavirus-19 Pandemic

DOI: 10.31038/JCCP.2020324

 

The 2019 American Heart Association/American College of Cardiology guidelines for the primary prevention of atherosclerotic cardiovascular disease virtually preclude aspirin use for adults ages 40-70 unless at long-term high risk (>10% threshold by 10-year risk calculators) [1]. The cardiovascular complications of coronavirus-19 (COVID-19) infection may require us to reconsider this, however, to take short-term high risk into account. Likened to a cytokine tsunami,elevated levels of interleukin-6 and C-reactive protein predict cardiac and respiratory failure, indicatingthat inflammation mediates excess morbidity and mortality [2-4].While dipyridamole has been associated with clinical improvement which was not observed with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers [5,6], the effect of aspirin on clinical outcomeshas yet to be reported. Based on evidence that inhibition of inflammation prevents cardiovascular events andthat low-dose aspirinconclusively reducedfirst heart attacks in middle-aged men in the randomized controlled Physicians Health Study [7,8], this latter approach has been recommended to protect athletes from theincreased risk of event-related cardiac arrest and sudden death triggered by inflammation due to exertional rhabdomyolysis [9-11]. Aspirin’s anti-inflammatory and anti-thrombotic effects may mitigate pandemic-related increased short-term risk, perhaps bluntingthe surge in coronary heart disease deaths which have occurredunder such conditions [12]. C-reactive protein levels can reliably stratify risk for low-dose aspirin as have coronary artery calcium scores for statin therapy [13,14] (Table 1).

JCCP-3-2-313-g001

Prophylactic low-dose aspirin usefor susceptible individuals presents a window of opportunity toreduce the cardiovascularcomplications of COVID-19 infection ahead of the second wave anticipated by the United States Center for Disease Control [15]. Based on inflammation as the root cause of atherothrombosis, a predominance of current clinical evidencesupports this interventionwithout a randomized controlled clinical trial asnecessary for novel interventions such as the high-dose interleukin-1 receptor antagonist tocilizumab [16]. Revised guidelines for primary prevention to accommodate short-term high risk may facilitate this goal as accomplished by subspecialty societies for treating acute myocardial infarction [17]. Preventing fatal strokes in young persons might be anunintended collateral benefit [18].

Keywords

Aspirin, Coronary heart disease, COVID-19 pandemic, Primarycardiovascular prevention

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