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A national survey on radiation oncology patterns of practice in Switzerland during the COVID-19 pandemic: Present changes and future perspectives☆ Highlights • We conducted a Swiss survey on patterns of practice during COVID-19 pandemic. • Dedicated IT solutions were implemented in all radiation-oncology departments. • Upfront endocrine treatments for breast and prostate cancer were privileged. • Use of hypofractionation for breast, rectal cancer and palliation was increased. The outbreak of the novel coronavirus disease-19 (COVID-19) has rapidly and drastically impacted worldwide the healthcare system. Despite an increasing number of recommendations becoming available in the last two months, measures adopted in radiation-oncology departments to overcome this situation are rapidly changing and may differ largely based on institutional and national practices. We conducted a national survey of all radiation oncology centers in Switzerland to better understand the early impact of the COVID-19 pandemic on our discipline. Methods A 53-questions online survey was finalized on April 6th, 2020 using available recommendations [1], [2], [3], [4], [5], [6], [7], [8] and distributed by email on April 07th, 2020 to the representatives of the 30 Swiss radiation oncology departments. The survey was finalized on April 24th, 2020 with answers from 22 out of 30 Swiss radiation oncology departments (Suppl. Fig. 1). Results Up to April 7th, 2020, approximately half (45%, 10/22) of the Swiss radiation-oncology departments had been confronted with patients diagnosed with COVID-19, with 73% of the centers (16/22) experiencing a reduction of their daily activity (Suppl. Figs. 1 and 2). As far as human resources were concerned, 18% of the departments suffered from staff shortage (4/22), with COVID-19 infection among staff members observed in 5 out of 22 centers (23%,) and part/full-time shift of collaborators in a COVID-19 unit imposed in 6 out of 22 centers (27%). Dedicated IT solutions for the COVID-19 crisis were implemented in all institutions. Remote access to the treatment planning workstations was available for staff members in 19 out of 22 centers (91%) and allowed for majority of the teams (17/22, 81%) to practice split staffing. In hospitals, the use of medical masks for all healthcare professionals was common practice in almost all centers (91%, 19/22). For patient’s care, remote consultations were offered whenever possible in all centers. When a physical presence in the department was necessary, patients were screened at the hospital entrance in more than 70% of the centers (16/22). Moreover, patient zoning based on COVID-19 status was proposed in 19 centers (86.4%). Medical masks were mandatory for all patients in 59% of the centers (13/22), reserved for patients with symptoms in 36 % of the centers (8/22), while one center (5%) did not recommend any protective equipment. For prostate cancer, radiotherapy treatment in the primary setting was delayed if not considered detrimental for low- and favorable intermediate-risk disease in almost all participating centers (90.9%, 20/22). The use of a neoadjuvant treatment up to an expected resolution of the peak of the pandemic was recommended by the 82% of the centers (18/22) if a concomitant androgen deprivation treatment (ADT) was indicated. For high-risk disease patients diagnosed during the pandemic, radiotherapy combined with ADT was the preferred treatment option recommended by the local tumorboards in 18/22 of the centers (82%). The proportion of centers using hypofractionated schedules for prostate cancer patients remained approximately the same, 86% (19/22) before and 91% (20/22) during pandemic. No shift towards an increased use of extreme hypofractionation was observed during the pandemic, with rates of centers using moderate or extreme hypofractionation, or both modalities, remaining stable over time (moderate: 50%, 11/22 vs. 55%, 12/22; extreme: 9%, 2/22 vs. 9%, 2/2; moderate + extreme: 27%, 6/22, vs. 27%, 6/22, before and during pandemic, respectively). For breast cancer, during the COVID-19 pandemic half of the centers (11/22, 50%) omitted radiotherapy boost unless the patient presented with significant risk factors of relapse (≤60 years, high-grade tumors, inadequate margins). In 2 out of 22 centers (9%), radiotherapy was omitted for patients aged ≥65 years, with invasive breast cancer <30 mm, with clear margins, grade 1–2, estrogen receptors (ER)+, HER2−, and node negative disease, who were planned for treatment with endocrine therapy. Lastly, none of the centers omitted radiotherapy for ductal carcinoma in situ (DCIS) breast cancer. The use of upfront endocrine therapy to delay radiotherapy initiation for breast cancer patients with ER+ cancer, either DCIS or invasive, was adopted by 50% of the centers. Compared to the pre-pandemic period, there was an 18% increase (from 64%, 14/22 to 82%, 18/22) in the rate of centers using moderate hypofractionation (i.e., 42.5 Gy/16 fx or 40 Gy/15 fx) for the majority of patients (all stages; intact breast and post-mastectomy and/or regional nodal irradiation) (Fig. 1 A). Extreme hypofractionated schedules (i.e., 26 Gy/5 fx daily or 28.5 Gy/5 fx once-weekly, as per the FAST and FAST Forward trials, respectively [9], [10] were adopted in one center (5%). Fig. 1 Use of hypofractionation for breast (A) and rectal cancer (B) before and during COVID-19 pandemic. Fig. 2 Survey questions for non-prostate, non-breast disease sites. (RT, Radiotherapy). Short course radiotherapy was the preferred neoadjuvant treatment for rectal cancer, with a 23% increase during the pandemic (from 41%, 9/22 to 64%, 14/22) (Fig. 1B). For other disease sites, with the exception of palliative radiotherapy for symptomatic bone metastases, no clear change of practice was observed (Fig. 2). Discussion This survey provides a snapshot of the April 2020 status of the Swiss radiation oncology departments following the COVID-19 outbreak and highlights three major aspects. First, confronted with the current pandemic, all radiation oncology departments were able to rapidly implement telemedicine. Second, all centers were able to reorganize institutional practices, with creation of zoning and use of dedicated protective equipment for patients and medical staff. Third, delay of radiotherapy treatments with hormonal manipulations when possible, associated with an increased use of hypofractionation for breast, rectal cancer and palliation were the pragmatic responses of the majority of the centers to the pandemic. Our work faces the limitation associated with reporting the evolution of radiation oncology practices in the earliest stages of the pandemic, when ASTRO/ESTRO recommendations for lung and head and neck cancer [11], [12] were not yet published, with an unequal number of online resources available for participants depending on when they answered the survey (Suppl. Fig. 3). Moreover, a single country survey risks to be influenced by several aspects, including national-specific clinical practices, the healthcare reimbursement system, and the influence of governmental legislations undertaken during the pandemic. Nevertheless, valuable information is emerging from this report which may provide basis to better understand the actual and future impact of COVID-19 pandemic on our discipline. Conflict of interest The authors report no conflict of interest. Funding None Appendix A Supplementary data The following are the Supplementary data to this article: Supplementary figure 1 Switzerland map with participating radiation-oncology departments. University Hospitals are marked with a red pinpoint. One university hospital and two satellite centers. Aarau and Baden. Cities in bold refer to radiation oncology departments confronted to COVID-19 patients up to the 7th April, 2020. Supplementary data 1 Rate of COVID-19 positive patients (Fig. 2A) and estimated reduction of daily activity (Fig 2B) in the Swiss radiation oncology departments on April 7th, 2020. Supplementary data 2 Total published ASTRO/ESTRO papers on COVID-19 over time versus COVID-19 deaths in Switzerland [13]. In green bars, numbers of survey participants per survey date completion. Acknowledgements The authors wish to thank the all the members of the Society of Swiss Radiation Oncologists (SRO) and the Scientific Association of Swiss Radiation Oncology (SASRO) for their contribution to this work. All data generated and analyzed during this study are included in this published article. ☆ The Editors of the Journal, the Publisher and the European Society for Radiotherapy and Oncology (ESTRO) cannot take responsibility for the statements or opinions expressed by the authors of these articles. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. For more information see the editorial “Radiotherapy & Oncology during the COVID-19 pandemic”, Vol. 146, 2020. Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.radonc.2020.05.047.

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