key: cord-0011731-iu4n270b authors: Achard, Vérane; Tsoutsou, Pelagia; Zilli, Thomas title: Radiotherapy in the time of the Coronavirus pandemic: when less is better date: 2020-03-19 journal: Int J Radiat Oncol Biol Phys DOI: 10.1016/j.ijrobp.2020.03.008 sha: af6624994c6c708477056d15e2156b1d4e3cecbe doc_id: 11731 cord_uid: iu4n270b nan The outbreak of Coronavirus disease 2019 in December 2019 has been declared a public health emergency by World Health Organization (WHO). Originating from China, the epidemic has spread to 115 countries in the world with more than 100 000 cases of COVID-19 that have been reported, including more than 4000 deaths (1) . After China, the epidemic has struck hardest in Italy with 827 deaths in few weeks, leading the Italian government to extend emergency Coronavirus measures, including travel restrictions and a ban on public gatherings to the entire country in an effort to contain the epidemic. On March 11 th 2020, the WHO declares the Coronavirus outbreak a pandemic. In addition to the challenge of containing the spread of COVID-19, the hospital management of infected patients remains a major burden for the health care system. Though not in the front line in fighting the disease, radiation oncologists are nevertheless directly impacted by this situation. First, radiation oncology departments, as other hospital departments, have to face staff shortage due to quarantine holding and requisitioning. Second, cancer patients treated in radiation oncology departments are often frail and immunocompromised and at risk of being severely affected if infected by COVID-19. The more time they spend in hospitals and public environment the more they are likely to be infected and/or to spread COVID-19. The "primum non nocere" of the Hippocratic Oath becomes more relevant than ever in this context of pandemic and leads us to another level of understanding of this principle. An understanding that is forcing us to rethink and adapt our current practices of treating cancer patients with the provision on high quality care always kept in mind. Certainly, prioritizing radiotherapy treatments and postponing non-essential procedures and/or visits are crucial for any radiation oncologist to deal with COVID-19 pandemic. At the same time, rethinking our institutional radiotherapy (RT) fractionations by implementing hypofractionated schedules may represent, when feasible, the essential paradigm to decrease the access of cancer patients to the hospital and limit the potential diffusion of COVID-19. Although hypofractionation has been validated in many tumor locations, its use, for several reasons and country-based differences, is often far to be considered a standard. For breast cancer, in some countries less than 15% of the postmastectomy and regional irradiations are delivered with hypofractionation (2), unlike in the UK and the Netherlands where moderate hypofractionated RT is currently used for regional treatments (3). In rectal cancer, despite the evidence coming from randomized trials (4), short-course RT is clearly underproposed in the neoadjuvant setting compared to long-course chemo-RT protocols (5, 6) . As for prostate cancer, all the level 1 evidence converges nowadays on the equivalence of moderate hypofractionation and standard fractionation (7) . Moreover, results of extreme hypofractionated schedules are very promising. Last but not least, single fraction RT is a validated option for patients with symptomatic uncomplicated bone metastases (8) that unfortunately remains internationally underutilized (9) . COVID-19 is an emerging infection disease of global public health concern. Radiation oncologists, as part of health-care workers community, are directly involved in the fight against the viral spread. They face however their own challenge which is to minimize the epidemic impact on cancer patients' treatment. Use of practical measures to mitigate the impact of treatment interruptions (10) but also wider implementation of hypofractionated schedules in the clinical practice can make our discipline adaptable in exceptional times such as these. Let us think about that and act accordingly. Probably, it is time to consider that less is better. World Health Organisation. 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