Impact of the COVID-19 Pandemic on Brachytherapy and Cancer Patient Outcomes: A Systematic Review

Abstract

To assess the impact of the COVID-19 pandemic on the use of brachytherapy as a treatment modality in patients with gynecologic and prostate cancers including treatment delays, increased burden of mortality and associated clinical outcomes. A comprehensive search of PubMed, Cochrane Library, CINAHL, Scopus, and Web of Science was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases were searched for studies published through January 2023 using MeSH terms and keywords related to "COVID and brachytherapy". Inclusion criteria included all studies reporting on the impact of COVID-19 on treatment delay, treatment omission, recurrence rates and clinical outcomes in patients requiring brachytherapy for prostate or gynecologic cancers. Data were extracted from two pairs of independent reviewers. Of the 292 screened records, 8 retrospective studies met the eligibility criteria and were selected. A total of 15,879 patients were included, of which 829 brachytherapy patients were identified. An Italian study reported an increase in the use of adjuvant radiation therapy (RT) in patients with uterine cancers during the lockdown period while the use of vaginal cuff brachytherapy remained stable. Hypofractionated regimens were the preferred approach in RT centers worldwide. Intracavitary brachytherapy for cervical cancer was limited to 3-4 fractions to limit personnel and patient exposure. RT treatment delay was the most common COVID-related care change ranging between 19% and 53% followed by treatment omission (2-28%). Causes of treatment delays and omissions were multifactorial: patient fear, COVID-19 infection, barriers to accessing care and operating room closures. Two studies reported modified brachytherapy approaches using single-application (SA) rather than multiple applications (MA) approaches with excellent local control, shorter overall treatment time, but at the expense of increased grade ≥2 vaginal, genitourinary and gastrointestinal events. For cervical cancer patients, overall treatment time (OTT) was significantly impacted by COVID-19 as reported by 2 studies from India. OTT >60 days occurred in 40-53% of patients with COVID-19 infection being the main cause of treatment delays of up to 3 weeks. This is the first systematic review to assess the impact of the COVID-19 pandemic on brachytherapy in patients with gynecologic and prostate cancers. Although many expert consensus recommendations have been published during the pandemic regarding radiation therapy, few studies evaluated its clinical impact on brachytherapy delivery and patient outcomes. The impact of the pandemic on gynecologic and prostate cancers is yet to be determined as well as the long-term outcomes on patients treated during the lockdown period.