Radiation therapy is an essential component of care for many people with hematologic cancers. During the ongoing coronavirus disease 2019 (COVID-19) pandemic and associated healthcare system challenges, administering radiation therapy may not always be safe or feasible. To help radiation oncologists make rational choices regarding radiation therapy for patients with hematologic malignancies during the pandemic, the International Lymphoma Radiation Oncology Group (ILROG) has issued new emergency guidelines.1

The guidelines, published in Blood, include recommendations for alternative radiation treatment schemes, such as modifying dose per fraction and frequency of daily treatment, and options for delaying or omitting therapy in certain cases.

Challenges of Radiation Therapy During the Pandemic

“The COVID-19 pandemic created serious new concerns to the health of immunosuppressed patients with hematological malignancies, as well as to their treatment providers,” Joachim Yahalom, MD, FACR, of Memorial Sloan Kettering Cancer Center in New York, New York, and lead author of the guidelines, told Hematology Advisor. “At the same time, more patients are referred for radiotherapy, as they are likely to benefit from localized radiotherapy as an alternative to longer or intensive immunosuppressive systemic treatments.”

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People with cancer can have weakened immunity due to several factors, including their underlying cancer and the anticancer treatment they are receiving. Thus, they are at higher risk for infection overall and it is estimated that their risk of contracting severe acute respiratory syndrome coronavirus 2 is as high as 2-fold higher than that of the general population.2

“The most pressing challenge in these circumstances is to provide an effective and safe treatment as normally indicated, while protecting the patient from exposure to the virus,” explained Dr Yahalom. “At the same time, we need to protect the healthcare staff and other patients from a potential carrier of the virus that still requires treatment.”

Key Recommendations From the Guidelines

While several organizations have previously issued general guidelines on cancer therapies during the global pandemic, previous radiation therapy guidelines released by ILROG have become standard over the years. The goal of these guidelines is to assist radiation oncologists in making rational decisions regarding potential changes and to reduce pressure during the current emergency situation.

“The ILROG guidelines provide shorter alternative schedules of radiotherapy under emergency conditions that require reductions in the number of treatment visits. These schedules were carefully vetted by a team of international experts and were deemed effective and safe under these special circumstances. They also provide caveats of when hypofractionation should be limited,” said Dr Yahalom.

The guidelines outline 3 strategies:1

  1. Omitting radiation therapy: The omission of radiation therapy should be considered when the benefit of treatment is outweighed by the risk for severe outcomes from COVID-19 infection (patients aged ≥60 years and/or presence of serious underlying health conditions). This strategy may be appropriate for certain patients with localized low-grade lymphomas, localized nodular lymphocyte Hodgkin lymphoma, and diffuse large B-cell lymphoma. It may also be an appropriate choice in the palliative setting.
  2. Delaying radiation therapy: This is available when few or no expected adverse effects on outcome are expected from delaying treatment. This option may be considered for patients with asymptomatic localized low-grade lymphomas, localized nodular lymphocyte predominant Hodgkin lymphoma, and in the palliative setting for low-grade lymphoma in stable patients. Delaying therapy may also be considered for patients who acquire a COVID-19 infection before starting radiation therapy, provided that their cancer is not progressing.
  3. Shortening radiation therapy course: When radiation therapy cannot be omitted or delayed, using alternative hypofractionation radiation therapy regimens may be beneficial. The goal of this approach is to maintain high cure or palliation rates without undue toxicity. The recommended altered dose and fractionation schedules outlined in this guideline were informed by radiobiological considerations and clinical experience. The recommended treatment schedules are suggested only for the emergency COVID-19 pandemic. Standard fractionation is recommended for patients with significant cardiac of lung exposure.

Potential indications for each strategy are described in more detail within the guidelines, along with caveats for specific clinical scenarios. Overall, the guidance is to prioritize more urgent treatments and decrease the number of daily visits for radiation therapy when possible, with utmost consideration of efficacy and safety.

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Applying the Guidelines in Practice

The development of these emergency guidelines began immediately following the COVID-19 crisis in Italy. At that time, ILROG established a special task force to address concerns about delivering radiation therapy in a setting of limited healthcare system capacity and compromised safety. The recommendations were generated through collaboration of experts from Asia, Europe, Australia, and North America and are applicable to different healthcare settings worldwide, according to Dr Yahalom.

“I learned from my colleagues that this guideline is frequently implemented in multiple centers around the world and we established a special team to monitor both efficacy and safety of the alternative schedules,” he said.

In practice, doctors will need to discuss the pros and cons of each alternative treatment strategy with patients and their families. “It is important to consider patient’s risk [for] disease progression, toxicity of treatment, as well as risk factors for COVID-19 infection complications. Access to daily treatments at this time may also be of some consideration to the patient and caregivers,” said Dr Yahalom.


  1. Yahalom J, Dabaja BS, Ricardi U, et al. ILROG emergency guidelines for radiation therapy of hematological malignancies during the COVID-19 pandemic [published online April 10, 2020]. Blood. doi: 10.1182/blood.2020006028.
  2. Al-Shamsi HO, Alhazzani W, Alhuraiji A, et al. A practical approach to the management of cancer patients during the novel coronavirus disease 2019 (COVID-19) pandemic: an international collaborative group [published online April 31, 2020]. Oncologist. doi: 10.1634/theoncologist.2020-0213.