1 Introduction

Coronavirus disease 2019 (COVID‐19) is an unprecedented pandemic that has already reached over 2 million confirmed cases globally, with at least 140,000 deaths as reported by the World Health Organization (WHO) as of April 16, 2020.1 More than 662,000 cases have been reported in the United States with more than 29,000 deaths.2 The overall crude mortality rate now stands at 6.6% (may possibly be lower due to under‐testing and under‐reporting of total confirmed cases), and is highly dependent on age group, comorbidities, and the locoregional resources medically.1 A report from the United States presented age‐stratified COVID‐19‐associated hospitalization rates among 1,482 patients during March 1–28, 2020, highlighting an alarmingly high rate of 74.5% at age > 50 years with underlining medical conditions.3 Based on a data summary report provided by New York City Health, as of April 14, 2020, the shares of a total of 6839 deaths reached 0.04%, 4.5%, 23.1%, 24.6%, and 47.7% for the age groups of 0–17, 18–44, 45–64, 65–74, and 75+ years old.4 All data suggest that adults at a more advanced age group are facing higher morbidity and mortality risks.

Clearly, with our aging population, cancer patients are among this most vulnerable group, which brings us to this editorial regarding special considerations for radiotherapy (RT) during a COVID‐19 pandemic. The global COVID‐19 paradigm is ever‐changing, thus this discussion is based on our current situation as of April 16, 2020, including increased risks of COVID‐19 exposure to healthcare workers,5 significant shortage of personal protective equipment (PPE)6 for healthcare workers, severely limited testing capacity only available for symptomatic patients,7 therapeutic drugs still being at experimental stage,8 and the prospect of vaccinations at least a year away (still under development),9 etc. Questions raised among our RT community include “Can quality‐assured RT treatment be safely provided to COVID‐19 positive patients?,” “How to best protect other cancer patients and staff from being infected?,” “What if patients are confirmed positive mid‐way through the RT treatment,” etc. In fact, a very recent case report from M.D. Anderson Cancer Center just revealed an asymptomatic nonsmall cell lung cancer patient who passed regular COVID‐19 screening but demonstrated internal development of multifocal ground glass opacities on the thoracic CT‐on‐rail scan prior to the first fraction of RT treatment. The patient was then subsequently confirmed COVID‐19 positive.10 To treat, or not to treat? There will not be a simple answer to the question. Herein, we have Dr. Pranshu Mohindra and Dr. Shifeng Chen from University of Maryland, Baltimore elaborating their proposition on “Quality assured radiotherapy can be delivered during COVID‐19 pandemic, ” and Dr. Courtney Buckey and Dr. Terence Sio from Mayo Clinic Arizona offering their opinions on “Radiotherapy treatment should be postponed for COVID‐19 positive patients. ”

Pranshu Mohindra, MD, MBBS is a radiation oncologist and an Associate Professor of Radiation Oncology at the University of Maryland School of Medicine, Baltimore. His primary area of clinical and research interest is in thoracic/lung, gynecological, and hemato‐lymphoid malignancies using both modern photon and proton‐based radiotherapy approaches. Relevant to this editorial, Dr. Mohindra leads the Scope of Practice, Policy and Procedure Management Workgroup of Quality and Safety Review Council in his department and also serves as Director of Billing and Compliance. In these roles, he oversees the development of Standard Operating Procedures for various departmental clinical activities and establishes uniform procedures system‐wise, along with overall clinical billing and compliance.

Courtney R Buckey, PhD, DABR is a medical physicist and Assistant Professor of Radiation Oncology at the Mayo Clinic in Arizona. Related to this editorial, her focuses are patient and staff safety, event reporting, introducing techniques like Humble Inquiry and the London Protocol to local incident investigation, and teaching quality and safety to physics residents. Dr. Buckey’s current AAPM participation includes serving as vice‐chair of Task Group 314‐Guidance for Fault Recovery in Radiation Therapy; a member of the Working Group for the Prevention of Errors, and the Women’s Professional Subcommittee; and a therapy track organizer on the Spring Clinical Meeting Subcommittee. She is currently the president‐elect of the Arizona Chapter of the AAPM.

Shifeng Chen, PhD is an Associate Professor, Associate Chief of Clinical Physics, and Director of the Dosimetry Training Program, in the Department of Radiation Oncology at the University of Maryland School of Medicine. He received his BS in Engineering Physics from Tsinghua University at Beijing, China, and a PhD degree of Physics from Florida State University. He then completed postdoctoral training in Radiation Oncology Physics at Duke University Medical Center. His clinical and research interests include Treatment Planning, GRID/LATTICE Radiation Therapy, Stereotactic Radiation Therapy, Thermal Therapy, Automation for Radiation Oncology, and Machine Learning. He has authored and coauthored 79 peer‐reviewed journal articles, 2 book chapters, and 82 conference abstracts.

Terence T. Sio, MD, MS is a radiation oncologist and Associate Professor of Radiation Oncology who specializes in both photon‐based and proton radiotherapies. His main focuses are in gastrointestinal, lung, and brain cancers including brain metastasis treatments using stereotactic radiosurgery. He has a strong interest in ion beam radiotherapies internationally.