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Our survey results : Impact of Covid on Thyroid Cancer Patients

Latest advice for patients having RAI Treatment Updated September 2020

Thyroid cancer: radioactive iodine treatment during COVID-19 pandemic (v3 Sep 2020)

Now that we are a few months in to the COVID-19 pandemic and have a greater understanding of the disease and it’s trajectory we have updated our guidance on RAI treatment. It is anticipated that the pandemic will result in services being disrupted for many months to come.

We have written the following guidance taking in to account both the risk patients face from cancer and from COVID-19 infection.

We recommend that radioactive iodine treatments can continue provided the local prevalence of COVID-19 is low and there is the appropriate infrastructure, staffing and COVID-19 testing available.

We appreciate there will be challenges in delivering a RAI service uniformly across the UK due to the differences in COVID-19 prevalence and its impact on local cancer centres so there will be inevitable variation in RAI services.

To reduce the risk of COVID-19 infection manifesting in the peri-RAI period:

• Consider self-isolation for the patient for 14 days before RAI treatment is due to be given. Other members of the household do not need to self isolate but should maintain excellent hand hygiene and aim to follow social distancing measures when away from the
  home. If the patient or any household member develops any symptoms suggestive of COVID-19 they should contact their thyroid cancer doctor as soon as convenient to discuss if any additional measures are required.
• Consider COVID-19 screening swab 48 (possibly 24-72) hours, depending on local laboratory turnaround time, before rhTSH administration or 48 (possibly 24-72) hours before admission if undergoing thyroid hormone withdrawal (THW). If COVID-19
  swab positive defer RAI until patient COVID-19 negative
• These recommendations will continue to be reviewed and updated in line with UK guidance on COVID-19 testing

Low iodine diet

• Preparation to continue as per usual local practice rhTSH (recombinant human TSH, Thyrogen™) preparation
• Continue as per usual practice if administered in the hospital setting
• For cancer centres covering a large geographic area that usually utilise community/district nurses for rhTSH administration, there may be difficulty accessing community rhTSH administration during the COVID-19 pandemic. In this setting there may be an opportunity to admit the patient two days earlier than the treatment date to allow for administering rhTSH in the hospital isotope room. This will avoid the patient having to undertake additional long distance travel ahead of their admission.

Inpatient stay

• Each centre will need to assess their current protocols for reviewing patients in their inpatient isotope room to take into account the potential for COVID-19 symptoms to manifest. The risk of COVID-19 symptoms developing in this setting will however be very small due to the self-isolation and baseline negative COVID-19 swab
• Consideration needs to be given at a local level to the post treatment imaging and discharge transport requirements
• On discharge, patient needs to have a letter with details on their treatment and radiation restrictions taking into account the potential scenario for subsequent admission with COVID-19 whilst still radioactive.
• For patients with young children: there may be greater difficulty for families to undertake the necessary radiation protection measures during lockdown as there may now be restrictions on the patient or child/children being in separate accommodation due to local COVID-19 restrictions regarding movement, hubs and bubbles.
• Consider radiation protection measures in context with the latest government advice on social distancing.

Day case treatment

Subject to radiation protection risk assessment it is possible to deliver 1.1GBq I131 on a day case basis. This has the advantage of avoiding an inpatient stay and where feasible may also allow increased capacity whilst a backlog of patients is treated. It is recommended that similar precautions are taken to minimise the risk of COVID19 infection around the time of treatment.

Low-risk patients: (adjuvant setting)

• A delay in RAI of up to 6 months is not expected to alter prognosis from DTC.

High-risk patients (metastatic disease)

• The risk/benefit scenario in these clinical situations are harder to determine.
• This cohort are likely to have longer radiation protection restrictions following RAI and may also be at higher risk for more severe COVID-19 infection. With the self-isolation period ahead of RAI treatment and the requirement for a negative COVID-19 screening swab before treatment, the risk of the patient falling ill with COVID-19 whilst radioactive is minimised.

The recommendations have taken in to account discussions amongst UK thyroid cancer clinicians as well as general COVID-19 oncological advice at local and national levels.

Professor Jon Wadsley

Dr Laura Moss

Thyroid Awareness Month

Thyroid cancer is on the rise. It’s a non-smoking related condition that can affect people of any age. Lorna Nickson Brown discovered she had thyroid cancer after she found a lump in her neck. Don’t put your neck on the line. If you find a lump, get it checked by a doctor.

Find out more

Please take our survey on the impact of COVID 19 for Thyroid Cancer Patients.

https://www.surveymonkey.co.uk/r/YWJZJKR

Dear Colleagues:

Thyroid Cancer: Radioactive Iodine Treatment during COVID-19 pandemic (2)

Now that we are a few weeks in to the COVID-19 pandemic and have a greater understanding of the disease and it’s trajectory we have revised our guidance on RAI treatment. It is anticipated that the pandemic will result in services being disrupted for many months to come so we cannot defer RAI treatment until the pandemic has completely passed.
We have written the following guidance taking in to account both the risk patients face from cancer and from COVID-19 infection.
We recommend that radioactive iodine treatments can be restarted provided the local prevalence of COVID-19 is low and there is the appropriate infrastructure, staffing and COVID-19 testing available. We appreciate there will be challenges in restarting a RAI service uniformly across the UK due to the differences in COVID-19 prevalence and its impact on local cancer centres so there will be variation in the resumption of RAI services.

To reduce the risk of COVID-19 infection manifesting in the peri-RAI period:

• Consider self-isolation for 14 days before RAI treatment is due to be given
• Consider COVID-19 screening swab 48 (possibly 24-72) hours, depending on local laboratory turnaround time, before rhTSH administration or 48 (possibly 24-72) hours before admission if undergoing thyroid hormone withdrawal (THW). If COVID-19 swab positive defer RAI until patient COVID-19 negative
• These recommendations will be reviewed and updated when NICE guidance is published

Low Iodine Diet

• Preparation to continue as per usual local practice

rhTSH (recombinant human TSH, Thyrogen) Preparation

• Continue as per usual practice if administered in the hospital setting
• For cancer centres covering a large geographic area that usually utilise community/district nurses for rhTSH administration, there may be difficulty accessing community rhTSH administration during the COVID-19 pandemic. In this setting there may be an opportunity to admit the patient two days earlier than the treatment date to allow for administering rhTSH in the hospital isotope room. This will avoid the patient having to undertake additional long distance travel ahead of their admission

Inpatient Stay

• Each centre will need to assess their current protocols for reviewing patients in their inpatient isotope room to take into account the potential for COVID-19 symptoms to manifest. The risk of COVID-19 symptoms developing in this setting will however be very small due to the self-isolation and baseline negative COVID-19 swab
• Consideration needs to be given at a local level to the post treatment imaging and discharge transport requirements
• On discharge, patient needs to have a letter with details on their treatment and radiation restrictions taking into account the potential scenario for subsequent admission with Covid19 whilst still radioactive.
• For patients with young children: there may be greater difficulty for families to undertake the necessary radiation protection measures during lockdown as the patient or children can no longer be in separate accommodation. Consider radiation protection measures in context with the latest government advice on social distancing.

Day case treatment

• Subject to radiation protection risk assessment it is possible to deliver 1.1GBq I131 on a day case basis. This has the advantage of avoiding an inpatient stay and where feasible may also allow increased capacity whilst a backlog of patients is treated. It is recommended that similar precautions are taken to minimise the risk of COVID19 infection around the time of treatment.

Low risk patients: (adjuvant setting)

• A delay in RAI of up to 6 months is not expected to alter prognosis from DTC.

High risk patients (metastatic disease):

• The risk/benefit scenario in these clinical situations are harder to determine.
• This cohort are likely to have longer radiation protection restrictions following RAI and may also be at higher risk for more severe COVID-19 infection. With the self-isolation period ahead of RAI treatment and the requirement for a negative COVID-19 screening swab before treatment, the risk of the patient falling ill with COVID-19 whilst radioactive is minimised.

The recommendations have taken in to account discussions amongst UK thyroid cancer clinicians as well as general COVID-19 oncological advice at local and national levels.

Professor Jon Wadsley
Dr Laura Moss

COVID-19 Advice for patients with thyroid cancer

We are aware that many patients with cancer have already received generic advice from the Chief Medical Officer regarding ‘shielding’ during the COVID-19 pandemic. The advice given below has been developed by UK thyroid cancer doctors and is tailored to specific thyroid cancer scenarios.

(i) Patients who have completed treatment for thyroid cancer
Patients who have previously received treatment for thyroid cancer such as surgery, with or without radioiodine (remnant ablation or radioiodine therapy), are not considered at higher risk of infection from COVID-19.

(ii) Patients in whom surgery for thyroid cancer is planned
Patients with significant symptoms and/or rapidly progressive disease should still be able to access surgery. For patients with cancers categorised as ‘low risk’ (where progression is considered to be slow) surgery may be delayed until a time when it is considered safer to proceed. Surgery may also be deferred for patients considered susceptible to severe COVID-19 infection or who may need intensive care monitoring after surgery. There will be variability in the provision of surgery across the UK due to the number of local COVID-19 patients and staff availability

(iii) Radioactive iodine therapy
Many centres ceased radioactive iodine treatment in the early days of the pandemic due to a combination of increased admissions and COVID-19 safety concerns.. In most cases, radioiodine therapy is not urgent and can be safely delayed. However, now that the acute pressures on the service are easing, centres are beginning to plan to restart this treatment. How soon it is possible to do this safely will depend on local circumstances. It is possible that patients will be advised to self-isolate and screened for COVID-19 prior to treatment to minimise the risk of becoming unwell following treatment. If you have concerns please discuss with your own hospital team.

(iv) TSH suppressive therapy
Patients on suppressive doses of thyroxine (i.e have a TSH target of <0.1mU/l) should continue on their current dose. Being on suppressive dose of levothyroxine does not increase the risk of COVID-19 infection.

(v) Multikinase inhibitors and chemotherapy
Patients who are receiving multikinase inhibitors (such as Lenvatinib or Sorafenib), or chemotherapy are at increased risk of severe illness from coronavirus and should follow government advice regarding shielding- https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19.
They should expect to hear from their centre and to have a discussion about the advisability of continuing treatment at this time in their particular circunmstances.

(vi) Previous radiotherapy
Patients who have previously received external beam radiotherapy to the neck may be at increased risk of severe illness with coronavirus and should also consider self-isolating.

V3.0 2nd May 2020

COVID-19 Advice for patients with thyroid cancer

(i) Patients who have completed treatment for thyroid cancer

Patients who have previously received treatment for thyroid cancer such as surgery, with or without radioiodine (remnant ablation or radioiodine therapy), are not considered at higher risk of infection from COVID-19.

(ii) Patients in whom surgery for thyroid cancer is planned

NHS England has stated that surgery for cancer should continue at present, although elective surgery is cancelled in many hospitals. More detailed advice about which operations should be prioritised will shortly be released to surgeons across the UK.

(iii) Radioactive iodine therapy

Patients awaiting radioiodine therapy may well find that their treatment is postponed. Whilst the treatment itself does not increase the risk of infection, subsequent radiation protection issues would seriously complicate the care of any patient who subsequently became unwell with COVID-19. In most cases radioiodine therapy is not urgent and can be safely delayed. If you have concerns please discuss with your own hospital team.

(iv) TSH suppressive therapy

Patients on suppressive doses of thyroxine (i.e have a TSH target of <0.1mU/l) should continue on their current dose. Being on suppressive dose of levothyroxine does not increase the risk of COVID-19 infection.

(v) Multikinase inhibitors and chemotherapy

Patients who are receiving multikinase inhibitors (such as Lenvatinib or Sorafenib), or chemotherapy are at increased risk of severe illness from coronavirus and should follow government advice regarding shielding- https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19.

They should expect to hear from their centre and to have a discussion about the advisability of continuing treatment at this time in their particular circunmstances.

(vi) Previous radiotherapy

Patients who have previously received external beam radiotherapy to the neck may be at increased risk of severe illness with coronavirus and should also consider self-isolating.

v1.0 23^rd March 2020

To be reviewed in 2 weeks