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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 4  |  Page : 186-189

Study of effect of Corona-19 pandemic on radiation oncology practice – Single institution experience


Department of Radiation Oncology, Kamineni Academy of Medical Sciences, Hyderabad, Telangana, India

Date of Submission25-Sep-2021
Date of Acceptance29-Sep-2021
Date of Web Publication09-Dec-2021

Correspondence Address:
Dr. Arpitha S Rao
Department of Radiation Oncology, Kamineni Academy of Medical Sciences, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrcr.jrcr_37_21

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  Abstract 


Context: The COVID-19 pandemic has posed a big challenge to provision of health care. Cancer patients are considered to be at higher risk of developing complications from COVID-19 as they are often immunosuppressed. At the same time, treatment delays and late diagnosis during the pandemic due to travel restrictions, staff shortage, active COVID infections to patients or family members, etc., can lead to tumor progression and poor oncological outcomes. Aims: This retrospective observational study was undertaken to know the effect of the corona pandemic and consequent lockdown on the radiation treatment of oncology patients in our department. Materials and Methods: Subjects of the study were the patients who attended the Oncology Department of Kamineni Academy of Medical Sciences, Hyderabad, which is a tertiary care center, during the COVID-19 pandemic. The study period was 6 months starting from the lockdown on April 24, 2020. Results: In our study, treatment of 16 out of 150 patients (10.67%) was affected due to the lockdown situation consequent to COVID-19 pandemic. Eight patients had treatment interruptions for more than 5 days, six patients discontinued their treatment, and two patients delayed their treatment due to lockdown. Eight patients tested positive for COVID-19 before starting treatment. Out of them, four did not come back for treatment. The mean delay in radiation treatment in the other four patients was 35 days. Two patients had CORAD scores consistent with COVID-19 but were reverse transcription–polymerase chain reaction negative. Two patients turned positive during treatment after which they did not come back. Totally 9.3% (14/150) of the patients' treatment was affected due to corona infection. Conclusions: In our study, almost 20% of the patients' treatment was affected directly or indirectly by the COVID-19 pandemic situation. This in turn may lead to rise in cancer mortality in future.

Keywords: Corona-19 pandemic, interruptions, treatment delays


How to cite this article:
Rao AS, Mohan FP. Study of effect of Corona-19 pandemic on radiation oncology practice – Single institution experience. J Radiat Cancer Res 2021;12:186-9

How to cite this URL:
Rao AS, Mohan FP. Study of effect of Corona-19 pandemic on radiation oncology practice – Single institution experience. J Radiat Cancer Res [serial online] 2021 [cited 2022 Aug 16];12:186-9. Available from: https://www.journalrcr.org/text.asp?2021/12/4/186/332106




  Introduction Top


The COVID-19 pandemic in India is part of the worldwide pandemic caused by severe acute respiratory syndrome coronavirus 2, which originated from China. The COVID-19 pandemic has posed a big challenge to provision of health care.

Cancer patients are considered to be at higher risk of developing complications from COVID-19 as they are often immunosuppressed by their disease or therapy. At the same time, treatment delays and late diagnosis during the pandemic due to travel restrictions, staff shortage, active COVID infections to patients or family members, etc., can lead to tumor progression and poor oncological outcomes with increased death toll in coming years. They also cause huge backlogs in treatment to be dealt with later by health-care providers. Appropriate planning and management of the oncology centers is therefore important to continue with cancer treatment services and simultaneously avoid the risk of COVID-19 infection to the patients and health-care staff.

This retrospective observational study was undertaken to know the effect of the pandemic and consequent lockdown on patient care in the Department of Radiation Oncology. Coronavirus is here to stay, and we have to live with it without compromising the cancer care. This study analyzed the shortcomings noticed in the past and helped to plan for a new normal in future.


  Materials and Methods Top


Subjects of the study were the patients who attended the Oncology Department of Kamineni Academy of Medical Sciences, Hyderabad, which is a tertiary care center, during the COVID-19 pandemic. The study period was 6 months starting from the lockdown on April 24, 2020. At the start of the lockdown, our institution constituted a COVID task force which discussed measures to have a sustained oncological practice with minimum health risk to the health-care workers and patients. At the outset, all nurses and staff were made aware of the need for personal protection and social distancing. They were trained regarding the proper use of personal protective equipment (PPE). The following measures were taken:

  1. Screening process: A screening desk was started at the entry point where a trained nurse in PPE would screen every person entering the department with infrared thermometer and pulse oximeter and fill a questionnaire for any symptoms of cold/cough/fever, including history of travel during the past 2 weeks. The main objective was to identify staff/patients/attenders symptomatic to COVID-19/primary contacts of COVID patients/high-risk persons and refer them to COVID care center
  2. Visitor/attendees' policy: Only one attender was allowed with each patient and minimum things were allowed to be carried inside the department. Radiotherapy appointments were more widely spaced to avoid crowding. All patients/attenders were explained about the measures being taken in the department to prevent the transmission of the infection and only those who were ready to comply with the same including wearing of face mask were allowed inside the department
  3. Adequate PPEs were provided to the staff
  4. Standard cleaning and disinfection policy were strictly adhered to
  5. Assistance was provided to staff for self-quarantine and transport was arranged during lockdown
  6. The consent process for radiotherapy included information regarding possible risk of infection of COVID-19 in spite of adequate precautions
  7. Mandatory high-resolution computed tomography (HRCT) chest and reverse transcription–polymerase chain reaction (RT-PCR) for COVID-19 were done for all patients before starting radiotherapy
  8. Reducing of working workforce (doctors, nurses, and ward staff) by 50% by rotation helped to reserve the other half to take over in case of some staff getting infected and being quarantined
  9. Shorter treatment schedules were preferred whenever there were available data on safety and efficacy of converting standard to hypofractionated schedules.[1],[2] For example, (1) the use of hypofractionated regimens whenever feasible in post mastectomy cases of carcinoma breast and (2) the use of shorter fractionation schedule for palliative cases.


This was a cross-sectional observational study involving compilation and analysis of data of all patients who took radiotherapy treatment during the study period. Issues studied included treatment modifications done during lockdown, treatment delays, interruptions, diagnosis of COVID infections among the patients, staff, and its impact if any on radiation treatment.

The study was approved by the Institutional Ethics Committee. A total of 150 patients were treated during the study period of 6 months, of whom 94 were female and 46 were male.


  Results Top


Out of 150 patients, 40 patients received palliative radiotherapy, 62 patients were on adjuvant radiotherapy, and 38 patients were on radical radiotherapy treatment. Out of 38 patients on radical radiotherapy treatment, 23 patients had head-and-neck cancers and all of them were staged either 4a or 4b. This clearly indicates that all of them had locally advanced cancers.

Treatment modifications

Three patients with palliative treatments were treated with shorter schedule on request from patients. One post mastectomy breast cancer patient was treated with hypofractionated schedule.

Treatment interruptions

Eight patients had treatment interruptions for more than 5 days due to lockdown. Six patients discontinued treatment during the lockdown, and five of them did not come back for treatment even after the lockdown was lifted. One patient completed the treatment after a gap of 7 weeks during which his disease had progressed, and within 1 month of finishing radiation, he developed metastatic disease.

Treatment delays

Two patients, who were diagnosed just before lockdown, came back after a gap of 4 months for treatment. One of these patients had progressed from stage 2 to stage 4.

In total, 16 out of 150 (10.67%) patients, treatment was affected due to lockdown.

COVID-19 among patients

Eight patients tested positive for COVID-19 (HRCT showing changes and RT-PCR positive) before starting treatment. Out of them, four patients did not come back for treatment and four patients completed their treatment after they turned RT-PCR negative. The mean delay in radiation treatment in these four patients was 35 days. All these eight patients were asymptomatic for COVID-19. Four other patients had CORAD 3 or 4 changes on HRCT, but RT-PCR was negative. Treatment was started after 15 days for these patients.

Two patients turned positive during treatment after which they did not come back to finish the treatment. They both were symptomatic to COVID-19 and had fever, myalgia, and weakness. The sources of infection for both these patients were other family members who turned positive. Out of 150 patients, 10 patients (6.67%) had RT-PCR-positive COVID-19 infection. Totally 14 out of 150 (9.3%) patients' treatment was affected due to COVID-19 pandemic.

COVID-19 among the staff

Among forty staff in the Oncology Department, ten turned COVID positive, and among them, three were asymptomatic. In addition, three staff had to be quarantined at home due to their family members being positive.


  Discussion Top


The first case of COVID-19 in India was reported on January 30, 2020. India currently is the second-worst affected country in the world. On March 24, 2020, the Prime Minister of India ordered a nationwide lockdown for 21 days, affecting the entire 1.3 billion population of India. On April 14, India extended the nationwide lockdown till May 3 which was followed by 2-week extensions starting May 3 and 17, 2020, with substantial relaxations. Our center witnessed a drop in the number of patients by around 50% at the time of lockdown to around 25%–30% after lifting of lockdown. The reasons for fall in the numbers were as follows:

  1. Lack of transport facilities from remote places
  2. Fear of contracting corona in the hospital/fear of dying due to corona in the background of a thought process that cancer is a death statement
  3. Family members in quarantine due to travel or corona positivity.


COVID-19 pandemic has affected every single aspect of life in many ways. Health care is no exception. Many oncological guidelines are recommending changes in practices for systemic therapy and surgery to minimize immune-compromising effects or adding comorbidities which could predispose to serious complications during the pandemic. In a nationwide analysis in China, undergoing chemotherapy or surgery was correlated with a higher risk of clinically severe COVID-19 events in cancer patients than not receiving chemotherapy or surgery (75% vs. 43%, P = 0·0026).[3] The one treatment modality which can be safely delivered with relatively less impact on systemic immune system is radiotherapy.[4] With nearly 50%–60% of the patients with cancer ultimately needing RT in their lifetime, in the setting of deferred chemotherapy and surgery, RT may play an even more important role in management of many cancers. Hence, strict protocols in radiation oncology centers are important to continue uninterrupted treatment for patients. With strict protocols for disinfection and social distancing in our center, we did not encounter any cross infection in our center. Two patients out of 150 patients treated had COVID infection, and in both of them, the source of infection was a positive family member.

The COVID-19 pandemic has impacted the care of cancer patients in many unknown ways and its full impact will be realized much later. All the head-and-neck cancer patients treated with radical radiotherapy in the study period belonged to either stage 4a or 4b. This clearly shows they presented with locally advanced disease. This could be because of the delay in diagnosis probably because of dental/ENT surgeons postponing or avoiding intraoral biopsy procedures apart from the general reasons cited above. In our study, 16 out of 150 (10.67%) patients' treatment was affected (delayed, interrupted, or discontinued) due to lockdown. Furthermore, 9.3% (14/150) of the patients' treatment was affected due to corona infection directly or indirectly. In total, almost 20% of the patients' treatment was affected.

If the findings of our study are extrapolated, on a national level, substantial number of cancer patients' diagnosis and treatment would have got delayed, interrupted, or discontinued due to corona pandemic. Patients who would have probably got cured of cancer by timely diagnosis and treatment would have lost the opportunity due to the prevailing pandemic. Recent studies estimate that delays in cancer diagnosis and treatment will increase the indirect death toll.[5] Studies in Europe have predicted that mortality in cancer patients could rise by 20%.[6]

It would be prudent to identify one cancer center in every region of our country to treat COVID-19-positive cancer patients in whom delaying treatment will be more detrimental than the COVID infection itself.[7],[8] In our study, none of the COVID-positive patients had severe symptoms and they all recovered from COVID uneventfully.

The pandemic has put a financial strain both on the hospitals and patients. Hospitals have to work in the scenarios of decreasing financial revenue due to less number of patients and growing expenditure to provide PPEs to staff, disinfection of centers, and treatment of infected or quarantined staff, transport facilities to staff, etc., Patients also had to undergo COVID testing as a protocol which was an added expenditure.

It is of utmost importance to counsel the patients. They are already drowned in the fear of cancer and need empathetic approach to help them come out of the fear of corona. Fear of dying an unrespectful death in the hospital if diagnosed with corona is deeply rooted in the minds of patients because of social stigma. This fear has forced many patients including cancer patients to avoid going to hospitals even in case of emergencies.


  Conclusion Top


While every effort to minimize infections in the department has to be undertaken, it is important to ensure that patients' treatment schedules are not compromised to the extent possible and minimize adverse oncological outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Achard V, Tsoutsou P, Zilli T. Radiotherapy in the times of the corona virus pandemic when less is better. Int J Radiat Oncol 2020;3:107. [doi: 10.1016/j.ijrobp.2020.03.008].  Back to cited text no. 1
    
2.
Loap P, Kirova Y, Takanen S, Créhange G, Fourquet A. Breast radiation therapy during COVID-19 outbreak: Practical advice. Cancer Radiother 2020;24:196-8.  Back to cited text no. 2
    
3.
Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-Co-V-2 infection: A nationwide analysis in China. Lancet 2020;21:335-7.  Back to cited text no. 3
    
4.
Dai M, Liu D, Liu M, Zhou F, Li G, Chen Z, et al. Patients with cancer Appear more vulnerable to SARS-CoV-2: A multi-centre study during the COVID-19 outbreak. Cancer Discov 2020;10:783-91.  Back to cited text no. 4
    
5.
Lai AG, Pasea L, Banerjee A, Denaxas S, Katsoulis M, Chang WH, et al. Estimating excess mortality in people with cancer and multimorbidity in the COVID-19 emergency. medRxiv. Epub Ahead of Print 29 April 2020. [doi: 13140/RG.2.2.34254.82242].  Back to cited text no. 5
    
6.
Wise J. COVID-19: Cancer mortality could rise at least 20% because of pandemic, study finds. BMJ 2020;369:m1735.  Back to cited text no. 6
    
7.
Nagar H, Formenti SC. Cancer and COVID-19 – Potentially deleterious effects of delaying radiotherapy. Nat Rev Clin Oncol 2020;17:332-4.  Back to cited text no. 7
    
8.
Huang J, Barbera L, Brouwers M, Browman G, Mackillop WJ. Does delay in starting treatment affect the outcomes of radiotherapy? A systematic review. J Clin Oncol 2003;21:555-63.  Back to cited text no. 8
    




 

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