|LETTER TO THE EDITOR
|Ahead of print
Radiotherapy practice during the COVID-19 pandemic and nation-wide lockdown: The Indian scenario
Naveen Mummudi, Sarbani Ghosh-Laskar, Anil Tibdewal, Jai P Agarwal
Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
|Date of Submission||04-Jun-2020|
|Date of Decision||10-Jun-2020|
|Date of Acceptance||22-Aug-2020|
|Date of Web Publication||27-Jan-2021|
Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this URL:|
Mummudi N, Ghosh-Laskar S, Tibdewal A, Agarwal JP. Radiotherapy practice during the COVID-19 pandemic and nation-wide lockdown: The Indian scenario. Indian J Cancer [Epub ahead of print] [cited 2021 Feb 25]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=308046
In India, the first case of the novel coronavirus disease (COVID-19) infection was reported on January 30, 2020. Since then the number of infected patients has risen steeply to more than 2.5 million cases and 50,000 deaths as on August 17, 2020. Cancer patients are more susceptible to this infection due to their systemic immunosuppressive state caused by both cancer and its treatment. Studies from across the globe also suggest inferior survival outcomes in patients with cancer who acquire COVID-19 infection., In an effort to tackle this unprecedented challenge, institutions around the globe began rationing their services in a bid to reduce infection rates among patients and healthcare workers. For example, at our institution, we scaled back our clinical operations by one-third. India witnesses approximately 1,200,000 new cancer cases every year and it is estimated that about two-thirds of cancer patients would require radiation therapy (RT). Currently, there are about 365 linear accelerators and 180 tele-cobalt therapy units in the country which are predominantly located in major cities. In India, a nation-wide lockdown was implemented on March 24, 2020, which along with existing challenges like huge population, resource constraints, and unequal distribution of cancer care facilities in urban and rural areas have compounded the ordeal for patients in seeking oncology care.
We conducted two online surveys (using Google forms) among radiation oncologists in the country. The first of the survey was conducted between 3rd and 7th April 2020, a week after the lockdown and when the number of infected patients in the country had not even crossed 5000, to study the challenges faced by the radiation oncology community during the pandemic and identify initiatives taken to tackle these issues—both at an individual level and collectively as institutes/organizations. There were 125 responses; half of them were from private, multispecialty hospitals. At that time of the survey, despite not having any COVID-19-positive patients in the hospital, about 22% of hospitals had ceased routine clinical care, possibly due to the lack of uniform directives and guiding principles for managing cancer patients. In fact, only 50% of these hospitals had any standard operating procedure manual to manage patients during the pandemic. About 17% of oncologists withheld starting RT for new patients, reasons for which included hospital administrative policy (13%), reluctance of staff to treat (3%), and patient's refusal to come for treatment (2%). In patients already on treatment, oncologists reported breaks in less than one-third of their patients (76%), while 14% reported a break in more than 30% of their routine patients. The nation-wide lockdown resulted in reduced access to public transport for the patients to travel for treatment which led to the breaks. To combat gaps during treatment, various measures were implemented; most commonly additional fractions (45%) and higher dose per fraction for a remaining fraction (24%) were utilized; 14% of participants reported not using any gap correction measures. 70% of oncologists made changes to existing treatment protocols, which was either in the form of hypo-fractionation (64%), delay in initiation of RT (51%), adopting less complex RT techniques (35%), or modified on-board imaging (37%). These changes were reflected commonly in palliative RT (85%), head and neck (42%), breast (54%), and prostate (33%) protocols. There was a general reluctance to implement these changes in gynecological and central nervous system (CNS) protocols, possibly to avoid long-term complications. A majority of the oncologists continued concurrent chemotherapy (49%) or took an individualized decision regarding radiosensitizing agents (38%). Operational alterations in the workforce were performed in most hospitals; most reported a fifty percent reduction (55%) and a few reported a one-third reduction in staff (31%). More than 90% of the respondents utilized telephonic consultations for either new or follow-up patients.
A second follow-up survey was conducted a month later to evaluate the real impact of the pandemic and lockdown measures became more evident. Various international professional organizations and societies published guidelines for managing cancer patients with RT during the pandemic.,,,,, The common theme in these guidelines was to prioritize patients based on their need for treatment and the expected impact of the treatment on survival outcomes. These guidelines and statements broadly put patients under three categories of priority; category 1 are those who cannot afford any delay in their treatment and require urgent RT; category 2 are those whose long-term outcomes will not be affected by a delay; RT could be safely deferred for months or omitted altogether for category-3 patients. Out of the 61 participants, more than two-thirds reported as working in an area deemed as COVID-19 “hot-spot.” However, all except one participant had not yet treated a COVID-19-positive patient. All the participants were aware of the various guidelines and consensus statements published in the past 2 months. However, only 30% felt that these guidelines were practically applicable in their setting. The recent, revised Indian Council of Medical Research (ICMR) guideline does not routinely allow testing of patients other than those who are either symptomatic or high-risk contacts. About 89% of the oncologists felt that it was appropriate to perform COVID-19 testing in patients who are being planned for starting RT. Since radiotherapy typically lasts between 4 and 6 weeks, multiple tests may be needed for each asymptomatic patient; most respondents (50%) were unsure about the ideal frequency of testing, while 35% suggested weekly testing.
In an untested asymptomatic patient, the predominant response was to start RT as usual in category 1, RT after testing in category 2, and delay RT in category-3 patients. However, in an untested symptomatic patient, the majority chose testing first regardless of category. When faced with a scenario of COVID-19 positive asymptomatic patient, the common response was to delay RT till negative test even in category 1 and 2 patients. This response pattern remained the same in the scenario of symptomatic, positive patients too. Most of the participants chose to start RT with all precautions in negative, but symptomatic patients in category 1. Almost two-thirds (62%) of the oncologists felt that with the current infrastructure in their department, they did not feel well equipped to initiate or continue treatment for a COVID-19 positive patient.
This heterogeneity in response highlights the uncertainties and current lack of clear guiding directives to manage radiotherapy patients. Oncologists are now grappling with decisions regarding patient care, which in normal times would not have been contentious. While institutes from China and few other western countries have shared their experience of treating cancer patients with COVID-19 infection,,, we face a unique set of challenges in managing COVID-19 positive cancer patients in our country. One, the testing is not available universally, limiting the number of asymptomatic cancer patients who can be tested; two, radiotherapy being a protracted, outpatient treatment, testing once may not suffice, as the patient can potentially get infected during the treatment; three, applying the prioritization process to an individual patient is difficult especially in a corporate set-up; four, the personal protective equipment (PPEs), which are the first and most important barricade against infection, are not wholly available for the healthcare workers, thus compromising the delivery of care. Last, the implementation of nation-wide lockdown to combat the pandemic has resulted in some collateral damage; patients already encumbered with a diagnosis of cancer are facing a fresh ordeal of delayed access to cancer care due to restricted public transport facilities.
As the pandemic threatens to loom over us for a long time, as oncologists, we have witnessed a paradigm shift in our approach to cancer care. Prioritizing of patients based on their need for treatment and its efficacy, decision on testing patients for COVID-19 before and during therapy, rationing of service and healthcare workers, use of personal protection equipment—through all these additional adversities, the pandemic has taught us few valuable lessons, which, no doubt, would go a long way in ensuring the safety and quality of treatment delivered.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al
. Cancer patients in SARS-CoV-2 infection: A nationwide analysis in China. Lancet Oncol 2020;21:335-7.
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 multicenter study during the COVID-19 outbreak. Cancer Discov 2020;10:783-91.
Tata Memorial Centre COVID-19 Working Group. The COVID-19 pandemic and the Tata Memorial Centre response. Indian J Cancer 2020;57:123-8.
] [Full text]
Munshi A, Ganesh T, Mohanti BK. Radiotherapy in India: History, current scenario and proposed solutions. Indian J Cancer 2019;56:359-63.
] [Full text]
Simcock R, Thomas TV, Estes C, Filippi AR, Katz MA, Pereira IJ, et al
. COVID-19: Global radiation oncology's targeted response for pandemic preparedness. Clin Transl Radiat Oncol 2020;22:55-68.
Coles CE, Aristei C, Bliss J, Boersma L, Brunt AM, Chatterjee S, et al
. International guidelines on radiation therapy for breast cancer during the COVID-19 pandemic. Clin Oncol (R Coll Radiol) 2020;32:279-81.
Guckenberger M, Belka C, Bezjak A, Bradley J, Daly ME, DeRuysscher D, et al
. Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement. Radiother Oncol 2020;146:223-9.
Thomson DJ, Palma D, Guckenberger M, Balermpas P, Beitler JJ, Blanchard P, et al
. Practice recommendations for risk-adapted head and neck cancer radiation therapy during the COVID-19 pandemic: An ASTRO-ESTRO consensus statement. Int J Radiat Oncol Biol Phys 2020;107:618-27.
Yerramilli D, Xu AJ, Gillespie EF, Shepherd AF, Beal K, Gomez D, et al
. Palliative Radiation Therapy for oncologic emergencies in the setting of COVID-19: Approaches to balancing risks and benefits. Adv Radiat Oncol 2020;5:589-94.
Combs SE, Belka C, Niyazi M, Corradini S, Pigorsch S, Wilkens J, et al
. First statement on preparation for the COVID-19 pandemic in large German Speaking University-based radiation oncology departments. Radiat Oncol 2020;15:74.
Wei W, Zheng D, Lei Y, Wu S, Verma V, Liu Y, et al
. Radiotherapy workflow and protection procedures during the Coronavirus Disease 2019 (COVID-19) outbreak: Experience of the Hubei Cancer Hospital in Wuhan, China. Radiother Oncol 2020;148:203-210.
Rivera A, Ohri N, Thomas E, Miller R, Knoll MA. The impact of COVID-19 on radiation oncology clinics and cancer patients in the U.S. Adv Radiat Oncol 2020;5:538-43.