|Year : 2020 | Volume
| Issue : 1 | Page : 3-7
Radiotherapy practice in the time of COVID-19 pandemic and nationwide lockdown: Experience from a resource-constrained center of Northeast India
Gautam Sarma, Jyotiman Nath, Partha Pratim Medhi, Mouchumee Bhattacharyya, Apurba Kumar Kalita
Department of Radiation Oncology, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India
|Date of Submission||18-May-2020|
|Date of Decision||08-Jun-2020|
|Date of Acceptance||19-Jun-2020|
|Date of Web Publication||25-Sep-2020|
Dr. Jyotiman Nath
Department of Radiation Oncology, Dr. B. Borooah Cancer Institute, AK Azad Road, Gopinath Nagar, Guwahati - 781 016, Assam
Source of Support: None, Conflict of Interest: None
The outbreak of novel coronavirus disease (COVID-19) that originated in Wuhan, Hubei Province, of China in December 2019 was declared as a pandemic on March 11, 2020, by the World Health Organization. As a measure to break the chain of transmission of the disease, the Government of India declared nationwide lockdown from March 24, 2020. This pandemic and nationwide lockdown impacted the healthcare system, and it became extremely difficult to carry out cancer-related services as both the patients and healthcare providers are at increased risk of infection. As a resource-constrained and high-volume patient center, we have formulated few sets of policies based on the available evidence which helped us to carryout patient care services in this time of crisis. Our policies will help other resource-constrained cancer hospitals to formulate their own policy.
Keywords: Cancer, COVID-19, pandemic, lockdown, radiotherapy
|How to cite this article:|
Sarma G, Nath J, Medhi PP, Bhattacharyya M, Kalita AK. Radiotherapy practice in the time of COVID-19 pandemic and nationwide lockdown: Experience from a resource-constrained center of Northeast India. J Radiat Med Trop 2020;1:3-7
|How to cite this URL:|
Sarma G, Nath J, Medhi PP, Bhattacharyya M, Kalita AK. Radiotherapy practice in the time of COVID-19 pandemic and nationwide lockdown: Experience from a resource-constrained center of Northeast India. J Radiat Med Trop [serial online] 2020 [cited 2023 Jun 3];1:3-7. Available from: http://www.jrmt.org/text.asp?2020/1/1/3/296115
| Introduction and Background|| |
Novel coronavirus disease that originated in Wuhan, Hubei Province, of China in December 2019 has now emerged as the largest global public health issue of this era. Initially diagnosed as a pneumonia of unknown cause, the pathogen was subsequently identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is a single-stranded RNA virus belonging to the Coronaviridae family. On February 11, 2020, the World Health Organization (WHO) announced a new name for this coronavirus disease; COVID-19. Earlier, there had been reports of outbreaks of respiratory illnesses caused by coronaviruses in certain parts of the world such as the SARS and the Middle East respiratory syndrome in the past. However, COVID-19 disease has spread like wildfire along the length and breadth of the globe, with now more than 2 million affected and nearly 140 thousand deaths across all the continents as of April 17, 2020.
The first cases reported from China in the late December 2019 were subsequently linked to a seafood and wet animal market in Wuhan, suggesting the zoonotic origin of the virus. Genomic sequence analysis of COVID-19 has shown 88% identity with two bat-derived SARS-like coronavirus, establishing bats as the most likely link between COVID-19 and humans., However, with emergence of reports of COVID-19 infection among people who did not visit the live animal market of Wuhan, the likelihood of human-to-human transmission of the virus was established by the end of January 2020. Its community spread has been primarily by direct contact or from aerosols generated by coughing or sneezing from an affected individual. With international travel and trade with China remaining unrestricted during this period, the virus silently spread to Europe, North America, and other parts of Asia gradually. The first cases in the European region were reported around January 24, 2020. By the beginning of March 2020, there was an explosion in the number of positive cases, and with a case fatality rate of around 2%–3%, a large number of people started dying, particularly in Italy, France, and Spain. In the absence of any definite vaccine or curative therapy directed toward SARS-CoV-2, the only effective means to combat the disease spread was by quarantine of cases and contacts besides strict travel restrictions, social distancing, and sanitization. At one point in time, the cases outnumbered the available medical facilities to such an extent that the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) had to publish medical ethics recommendations to consider triage protocols by caregivers. Thereafter, the WHO on March 11, 2020, declared COVID-19 disease as a pandemic.
In India, the first case of coronavirus disease was detected in Kerala, on January 30, 2020, and by March 11, 2020, the number of cases reached 50, with almost all the cases having a history of international travel or contacts with travelers from SARS-CoV-2-affected parts of the world. To implement the policies of social distancing to stop further spread of the disease, the country went into lockdown from March 24. At the time of declaring the lockdown, India had less than 600 positive cases of COVID-19 nationwide. In the State of Assam of Northeast India, till May 18, 2020, 102 have been tested positive for COVID-19. As a result, all routine activities except essential services have come to a standstill in the country.
Dr. Bhubaneswar Borooah Cancer Institute is a tertiary cancer care center in the State of Assam of Northeast India. The Department of Radiation Oncology is equipped with one X-ray simulator, one wide bore CT simulator, two cobalt teletherapy machines, three linear accelerators, and one HDR brachytherapy unit. More than 350 patients are treated in the Department of Radiation Oncology daily. The Institute caters to patients from all the Northeast states of India as well as some from the State of West Bengal.
During this COVID-19 pandemic and nationwide lockdown, we have made a few changes in our patient care services and radiotherapy (RT) treatment protocols. These changes were made after going through recently published various treatment guidelines in the international journals, published literature in high impact journals, government advisories, and hospital policies. This article will help resource-constrained cancer institutes to formulate treatment policies during the COVID-19 pandemic. The article was approved by the expedited review board of the institutional ethics committee.
| Nationwide Lockdown and Institutional Preparedness|| |
Chinese researchers have published their experience with COVID-19 and have identified high-risk groups which include elderly patients, patients with severe comorbidities, and cancer patients. Patients with cancer are known to be at an increased risk for community-acquired infections as they are immunosuppressed because of the malignancy and also anticancer treatment.
To ensure the safety of the patients, the hospital authorities implemented several measures immediately after the outbreak was announced.
The hospital opened only one entrance and one exit with a newly established triage area to take body temperatures in addition to the recording of travel and contact history for all patients and attendants entering the hospital. It was made compulsory for everyone to wash hands with soap under running water at least 20 s before entering the hospital, for which all the logistics were made available with a trained health worker, demonstrating the steps of hand washing on shift basis. Anyone with a body temperature over 37.3° C and recent travel history were transferred to a newly established fever clinic. Persons with high suspicion were then referred to Gauhati Medical College and Hospital which was converted to State Nodal COVID Hospital for further investigation and management. Patients were discouraged to come with more than one attendant. It was mandatory for everyone inside the hospital campus to wear a face mask.
During outpatient consultation, a minimum 1-m distance criterion was strictly followed. Only one attendant was allowed inside the consultation room at a time to reduce congestion. Routine admissions such as for insurance, cashless facility, or logistic issues were suspended.
The hospital administration also nominated few doctors from the institute for training in the State Nodal Training Center for COVID-19 management. Following the training, they were made nodal officers for the management of suspected cases of COVID-19 in the institute.
The stable patients who were not in need of inpatient care are discharged at the earliest. Hand washing practice was demonstrated regularly in the inpatient ward by nursing staff and medico-social counselors. The hospital administration also developed an isolation ward to keep any suspected case of COVID-19 if the situation arises.
Clinicians and other healthcare providers are certainly at higher risk of getting infection than the public at large. In radiation oncology, especially the RT technologists (RTTs) are at high risk as most of our patients are of head-and-neck cancers (some with tracheostomy), and COVID-19 transmission primarily occurs by respiratory droplet spread. To minimize the risk of exposure to the healthcare providers, the management took a policy to implement 50% workforce at work with the rest 50% to work from home on a rotation basis. The people on work from home were engaged to provide teleconsultation services to the patients. We received a good feedback from the patient and the caregivers.
The management provided required personal protective equipment such as N95 mask, gloves, and safety goggles for the clinicians and other healthcare providers as per the recommendations of the Ministry of Health and Family Welfare, Government of India. In our department, N95 mask, hand gloves, safety goggles, face shields, and water proof aprons are used by RTTs and mold room technicians during patient treatment. The masks, goggles, face shield, and aprons are worn for the duty shift by the RTTs and replaced only if soiled. Separate hand gloves are used for every patient. Clinicians use either surgical mask or N95 mask for communication with patients as the results of a randomized trial recently published in the JAMA Oncology compared N95 versus surgical masks for preventing flu among healthcare personnel revealed no significant difference between the two.
The lockdown immediately impacted on the RT treatment delivery in our institute, as more than 50% of patients who were on RT come to the hospital on an outpatient basis from nearby districts. Thus, there was a dropdown of almost 50% in daily attendance of patients in the different RT treatment units. The hospital authorities implemented a telephonic consultation project with the patients and caregivers to help them in this time of uncertainty. Patients scheduled for follow-up were identified from hospital records and contacted over telephone. They were advised to defer hospital visit if found asymptomatic. The institute also provided transportation services for the patients undergoing treatment as and when required.
The Medical Council of India published telemedicine practice guidelines also allowed to communicate with patients and to prescribe supportive care and medicine via various electronic medium.
Radiotherapy machine area
As the RT machine premises is a potential area of human crowd, frequent announcements were made in the machine waiting area regarding the need of social distancing. Patients were also advised over phone to come for the treatment in their allotted time slot only. Extra space was created in the department to keep all the head-and-neck thermoplastic molds separated from each other. Treatment of the patients with tracheostomy and feeding nasogastric tube was done only after completion of other cases with utmost precautions. All RTTs and support staff were mobilized and trained in infection prevention and control practices.
| Site-Wise Management during Covid-19 Crisis|| |
Based on the available evidence, treatment protocols for common sites of cancer were formulated in the department, and this helped us with early decision-making in patient management using RT.
Cancer patients most vulnerable to COVID-related serious events are:
- Patients on cytotoxic chemotherapy
- Patients on radical RT for lung cancer
- Hematolymphoid malignancies at any treatment stage
- Patients on immunotherapy or other antibody treatments
- Patients on targeted therapies that can affect immune system (protein kinase or poly(ADP)ribose polymerase inhibitors)
- Bone marrow transplant in the last 6 months or on immunosuppressive drugs
- Age more than 60 years or cardiorespiratory diseases.
Following are various evidence-based treatment protocols that were made to help smooth running of our radiation oncology facility during this COVID-19 crisis. This has helped us in reducing workload and total treatment time without compromising disease outcome. We have started hypofractionation schedules in many clinical scenarios, such as breast, prostate, and lung cancer.
Patients of head-and-neck cancer requiring radical RT with concurrent chemotherapy should not be delayed; at most, they can be deferred up to 4 weeks during the period of lockdown. Similarly, postoperative patients with high-risk pathologic features should be offered adjuvant treatment without any delay; however, in patients with intermediate risk, RT can be deferred up to 4 weeks.
Head-and-neck cancers are treated using conventional technique and fractionations. Intensity-modulated RT and image-guided RT (IMRT and IGRT) with simultaneously integrated boost are used to treat mainly nasopharyngeal cancer. Objective assessment of speech, swallowing function, and nutrition counseling is done by a radiation oncologist.
Priority should be given to the patients requiring definitive RT for cancer cervix, cancer vagina, and cancer vulva or patients presenting with bleeding and painful metastases. Brachytherapy was given to the patients treated with radical intention.
Adjuvant RT for postoperative patients of Ca cervix, Ca vulva, and high-risk and high–intermediate-risk Ca endometrium can be deferred up to 6–8 weeks.
Patients requiring only vaginal brachytherapy for low–intermediate-risk Ca endometrium may be delayed further or omitted after discussing risk/benefit ratio with the patient.
Patients requiring whole-breast RT for early breast cancer; once weekly fractionation regimen of 28.5 Gy in 5.7 Gy weekly fractions over 5 weeks can be followed. Tumor boost of 10 Gy in 3 fractions is given only for high-risk patients, which is avoided for low-risk patients. For patients aged 70 years and above with clinical stage 1 and estrogen receptor positive (ER+) after lumpectomy, no adjuvant RT is offered.
Patients requiring postmastectomy RT (PMRT), a dose of 43.5 Gy in 15 fractions over 3 weeks is delivered. PMRT may be avoided for the postmenopausal patients with pT1-2 N 1-3.
No adjuvant RT is offered for patients with ductal carcinoma in situ with ER+ status. Brachytherapy procedures for breast cancer are also abandoned and replaced by other modalities of treatment as feasible during this crisis time.
For patients with good performance status and younger than 65 years, the standard 60 Gy dose is planned along with concurrent temozolomide. However, for patients more than 65 years, a hypofractionated regimen of 40 Gy in 15 fractions over 3 weeks is planned. For those patients with poor performance status, a palliative course of RT of 20 Gy in 5 fractions over 1 week is offered.
Patients with grade III meningioma are treated with adjuvant RT to a dose of 50.4 Gy in 28 fractions with three-dimensional conformal RT (3DCRT) technique. In this time of crisis, no adjuvant RT is planned for grade I and II meningioma patients.
Patients of stage III non-small cell lung cancer (SCLC) are treated with 55 Gy/20# when RT is delivered as the sole modality of treatment or as a part of sequential treatment. However, a conventional dose of 60 Gy/30# is planned during concurrent chemoradiation.
We have started treating limited-stage SCLC patients with hypofractionation regimen of 40 Gy/15#.
For low-risk prostate cancer patients, no RT treatment is offered. Even in intermediate- to high-risk patients, we are offering neoadjuvant androgen deprivation therapy (ADT) for 3–6 months. In adjuvant or salvage setting also, ADT with watchful waiting policy is adopted.,
Burden of cancer of esophagus is very high in this part of world. All curable patients are treated with RT ± chemotherapy. Total dose delivered is 50.4 Gy/28# in two phases. In the first phase, 39.6 Gy is delivered in 22 fractions using conventional AP-PA portals. In the second phase, 10.8 Gy is delivered in 6 fractions using three-field techniques to reduce cord dose. For some selected patients, 3DCRT treatment is planned, but IMRT or IGRT is avoided. No intraluminal RT is done in the department during this COVID crisis.
Adjuvant RT is considered only for patients with margin positive resection. Dose of 50 Gy in 25 daily fractions is planned with 3DCRT technique. For patients with unresectable gastric cancer, radiation is omitted and treated with chemotherapy only.
Single fraction palliative RTs are delivered on Saturdays only. All painful bony metastases are treated with single 8 Gy RT. A short-course regimen of 20 Gy/5# is planned for patients with cord compression with soft tissue mass, painful primary disease, superior vena cava obstruction, or brain metastases. For patients requiring hemostatic RT, single fraction of 6 Gy is delivered. For patients with bone metastases, if pain can be controlled with analgesics and there is no immediate risk of fracture, palliative treatment can be delayed.
| Conclusion|| |
SARS COVID-19 outbreak has severely impacted the healthcare system worldwide. It is extremely difficult to carry out comprehensive cancer services in this time of pandemic. Most of the patients are at increased risk for infection as they are immunosuppressed because of their malignancy and anticancer treatment. At this juncture, several clinical societies have published treatment guidelines to help institutes to treat patients during the pandemic. Based on these guidelines and government advisories, we have worked out our treatment and patient care policies to deal with the pandemic. This will help us minimize the disease transmission among our patients as well as healthcare providers. We hope that our treatment protocols will help resource-constrained cancer hospitals to formulate their own new treatment protocols and patient care policies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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