Dillip Kumar Parida, Sandip Kumar Barik, Adhar Amritt, Minakshi Mishra, Poornima Devi, Saroj Kumar Das Majumdar

1Department of Radiotherapy, All India Institute of Medical Sciences, Bhubaneswar 751019, India.

Introduction

The emergence of "Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)" caused by the novel coronavirus (COVID-19) had its origin in Wuhan, China, in November–December 2019.By May 27, 2021, the pandemic has affected over 220 countries, with 169,094,393 coronavirus cases and 23,512,509 deaths [1].India reported its first case of COVID-19 infection on January 30, 2020 [2].The rise of COVID-19 cases brought a barrage of many unforeseen problems for cancer patients and health care workers.Thus, a robust and systematic policy must be followed for the cancer facility's smooth functioning.Currently, India has 273,67,935 cases with 3,15,263 deaths as on March 27, 2021 [3].The second wave in India started from March 2021 and continued till August 2021 with a peak patient peak load of approximately 4 lacks of new cases in early May 2021.The Third wave started in late November 2021 and is still continuing and in weaning phase.Delta and Omicron variant were the majority strains during 2nd and 3rd wave respectively.

Patients with cancer are at a higher risk of infection with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2) than the general population and deteriorate more rapidly than those without the disease [4].Cancer patients are more immunosuppressed than their counterparts caused by either chemotherapy, prolonged steroid usage, radiotherapy, or the disease itself, making them more vulnerable to COVID-19 infection [4, 5].An increase in death is also observed in older cancer patients and those with other comorbidities [6, 7].

In India, a radiation oncology department is mostly overloaded as it treats patients with curative, palliative, radiotherapy as well as chemotherapy.Our department also manages a daycare center and inpatients ward.The majority of our patient receives their treatment on a daycare basis.In COVID pandemic, they face the challenge of staying safe from family and relations while at home, from fellow passengers while traveling, and from other infected patients while in hospital.Radiation and chemotherapy are given in a scheduled manner over a period of time.A gap in treatment due to disruption either due to COVID-19 infection to patients or staff leads to the suboptimal result and, many times, disease progression.Therefore, it becomes a priority for the department to keep the patients safe from COVID while maintaining its functionality by supporting the health care workers, technical staff, and others.The department has a more significant challenge.Hence, it is required to form strict policies and protocols for patients and staff to stay safe from formulate COVID and provide uninterrupted service to cancer patients.

This paper highlights the essential steps taken at a different level at AIIMS, Bhubaneswar, to tackle the COVID-19 pandemic for smooth functioning of the cancer care facility.

Departmental data in COVID-19 pandemic times (Figure 1)

During COVID-19 pandemic, cancer care services and emergency services were functional even though most hospital department services were closed.Even though the department of radiotherapy was open for all its services, still people found it difficult to access it.The difficulty in accessing services was mainly due to nationwide lockdown, travel restriction, fear among people to venture out of their homes.

During the preceding year before pandemic, i.e.(From January 2019 to December 2019), the department witnessed 14,446 follow-up patients, 5015 new cases registered, 1070 patients admission, and 6790-day care admissions.In the same year, 2019, total brachytherapy sittings delivered were 132, and the total number of fractions of radiotherapy delivered were 10,508.While in the year 2020 (From January 2020 to December 2020), there were 12,257 follow-up patients, 3212 new cases, 704 in patients admissions, 5925-day care admissions, 175 brachytherapy sittings, and 9894 fractions of radiotherapy delivered.Though the numbers of patients in the year 2020 showed a decrease in the number compared to the previous year, a substantial number of patients have benefitted even in the pandemic situation.

The workflow of pandemic management at AIIMS Bhubaneswar at hospital level and departmental level are depicted in (Table 1)

Patients affected with COVID-19 (Figures 2–5)

Figure 2 COVID positivity in patients undergoing radiotherapy

Figure 3 Total deaths in radiotherapy COVID positive patients

Figure 4 COVID positivity in day care patients

Figure 5 Total deaths in chemotherapy patients

In the first wave from March 2020 to December 2020, 319 patients underwent radiotherapy, and around 540 patients underwent chemotherapy in daycare.Out of 319 patients, 28 patients became positive for COVID-19 during radiotherapy.Out of 28 patients, there were three deaths.One patient died due to complications of COVID-19, while two died due to disease progression.Out of 28 patients, two were symptomatic for fever, while 26 were asymptomatic.

In patients undergoing chemotherapy, 64 patients became positive for COVID-19, with eight deaths reported.3 patients died due to COVIS-19 complications, and the rest five died due to disease progression.Of 64 patients, 12 patients were symptomatic for fever, while 52 were asymptomatic for COVID-19.

Screening of patients before the start of treatment (radiotherapy and chemotherapy)

All patients about to start either radiotherapy or chemotherapy have to undergo mandatory screening with COVID-19 Reverse Transcriptase Polymerase Chain Reaction (RTPCR).Only RTPCR negative patients could continue treatment, and positive patients were referred for COVID-19 management.This was done to ensure a COVID-19 free area in the radiotherapy machines, daycare chemotherapy, patients department, and waiting room.Patients undergoing radiotherapy also underwent regular RTPCR for COVID-19 weekly/biweekly depending on the number of active cases in the state.While patients came for chemotherapy, RTPCR was repeated every three weekly cycles.Patients were asked to undergo a COVID-19 Rapid antigen test (RAT) for weekly chemotherapy cycles.From March 2020 to January 2021, about 1087 COVID-19 RTPCR tests were conducted for radiotherapy patients and 12,200 COVID-19 RTPCR tests for chemotherapy patients in daycare.

Adaptation in radiotherapy treatment

The various adaptation to radiotherapy treatment was made in mind so that the patient can safely completed the therapy without any significant hindrance.The main challenge was to keep the department running so that patients didn't have to suffer due to the closure of the lone government facility in the state capital.There was a need to segregate asymptomatic COVID-19 cancer patients from other cancer patients to keep other cancer patients and staff safe from contracting the infection.

All patients who were planned for radical radiotherapy were given preference for early starting of radiotherapy.Hypofractionation with or without simultaneous integrated boost was the preferred dosing schedule followed.The department rapidly adapted to a hypofractionated regimen for carcinoma prostate, rectum, glioma, etc.High-risk diseases with positive margins multiple nodal involvements with extracapsular spread prioritized early adjuvant therapy.For diseases with intermediate-risk factors, priority was given to patients with more chances of disease recurrences like ≥ 2 intermediate-risk factors.Cases with fewer recurrences risks, like having ＜ 2 intermediate risk factors, were kept under observation.Patients who have defaulted or discontinued treatment on returning were screened with COVID-19 RTPCR before starting any treatment.These patients were clinically examined to see any disease response or progression signs.If the patient has clearcut signs of disease progression, the treatment was discontinued, or the remaining dose was given in a hypofractionated manner.Patients with a gap of 7 to 14 days who responded to treatment were started with their original schedule following gap correction dose calculation.

All patients for brachytherapy are screened for COVID-19 infection.The procedure is done in a highly aseptic environment (Operation Theater) after donning full personal protective equipments.Currently, the center is offering brachytherapy services to gynaecological malignancies only.Brachytherapy for other sites like breast, head, and neck is now is not done as there are other highly conformal newer techniques for same.No change in dosage schedule was allowed (Preferred schedules are 6Gy x 4# or 7Gy x 3#).However, if the patient has a problem coming to the hospital 9Gy x2 # was allowed in such cases.

Palliative radiotherapy services were held high priority for those patients who would have a substantial benefit (neurological cord

compression, hemostatic RT, symptomatic brain metastases, painful bony lesions).8 Gy single fractionated Radiotherapy is preferred.If multiple fractionations are indicated, 20 Gy/5# and 30Gy/10# are also preferred.Patients undergoing radiotherapy treatment were followed up every week using all precautionary measures, and COVID appropriate behavior was also enforced during the examination.

Adaptation in chemotherapy treatment

The adaptation of chemotherapy schedules was made considering the patient's age and other co-morbid conditions.Dose intense and dosedense schedules were not chosen as far as feasible.Adults ＞ 70 years were preferred not to give any chemotherapy at all.If it has to be delivered, metronomic chemotherapy was given.Adults ＜ 70 years with comorbidities were given chemotherapy after 20% dose reduction after comorbidity adjustment.Continuous infusion chemotherapy was replaced with oral chemotherapy (Capecitabine in place of 5-Fluorouracil (5FU)) or hormonal therapy (ER + ve breast cancer) wherever possible.Triplet chemotherapy regimen was replaced by doublet regimen.No concurrent chemotherapy plan was abandoned; however, patients with ＞ 60 years, where concurrent chemotherapy role shows no clear benefit was given the option of omitting concurrent chemotherapy.Pain and palliative clinic run by the department was ensured to be fully functional and serving the needy.

Steps taken During 2nd and 3rd waveSimilar protocols and policies were in place during 2nd wave.47 patients became positive during treatment and eight patients died due to COVID related complications.3rd wave in India was not disastrous compared to 1st and 2nd wave of COVID Pandemic.Considering mild symptoms of Omicron variant,Government also did not impose strict restrictions.Still the OPD service of our institution was closed for a period of 2 weeks.In the 3rd wave till now 21 patients became positive.No patients died in third wave due to COVID related complications.

Conclusion

COVID-19 pandemic being an infective virus, it is essential to contain the disease both inpatients staff and prevent further transmission to other healthy cancer patients.In a busy cancer center with a huge workload and limited recourses, it is of utmost importance to formulate and strictly implement a treatment protocol that must be reviewed time and again to save cancer patients' lives.

Protocol and policies should be strictly implemented from time to time depending on situation which will allow smooth functioning of the department and seamless delivery of health care facilities to cancer patients.

Competing interests

The authors declare no conflicts of interest.

Citation

Parida DK, Barik SK, Amritt A, Mishra M, Devi P, Das Majumdar SK.Pandemic adaptation in oncological management-a tertiary care radiation oncology center experience.Cancer Adv2022;5:e22004.doi: 10.53388/2022522004.

Executive editor:Nuo-Xi Pi.

Received:02 February 2022,Accepted:08 February 2022, Available online: 16 February 2022

? 2022 By Author(s).Published by TMR Publishing Group Limited.This is an open access article under the CC-BY license.

(http://creativecommons.org/licenses/BY/4.0/).

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