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Year : 2020  |  Volume : 16  |  Issue : 3  |  Page : 634-637

COVID-19 pandemic: Radiotherapy precautions and preparedness

Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Date of Submission01-Apr-2020
Date of Acceptance29-Apr-2020
Date of Web Publication18-Jul-2020

Correspondence Address:
Jai Prakash Agarwal
Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_405_20

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 > Abstract 

The novel coronavirus (COVID-19) pandemic has disrupted healthcare delivery across the globe. Cancer patients are at a higher risk of acquiring this infection due to their immunosuppressed state. Timely care of patients while ensuring safety of healthcare workers is need of the hour. We list few precautionary measures that can be taken at all radiotherapy centres, during the pandemic to curb and combat the spread of this disease.

Keywords: Cancer, corona virus, COVID-19, radiotherapy

How to cite this article:
Mummudi N, Tibdewal A, Ghosh-Laskar S, Agarwal JP. COVID-19 pandemic: Radiotherapy precautions and preparedness. J Can Res Ther 2020;16:634-7

How to cite this URL:
Mummudi N, Tibdewal A, Ghosh-Laskar S, Agarwal JP. COVID-19 pandemic: Radiotherapy precautions and preparedness. J Can Res Ther [serial online] 2020 [cited 2021 Jan 28];16:634-7. Available from: https://www.cancerjournal.net/text.asp?2020/16/3/634/289971

 > Introduction Top

The 2019–2020 severe acute respiratory syndrome coronavirus 2 is caused by the infection with the novel coronavirus (COVID-19) and was first identified in Wuhan, Hubei, China, in December 2019. The World Health Organization declared it as a Public Health Emergency Of International Concern on January 30, 2020; subsequently, the outbreak was recognized as a pandemic on March 11, 2020.[1] In India, the first case of the COVID-19 was reported on January 30, 2020. As on March 31, 2020, there are a total of 1238 cases and 35 deaths in the country according to the Ministry of Health and Family Welfare (MOHFW); worldwide, about 860,000 patients have been infected and more than 42,000 have succumbed.[2],[3] The epidemic diseases act, 1897, has been invoked in most states and union territories as a consequence educational institutions and commercial establishments have been shut down. In addition, the country went into a nationwide lockdown for a period of 21 days from March 24, 2020.

Even at such a challenging time, as medical professionals, our primary responsibility remains providing optimal care to our patients. Of equal importance, is to ensure the safety and protection of all the health-care workers involved. Institutional and departmental policies and organizational procedures may need to be reviewed to ensure this twin objective of optimizing patient care without compromising on safety to the health-care provider. The MOHFW has provided advisory for hospitals and medical education institutions in the country to tackle the unprecedented increase in patients infected with COVID-19.

Cancer management during the COVID-19 pandemic requires the consideration of risks and benefits for both patients and staff. Data from China show that patients with malignancy are at a significantly high risk of infection with COVID-19, due to their immune-suppressed state, resulting from the cancer process and its treatment such as chemotherapy or surgery. Furthermore, importantly, cancer patients have a 5-fold higher risk of admission to the intensive care unit, invasive ventilation, and death compared with patients without cancer.[4] Health-care workers being at the “front-line” are at risk of developing cross-infection; China and Italy have reported a large proportion of their health-care workforce infected and few of them succumbed.[5] Personal-protective equipment (PPE) shortages have been described in the many affected facilities, but providing health workers PPE should be high priority. Additional measures to provide them physical, social, family, and psychological support would go a long way in preserving this valuable resource in such times of need.[6]

However, reduced health-care workforce, despite these measures, may result due to illness (self or family member), fear of occupational exposure, and halting of nonessential services (transport and day-care facilities). With this reduction, curtailing the number of cancer treatments delivered would become inevitability and rationing of oncology services a reality. High-volume centers will have greater difficulty providing service when staff levels are decreased and will have greater challenges in resource allocation. Ethical decision-making may have to be exercised. Applying the “principle of distributive justice,” patients need to be treated fairly and equitably, according to the need; people who are well, may need less medical care than the sick.[7] Prioritizing patients based on their need for the treatment and its efficacy is one way of deciding who is “more or less.” A suggested method that can be followed is categorizing tumor into rapidly proliferating (Category 1: lymphoma, head and neck, lung, cervical cancer, etc.) and relatively less aggressive (Category 2: breast, prostate, etc.) tumor types.[8],[9]

  • Priority 1: Radical, curative intent radiotherapy (RT) for Category 1 tumors and patients who have already started treatment
  • Priority 2: Urgent palliative RT, for example, patients with malignant spinal cord compression who have salvageable neurological function and superior vena caval obstruction syndrome
  • Priority 3: Radical RT for Category 2 tumors; adjuvant RT for aggressive tumor biology or gross residual disease
  • Priority 4: Palliative RT, if that would reduce the need for further interventions
  • Priority 5: Adjuvant RT, if R0 resection and there is a ≤20% risk of local recurrence at 10 years.

Many professional organizations and institutions have suggested general and disease-specific radiation therapy guidelines for managing patients during the pandemic.[8],[10],[11],[12],[13],[14],[15] Few centers from China and Italy have also shared their experience in managing the department and patients during the pandemic.[16],[17],[18],[19],[20],[21] We have also learnt few lessons from the centers that managed patients during other disasters of similar or larger scale.[22],[23],[24],[25],[26] We, being a large tertiary care center and situated at one of the hotspot of the pandemic in the country, provide a list of precautionary measures that we undertook and which can be implemented at other RT centers.

 > Patient Care Top

All the general public safety measures recommended by national and international bodies like avoidance of crowded places (including social distancing), wearing of surgical mask in public spaces, following hand hygiene are equally applicable to cancer patients.

 > Outpatient Department Top

  • Patients should be screened and triaged before they enter the hospital premise. Patients with infective symptoms can be managed according to existing institutional directives, including wearing PPE, isolation, etc.
  • Patients should also be discouraged to come to the health-care facility with more than one family member, unless necessary (restricted to a wheelchair or trolley, pediatric patient, etc.)
  • Patients who have visited the hospital for routine follow-up can be advised to reschedule their appointment to a later date or can be offered telephonic/video consultation (see below)
  • Patients who are scheduled to reach the hospital for follow-up can be identified from the hospital records and contacted telephonically. In a study evaluating whether telephonic follow-up offers a convenient and equivalent alternative to physical examination of radically treated lung cancer patients, telephonic follow up (FU) proved to be feasible and promising in radically treated lung cancer patients.[27] This remote consultation can also be extended to patients who seek expert opinion through online portals
  • By maintaining a network of radiation oncology professionals and by liaising with them, patients can be appropriately referred to an oncology center close to their place of residence to avoid traveling longer distances
  • Patients can be provided with referral letters for treatment electronically through mail/online portal
  • During outpatients' consultation, minimum 1 m distance may be maintained
  • Keeping up with punctuality for appointment and consultation timings will aid in decongestion of the outpatient department (OPD)
  • Invasive follow-up investigations may be postponed/avoided especially, if not planned to be acted upon immediately.

 > Radiotherapy Treatment Top

  • Patients due for RT treatment simulation and starting can also be triaged and prioritized based on their diagnosis, prognosis, and urgency for initiating treatment
  • Hypofractionation schedules have proven to be beneficial in many clinical scenarios (breast, prostate, and lung cancer) and should be pursued where appropriate
  • Palliative RT treatment for symptomatic relief can be delivered in single fraction or weekly once regimens
  • Patients with infective symptoms but tested negative for COVID-19 or patients having cough/dyspnea due to existing illness may be allowed to continue treatment with adequate protective equipment
  • In patients with suspected or proven COVID-19 infection and who are symptomatic treatment may be deferred until resolution or till they are deemed noncontagious by local health bodies
  • Patients with suspected or proven COVID-19 infection but who are asymptomatic may also be deferred treatment until their resolution or till they are deemed noncontagious by local health bodies
  • In selected patients (successfully treated or asymptomatic) requiring prompt initiation or continuation of RT, treatment may be allowed after observing all the necessary precautions
  • The decision to use or defer concurrent therapies such as chemotherapy/targeted and immunotherapies should also be considered based on the risk-benefit ratio, for a particular patient. The issues of age and presence of comorbidities are significant considerations
  • Similar precautions can be extended to brachytherapy treatments.

 > Machine Area Top

  • Appointments of patients on treatment can be staggered throughout the day to avoid the congestion at the machine area
  • Review of patients on treatment can be done while they are awaiting treatment or telephonically to reduce footfalls in the OPD and also to reduce the thoroughfare through other areas of the hospital
  • Onboard imaging may be minimized to reduce the treatment time. If at all image guidance has to be done, the presence of consultants/physicians at the machine console may hasten the image-guided procedures
  • If required radiation therapy technicians (RTTs) can also be empowered to execute few of these procedures on their own, in case of shortage of staffs, based on their training and/or under remote supervision
  • In case of availability, infected patients may be treated on a separate machine/or in a separate time slot with all necessary precautions for the technologists and other care providers to minimize the number of personnel exposed
  • Patients may be distributed on all available machines to reduce overcrowding
  • Credible updates and information related to COVID-19 infection and its mode of spread, etc., can be displayed/broadcast in patient-waiting areas to disseminate the awareness.

 > Inpatient Care Top

  • Routine admissions (for insurance/cashless facilities) can be suspended
  • In patients requiring inpatient care, adequate precautionary measures should be strictly observed, especially if the patient is the elderly, frail, or in the presence of multiple/uncontrolled comorbidities
  • Patients who are stable and not in need of inpatient care should be discharged at the earliest
  • Wards should mobilize additional resources including masks, gloves, and other PPE
  • All doctors, nurses, and support staff should be mobilized and trained in infection prevention and control practices
  • Overcrowding is to be avoided. Routine visiting hours by relatives may be suspended
  • In centers without adequate staff/supportive care, patients may be referred to higher/dedicated centers
  • For proven cases, a separate area of the hospital should be identified for admission and isolation, so that the support of uninvolved medical and other hospital staff, thereby the exposure can be limited.

Staff and administrative issues

  • High-risk individuals, especially those with uncontrolled hypertension, diabetes mellitus, pregnant individuals, or patients with pulmonary conditions should be identified and advised to stay away from the areas of direct exposure or asked to proceed on leave. Such individuals can still contribute significantly by engaging in telephonic consults, making rotas for staff, preparing work-related documents, and other administrative activities
  • The number of physicians, technologists, and physicists can be modulated such that the numbers working can be reduced to at least one-third by modifying their shifts, work hours; this would lead to the creation of a reserve workforce without decreasing the working hours or affecting patient treatment
  • Academic events, activities may be suspended till the resolution of the pandemic
  • It is important that all staff realize the importance of revealing their personal, travel, and contact history to be able to meaningfully control contact and exposure and to keep in mind that all the exposures to the virus will not happen at work but may also occur in social circles, during travel to work, etc.

All measures and precautions should be reviewed and revised regularly by the professionals involved as the pandemic continues to evolve. Constant communication with patients and staff involved regarding the policy changes and updates is of paramount importance to avoid the panic and apprehension. The key to controlling the spread of the pandemic lies in being aware, alert, and taking appropriate, timely action.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 > References Top

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Ministry of Health and Family Welfare. Available from: https://www.mohfw.gov.in/. [Last accessed on 2020 Apr 01].  Back to cited text no. 2
COVID-19 Map. Johns Hopkins Coronavirus Resource Center. Available from: https://coronavirus.jhu.edu/map.html. [Last accessed on 2020 Apr 01].  Back to cited text no. 3
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.  Back to cited text no. 4
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Udwadia ZF, Raju RS. How to protect the protectors: 10 lessons to learn for doctors fighting the COVID-19 coronavirus. Med J Armed Forces India. 2020;76:128-131.  Back to cited text no. 6
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Overview | COVID-19 rapid guideline: delivery of radiotherapy | Guidance | NICE [Internet]. NICE; 2020. Available from: https://www.nice.org.uk/guidance/ng162. [Last accessed on 2020 Mar 31].  Back to cited text no. 9
Coronavirus (COVID-19): Cancer Treatment Documents. The Royal College of Radiologists. Available from: https://www.rcr.ac.uk/college/coronavirus-covid-19-what-rcr-doing/coronavirus-covid-19-resources/coronavirus-covid-19-1. [Last accessed on 2020 Apr 01].  Back to cited text no. 10
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Krengli M, Ferrara E, Mastroleo F, Brambilla M, Ricardi U. Running a radiation oncology department at the time of coronavirus: An Italian experience. Adv Radiat Oncol. 2020. doi: 10.1016/j.adro.2020.03.003. Online ahead of print.  Back to cited text no. 16
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