BRIEF COMMUNICATION

Year : 2020  |  Volume : 16  |  Issue : 3  |  Page : 638-640

An advisory by the association of radiation oncologists of India for radiation therapy patients and staff among COVID 19 pandemic

Kaustav Talapatra¹, Manoj Gupta², Kishore Singh³, GV Giri⁴, Rajesh Vashistha^5
1 Department of Radiation Oncology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India
² Department of Radiation Oncology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
³ Department of Radiation Oncology, Maulana Azad Medical College, New Delhi, India
⁴ Department of Radiation Oncology, Sri Shankara Cancer Hospital and Research Centre, Bengaluru, Karnataka, India
⁵ Department of Radiation Oncology, Max Superspeciality Hospital, Bhatinda, Punjab, India

Correspondence Address:
Kaustav Talapatra
Department of Radiation Oncology , Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jcrt.JCRT_687_20

Covid19 has become a major public health problem in India and the rest of the world. The dramatic rise in the incidence of COVID 19 cases has severely challenged our healthcare system and forced us to work with limited infrastructure, resources, and workforce. However, even in this time of adversity, we as oncologists cannot neglect the seriousness of cancer care and the utmost attention it requires for the timely management of our patients. Hence, the Association of Radiation Oncologists of India has come up with an advisory for radiation therapy keeping in mind such aspects.

Keywords: Advisory, COVID, radiotherapy

> Introduction

• Undergoing treatment in the form of chemotherapy, radiotherapy, immunotherapy, and targeted therapy
• Patients with hematological malignancies
• Transplant patients on immunosuppressive therapy
• Elderly cancer patients with medical comorbidities.

• Any cancer patient with symptoms of influenza-like illness fever, cough and breathing difficulty
• Contact with suspected and confirmed COVID19 cases in the past few weeks
• Traveled to any of the countries where local transmission going on (the World Health Organization document)
• Health-care worker caring for a confirmed COVID19 patients
• Severe pneumonia or Acute respiratory distress syndrome
• A person living in the same household as COVID 19 case or direct contact with COVID 19 case without proper personal protective equipments (PPE)
• Face-to-face contact with COVID 19 cases within proximity.

• Follow social distancing
• Wear mask
• Stay at home as much as possible
• Avoid crowded areas
• Wash your hands frequently and correctly with a soap/sanitizer
• Consider delaying your palliative radiotherapy if it is only for minor symptom relief and has no impact on outcome or disease control
• Elderly patients, especially with symptoms, are at the highest risk and extra precaution should be taken.

• Provide a clean and spacious waiting area with adequate distance between chairs
• Provide mask and hand hygiene aids such as a sanitizer, handwash, and gloves at outpatient area
• Protocol for temperature and vitals checking for patients
• Special care to suspected/vulnerable patients by dedicated and trained staff
• Protocol for COVID 19 screening and isolation
• All international travelers should submit self-declaration form which can be submitted at the counters
• Certain countries are high transmission countries, and travelers from those countries are advised to undergo 14 days of self-quarantine from date of arrival
• All such suspected patients should be handled as per institutional policies and guidelines/helplines provided by the government.

• Telephonic/video consultation
• Postpone elective posttreatment follow-up
• Prioritize appointments
• Schedule timely appointments and stick to time to decrease patient waiting
• Reports to be seen online/electronically without personal visits to the department.

• Maintain a safe distance between caregiver and any patient who is coughing/sneezing or even without such symptoms
• Take a detailed history of recent travel to COVID 19 infected area or close contact with a person infected with the coronavirus
• Check for any symptoms of viral infection in all patients.

• Clean, trained, and dedicated staff
• Shift postings
• Staff separated by time and location
• Provide safety measures such as gloves, masks, and aprons for all staff
• Screening of staff.

• Ensure compliance by the patient of their scheduled time
• Thermal screening/temperature screening outside the treatment area
• All the patients to wear a mask
• Attendants to stay outside except when it is essential. In such situations, attendants also need to comply with wearing a mask and undergo thermal screening/temperature screening
• Treating technologists are expected to wear appropriate PPE
• Only one technologist should go inside the room for the set up of patients
• Orfit cast not to be piled over each other but should be placed separately
• Couch to be sanitized at regular intervals
• If possible, divide technologists into two groups, each group working for 1 week and 1 week rest or should be in two shifts (forenoon and afternoon) provided treating the same group of patients
• During radiation treatment planning scan just keep an eye on any finding of peripheral consolidation patches in the lung region if it is part of the scanning area. If found then, COVID testing is mandatory.

• Delay treatment in low priority patient
• The benefit of cancer treatment should be assessed over the risk and complications of COVID 19 infection.

1. Priority high: patients undergoing radiation with radical intent for cure in which delay in treatment onset may jeopardize the outcome
2. Priority moderate: radical radiotherapy for less aggressive tumors or urgent palliative RT such as in patients with malignant spinal cord compression to avoid neurological damage
3. Priority low: radiation in an adjuvant setting where a complete resection of disease with good margins and <15–20% risk of recurrence over 10 years and patients with less aggressive tumors where radiation is a part of treatment protocol but can be postponed owing to the low-risk category and slow growth of the tumor.

• Prioritize: Categorize treatment based on its necessity for radiation
• Delay: Delay treatment of elective low grade, low-risk tumors such as breast and prostate
• Remote consultation for outpatient services and follow-up where feasible
• Shorten the treatment: The use of biologically equivalent dose hypofractionated schedule to minimize hospital visits. Shortened schedules can be used at feasible sites to minimize exposure and reduce the healthcare burden
• Concurrent chemotherapy to be avoided as far as possible along with a hypofractionated schedule to avoid toxicity
• Special consent form to be designed for change in RT schedule such as hypofractionation and to be signed by patients.



• Examples:



• Breast cancer: A regimen of 40–42.5 in 15–16 fractions to post breast conservation surgery (BCS) breast/chest wall instead of 5–6 weeks protocols followed by boost as appropriate in BCS setting. There is also emerging evidence for 26 Gy/5#/1 week in appropriately selected patients^[2],[3]



• Head-and-neck cancers: simplify techniques: simpler planning techniques instead of complex intensity-modulated radiotherapy plans whenever feasible can be used to reduce machine burden and optimize treatment^[4]



• Rectal cancer: The usage of short-course radiotherapy in appropriately selected patients^[5]
• Prostate Cancer: It may defer radiotherapy in very low, low and favorable intermediate-risk patients. Moderate hypofractionation and ultrahypofractionated stereotactic body radiotherapy to be used in appropriate patients.^[6]

> Conclusion

> References

1.	Clinical Guide for the Management of Cancer Patients during the Coronavirus Pandemic. NHS; 17 March, 2020.
2.	Brunt AM, Havilland J, Sydenham M, Algurafi H, Alhasso A, Bliss P, et al. FAST phase III RCT of radiotherapy hypofractionation for treatment of early breast cancer: 10-year results (CRUKE/04/015). IJROBP 2018;102:1603e-4.
3.	Brunt AM, Wheatley D, Yarnold J, Somaiah N, Kelly S, Harnett A, et al. Acute skin toxicity associated with a 1-week schedule of whole breast radiotherapy compared with a standard 3-week regimen delivered in the UK FAST-Forward Trial. Radiother Oncol 2016;120:114-8.
4.	Patil V, Noronha V, Chaturvedi P, Talapatra K, Joshi A, Menon N, et al. COVID-19 and head and neck cancer treatment. Cancer Res Stat Treat 2020;3:15-28.     [Full text]
5.	Tchelebi LT, Haustermans K, Scorsetti M, Hosni A, Huguet F, Hawkins MA, et al. Recommendations for the use of radiation therapy in managing patients with gastrointestinal malignancies in the era of COVID-19. Radiother Oncol 2020;148:194-200.
6.	Zaorsky NG, Yu JB, McBride SM. Prostate Cancer Radiotherapy Recommendations in Response to COVID-19 [published online ahead of print, 2020 Apr 01]. Adv Radiat Oncol. 2020;10.1016/j.adro.2020.03.010. doi:10.1016/j.adro.2020.03.010.