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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 467-474

The impact of COVID-19 pandemic on the practice of radiotherapy: A retrospective single-institution study


Department of Radiotherapy, Mahavir Cancer Sansthan, Patna, Bihar, India

Date of Submission25-Jul-2020
Date of Decision30-Jul-2020
Date of Acceptance17-Aug-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Richa Chauhan
House No. N/35, Prof. Colony, Kankarbagh, Patna - 800 020, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_255_20

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  Abstract 


Background: The ongoing coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 led to the imposition of a nationwide lockdown as a control measure, which in turn disrupted the diagnosis and treatment of other diseases including cancer.
Objectives: The primary objective of this study was to assess the impact of the COVID-19 pandemic on patients receiving radiotherapy and whether it correlated with the patients' age, gender, site of disease, and intent of radiotherapy. The secondary objective was to assess the compliance to radiotherapy and the treatment modifications, if any.
Materials and Methods: This is a retrospective analysis of all patients planned for radiotherapy at the Mahavir Cancer Sansthan, a tertiary cancer center, in Patna, India from January 1, 2020, to May 31, 2020. The study cohort was divided into two groups: Group A comprised patients who received radiotherapy in the period before the lockdown and Group B comprised patients who received radiotherapy during the lockdown. Data regarding the age, gender, site of disease, intent of treatment, completion of planned treatment, use of concurrent chemotherapy, and modifications of the radiation protocol, if any, were analyzed. The categorical variables were compared using the Chi-square test.
Results: A total of 1412 patients were planned for radiotherapy during the study period. Of these, 1020 patients, 759 in Group A and 261 in Group B, actually received radiotherapy during the entire study period. The proportion of female patients decreased by 10.5% and that of patients receiving palliative intent radiotherapy increased by 12% during the lockdown. Head and neck, gynecological, and breast cancers were the most common cancer types in both the periods. There was no significant difference in the compliance to radiotherapy between the two groups (88.2% in Group A and 90.8% in Group B). Similar protocols were used during both the periods in patients being treated with a curative intent, but there was a significant increase in the use of single fraction radiation treatment in patients being treated with palliative intent with conventional fields.
Conclusions: There was a sharp decline in the number of patients, especially women, during the lockdown. The number of patients being treated with palliative intent increased significantly, with an increased use of single-fraction radiation treatment.

Keywords: Cancer, coronavirus disease 2019, lockdown, radiotherapy


How to cite this article:
Chauhan R, Trivedi V, Rani R, Singh U, Singh V, Shubham S, Kumari S, Uniyal A. The impact of COVID-19 pandemic on the practice of radiotherapy: A retrospective single-institution study. Cancer Res Stat Treat 2020;3:467-74

How to cite this URL:
Chauhan R, Trivedi V, Rani R, Singh U, Singh V, Shubham S, Kumari S, Uniyal A. The impact of COVID-19 pandemic on the practice of radiotherapy: A retrospective single-institution study. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Oct 28];3:467-74. Available from: https://www.crstonline.com/text.asp?2020/3/3/467/295502




  Introduction Top


The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread widely in India and across the globe.[1],[2],[3] On January 12, 2020, the World Health Organization (WHO) confirmed a novel coronavirus to be the cause of a respiratory illness in a cluster of people in the Wuhan City in the Hubei province, China, reported to the WHO on December 31, 2019.[4] The first case of COVID-19 in India was reported on January 30, 2020 in Kerala; the number of cases rose to three by February 3, 2020.[5] There was no significant rise in the number of cases in the month of February; however, the number of cases started rising in the month of March 2020.[6] The Government of India responded quickly by invoking the provisions of the Epidemic Diseases Act, 1897. This was followed by a nationwide lockdown in a phased manner from March 22 to May 31, 2020.[7],[8],[9] The imposition of strict restrictions was essential for containing the spread of the virus and building the health-care infrastructure.[10] However, these restrictions and the unprecedented burden of COVID-19 on our health-care system have disrupted the diagnosis and treatment of other diseases including cancer.[11] Patients with cancer have been recognized as a highly vulnerable group in the current pandemic both due to their immunocompromised status caused by cancer and its treatments which make them more prone to SARS-CoV-2 infection as well as the limited availability of cancer treatment facilities.[12],[13],[14]

Radiotherapy is one of the primary modalities used in the treatment of cancer, but the high cost of machines, associated infrastructure, and the requirement for trained personnel have restricted its availability to only a few urban centers of India.[15] Therefore, the travel restrictions imposed as a part of the lockdown are likely to have affected the access to this mode of treatment for patients coming from the distant places to urban cancer centers.[16] Although various guidelines have been proposed regarding the practice of radiotherapy to combat the COVID-19 crisis and ensure treatment for those who require it the most, their practical utility needs to be assessed.[17],[18] Considering this background, we planned this study with an aim to assess the impact of the current COVID-19 pandemic on the patients receiving radiotherapy as a part of their cancer treatment at a large hospital for comprehensive cancer care in Eastern India.


  Materials and Methods Top


General study details

This is a retrospective analysis of all patients with cancer planned to receive radiation treatment in the Department of radiotherapy at the Mahavir Cancer Sansthan, a tertiary cancer center in Patna, India, from January 1, 2020, to May 31, 2020. Given the retrospective nature of the study, approval from the Institutional Ethics Committee was not required as a part of our institutional protocol, and the need for obtaining written informed consent was also waived. The study was conducted according to the various ethical guidelines, including the declaration of Helsinki and the guidelines established by the Indian Council of Medical Research.

Participants

The inclusion criterion was all patients who were planned for and who received radiotherapy at our center during the study period. Patients who defaulted after planning radiotherapy were excluded from the analysis. The present study was divided into two periods: A was the period before the lockdown, and B was the period of the lockdown in the state of Bihar. Accordingly, for the analysis, the patients were divided into two groups, namely A and B. Group A comprised patients treated from January 1, 2020, to March 20, 2020, which was the period before the lockdown. Group B comprised patients treated from March 21, 2020, to May 31, 2020, which was the period of the lockdown.

Variables

Our primary objective was to assess whether the effect of the COVID-19 pandemic varied in patients with cancer depending on their age, gender, site of disease, and intent of radiotherapy. Our secondary objective was to assess the compliance to radiotherapy and the modifications in the radiation protocols, if any, during the pandemic.

Study methodology

The registration numbers of all the patients receiving radiotherapy during the study period were extracted from the entry register, and the paper files were then accessed to obtain the required data.

Statistics

Sample size calculation was not done, as the study included all consecutive patients with cancer who received radiotherapy during the study period. For our primary endpoint, the data regarding the patients' age, gender, site of disease, and intent of treatment were analyzed to assess if these factors affected the number of patients receiving radiotherapy during the pandemic. Additional data regarding the completion of the planned radiotherapy treatment, use of concurrent chemotherapy, modifications of radiation fractionation, and planning techniques were also evaluated to assess our secondary end points of compliance to radiotherapy and modifications of radiation protocol. Data were entered in Microsoft Excel and categorized into Groups A and B. The Chi-square test was used to compare the categorical variables between the two groups. A two-sided P ≤ 0.05 was considered statistically significant.


  Results Top


Patients details

A total of 1412 patients were planned to be treated with radiotherapy during the study period from January 1, 2020, to May 31, 2020. There were 939 patients in Group A (prelockdown period) and 473 in Group B (lockdown period). The number of patients who defaulted from treatment was 180 (19.2%) for Group A and 212 (44.8%) for Group B. Finally, a total of 1020 patients, 759 in Group A and 261 in Group B, were started on radiotherapy. These 1020 patients were further evaluated for the primary and secondary endpoints of the study [Figure 1].
Figure 1: The flow of patients included in the study evaluating the pattern of radiotherapy in the prelockdown and lockdown periods

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The number of new patients receiving radiotherapy decreased from January to March 2020 became the lowest during the first lockdown, and then, gradually increased during the subsequent lockdowns [Figure 2].
Figure 2: Trend in the number of new patients undergoing radiotherapy. The months on the X-axis indicate the months in 2020

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The age distribution was similar in both the groups. The age group analysis showed that about 85% of the patients were aged between 30 and 70 years in both the groups. The number of patients aged over 70 years was 39 (5.1%) in Group A and 12 (4.6%) in Group B [Figure 3].
Figure 3: Age distribution of patients who received radiotherapy during the study period. Group A indicates the patients treated during the prelockdown phase and Group B indicates the patients treated during the lockdown phase. The color bars indicate the age in years of the patients

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A gender-wise analysis showed that there were 411 (54.1%) female patients in Group A; this number decreased to 114 (43.7%) in Group B. Similarly, the number of male patients decreased from 348 in Group A to 147 in Group B, but their proportion increased from 45.8% to 56.3%. The difference of 10.5% seen was statistically significant (P = 0.0035) [Table 1] and [Figure 4].
Table 1: The distribution of gender, intent of treatment, use of concurrent chemotherapy, and radiotherapy completion in the cohort of patients receiving radiotherapy during the study period

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Figure 4: Gender-wise distribution of patients who received radiotherapy during the study period

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In both the groups, the three most common sites of occurrence of cancer were the head and neck, breast, and female reproductive organs. The number of patients with head and neck, breast, and gynecological cancers were 265 (34.9%), 133 (17.5%), and 170 (22.4%), respectively, in Group A and 103 (39.6%), 38 (14.6%), and 49 (18.8%), respectively, in Group B. Although there was an increase in the proportion of patients with head and neck cancer and a decrease in the proportion of patients with gynecological and breast cancers from period A to B, the difference was not statistically significant [Table 2].
Table 2: Site-wise distribution of patients receiving radiotherapy during the study period

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Treatment details

The analysis of the intent of treatment showed that 588 (77.5%) patients were treated with a radical intent in Group A, whereas only 171 (65.5%) were treated with a radical intent in Group B. Conversely, the proportion of patients treated with a palliative intent increased from 171 (22.5%) in Group A to 90 (34.5%) in Group B. The number of patients treated with palliative intent increased by 11.96% from period A to period B, and the difference was statistically significant (P = 0.0001) [Table 1] and [Figure 5].
Figure 5: The distribution of the intent of treatment in patients who received radiotherapy during the study period

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The average number of radiation fractions delivered per day was 294 in Group A and 130 in Group B. The average number of concurrent chemotherapy infusions per day was 18 in Group A and 10 in Group B [Figure 6]. The number of patients receiving concurrent chemotherapy, decreased from 261 (34.4%) in Group A to 83 (31.8%) in Group B, but this difference of 2.6% was not statistically significant (P = 0.44) [Table 1].
Figure 6: Number of chemotherapy infusions and radiotherapy fractions delivered to patients in Groups A (prelockdown period) and B (lockdown period) (No = Number)

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There was no modification in either the radiation fractionation or the concurrent chemotherapy regimens used for the patients being treated with a curative intent in both the groups. However, there was a significant modification in the radiation protocol and the planning technique used in patients being treated with a palliative intent. The number of patients treated with conventional field without computed tomography simulation was 35 (20.5%) in Group A and 30 (33.3%) in Group B, with a statistically significant difference of 12.9% (P = 0.02). Similarly, there was a significant increase in the use of single fraction radiation protocol in patients being treated with palliative intent during the period B. Only 10.5% of the patients in Group A received single fraction radiation as compared to 23.3% in Group B (P = 0.005). There was an insignificant decrease in the use of more prolonged radiation protocols such as 40 Gy/16#, 30 Gy/10#, and 20 Gy/5# for the patients treated with palliative intent during the pandemic [Table 3].
Table 3: Details of radiation technique and the fractionation used for treating patients with a palliative intent during the study period

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The compliance to the planned treatment protocol was similar in both the groups. The proportion of patients who completed radiotherapy was 90.8% in Group B as compared to 88.3% in Group A (P = 0.26).

Coronavirus disease 2019 screening

Screening for COVID-19 was done for every patient before starting the radiation treatment and weekly thereafter while undergoing radiation. Patients who were asymptomatic were not tested prior to starting radiotherapy. There was no patient who tested positive for COVID-19 while on radiotherapy during the study period in our hospital.


  Discussion Top


Our study showed a significant decrease in the number of patients planned for radiotherapy and a sharp decline of 65.6% in the number of new patients starting radiotherapy at their scheduled time during the lockdown period. However, once the treatment was started, similar number of patients completed the planned radiation protocol in the prelockdown and lockdown periods. The age distribution of patients was similar in both the groups, but there was a significant decrease of 10.5% in the number of female patients coming for radiotherapy during the lockdown period. The three most common sites for the occurrence of cancer were head and neck followed by gynecological and breast, both during the prelockdown and the lockdown periods. Curative intent radiotherapy was delivered to 77.5% of the patients in the prelockdown period as compared to only 65.5% during the lockdown period. The proportion of patients receiving palliative-intent radiotherapy increased by 12% during the lockdown. There was no modification in the radiation fractionation or the use of concurrent chemotherapy in the patients being treated with curative intent in either of the two groups. However, there was a significant modification in the radiation protocol and the planning technique used in patients being treated with palliative intent during the lockdown period, with a significant increase in the use of single fraction radiotherapy with conventional open fields.

This is one of the first studies from our region comparing the number and distribution of patients coming for radiotherapy before and during the lockdown period among the COVID-19 pandemic. The present study has been conducted at one of the largest charitable cancer hospitals of Eastern India. Being a charitable cancer hospital, most of our patients belong to the low socioeconomic stratum and come from the distant rural areas for their treatment. Radiotherapy remains a valuable treatment option for cancer during this pandemic for various reasons. Radiotherapy protocols are only moderately immunosuppressive when compared to chemotherapy, and can be altered as required; radiation is a good alternative to surgery in many cancers and can be delivered safely to the patients with the use of proper personal protective equipment, both by the patient and the health-care personnel.[19] In addition, radiotherapy is delivered in a setup that does not routinely require the use of critical hospital resources such as the intensive care unit and ventilators.

The current COVID-19 pandemic has disrupted the routine management of all other noncommunicable diseases, including cancer, in some way or the other.[11] Cancer being a deadly disease, we can say that patients with cancer are one of the worst affected groups because of the redistribution of health-care facilities, imposed lockdown, and the limited availability of cancer hospitals in India.[13],[20] During the lockdown period, the number of patients scheduled for radiotherapy was reduced as a part of our departmental policy. This was done with the intent of decreasing the patient load on the machine and the waiting area, so that proper sanitization and social distancing could be maintained for the safety of patients and the hospital staff. Besides, about 45% of the patients planned for radiotherapy during the lockdown defaulted from their treatment. The drop in the number of patients coming for radiotherapy was most drastic during the first phase of the lockdown; thereafter, the number gradually improved during the subsequent phases. The most important cause for the drop in the number of patients was the restriction on the public transport.[16] As most of our patients belong to the low socioeconomic stratum and come from remote villages, they are entirely dependent on the public transport system for their travel.[15],[21] Another important cause for the drop in the number of patients was the fear of getting infected with the coronavirus. As a result, many patients who required adjuvant postoperative radiotherapy and were not symptomatic decided to defer their treatment. Radiotherapy usually requires weeks of continuous treatment that can extend from 1 to 7 weeks, depending on the intent of treatment and the fractionation used. The unavailability of accommodation near the cancer center, due to the closure of hotels and guest houses and the reluctance of the local people to rent their premises to patients with cancer because of the fear of COVID-19, was another important reason for patients not reporting for radiotherapy treatment. A major problem with our patients is their financial status. Most of them depend on government funds and schemes for financial assistance for their cancer treatment, the sanction of which got delayed due to sudden closure of all offices. Although travel for medical emergencies and treatment was allowed during the lockdown, a lack of clarity on advisories issued by the government, particularly among the illiterate patients was another cause for the patients not taking their planned treatment. The decrease in the number of female patients during the lockdown could probably be explained by the fact that female patients, especially from the low socioeconomic strata and rural background, are dependent on the male members of their families to travel long distances. The sudden lockdown and imposed travel restrictions might have forced the earning male members to stay back at their place of work, and thus they could not go back home to bring their female relatives to the hospital. Further, breast cancer being the most commonly occurring cancer in India, it is very common in our female patients with cancer.[22] Patients with breast cancer requiring adjuvant radiation are usually asymptomatic, and hence, they preferred to defer the treatment as they feared COVID-19 more than cancer progression. Besides, in our society, most of the household responsibilities are taken care of by the female members; therefore, many of them might have intentionally delayed their treatments with the intention of saving the limited resources for the family by not spending it on themselves.

Low cancer awareness, and the lack of easy access to affordable cancer treatment leads to diagnosis in an advanced stage in a large number of our cancer patients.[23] Palliative-intent radiotherapy being an effective modality, it is used in patients presenting in the advanced stages of disease.[24] Our study reported a significant increase in the number of patients coming for palliative-intent radiotherapy. A similar increase in the number of patients coming for palliative treatment has also been reported by Ghosh et al. They concluded that patients receiving palliative treatment worried more about disease progression than acquiring COVID-19. This is likely because they were aware of their poor prognosis and were concerned about further deterioration of their condition if they delayed the treatment.[25] Another reason could be the unbearable pain and other symptoms that these patients suffer, for which they seek relief through palliative radiotherapy. The large proportion of patients with head and neck cancer could be explained by the highly prevalent use of tobacco, particularly smokeless, among the men in this part of the country.[26] A 4.7% increase in the number of patients with head and neck cancer seen during the lockdown period could have resulted from the deferral of surgery and referral for nonsurgical treatments. Though breast cancer is now the most common cancer type in India, cervical cancer is still more common than breast cancer in many rural areas, as was also seen in our study.[27] Low screening, practically no vaccination, and the presence of other risk factors such as early marriage, multiparity, low socioeconomic status, etc., in a predominantly rural population also contribute to the large number of cervical cancer cases.[28]

Our study showed no significant change in the use of concurrent chemotherapy during the lockdown period. A study by Patil et al. that compared the pattern of care among patients with head and neck cancer before and during the pandemic also showed that there was no change in the pattern of selection of patients for concurrent chemotherapy during the pandemic period.[29] There was no change in the radiotherapy fractionation protocol of patients treated with a curative intent, and the overall proportion of patients completing the planned radiation protocol was also similar between the prelockdown and the lockdown periods. Though the use of various hypofractionated radiation protocols have been recommended during the COVID-19 crisis,[17],[18] their implementation is still limited to the trial settings.[30] Our decision to not use hypofractionated radiotherapy was influenced by the toxicity concerns regarding the high dose per fraction, especially with concomitant chemotherapy. However, we treated a significantly higher number of patients with single-fraction radiotherapy in the palliative setting during the lockdown period. Single fraction radiotherapy is a valid option for patients requiring palliative radiotherapy, especially for those with symptomatic uncomplicated bone metastases.[31] With the use of single-fraction radiotherapy with conventional fields, the patients could both complete the treatment and return home on the same day. In addition to solving the issue of accommodation for the patient and their caregivers, this protocol also decreased the patient load on the radiotherapy machine. Similarly, Patil et al. also preferred the use of oral metronomic chemotherapy over intravenous chemotherapy as a part of the palliative treatment regimen, as it did not require hospital admission and was less toxic with good outcomes.[29]

Being retrospective and observational in design, our study had several limitations. The cause for defaulting from the treatment or delaying radiotherapy could not be assessed. As we enrolled all consecutive patients whose radiotherapy was started during the study period, the database comprised a diverse group of patients with cancers arising in various sub-sites and different staging systems. Thus, a generalized stage-wise distribution of patients coming for the treatment in the prelockdown and lockdown periods could not be assessed. Moreover, no follow-up data have been included, which could have provided insights into the patient-related outcomes.


  Conclusion Top


There was a sharp decline in the number of patients receiving radiotherapy, especially female patients, during the lockdown. The number of patients being treated with palliative intent radiation increased significantly with an increased use of single-fraction radiation treatment. Being sudden, unexpected, and beyond the wildest of our imaginations, the current COVID-19 pandemic has jeopardized the treatment of patients suffering from other diseases, including cancer. This never-seen-before crisis has forced everyone to clear the bushes and create their own paths. We hope that simple observational studies like ours will expand our knowledge and the experience of using radiotherapy in patients with cancer during the pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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