METHODS
In late March 2020, a national survey was designed for Turkish radiation oncologists who were actively
practicing and members of the Turkish Society for Radiation Oncology (TSRO). The survey created
with an online survey program (www.SurveyMonkey.com), including 28 focused items. It was sent to all
members of the TSRO on April 4th 2020.
RESULTS
Of responders, 17% noted to already complete these arrangements even before the first case announced.
All of the responders declared that their team members, including the secretaries, nurses, and radiation
therapists in the clinic, worked with appropriate protective equipment. While one-third of the centers
(35%) stated to implement a weekly shift, the other 1/3 (29%) chose to use daily shifts for social distancing
and decreasing staff contact. Sixty-two percent of all responders indicated that multidisciplinary
tumor boards discontinued, and the remaining 38% stated to continue with online video conferencing
programs (65%) or meeting in large rooms with a limited number of attendees social distancing (35%).
CONCLUSION
Our survey revealed the importance of early precautions, communication by other Radiation Oncology
Departments, following published guidelines during the COVID-19 pandemic, and the importance of
using web-based applications for multidisciplinary tumor boards.
Keywords: COVID-19; radiation oncology; survey
During the outbreak, almost all radiation oncology
departments have become inherently an unsafe environment
of viral transmission for both patients and
staff, due to crowded waiting rooms, daily treatments
over weeks, shared liner accelerators, and relatively frequent
contacts of patients with radiotherapists, nurses
or radiation oncologists. Worldwide radiotherapy centers
have struggled with strict measures to stay operative,
while early practical recommendations based on
initial experiences with the COVID-19 outbreak were
published.[
Just after the first case reported in Turkey on March
11, 2020, The Turkish Ministry of Health reacted quickly
and subsequently took some series of measures, while
the burden of COVID-19 outbreak on the health-care
system became more visible in a relatively short period.
When general recommendations and guidelines were
emerging, most Turkish radiotherapy centers adapted
with adjustments in line with announced precautions.
We aimed to assess how Turkish Radiation Oncology
departments responded to the COVID-19 outbreak
and to what extent adapted their routine practice per
recent guidelines and recommendations.
In the first section of the survey, demographics, and line of work data (i.e., age, gender, type of hospital, and professional title of the physicians) were questioned to identify factors that could influence responses. Hospital types were divided into four groups; university hospitals, state training, and research hospitals, public/city hospitals, and private hospitals, and the academic titles were within three groups professor/associate professor, radiation oncologist/assistant professor, and radiation oncologist resident.
In the second section of the survey, incorporation of the previous clinical routine process into new pandemic burden was evaluated along with the timing and extent; the need to acquire input from other radiation oncology clinics related with arrangements, the start date of precautions, the protective equipment usage, any changes in schedules or shifts, the social distance in waiting room and treatment device, and the continuity of tumor boards.
In the third section of the survey, re-arrangements performed for the treatment and follow-up in the pandemic were evaluated, such as postponing of treatment/follow-up, modifications in prescriptions/ fractionation, the recommendation of prophylaxis for COVID, approach to patients suspected/diagnosed with COVID.
Department Re-arrangements
The response has demonstrated that the communication
rate with other departments for exchanging considerations
related with COVID precautions was 71%.
Almost 2/3 of the responders (59%) stated that all re-arrangements
of the clinical process were performed in the
same week of the first case in Turkey; while 17% of responders noted to already complete these arrangements
even before the first case announced. All of the responders
declared that their team members, including the
secretaries, nurses, and radiation therapists in the clinic,
worked with appropriate protective equipment. While
one-third of the centers (35%) stated to implement a
weekly shift, the other 1/3 (29%) chose to use daily shifts
for social distancing and decreasing staff contact.
Sixty-two percent of all responders indicated that multidisciplinary tumor boards discontinued, and the remaining 38% stated to continue with online video conferencing programs (65%) or meeting in large rooms with a limited number of attendees social distancing (35%). Almost all participants declared to adopt regulations to maintain social distancing in the waiting rooms.
Patients Treatment and Follow-up Data
At the beginning of pandemic, 41% of the responders
decided to defer the start of the treatment of already
simulated patients, and 62% rearranged the sequencing
of radiotherapy in patients with indications at the consultation
to postpone the start of radiotherapy (Fig.
Eighty-one percent of the responders stated to revise fractionation schemas according to published ESTRO, ASTRO, and TSRO recommendations, and most common sites found reasonable to be modified prostate cancer (34%), palliative cases (31%), and breast cancer (23%). The majority (89%) noted to prefer prescribing hypofractionated regimens for new patients.
An extended gap between treatment time slots in
linear accelerators for patients under treatment was noted to be implemented by 61% of the responders.
Ninety-two percent of the responders affirmed to carry
out weekly see visits of their patients under treatment
if presented with a new symptom or complaint. Almost
all the responders (98%) postponed routine follow-up
appointments of previously treated patients if there is
no complaints, while 88% of the responders noted to
cancel the first routine follow-up after the recent completion
of radiotherapy (Fig.
The responders were asked whether to recommend any medications for COVID-19 prophylaxis, and 55% declared that they did not, while 32% recommended empiric vitamin supplements.
1/5 (19%) of the responders declared that they had patients under treatment carrying suspicion for COVID- 19 infection; of these responders, 80% declared to give treatment break during radiotherapy, and 20% continued treatment with additional precautions of extra clothing, gloves, goggles, and masks.
There are several reasons for the emergence of this
consensus; first of all, before the COVID-19 outbreak in our country, we had the chance to take crucial lessons
from other countries, especially Italy's experience.
[
At the beginning of the outbreak, all major institutions
were announced as pandemics hospitals by the
Ministry of Health, and hospitals judiciously tried to
find ways to reduce their routine patient volumes in order
to avoid possible exaggerated burden with COVID.
This intent was pronounced by almost ¾ of our responders
(71%) preferring hypofractionated schemes over
conventional ones according to encouraging diseasesite
specific guidelines or recommendations initially
by TRSO, ASTRO, ESTRO, and other groups.[
In the lack of evidence-based prophylaxis with
medication and in the presence of excessive fear to get
sick with COVID-19, we asked our colleagues whether
they are recommending any prophylaxis with any drugs
or supplements and interestingly revealed that 32% of
them recommended vitamin supplements while over
the half of the responders, did not recommend any
medication (e.g., hydroxychloroquine). We believe our
responders could fight with the social distress of requesting
prophylaxis, especially in the absence of evidence
that was pointed out lately.[
The patient, with confirmed-COVID-19 infection
or with just symptoms lacking a positive test, needs to be considered a possible health threat for the safety of
radiation oncology staff, as well as for the other patients
and families, in RO departments; therefore, precautions
are necessary to decrease the transmission risk.
In Spain, 78% of the COVID positive patients were reported
to complete their radiotherapy courses without
any major events,[
We can tell from our colleague's responses that almost
all of the radiotherapy departments performed
rotations in personnel workflow, mostly using weekly
or daily shifts, followed by 2-weekly or three-daily shifts
depending on the eligibility of the staff and the workload
as emphasized by many recent reports.[
Unfortunate was the documentation of discontinuation
of multidisciplinary tumor boards by 62%
of our colleagues in their institutions in this survey,
while the tumor boards were reported to continue by
38% of participants without any break with online
video conferencing programs (65%) or meeting in
large rooms with a limited number of attendees with
social distance distancing (35%). As this pandemics
was unexpected and sudden, many institutions could
not adapt secure multidisciplinary online connection
options as necessarily fast as possible at the time of
this survey. However, most were evaluating affordable
and secure options to defeat the infection risk in multiple
meetings per week to continue necessary interdisciplinary
interaction, which would probably be a
part of long term telemedicine efforts among physicians
and between physicians and patients.
Peer-review: Externally peer-reviewed.
Conflict of Interest: All authors declared no conflict of interest.
Ethics Committee Approval: The study was approved by the Koc University Scientific Research Ethics Committee (No: 2020.110.IRB1.021, Date: 25/03/2020).
Financial Support: None declared.
Authorship contributions: Concept - D.S., U.S., E.Y.A., Ş.Ş., N.K.D., E.T., Y.B.; Design - D.S., N.K.D., Ş.Ş., E.Y.A.; Supervision - U.S., Y.B., E.T.; Funding - None; Materials - N.K.D.; Data collection and/or processing - E.Y.A., Ş.Ş., D.S.; Data analysis and/or interpretation - Y.B., Ş.Ş.; Literature search - Ş.Ş., E.Y.A., D.S.; Writing - D.S., Y.B.; Critical review - E.T., U.S.
