METHODS
We retrospectively reviewed the records of 1063 patients (median age 63 years; range 3-93 years) who
were treated in RT centers from March 2020 to March 2021. The study cohort was divided into two
groups: Group A consisted of patients who received RT in the first 6 months and Group B comprised
patients who received RT in the second 6 months.
RESULTS
The age distribution was similar in both groups. The analysis of the intent of treatment showed that 585
(55%) patients were treated with a radical intent in Group A, whereas only 478 (45%) were treated with a
radical intent in Group B. Lung, breast, and genitourinary cancers were the most common cancer types in
both periods. There was a significant decline in the number of female patients in Group B. Test results of
31 (2.9%) patients, 8 (25.8%) women and 23 (74.2%) men, who had nasopharyngeal swabs, were positive.
CONCLUSION
This study shows that oncology patients in our region are more worried about disease progression than
the pandemic and insist on going to RT, especially during the first 6-month period when the pandemic
was thought to be temporary. As a result of careful precautions, treatments in the clinics continued
without contamination.
Keywords: COVID-19; clinical characteristics; radiotherapy; workflow
The 2019 coronavirus disease (COVID-19), a severe
acute respiratory syndrome caused by the coronavirus
2 (SARS-CoV-2), was first reported on December 31, 2019, in Wuhan, China. The World Health
Organization (WHO) declared COVID-19 "an urgent
public health problem at the international level" in January
2019 and a pandemic in March 2020.[
W
The first COVID-19 case in Turkey was announced
on March 10, 2020, and took precautions restricting
daily life were rapidly implemented by MoH and other
relevant institutions. Pandemic committees were established
in all provinces and chaired by governors. The
first COVID-19 death in Turkey occurred on March
17, 2020.[
Among the various measures implemented, all private
and public hospitals were transformed into pandemic
hospitals. This allowed the allocation of intensive
care and inpatient services in these hospitals to
COVID-19 patients and suspended diagnosis, treatment,
and surgical procedures, except for emergencies.
In addition, hospital staff rotated in these hospitals in
the Eastern Black Sea Region as well as throughout the
country. Higher cases of severe illness, intensive care
admissions, and mortality rates have been reported for
COVID-19 patients of advanced age (>65 years of age) or with medical conditions such as hypertension, heart
failure, diabetes mellitus, and immunosuppression.[
Cancer patients are immunocompromised as a result
of the disease and the associated surgery, chemotherapy,
and other immunosuppressive drug treatments,
making them more prone to infectious diseases.
In addition, the fact that cancer patients are generally
elderly, often with other diseases in addition to cancer,
further increases their risk for COVID-19. Early reports
from China and Italy show that cancer patients,
in particular, may be more susceptible to COVID-19
and have higher mortality and morbidity compared to
non-cancer patients.[
The overall objective of the study was to investigate
the effects of the COVID-19 pandemic on the process
of RT centers in northeastern Turkey. This study reports
on the precautions that were taken in our oncology
centers, the number of patients receiving oncological
treatments, the patient groups applying for clinics, and
the number of healthcare professionals who got the disease.
In addition, the year of study was divided into two
6-month periods in order to to examine the changes and
impact of the pandemic on oncology centers over time.
Patients
All patients who planned for and received RT at our
center during the study period were included in the
study. We evaluated the year of study in two periods,
the first 6 months and the second 6 months. Data include
patient age, sex, location of primary tumor, stages,
treatment fields, treatment intent, treating clinician"s
definition as curative (including preoperative, postoperative,
prophylactic) or palliative, RT doses, fractionation
schedule, and status of concurrent chemotherapy.
Statistical Analysis
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.
RT: Radiotherapy.
Primary tumor regions were as follows: 28.1% (299)
lung, 23.9% (254) breast, 4.9% (52) head and neck, 15.2% (162) genitourinary, 8.9% (94) gastrointestinal,
5.6% (60) gynecological, 2.9% (31) soft tissue sarcoma,
and 71% (6.7) other. Metastatic disease was reported
for 478 (45%) patients. In both groups, the three most
common sites of occurrence of cancer were lung, breast,
and male reproductive organs. The number of patients
in Group A with lung, breast, and genitourinary cancers
were 167 (27.4%), 132 (29.2%), and 78 (22.4%),
respectively, and in Group B 132 (29.2%), 95 (21%),
and 74 (18.5%). Although there was an increase in the
proportion of patients with lung cancer and a decrease
in the proportion of patients with genitourinary and
breast cancers from the first to second period, the difference
was not statistically significant. The analysis of
the intent of treatment showed that 354 (58%) patients
were treated with a radical intent in Group A, whereas
231 (51%) were treated with a radical intent in Group
B. Conversely, the proportion of patients treated with
a palliative intent also decreased from 256 (42%) in
Group A to 222 (49%) in Group B. The number of patients
treated with palliative intent increased by 11.96%
from the first to second period, and the difference was
statistically significant (p<0.001) (Fig.
Management of COVID-19 Patients
Test results of 31 (2.9%) patients, 8 (25.8%) women
and 23 (74.2%) men, who had nasopharyngeal swabs
were positive. Median age was 68 (range 19-89), and
reported symptoms were fever 21 (67.7%), sore throat 17 (54.8%), pneumonia 15 (48.4%), muscle pain 24
(77.4%), cough 23 (74.2%), dyspnea 14 (45.2%), and
anosmia and ageusia 11 (35.5%). A complete list of
symptoms is available in Table
Workflow Modifications
Our report demonstrates how RT departments in Eastern
Turkey coped with the COVID-19 disturbance.
Significant reorganization and modifications in RT
practice were quickly implemented in response to COVID-
19. Our priority was to achieve a delicate balance
between patient care and confidence while protecting
the healthcare professionals, particularly in the initial
stages of the pandemic. Approximately 50 new accesses
every week enrolled in all divisions for RT treatments.
We performed a nasopharyngeal swab screening for all
patients before scheduled RT. In each session, patients
were queried for suspicious symptoms (fever >37.5°C,
cough, dyspnea, flu syndrome, conjunctivitis, and diarrhea). In the likelihood of COVID-19, patients were
restricted access to the division and isolated in dedicated
zones, pending nasopharyngeal swab, and assessed
for potential transfer to a COVID-19 hospital
in the region. Additionally, patients and their relatives
from abroad were not admitted to the department
within a 14-day quarantine period. In order to prevent
the transmission of COVID-19, a reorganization of the
operation was also carried out in oncology centers in
our region in accordance with MoH guidelines and
recommendations from the Turkish Society for Radiation
Oncology (TROD). An appropriate working
model was constructed to ensure the social distancing
of employees throughout the workplace.
Patient admissions were reduced in outpatient clinics in the 1 month of the pandemic. Admission to the hospital was restricted only to patients and a single accompanying individual at their established time out of clinical necessity. Waiting rooms for patients were arranged with seats located at a safe distance between each other. All patients, visitors, and staff had to wear two surgical masks, one over the other, during the pandemic. Before patients and caregivers entered the hospital and clinics, their temperatures were checked in the physical distancing patient corridor.
One critical group of cancer patients is those over the age of 65. The restrictions resulting from the pandemic caused disruptions in access to health services for this age group. Patients with cancer diagnosis treatment were able to access oncology centers with permission letters from health institutions. However, those with cancer symptoms who had yet to be diagnosed faced problems in reaching oncology centers for diagnosis and treatment.
As a result of intercity travel restrictions in response to the pandemic, the flow of patients from small cities to well-equipped centers in large metropolitan areas almost completely stopped. Patients either started treatment in oncology centers in the city they were in or waited until the transportation ban to metropolitan areas was lifted.
In the Eastern Black Sea Region, the number of patients in radiation oncology centers began to increase, especially 1 month after the onset of the pandemic.
In the following months, appointment restrictions were extended. Due to pandemic precautions and lack of personnel, there were limitations in external RT applications. Chemotherapy and hormonotherapy options were prioritized in order to reduce hospital capacity according to the region and type of cancer.
In order to reduce the number of people in our RT centers while at the same time prevent employees from being infected, isolated teams consisting of radiation oncologists, health physicists, nurses, and RT technicians were established in most centers, and these teams worked in different shifts ranging from a few days to a week.
MoH guidelines in RT centers, TROD, and international professional organizations (such as the American Society for Radiation Oncology, European Society for Radiation Oncology) have been shown to be effective and increasingly popular hypofractionated treatment schemes have been frequently applied.
Although there was no change in concurrent chemotherapy regimens used for patients treated for curative purposes in both groups, palliative treatments were altered by selecting programs with less fractions.
Staff Training
Employees received occupational health and safety
online trainings on handwashing, distance rules, and
proper use of personal protective equipment, such as
masks, goggles, gloves, and gowns. Recommendations
regarding family and social life were also included in
the trainings. Treatment machine staff was required
to wear protective visors while laying patients on the
treatment table due to close contact.
Personal Equipment
In clinics where there was direct contact with people
with suspected infection or a risk of contamination,
employees were provided with fully closed eye or face
protection/visors, protective clothing, respiratory protection
(FFP2 or FFP3) ventless masks, and gloves.
Business trips, conferences, congresses, and other events organized abroad were postponed when possible. Online congresses and meetings were held in the autumn months when the pandemic was still under control. In cases where it was necessary to do so, audio and visual communication facilities were used. In cases where travel was necessary due to work, the recommendations of the MoH were followed.
Vaccinations were launched across Turkey in January 2021, with priority given to health workers, who received two doses within 28 days. In the first phase of the vaccination program, more than one million healthcare workers had received their first dose of vaccine. Vaccination continued by age group, starting with people aged over 80 and some high-risk groups with underlying conditions.
This study is one of the first from our region comparing the number and distribution of patients seeking RT during the COVID?19 pandemic. The present study was conducted at the largest radiation oncology center in the Northeast Turkey. RT remains a valuable treatment option for cancer during this pandemic for various reasons.
In northern Turkey, radiation oncology clinical procedures went uninterrupted during the 1 year of study at our RT centers despite COVID-19. A screening workflow was performed before all patient admission. Patients were notified regarding the requirements for entering RT areas. Modifications were implemented to fit special COVID-19 protection requirements.
Slotman et al.[
The COVID-19 protection and prevention measures
effectively allowed for a safe and seamless clinical
operation in our RT centers and prevented transmission
of COVID-19 infections. It was determined that
the transmission paths of our employees who got sick
were from their spouses at home. Thanks to the measures
in our clinic, there was no transmission from
these personnel to other healthcare professionals.
During the COVID-19 pandemic, implementation
of hypofractionated RT schedules may have reduced
the commute of patients to the hospital. There are several
other explanations and suggestions for conducting
RT as well. Through these recommendations, radiation
oncologists may be able to more adequately provide
patients with the needed RT during the pandemic. It
should be taken into account that most recommendations
have been made in a comparatively short time
in response to the pandemic, and futher discussion
and evidence for some recommendations are needed.
In addition, many have recommended deferring or
excluding RT in nonurgent cases. In situations where
higher daily doses were applied and fractions reduced,
the number of patients going to the oncology centers
was much less. However, in our region, such solutions
were not possible during the pandemic period, especially
for curative treatments, due to lack of experience
and the low amount of insurance reimbursement. The
concern about the possibility of transmission of COVID-
19 in the early stages of the pandemic caused financial
anxiety for many people over time. Although
healthcare professionals were rewarded with extra
wages in the first 3 months of the pandemic in Turkey,
their earnings have started to decline over time due to
the country"s complex processes.
Our study reported a significant increase in the
number of patients coming for curative RT, especially
in Group A, though a decrease was shown for Group B.
This is likely because patients in Group B were aware of
deaths of COVID-19 and were no longer willing to go
to hospitals. On the other hand, there was a slight decrease
in palliative RT compared to curative treatments.
A study by Glosh et al.,[
Despite the pandemic in Northeastern Turkey and
the high number of daily patients in our division, the limited number of positive cases in our unit suggested
that disinfection procedures were clearly delineated
and implemented. In summary, we had a successful
year in such a way as to set an example for all healthcare
organizations in all pandemics, measures taken such as
mask-related measures, care for personal hygiene and
isolated living, and close symptom monitoring in the
clinic, which are among the leading measures taken in
struggling the COVID-19 pandemic.
Peer-review: Externally peer-reviewed.
Conflict of Interest: All authors declared no conflict of interest.
Ethics Committee Approval: The study was approved by
The Karadeniz Technical University Faculty of Medicine
Ethics Committee (No: 2021/55, Date: 05/05/2021).
Financial Support: This study has received no financial
support.
Authorship contributions: Concept - Ö.A., L.S.; Design -
Ö.A., L.S., S.K.; Supervision - E.C.; Funding ? None; Materials
- Ö.A., L.S., S. R., A.Y.Z., Z.B.; Data collection and/or
processing - Ö.A., L.S.; Data analysis and/or interpretation
- Ö.A., L.S.; Literature search - Ö.A.; Writing - Ö.A., S.K.,
S.R.; Critical review - Ö.A., E.C., S.K.
