Introduction
Coronavirus Disease 19 (COVID-19) was the name
given to a novel pneumonia that first emerged in Wuhan
(Hubei province, China) in December 2019.[]
Shortly after, the virus was isolated and associated with
the severe acute respiratory syndrome coronavirus (SARS-CoV) and was given the name SARS-CoV-2.
Like SARS-CoV-1 and MERS-CoV (Middle East respiratory
syndrome coronavirus), this virus is transmitted
primarily through aerosols in poorly ventilated areas.
[] Coronaviruses are named after the "Corona" spikes
produced by the S glycoprotein protruding into the viral
capsid, and this protein is responsible for binding to the host receptor angiotensin-converting enzyme
2 (ACE2).[] The most commonly reported symptoms
are fever, cough, and shortness of breath, while
the leading cause of death is acute respiratory distress
syndrome, myocardial damage, and renal failure.[,]
ACE2 receptors are present in many tissues, including
the cornea, nose, lungs, esophagus, heart, stomach,
liver, ileum, colon, gallbladder, kidneys, and testes.[]
A recent study has reported increased ACE2 expression
in the lungs with age, and it has been noted that
individuals over the age of 60 years and/or older adults
with weakened immune systems are highly susceptible
to COVID-19.[] Since cancer is more common in the
older adult population, and ACE2 expression increases
with age, cancer patients are more likely to experience
severe symptoms when infected with SARS-CoV-2.[]
To ensure the continued access of cancer patients to
effective treatment and care, healthcare workers over
the world have changed the way they work due to mitigate
the risk of COVID-19 infection.[] Several organizations
have conducted surveys to assess changes in
practices during the pandemic and strategies for coping
with the rapid daily changes.[] Difficulties in the provision
of cancer care have been reported recently in many
countries.[] Cancer patients are one of the most vulnerable
groups due to their occasional at-risk clinical
conditions and ongoing treatments.[-] For patients
undergoing or scheduled for radiation therapy, radiation
oncology (RO) departments have adjusted their management
protocols to maintain their ability to provide
optimal care to all patients.[] The American Society
for RO (ASTRO) surveyed more than 500 physician
heads of departments in the United States to understand
the impact of the pandemic, and to identify the changes
implemented to cope with them.[] and the same questionnaire
was used also by the European society for radiotherapy
and oncology (ESTRO) for a similar survey.
Organizations working in the oncological field
have published specific patient care guidelines for
both ancillary and palliative care.[,] TR Ministry
of Health and Ministry of Interior announced to the
public the personal protective measures (hand hygiene,
respiratory hygiene rules), environmental precautions,
physical distance measures, and travel-related precautions
and restrictions to be applied.[] During the
pandemic, radiotherapy clinics have had to face the
unique challenge of maintaining a virus-free environment
for both the patients and staff while continuing
to provide uninterrupted treatment. The ministry of
health made the decision to postpone all elective surgeries
and to reassign outpatient clinics and inpatient wards for COVID-19 patients, along with the associated
hospital staff. Although most hospitals with radiotherapy
units were declared COVID-19 referral hospitals,
it was decided to continue with the provision of
cancer treatments without interruption, and on April
14, 2020, the ministry of health announced that oncology
department personnel should not be reassigned to
COVID-19 units.[]
Cancer patients are at a greater risk of developing
severe symptoms of COVID-19, and therefore, the
entire clinical decision-making process for oncological
care is under revision, with the aim being to balance
the risk-benefit for each treatment delivered to
patients. This necessitates a significant restructuring of
the safety measures affecting the operational processes
of healthcare workers, including radiation oncologists,
and it is believed that this will have practical and psychological
consequences for both cancer patients and
healthcare workers.[]
While there have been several studies assessing the
changes in cancer treatment after the start of COVID-
19 pandemic, no study has been conducted to date
from the point of view of the physicians. In this survey
study, we assess the changes in the daily practices of
Turkish radiation oncologists.
Methods
Study Participants
An online questionnaire was developed through
Google Forms and sent out to oncologists registered
with the Turkish society for RO (TROD), with three
reminders sent out to the participants over the course
of a week. No gifts or payments were made to the study
participants, and participation was voluntarily.
Statistics
The study was carried out following the principles of
the Declaration of Helsinki and all applicable regulations.
No statistical analyses were performed.
Descriptive data were presented as mean or median
values for continuous variables, and frequencies and
percentages for categorical variables.
Ethics
The study was approved by both the Turkish Ministry
of Health and the Ethics Committee at Eskişehir Technical
University Social and Human Sciences Scientific
Research and Publication Ethics Committee (May 05,
2022-70094) and carried out by the Declaration of Helsinki
principles and all applicable regulations.
Results
Of the recipients, 98 radiation oncologists completed
the online questionnaire, more than half of whom
were working in training and research public hospitals,
followed by those working in university hospitals.
Approximately 72% of the respondents were specialists
and residents.
Following the first recorded case in Türkiye, 69% of
radiation oncologists stated that additional measures
were taken regarding COVID-19 in their outpatient
clinics, wards, and radiotherapy units. In the pandemic,
the clinics, and outpatient clinics, where 35% of the
radiation oncologists" patients were hospitalized and
treated were moved to different parts of the hospital.
This has resulted in approximately 70% worsening of
RO patient (Fig. 1). Since, the beginning of the pandemic
in Türkiye, 52% of radiation oncologists have
not been assigned to services related to COVID-19.
Following the circular of the TR Ministry of Health on
Medical Oncology-Hematology-RO physicians, this
rate increased to 75%. However, despite this circular
of the Ministry of Health, 60% of radiation oncologists
stated that they continued to work in COVID-19 services
due to pressure from the hospital management
and 12%, because the Ministry had forbidden their
right to resign or take medical leave. Nearly half of
the respondents stated that radiotherapy and inpatient
services had been disrupted as a result of their transfer to other services. During the provision of COVID-19
services, no radiation oncologist cross-infected their
patients.
Fig 1: The replacement of the oncological outpatient or
inpatient clinics after the COVID-19 pandemic.
In this period, 75% of the respondents stated that patient
management in their department had deteriorated
due to the reassignment of physicians to other clinics
to provide COVID-19-related care. The clinics affected
most were surgical oncology and radiology, respectively
(Fig. 2). Some 23% of the respondents said that they had
had to refer their patients to other RO centers. Around
half of the radiation oncologists surveyed stated that
they were shunned by the society due to fear of transmitting
the COVID-19 infection (Fig. 3). Some 39% of
radiation oncologists reported a loss of income, with the
majority reporting an income loss of 20%, while others
reported losses in the 21-40% range (Fig. 4). Only five
radiation oncologists stated that they received psychiatric
or psychological support during this period.
Fig 2: The ratio of the difficulties of oncological patient
management due to other services.
Fig 3: Social exclusion of radiation oncologists for fear
of transmitting COVID-19 infection.
Fig 4: The reduction of the oncologists" income during
the COVID-19 pandemic.
Discussion
The present study reveals that oncology services have
been interrupted due to the regulations applied by
the Turkish Ministry of Health and local hospital administrations
during the COVID-19 pandemic. More specifically, the daily oncological treatment practices of
radiation oncologists have been severely disrupted, and
patients have experienced a decline in access to treatment
in this period.
This study has shown further that radiation oncologists
have encountered problems in patient management
since the onset of the COVID-19 pandemic,
although the TROD immediately got involved once
the virus reached Türkiye and cooperated with the
Ministry of Health. TROD kept its members informed
through regular announcements, developed guidelines
for the management of radiotherapy departments, and
provided recommendations for region-specific treatment
modifications. Almost all RO departments followed
the TROD recommendations, as well as other
international guidelines (ESTRO, ASTRO) in regard to
changes in treatment during the COVID-19 pandemic.
[] As a result of these regulations, radiation oncologists
were able to make progress in patient management.
On the delayed decision of the Ministry of Health,
radiation oncologists returned to work in their own departments,
although it would seem some of those working
in public hospitals may have experienced mobbing,
or to have been compelled to work in COVID-19 clinics
due to financial concerns, as the decline in income
associated with the pandemic may have also been a factor
for some radiation oncologists. Another reason for
having to work in COVID-19 clinics may have been the ban issued by the Ministry of Health on the rights of all
physicians to resign or to take medical leave. The fact
that many radiation oncologists required psychological
support can be explained by these prohibitions and the
society's negative distancing from physicians. A study
by Romeo et al.[] reported that all health-care providers,
as well as cancer patients, reported a need for
support after experiencing psychological distress, faced
difficulties in changing their personal cognitive beliefs,
or were affected by a lack of social support.
Recent studies have shown adherence to chemotherapy
to have been impaired by the fear of COVID-
19 and COVID-19 regulations.[,] Some RO
departments temporarily closed their radiotherapy
units, as most radiation oncologists were infected with
COVID-19 during the early pandemic.[] A study by
Filippi et al.[] showed that the Italian health-care system
and radiation therapy facilities were overwhelmed
by the emergency. In the present study, the referral of
oncology patients to other RO departments may result
from these issues.
In the long term, the motivation of radiation oncologists
may be reduced as a result of their increased
workload. Another problem faced by oncology patient
management was the loss of multidisciplinary patient
management due to the difficulty in scheduling surgery
and other oncology-related departments.
An emergency plan regulation for radiation oncologists
may be necessary to ensure the maintenance of cancer treatment management in the event of emergencies
such as pandemics.
Conclusion
Although radiation oncologists tolerate oncological patient
management changes, the prolonged pandemic
may have a marked effect on the motivation of oncologists
and may be detrimental to their multidisciplinary
patient management practices. Further studies are
needed to establish new regulations for radiation oncologists
in emergencies such as 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 Eskişehir Technical University Social and Human
Sciences Scientific Research and Publication Ethics Committee
(no: 70094, date: 05/05/2022).
Financial Support: None declared.
Authorship contributions: Concept - F.T., İ.B., D.S.;
Design - D.S.; Supervision - F.T., İ.B.; Funding - F.T., İ.B.;
Materials - İ.B.; Data collection and/or processing - F.T.,
İ.B., D.S.; Data analysis and/or interpretation - F.T., D.S.;
Literature search - F.T.; Writing - F.T., İ.B.; Critical review
- F.T., İ.B., D.S.
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