|Year : 2021 | Volume
| Issue : 2 | Page : 72-77
Impact of covid-19 on cancer care – A single institution experience – Government Arignar Anna Memorial Cancer Hospital & Research Institute (RCC), Kanchipuram
IM Jarfin, V Srinivasan, S Ashok Kumar
Department of Radiation Oncology, Government Arignar Anna Memorial Cancer Hospital & Research Institute (RCC), Kanchipuram, Tamil Nadu, India
|Date of Submission||18-Aug-2021|
|Date of Acceptance||24-Mar-2022|
|Date of Web Publication||24-Aug-2022|
I M Jarfin
Department of Radiation Oncology, Government Arignar Anna Memorial Cancer Hospital & Research Institute (RCC), 21–22 A, AMJ Bhavan, Putharivilai, Parakadai, Kuzhicode (P.O), Kanniyakumari District, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: COVID-19 has impacted health care all over the world. In this article, we will discuss how the pandemic has influenced daily practice and treatment protocols in cancer care in our institution, during the course of its two waves, i.e., from March to September 2020 and March to June 2021. Materials and Methods: Several measures were taken to ensure safety and treatment of cancer patients. Setting up of isolation wards, admission of all patients for treatment, increasing radiotherapy machine ‘on time’, periodic sanitation, treatment area hygiene, personal protection equipments for medical personnel were some of them. Changes were made in radiotherapy, medical oncology, surgical oncology and anaesthesia practices. Patients who became COVID positive were managed in a Covid Care Centre, outside the premises of our institution. Results: The number of patients treated and procedures done in our institution during the first wave of the pandemic in 2020 was much lower compared to the same time period in 2019. But that was not the case with the second wave in 2021. Among the health care workers who tested positive for the virus during the two waves, none required hospitalization and no deaths occurred. Conclusion: Covid-19 has definitely influenced our cancer care for a transient period during the first wave. Modifications in treatment procedures were done only for a short period before we switched back to standard department protocols. With the onset of the second wave, taking previous wave’s experiences into consideration, measures were taken to ensure safe and continuous cancer treatment delivery.
Keywords: Cancer care, COVID – 19, radiotherapy
|How to cite this article:|
Jarfin I M, Srinivasan V, Ashok Kumar S. Impact of covid-19 on cancer care – A single institution experience – Government Arignar Anna Memorial Cancer Hospital & Research Institute (RCC), Kanchipuram. Bengal J Cancer 2021;1:72-7
|How to cite this URL:|
Jarfin I M, Srinivasan V, Ashok Kumar S. Impact of covid-19 on cancer care – A single institution experience – Government Arignar Anna Memorial Cancer Hospital & Research Institute (RCC), Kanchipuram. Bengal J Cancer [serial online] 2021 [cited 2023 Mar 25];1:72-7. Available from: http://www.bengaljcancer.org/text.asp?2021/1/2/72/354414
| Introduction|| |
Covid-19 pandemic by the SARS-CoV-2 virus has caused considerable mortality, morbidity and a huge impact on the health care delivery. Cancer patients were one among the worst affected group of patients due to this pandemic owing to their immunocompromised states and long treatment schedules required to treat cancers. Challenges observed were ensuring continuity of cancer treatment and minimizing the risks of transmission to this vulnerable population. Furthermore, the nature of malignancy demands immediate interventions, which cannot be delayed. Taking these into consideration, we took necessary steps to ensure safe and continuous treatment delivery to the cancer patients amidst this crisis.
| Materials and Methods|| |
Our institution is Government Arignar Anna Memorial Cancer Hospital & Research Institute, a Regional Cancer Centre in Kanchipuram, Tamil Nadu, India. The Radiation Oncology department of our institution is equipped with a Linear Accelerator CLINAC 2100C, A HDR Microselectron, one Telecobalt machine and a CT simulator. The Surgical Oncology department has one major and one minor operation theatres, complete endoscopic facility, vessel sealing advanced bipolar system, cordless ultrasonic dissectors, HD laparoscope system etc. Our Medical Oncology department caters to the needs of the cancer patients with both Day Care and Inpatient based chemotherapy. We have a Palliative Care department which tends to the needs of the terminally ill patients requiring supportive care. Our Radiology department is equipped with 500 mA X-ray, USG, Mobile X-ray and CT machines.
Safety measures taken during the course of the pandemic’s two waves, i.e., from March to September 2020 and March to June 2021 are as follows:
Patients and attenders were advised to maintain an adequate social distancing of atleast 1 metre and waiting areas were marked and modified to ensure that. Wearing masks was made compulsory and they were provided with hand sanitizer upon entry into the hospital. Their body temperature, oxygen saturation were recorded before they enter into the OPD. Attenders count was limited to one attender per patient so as to reduce overcrowding as much as possible., The number of routine follow ups per year of asymptomatic healthy patients post cancer treatments and palliative care patients were reduced., Pain and palliative care medications were given for longer durations to cover for the time interval between two visits.
All patients who should receive cancer treatment were initially admitted in an isolation ward. Only a single permanent attender per patient was allowed and no visitors were allowed. All patients undergo an RT-PCR test and were shifted to their respective wards with the arrival of a negative result. Suspected patients were also screened for Covid-19 changes with a CT-Chest.
The following strategies were undertaken in our various departments to decrease covid-19 exposure, strain on resources, while at the same time ensuring reasonable treatment to cancer patients.
Radiation oncology department
Modifications done in treatment procedures are as follows. Radiotherapy machine on time was increased to reduce crowding. Periodic sanitization of machines, table tops, entry gates, immobilization casts, treatment area was done. Radiotherapy technologists were provided with personal protective equipments and were rostered to work in shifts to reduce covid-19 exposure.
Curative intent treatments were continued with the standard conventional fractionation regimens. Standard Hypofractionation regimens were employed in palliative intent treatments. Concurrent chemotherapy was omitted in patients >60 years of age. Emergency radiotherapy was continued as usual. Less number of fractions were employed in Intra Cavitary Brachytherapy (ICBT) for carcinoma cervix.
Before the pandemic, Intracavitary Brachytherapy (ICBT) for Carcinoma Cervix was given in 3#’s, 7Gy/# (with EBRT 45Gy/25#). During the pandemic, it was given in 2#’s, 8Gy/# (EBRT 50Gy/25#), achieving similar Biologically Effective Doses.
Medical oncology department
Metronomic chemotherapy, by way of oral chemotherapeutic agents, was administered wherever possible. Concurrent chemotherapy was omitted in palliative intent treatments. Less toxic regimens feasible in daycare were preferred.
Surgical oncology department
Smoke evacuation system was used to absorb electrocautery smoke. Use of laparoscopy, electrocautery devices in surgeries was limited. When survival results are comparable, radiation was preferred over surgery. RT-PCR and CT Chest covid screening were done prior to all major surgeries and endoscopic procedures. Theatres were modified to include donning and doffing areas.
Regional anesthesia was preferred over general anesthesia wherever feasible. Viral filters in the anesthesia breathing circuits, special tubing setup for disposing exhaled air through underwater system containing hypochloride were used. Video Laryngoscopes were used for intubation.
Management of Covid-19 cases
Patients who became positive for Covid 19 were shifted to a Covid Care Centre outside the premises of our institution, treated and were referred back after a quarantine period of 2weeks for resuming the cancer treatment.
Vaccination camps were conducted in our institution for the vaccination of health care workers. Covishield and Covaxin were the two vaccines administered.
With the decline in the number of cases after the first wave of the pandemic, we switched back to the standardized department protocols but the basic safety measures were followed and they remained as a part of the new normal. During the second wave between March and June of 2021, the treatment modifications were reemployed temporarily and safety measures were followed as usual. With the experience of the previous wave in mind, measures were taken with ease to ensure safe and uninterrupted treatment of cancer patients.
The data regarding this institutional experience were collected from electronic records of our hospital.
| Results|| |
The following were the observations made during the course of the pandemic in the number of patients treated and the number of procedures done in our institution.
The total number of patients who received treatment during the period of March – September 2020 i.e., the first wave of the pandemic, in our institution was much less when compared with the previous year’s data.
The number of new cases registered in our institution during the period of March to September was 4396 in 2019 and 2656 in 2020, a 40% decrease.
Number of outpatients treated during this period in the year 2019 was 23795, whereas it was 14940 in the year 2020, a 37% decrease. Number of inpatients treated during this period in 2019 and 2020 were 3737 and 2801 respectively, a 25% decrease.
Radiation treatments received during the period of March – September in 2019 were, Teletherapy – 23795 and Brachytherapy – 280. During the same time period in the year 2020, 11815 teletherapy exposures and 110 brachytherapy insertions were given. Teletherapy saw a fall of 50%, while brachytherapy insertions fell by 61%.
The weekly and daily average of number of patients receiving EBRT during March – September decreased from 793 and 158 patients respectively in 2019 to 393 and 78 patients respectively in 2020.
Since brachytherapy for Ca cervix was found to have improved 5 year overall survival compared to EBRT alone (65% vs 50%) as per our institution experience, brachytherapy for carcinoma cervix was offered to all patients completing EBRT provided they are willing for the procedure. But the number of brachytherapy insertions decreased from 9 cases per week in 2019 to 4 cases per week in 2020.
Number of chemotherapies administered on inpatient basis during the period of March – Septemer 2019 was 787, and it was 560 for the same period in 2020, a 29% decrease.
The palliative care census between March – September of 2020 was 773 compared to 1283 in 2019, a 40% decrease.
The number of cases operated by the surgical oncology department during the period of March – September also had a significant variation compared to the previous year. The number of major cases fell from 171 in 2019 to 153 in 2020, a 11% decrease and the number of minor cases decreased from 1342 in 2019 to 939 in 2020, a 30% decrease.
The number of imaging procedures done by the radiology department during March – September 2020 also showed a decline, when compared with 2019, with the exception of CT scan. The number of CT scans increased from 220 to 378, a 72% increase. The number of USG’s decreased from 1783 to 1260, a 29% decrease. The number of image guided biopsies decreased from 1041 to 913, a 12% decrease. The number of X rays taken decreased from 1245 to 1150, an 8% decrease.
The number of cases screened for cancer in our institution saw a huge drop during the first wave of the pandemic in 2020. The number of cases screened during the period of March to September was 9948 in 2019, which fell to 1886 in 2020, an 81% decrease.
During the period of May – September 2020, a total of 520 swab tests were taken in our institution, of which 35 (6.7%) tested positive for SARS COV 2. Among those who tested positive, 9 (26%) were hospital personnel and the rest 26 (74%) were patients.
Coming to the second wave of the pandemic, during the period of March to June 2021, the number of patients treated and procedures done in our institution was higher compared to the previous years unlike the first wave.
The number of new cases registered in our institution during the period of March to June was 2443 in 2019, 1383 in 2020 and 5569 in 2021.
The number of outpatients treated during the period of March to June varied from 13191 in 2019 to 9664 in 2020 to 14059 in 2021. The number of inpatients treated during this period was 2101 in 2019; 1748 in 2020 and 2366 in 2021.
The number of patients who received teletherapy treatment during this period ranged from 7441 in 2019 to 4940 in 2020 to 8251 in 2021. Similarly, the number of brachytherapy insertions for this period were 58 in 2019; 12 in 2020 and 86 in 2021.
The number of brachytherapy cases per week during the period of March – June for the years 2019, 2020 and 2021 were 9, 5 and 9 respectively.
The total number of chemotherapies administered during this period showed the following variations; 2437 in 2019; 3414 in 2020 and 4764 in 2021.
The number of patients who received palliative care during this period in 2021 (573 patients) was higher than 2020 (395 patients), but lesser than2019 (789 patients)
The variation in the number of cases operated by the surgical oncology department during this period also had the same pattern as radiotherapy procedures. The number of major cases were 146 in 2019; 88 in 2020 and 192 in 2021. The number of minor cases were 714 in 2019; 527 in 2020 and 973 in 2021.
The variation in the number of imaging procedures and other procedures done by the radiology department during this period also followed the same pattern as radiotherapy and surgeries with the exception of CT scans as they were constantly used in Covid-19 screening. The number of CT scans increased from 96 in 2019 to 179 in 2020 to 360 in 2021. The number of USG scans done was 718 in 2019; 333 in 2020 and 772 in 2021. The number of X-Rays done during this period was 676 in 2019; 605 in 2020 and 1202 in 2021. The number of biopsies done were 629 in 2019; 560 in 2020 and 986 in 2021.
During the second wave, the number of cases screened for cancer in our institution was comparatively higher than the first wave but not as high as 2019. The number of cases screened during the period of March to June was 6408 in 2019, 1323 in 2020 and 3140 in 2021.
During the period of March – June 2021, a total of 601 swab tests were taken in our institution, of which 57 (9.5%) tested positive for SARS COV 2. Peak incidence was in May 2021 with 32 samples (19%) testing positive out of the 172 swab tests taken.
| Discussion|| |
Covid-19 has definitely affected the cancer care in our institution. The main reasons for this are as follows.
The main problem is the delay that happens in diagnosis and treatment of cancers. Contributing factors include lack of awareness about the nature of cancers among patients, accompanied by the many difficulties caused by this covid-19 pandemic accessing medical care in many institutions which have now been converted into covid care centres, with no resources for elective procedures, irrational fear of the virus among the patients without proper awareness about the safety precautions, financial difficulties incurred as a result of loss of jobs during this pandemic, lockdown restrictions imposed to contain the spread of the virus, with no public transportation, making it difficult for patients who can’t afford private transportation to reach hospitals. The delay in starting treatment can lead to disease progression resulting in unwarranted change of treatment plans. It may also adversely affect the local control of tumors and overall survival of patients.,, In worst case scenarios, these circumstances may lead to change in the intent of treatment from curative to palliative.
Prolonged hospital stay for cancer patients is another problem caused by this pandemic. The patients coming for cancer care have to be admitted in isolation wards till they test negative for the virus which adds to the long duration of cancer treatment and also results in a prolonged stay in the hospital. The patients testing positive for the virus while on treatment amidst proper precautions have to be shifted to covid care centres for treatment. This increases the overall duration taken to complete cancer treatment, and may decrease its efficacy. Radiotherapy which could normally have been given on OPD basis, now has to be given preferably with hospital stay. Single attender per patient for the entire duration of treatment is a policy adapted during these times. Such steps taken to reduce the risk of patients catching the covid-19 infection during cancer treatment add to the financial difficulties incurred by the patients and attenders and hence decreases their morale in addition to the emotional aspects associated with cancers. These reasons may result in patients defaulting cancer treatment in the middle. In order to combat these difficulties, multiple counseling sessions were conducted for patients admitted in our hospital by health care and social workers.
Inspite of all these difficulties, the relative increase in the number of patients treated in our institution during the second wave compared to the first wave, reflects a rebound phenomenon as the obstacles posed by the first wave are now being overcome by an increase in understanding among the patients about the restrictions during the pandemic and the nature of the two illnesses covid-19 and cancer.
| Conclusion|| |
So, in addition to the safety and therapeutic measures taken by the health care providers, further patient education regarding the effective utilization of the available resources for the early detection and treatment of cancer is also needed so as to be prepared for such a situation in the future.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Society of Clinical Oncology. A guide to cancer care delivery during the Covid-19 pandemic. Available from: https://www.asco.org/sites/new-www.asco.org/files/content-files/2020-ASCO-Guide-Cancer-COVID19.pdf
. [Last accessed on Jul 29, 2021].
The Tata Memorial Centre COVID-19 Working Group. The COVID-19 pandemic and the Tata Memorial Centre response. Indian J Cancer 2020;57:123-8.
] [Full text]
Cancer Patient Management During the COVID-19 Pandemic. ESMO [Internet]. Available from: https://www.esmo.org/guidelines/cancer-patient-management-during-the-covid-19-pandemic
. [Last accessed on Jul 29, 2021].
COVID-19 recommendations and information - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO) [Internet]; 2020 [cited Jul 30]. Available from: https://www.astro.org/Daily-Practice/COVID-19- Recommendations-and-Information/Clinical-Guidance
. [Last accessed on Jul 29, 2021].
Coles CE, Aristei C, Bliss J, Boersma L, Brunt AM, Chatterjee S, et al
. International guidelines on radiation therapy for breast cancer during the COVID-19 pandemic. Clin Oncol (R Coll Radiol) 2020;32:279-81.
Wei W, Zheng D, Lei Y, et al
. Radiotherapy workflow and protection procedures during the coronavirus disease 2019 (COVID-19) outbreak: Experience of the Hubei Cancer Hospital in Wuhan, China. Radiother Oncol 2020;148:203-10.
Thomson DJ, Palma D, Guckenberger M, Balermpas P, Beitler JJ, Blanchard P, et al
. Practice recommendations for risk-adapted head and neck cancer radiation therapy during the COVID-19 pandemic: An ASTRO-ESTRO consensus statement. Int J Radiat Oncol Biol Phys 2020;107:618-27.
Caravatta L, Rosa C, Di Sciascio MB, et al
. COVID-19 and radiation oncology: The experience of a two-phase plan within a single institution in central Italy. Radiation Oncology 2020;15:226.
Oliveira HF, Yoshinari GH Jr, Veras IM, de Almeida Jr WJ, Freitas NMA, Castilho MS, et al
. Impact of the COVID-19 pandemic on radiation oncology departments in Brazil impact of COVID-19 on Brazilian radiotherapy. Adv Radiat Oncol 2021. doi: 10.1016/j.adro.2021.100667.
Chen Z, King W, Pearcey R, Kerba M, Mackillop WJ, The relationship between waiting time for radiotherapy and clinical outcomes: A systematic review of the literature. Radiother Oncol 2008;87:3-16.
Raphael MJ, Biagi JJ, Kong W, Mates M, Booth CM, Mackillop WJ The relationship between time to initiation of adjuvant chemotherapy and survival in breast cancer: A systematic review and meta-analysis. Breast Cancer Res Treat 2016;160:17-28.
Biagi JJ, Raphael MJ, Mackillop WJ, Kong W, King WD, Booth CM Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer: A systematic review and meta-analysis. JAMA 2011;305:2335-42.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]