Abstract
Aim: Radiation therapy is a cornerstone of oncological treatment and oncological patients show greater risk of developing complications related to COVID-19 infection. Stringent social restrictions have ensured a significant reduction in the spread of the virus, but also gave rise to a number of critical issues for radiation oncology wards. For this reason, the Directors of the Radiation Oncology Departments (RODs) of Lazio, Abruzzo and Molise regions shared their experience and ideas in order to create a common document that may assist in facing the negative impacts of the pandemic on radiation oncology wards and patients. Patients and Methods: The study was conducted according to the Estimate-Talk-Estimate method. Five issues were proposed and rated. Among approved issues, statements were proposed anonymously, then harmonized and finally voted on according to a Likert scale from 1 to 9. Those for which an agreement of 7-9 was observed were finally approved. Results: The document was developed with 42 statements dealing about safety measures for patients and staff, organization of clinical and work activities, usage of Information Technology systems for meetings/smart working. An agreement was recorded for 34 statements. Conclusion: This document sets out some recommendations for RODs and can provide valuable management information for Oncological Radiotherapy wards.
In December 2019, an outbreak of respiratory diseases caused by a novel coronavirus, acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was detected in China for the first time, and led to what is now called the COVID-19 pandemic. In September 2020, almost a year since the start of the pandemic, more than 30 million confirmed SARS-CoV-2 infections have been reported in 204 different countries, claiming more than one million lives worldwide (1). At the present time, no country in which vaccines have been administered has obtained herd immunity yet. On a global level, Italy was one of the earliest and most affected countries to be hit by the epidemic. To date, there have been more than three million cases and over 100,000 deaths nationwide (2).
The healthcare system of our country has had to cope with the emergency, including our Radiation Oncology wards. Radiation therapy is a cornerstone of oncological treatment. It is estimated that about 60% of oncologic patients require radiation therapy, and that oncologic patients are at greater risk of developing complications related to COVID-19 infection (3). Stringent social restrictions ensured a significant reduction in the spread of the virus, but also gave rise to a number of critical issues for Radiation Oncology wards including: access control, personal protective equipment, regulation of human contact within the hospital, training of dedicated teams, creation of forced flows, hygiene and cleaning, therapy planning, interruptions or delays in treatment, and visits.
In early 2020, the Italian Association of Radiotherapy and Clinical Oncology (AIRO) implemented a survey among the Directors of Radiation Oncology Departments (RODs) in order to identify strategies implemented in Italian radiotherapy facilities (4). Moreover, the Directors of the RODs of Lazio, Abruzzo and Molise regions took a further step forward by sharing their experience and ideas in order to create a common document that may assist in facing the negative impacts of the pandemic on radiation oncology wards and patients.
Patients and Methods
The study was conducted according to the Estimate-Talk-Estimate method (5), First of all, five topics of interest were identified, grouped as follows: Safety measures for patients and staff, organization of clinical and work activities, usage of Information Technology (IT) systems for meetings/smart working, tumor diagnosis rebound and reduction of access to diagnostic imaging tests. All Authors gave their contribution as members of the Board. Each member was requested to rate the five topics anonymously. The last two, tumor diagnosis rebound and reduction of access to diagnostic imaging tests, were deemed of secondary interest. Therefore, statements were proposed by the Board about the remaining three topics.
Subsequently, in an independent and anonymous form using e-mail, the Board modified the statements or proposed new ones. The facilitators (MFO, RMD) then harmonized and synthesized the statements, which were voted on in a second live meeting. Voting was anonymous and independent. The voting system provided for assignment of a score of between 1 and 9, according to the Likert scale. Scores between 1-3 represented disagreement (1 maximum disagreement, 3 slight disagreement); scores 4-6 uncertainty, while scores 7-9 represented agreement (7 slight agreement, 9 maximum agreement). It was possible to reformulate Statements and re-vote on them during the online meeting. For each statement, the median of the votes was calculated in order to define the overall agreement/disagreement. The final document, setting out all the recommendations by the Directors of the RODs of Lazio, Abruzzo and Molise, is herein reported including all the statements, even those with scores 7-9, which were finally approved by all the participants.
Results
The 23 Directors of the RODs of Lazio, Abruzzo and Molise were invited to participate in the preparation of a document setting out common recommendations applicable during the COVID-19 period. Twenty-one participants (91%) joined the project and participated in all the phases described above.
Table I shows the results and the scores for the 42 final statements, all in their definitive version. Recommendations that were strongly agreed upon were those regarding triage procedures for new patients (by telephone/access to the RODs), detection of body temperature, respecting social distancing in waiting rooms, strict time adherence (in order to avoid crowds), regular disinfection of immobilization systems and couches, improvement of IT to allow remote consultations and multidisciplinary meetings. Uncertainty was expressed about the use of digital applications to monitor treatment evolution and toxicity after treatment end and for follow-up visits (median score of 5); the delay of deferrable treatments and visits (median score of 6); the creation of a network among RODs located in COVID-19 centers and those in non-COVID ones (median score of 6); and the execution of at least two nasopharyngeal and oropharyngeal swabs before leaving home isolation, both for patients and employees who had contact with a COVID-19 patient and who were not sure that all the necessary measures had been followed (median score of 5). Moderate to mild disagreement emerged with regard to not carrying out disinfection between two COVID-19-positive patients treated sequentially (median score of 2); performing a computed tomography lung scan in the RODs of patients who develop COVID-19 symptoms during radiotherapy (median score of 3); or in order to perform diagnostic imaging in suspected symptomatic patients (median score of 3). Another point that generated disagreement regarded the issue of a period of home quarantine for in-patients or employees who had contact with a COVID-19-positive patient and who were not sure that all the necessary safety measures had been followed (median score of 3). There was mild to moderate agreement among the participants with regard to the remaining statements. Statements 16-19, 24, 27, 32 and 39-40 were reformulated and re-voted upon. Agreement did not change for all but one statement, namely that regarding the creation of different protocols for RODs located in COVID or non-COVID centers (recommendation 24), where the proposed reformulation led to a shift from disagreement of the participants (median score of 3) to a slight uncertainty (median score of 6).
Final statements developed by working groups around the restart of the Radiation Oncology Departments in the post-emergency COVID-19 period.
Discussion
Even during the course of infectious epidemics, radiotherapy is to be considered an essential asset and RODs must continue to provide their services. Consequently, in the Lazio region the restrictions adopted for outpatient activities did not affect radiotherapy services.
This document sets out some recommendations (Likert scale 7-9) approved by the Abruzzo, Molise and Lazio Directors of RODs and can provide valuable management information for oncological radiotherapy wards, as well as for visitors to these centers, by distribution of the abovementioned document.
The reduction of the risk of infection thanks to access control is the first step for proper internal management. Access to a ward, in sanitized environments and organized according to social distancing rules, must be limited only to those patients previously screened through triage (telephone contact, temperature measurement, epidemiological and clinical anamnesis for risky symptomatology) and in relation to their physical and psychological conditions.
It is necessary for patients with clinical suspicion of COVID-19 to undergo a swab before having access to radiation treatment. In this regard, nasal swab tests for asymptomatic patients are carried out in line with the provisions set out by the respective Health Departments, especially in those centers where infusion therapy is also administered.
In patients affected by COVID-19 and when treatment cannot be postponed, treatment must be provided through hospitalization with the necessary measures to ensure that the flow and timing of patients does not overlap with that of non-COVID patients.
To avoid transmission of SARS-CoV-2, the use of surgical masks and hand sanitizers are obligatory, and patients must be provided with a mask by the ward staff should they not have one.
It is recommended that all the staff of the ROD undergo periodic health screening with nasal swab tests/serology tests, and it will also be necessary for staff to be equipped with all available and suitable protection for the procedures to be carried out. In the case of patients with COVID-19 undergoing radiation therapy, it is possible to select dedicated personnel, previously trained and prepared, to be solely assigned to the management of SARS-CoV-2-infected patients.
If there is close contact between a staff member and an infected patient, it is possible to keep working, while simultaneously undergoing a health screening program, carried out in accordance with regional directives. According to the trend of contagion, urgency, the resources of the center and the number of patients who are undergoing therapy, it may be possible to adapt the working shifts to these special needs.
The working methods used during the pandemic brought to light the need for hospitals to improve their IT network. In particular for certain pathologies, and especially for healthcare personnel not in direct contact with patients (for example physicists and dosimetrists), telemedicine and smart working are important and effective methods of work to be implemented based on the progress of the pandemic and with due consideration for the transmission of sensitive data. In this regard, online multidisciplinary consultations and meetings play an important role.
During the emergency period of a pandemic, hypofractionated treatments must be preferred only when supported by evidence from the literature.
It is useful to evaluate the psychological state of both the patient and health workers in order to implement dedicated treatment plans, which can be ascertained, if necessary, through questionnaires and with the support of psychology wards.
Finally, it is also be necessary to create a supportive regional network between radiotherapy centers for the transfer of patients, if necessary, to ensure continuity of care even in the case of ‘catastrophic’ events.
In conclusion, this document sets out some recommendations for RODs and can provide valuable management information for Radiation Oncology wards, and has led to the sharing and promotion of similar solutions for RODs of Lazio, Abruzzo and Molise.
Footnotes
Authors’ Contributions
All Authors actively participated in all Board meetings. The article and the final document of recommendation was written by Martina De Angeli and Dimitri Anzellini, and revised by Rolando M. D’Angelillo and Mattia F. Osti.
Conflicts of Interest
The Authors declare that there are no conflicts of interest.
- Received May 22, 2021.
- Revision received June 8, 2021.
- Accepted June 10, 2021.
- Copyright © 2021 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.
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