key: cord-0756846-k4jqhwc0
authors: Singh, Hemant Kumar; Patil, Vijayraj; Ganne, Chaitanya; Nair, Deepa
title: Preparedness of the cancer hospitals and changes in oncosurgical practices during COVID‐19 pandemic in India: A cross‐sectional study
date: 2020-08-25
journal: J Surg Oncol
DOI: 10.1002/jso.26174
sha: df01e9d0558a4d3db5c463b11cb2e3647422bf92
doc_id: 756846
cord_uid: k4jqhwc0

BACKGROUND AND OBJECTIVES: Coronavirus disease‐2019 (COVID‐19) pandemic has impacted cancer care across India. This study aimed to assess (a) organizational preparedness of hospitals (establishment of screening clinics, COVID‐19 wards/committees/intensive care units [ICUs]/operating rooms [ORs]), (b) type of major/minor surgeries performed, and (c) employee well‐being (determined by salary deductions, paid leave provisions, and work in‐rotation). METHODS: This online questionnaire‐based cross‐sectional study was distributed to 480 oncosurgeons across India. We used χ (2) statistics to compare responses across geographical areas (COVID‐19 lockdown zones and city tiers) and type of organization (government/private, academic/nonacademic, and dedicated/multispecialty hospitals). P < .05 was considered significant. RESULTS: Total of 256 (53.3%) oncologists completed the survey. About 206 hospitals in 85 cities had screening clinics (98.1%), COVID‐19 dedicated committees (73.7%), ward (67.3%), ICU's (49%), and OR's (36%). Such preparedness was higher in tier‐1 cities, government, academic, and multispecialty hospitals. Dedicated cancer institutes continued major surgeries in all oncological subspecialties particularly in head and neck (P = .006) and colorectal oncology (P = .04). Employee well‐being was better in government hospitals. CONCLUSION: Hospitals have implemented strategies to continue cancer care. Despite limited resources, the significant risk associated and financial setbacks amidst nationwide lockdown, oncosurgeons are striving to prioritize and balance the oncologic needs and safety concerns of cancer patients across the country.

time-to-initiate-treatment affecting survival and increasing anxiety among patients 4 and finally a long drawn course of oncological treatment, that can get significantly affected during the pandemic. The resultant immune suppression 5 poses a greater risk to COVID-19 infection, more so if they have received treatment within the previous month. 6 An estimated 192 000 patients are likely to have delays in the timely diagnosis of cancer as projected by the Indian Council of Medical Research, 7 adding to the backlog of patients who await treatment at many oncology institutes.

With a mere 2.2% of the gross domestic product being invested in public health, 8, 9 a country like India with a population of more than 1.3 billion will have to surmount the challenge of controlling the pandemic and restoring cancer care to normalcy. This study aims to understand how rapidly the oncology hospitals adapted to the pandemic and the needs of the patients to provide for the necessary oncology services particularly with regards to surgery for cancer and preparedness of the hospitals across the various cities and importantly COVID-19 zones.

Oncosurgical care during the pandemic was assessed based on (a) preparedness of the hospital by establishment of COVID-19 screening clinics, COVID-19 wards/committees/intensive care units (ICUs)/operating rooms (OR), (b) major and minor surgeries being performed, and (c) employee well-being determined by deductions in salary, provisions for paid leave and to work in-rotation. We compared these across geographical hospitals (ie, COVID-19 lockdown zones and city tier) and administrative organization of the facility (ie, government vs private, academic vs nonacademic, and dedicated hospitals vs multispecialty hospitals).

Oncosurgeons (consisted of surgical oncologists, gynec-oncologists, and head and neck oncosurgeons) practicing in India across various oncology hospitals were invited to participate in an anonymous online questionnaire-based cross-sectional study (Supplemental File 1), between 18 and 27th May 2020 (during the nationwide lockdown), where the data were collected with no identifiers recorded from the participating individuals. Participants were recruited through social networking websites, personal messages, and emails.

The questionnaire was designed to include sections on (a) demography, (b) hospital preparedness, (c) surgical practices, and (d) remarks section to record the issues not covered by the survey.

Definitions used in the survey regarding lockdown zones, 10 adequate personal protective equipment 11 (PPE), and major surgeries are as shown in Table 1 . The cities were classified as tier-1, 2, and 3. 12 We assessed the following in the survey 1. Hospital preparedness determined by the establishment of screening procedures for COVID-19 and dedicated committees/ wards/ICUs/ORs for COVID-19. Red zones/hot spots are defined by taking into account the number of active of cases, doubling the rate of confirmed cases, extent of testing, and surveillance feedback. There is severe restriction of activity of the people that live within the defined zone.

the facility (ie, government vs private, academic vs nnonacademic, and dedicated hospitals vs multispecialty hospitals).

All responses were grouped into categorical variables (nominal or ordinal). Once the responses were paired, the data were analyzed using χ 2 tests to answer the pertinent questions. Conditional formatting was used to sort layered responses. Two-tailed P < .05 was considered significant.

Of the 480 oncosurgeons, 256 (53.3%) from 206 hospitals in 85 cities completed the survey. Ten oncosurgeons declined participation (five had their hospital completely shut down due to pandemic; three worked in set-ups with limited beds; and two were on maternity leave). The mean age was 37 ± 7years, (range, 31-66 years). The demographic details are enumerated in Table 2 .

Hospitals adopted organizational changes to combat the pandemic. Newly diagnosed cancers were continued to be evaluated by most of the oncosurgeons (96.1%) ( Figure 1A and Supplemental File 2). Oncosurgeons were compelled to consider surgery for inadequately staged patients (16%). All lockdown zones were equally affected by such concerns (Supplemental File 2).

Oncosurgeons are faced with the problem of inadequate supply of PPEs. Oncosurgeons used N95 respirators (94.2%) or surgical masks (78.1%) or powered air-purifying respirators (PAPR; 28.9%) for respiratory protection. However, the exclusive use of these was very infrequent (N95: 15%, surgical masks: 4.2%, and PAPR < 1%). Oncosurgeons used gowns designed either for COVID-19 (51.7%) or HIV protection kit (Table 1 ) (73.2%) or regular surgical gowns (56.5%).

Exclusive use of the three suit designs was also infrequent (COVID-19 suits: 11.7%, HIV kit gowns: 18%, and regular surgical gowns: 11%). PAPR and gown designed for COVID-19 were used more often in tier-1 cities compared with tier-2/3 (PAPR: 36.4% vs 20% vs 27.8%, P = .04; COVID gowns: 58.3% vs 39.3% vs 59.5%, P = .018).

F I G U R E 1 A, OPD practices, oncology practices, and employee welfare. B, Provisions at the radiotherapy (RT) centers. C, Oncological subspecialties: major and minor surgeries. COVID-19, coronavirus disease-2019; NACT, neoadjuvant chemotherapy; OPD, outpatient department [Color figure can be viewed at wileyonlinelibrary.com] Face shields to protect from aerosols were used by 90% of oncosurgeons, particularly in red zones compared with orange/green (93.7% vs 87.5% vs 80%, P = .049) (Supplemental File 2).

Oncosurgeons reported adequate availability of PPE among their colleagues in anesthesia (88.3%), scrub nurses (86.7%), and surgical assistants (89.1%). We specifically did not collect information on which component was unavailable. Tier-3 cities, nonacademic institutions, and green zones as compared with tier-1, academic institutes, and red zones did not have an adequate supply of PPE for the surgical team (Supplemental File 2).

Routine preoperative COVID-19 testing was practiced by 57.9% of oncosurgeons. Testing was done more frequently in the tier-1 (80%, P < .001), academic (62.6%, P = .05), red zones (63.5%, P = .06), and multispecialty hospitals (P = .013) as compared with tier-3, nonacademic, green zones, and dedicated hospitals. Almost 80% of oncosurgeons continued major surgeries across all subspecialties of oncology but for hepato-pancreato-biliary (HPB), thoracic oncology, and cytoreductive surgeries (CRS)/hyperthermic intraperitoneal chemotherapy (HIPEC), which were reduced to 61%, 57%, and 32%, respectively ( Figure 1C ). Dedicated oncology hospitals (74.1% vs 44.1%, P < .001) and hospitals in green zones (60% vs 44.5%, P = .023) continued their elective cancer surgeries compared to multispecialty hospitals and red zones despite the lockdown, respectively. These Only 60% of oncosurgeons continued to perform microvascular reconstruction. A higher proportion of private hospitals performed microvascular reconstruction more than government hospitals (63.9% vs 40.7%, P = .017), while the practice of pedicle flaps over free flaps did not differ with hospitals. However, the decision to perform a tracheostomy was the same across all oncosurgeons and was determined by the extent of primary resections. The types and extent of surgeries performed did not differ between the tier of the city and zones (Table 1 and Figure 1B ).

Oncosurgeons reported that their patients were anxious (60%) about getting the appropriate treatment during the pandemic. This concern was higher in tier-3 cities (77.1% vs 60.5%, P = .029) and government hospitals (82.7% vs 55.4%, P = .006). Oncosurgeons also felt that stage-IV patients/palliative patients may not get the appropriate care (32.2%), particularly in government (47.6% vs 29.3%, P = .07) and tier-3 hospitals (46.2% vs 28.3, P = .11).

Oncosurgeons in private hospitals (54%) reported salary cuts ranging from 10% to 95% (<20% deduction: 6.4%, 20%-50% deduction: 21.4%, >50%: 22.5%) working in the private hospitals (P < .001) while 34.1%

were affected in the government hospitals. Oncosurgeons (68%) had the provision of transportation to work, more in academic hospitals as compared with nonacademic hospitals (72.7% vs 60.8%, P = .004).

Oncosurgeons were allowed to work in rotation (47%), particularly in tier-1 cities (58.7% vs others, P = .003), in government hospitals (71% vs others, P = .001) (Supplemental File 2 and Figure 1A ).

The results of this study indicate that there were major setbacks to cancer care in tier-1 cities and these hospitals had adopted strategies to combat the pandemic. Hospitals in red zone deferred more surgeries in response to NACT, deferred RT/chemotherapy if only marginal benefit and treatment of preinvasive diseases than in the green zones. The nature of surgeries was not influenced by red zones.

Complex reconstruction and use of technologies were seen more in private hospitals, government hospitals had better preparedness and Preoperative COVID-19 testing has not been recommended in many guidelines given low the positive predictive value of swab testing is 47.3% to 84.3%. 15 Hence, standard precautions are mandatory even if the patient tests negative. However, a COVID-19 positive patient has higher postoperative mortality and morbidity, 16 hence many hospitals recommend preoperative testing. Testing is aptly suited for major and prolonged surgeries, those involving aerosol-generating procedures or having higher morbidity like pancreatic surgery. As expected, due to the fast rates doubling rates of infection the preoperative testing was done more in tier-1 (P < .001), the red zones (P = .06), and academic institutes (P = .057) as compared with tier-3, green, and nonacademic institutes.

In the paucity of an accurate investigation to diagnose this infection with certainty, adequate PPE is paramount, especially in high-risk cases. The N95 respirators mask is recommended for high-risk procedures by the Centers for Disease Control and Prevention of United States 17 and China. 18 In our study, exclusive use of N95 respirators for all surgeries was seen in only 15%, however, the entire surgical team at MD Anderson Cancer Hospitals 19 used N95 respirators for surgeries of the aero-digestive tract. There is a global shortage of PPE and hence decontamination procedures have been described 20 to circumvent this problem. Given that COVID-19 can be transmitted through body fluids and aerosols that are generated during procedure, 21 impermeable gowns are recommended as part of PPE. 22 We noted only a small proportion of the surgeons used impermeable gowns (30%) routinely. Therefore, regular surgical gowns and regular surgical masks seem inadequate to venture into high-risk surgeries. We also saw PPE shortage for the entire surgical team. This is a matter of concern as a small breach can lead to disruption of services.

Breast, HN, gynecology, and colorectal oncology formed the major chunk of oncologic work in India, in agreement with the results of Shrikhande et al. 23 Major surgeries in HPB, CRS/HIPEC, and thoracic oncology are resource-intense procedures with perspectives of PPE use, critical care support, and blood blank supplies, hence we observed that oncosurgeons were reluctant to operate such cases.

Concerns have been raised in MIS due to the isolation of viral particles in plumes of cautery. However, no transmission of infection has been documented through the smoke. Use of high-efficiency particulate air filters, low intra-abdominal pressures during surgery, minimal usage of energy devices, small port sizes, and evacuation of gases before the extraction of the specimen have been recommended. 24 This concern was seen across all the oncosurgeons in our study with a decrease in MIS cases in agreement with the results of Shrikhande et al. 23 Telemedicine options are being explored by many hospitals to maintain the continuum of care, especially for oncologic surveillance.

Being a resource centered project, private and hospitals in tier-1 cities used telemedicine for cancer surveillance and patient care.

Also, telemedicine focuses on patient's capabilities to use digital health services which may be limited in tier-2/3 due to poverty and illiteracy in a developing country.

We propose a "FREE" corridor similar to "GREEN" corridors which are established for an organ transplant. This free corridor shall be a cleared-out route with special permission during lockdown for cancer patients and health care workers to use public/private transport to reach the destined hospital. In this study, we noted that the majority of the cancer hospitals are located in tier-1, which are the red zones. Consequently, this can transmit the infection from a high-risk zone to low-risk zones. This can be overcome by the "DECENTRALISATION" of cancer care. Decentralization would allow cancer care to be within reach of every individual providing additional financial and social security to the patients. We understand that decentralization is a long-drawn process and has political, administrative, and financial connotations. 

We thank all participating oncosurgeons who completed the survey.

All the authors declare that there are no conflict of interests. 

The data that support the findings of this study are available from the corresponding author upon reasonable request. 

Major surgeries peformed by oncosurgeons Breast oncology 109

Abbreviations: COVID, coronavirus disease; HPB, hepato-pancreato-biliary

intensive care units; NGO, nongovernment organization; ORs, operating rooms. REFERENCES 1. Coronavirus disease (COVID-2019) situation reports-176

Cancer management in India during Covid

Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy

Survival impact of increasing time to treatment initiation for patients with head and neck cancer in the United States

Radiotherapy combination opportunities leveraging immunity for the next oncology practice

Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China

Public health challenges in India: seizing the opportunities

Union Budget 2020-21 Budget Highlights

Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic

Location and agglomeration factors predicting retailers' preference for Indian malls

The influence of the SARS-CoV-2 pandemic on esophagogastric cancer services: an international survey of esophagogastric surgeons

History of the FIGO cancer staging system

Sensitivity of Chest CT for COVID-19: comparison to RT-PCR

The effects of COVID-19 on perioperative morbidity and mortality in patients with hip fractures

Personal Protective Equipment: Questions and Answers

For different groups of people: how to choose masks

Changing practice patterns in head and neck oncologic surgery in the early COVID-19 era

N95 mask re-use strategies

Detection of SARS-CoV-2 in different types of clinical specimens

COVID-19): Guidelines on rational use of Personal Protective Equipment

Outcomes of elective major cancer surgery during COVID 19 at Tata Memorial Centre: implications for cancer care policy

SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic

Abbreviations: COVID, coronavirus disease; NACT, neoadjuvant chemotherapy; PAPR, powered air-purifying respirator