key: cord-0890578-npi03i7q authors: Malicki, J; Martenka, P; Dyzmann-Sroka, A; Paczkowska, K; Leporowska, E; Suchorska, W; Lamperska, K; Pieńkowski, P; Chicheł, A; Mocydlarz-Adamcewicz, M; Urbaniak, D; Bajon, T; Cybulski, Z; Bąk, B; Machtyl, A; Adamska, K; Kaźmierska, J; Milecki, P; Marszałek, A title: Impact of COVID-19 on the performance of a radiation oncology department at a major comprehensive cancer centre in Poland during the first ten weeks of the epidemic date: 2020-08-16 journal: Rep Pract Oncol Radiother DOI: 10.1016/j.rpor.2020.08.001 sha: a6f03d1b52596a08c07ca68afe5f9d1458a23a9d doc_id: 890578 cord_uid: npi03i7q The outbreak of SARS-CoV-2 coronavirus rapidly altered radiotherapy service delivery around the world. Aim. The main objective of this study was to assess the impact of precautionary measures implemented in response to the COVID-19 pandemic on the performance of a radiation oncology departments and on mitigation the risk of COVID-19 contagion between and among patients and staff. Methods. The study period was from March 15 until May 22, 2020. We evaluated total number of patients irradiated and those who initiated treatments, taking into account tumours localisations. We assessed the relationship of potential risk of contagion with patients’ domiciles locations in regions with high number of COVID19 case. Results and conclusions. The number of patients treated with radiotherapy during the study period decreased due to precautionary measures. After five weeks, the number of radiotherapy treatments began to increase. Just over half of the radiotherapy patients (53.5%) treated at the GPCC reside in the city of Poznan or in one of the ten surrounding counties where COVID19 incidence was low and reached at the end of the study period cumulative number of cases n = 204. The precautionary measures were effective qRT-PCR tests were performed in 1545 individuals (patients and hospital staff) revealing four staff members and none patient with a positive PCR result. Immunoglobulin testing was performed in 1132 individuals (patients and hospital staff). A total of 63 individuals were positive for antibodies. The outbreak of SARS-CoV-2 coronavirus disease started in 2019 (COVID-19) has and rapidly altered radiotherapy service delivery around the world. 1, 2, 3, 4, 5 However, the specific precautionary measuares implemented at cancer centres and radiation oncology departments have varied widely depending on local factors and situation. 6, 7, 8 An important factor influencing the measures implemented is the incidence of COVID-19 in the area where patients and hospital staff live. 9, 10, 11 In response to the COVID-19 pandemic, in March 2020 the government of Poland implemented a series of measures designed to limit public activities (https://koronawirusunas.pl/; accessed from 8 th of March. The specific measures are shown in Table 1 by date of implementation. Table 1 . Specific measures designed to limit public activities due to COVID-19 spread by date of implementation. Insert Table 1 The restrictions related to COVID-19 have affected many aspects of daily life. Health care system was also influenced. Due to the risk of widespread contagion and the restrictions imposed by the state of epidemic, treatment for medical conditions unrelated to COVID-19 has been severely affected, including radiotherapy for cancer patients. Although radiotherapy can be conditionally interrupted or postponed in some patients, However, in most cases uninterrupted radiotherapy is essential for optimal treatment effects. However, during the pandemic status, radiation oncology departments worldwide have been forced to implement numerous prophylactic and precautionary measures. To our knowledge, the impact of these precautionary J o u r n a l P r e -p r o o f measures on radiation therapy for patients with cancer in Poland has not been assessed, till now. The main objective of this study was to assess the impact of precautionary measures implemented in response to the COVID-19 pandemic on the performance of a radiation oncology departments in given cancer centre in Poland. Secondly, we describe the measures introduced to reduce the risk of COVID-19 contagion between and among patients and staff. This observational study was performed to assess the impact of the COVID-19 epidemic-specifically, the precautionary measures implemented at our centre (Greater Poland Cancer Centre; GPCC)-on the clinical practice of radiation oncology at our centre. To assess the impact of these measures, we determined the number of patients treated with radiotherapy during the 10-week period from March 15 to May 22, 2020 at the peak of the pandemic restrictions and compared these to the usual number of patients treated prior to the pandemic. We also sought to correlate the place of residence of both patients and staff with the severity of the epidemic (i.e., the incidence rate) in that region. To mitigate the risk of disease spread to or among staff and patients, the GPCC and the radiation oncology department introduced a series of precautionary measures. All efforts were directed to minimize the risk that anyone (patient or staff member) infected by SARS-CoV-2 would enter the hospital or radiation oncology department. These measures included the establishment of a new designated laboratory to perform testing for COVID-19, with the daily capacity to evaluate 100 nasopharyngeal swab samples (using quantitative reverse-transcription polymerase chain reaction [qRT-PCR]) and 100 serum antibody tests. Importantly, this testing activity did not alter in any way the regular laboratory work related to diagnostic tests for cancer patients. For qRT-PCR testing, the swab was obtained from the posterior wall of the nasopharynx. Viral RNA was automatically isolated using MagCore Viral Nucleic Acid Extraction Kit (RBC Bioscience, Taiwan). RT-PCR was performed using the qPCR SARS-CoV-2 kit (Vitassay Healthcare S.L.U, Spain) and the CFX96 Touch Real-Time PCR Detection System (Bio-Rad, CA). Anti-SARS-CoV-2 antibodies, such as immunoglobulin M and G (IgM and IgG) antibodies in serum were determined using the COVID-19 Rapid Test Kit (Biopanda Reagents Ltd. Belfast, United Kingdom) and 2019-nCoV IgG/IgM Detection Kit (Nanjing Vazyme Medical Technology Co., Ltd. Nanjing, China). These tests used qualitative immunochromatography methods for the detection of IgM and IgG antibodies to SARS-CoV-2. For the reason of assessing the potential risk of contagion by patients' domiciles locations in regions with high number of COVID19 case, we used outcomes for a year of 2013 from the study performed by Paczkowska. 12 The population of the city of Just over half of the radiotherapy patients (53.5%) treated at the GPCC reside in the city of Poznan or in one of the ten surrounding counties ( Figure 1 ). Table 2 . Insert Figure 1 The most populous regions in the hospital's coverage area are the city and county of Poznan, where more than one-third of radiotherapy patients (35.3%) reside, J o u r n a l P r e -p r o o f according to data from a study conducted in 2013. 12 We used these data for the patients in the study period (March 15 to May 22, 2020). Note that the percentage of oncology patients treated with radiotherapy at the GPCC with domiciles in the city and county of Poznan was 33.6% lower than for whole Poznan subregion (grouping all 11 counties) and lower than the figure (52%) calculated for Poland in the ESTRO-HERO study. 13, 14 The geographic origin (i.e., place of residence) of patients treated with radiotherapy at the GPCC is shown in Table 2 . Table 2 . Geographic origin (city or county of residence) of patients who received radiotherapy at the Greater Poland Cancer Centre in 2013. The table shows the subregions with major cities, counties, population, cancer incidence, number of patients from each region, and percentage of patients from each region relative to the cancer incidence in that subregion. 12, 15 Insert Insert Table 3 As In the Greater Poland region, with a population of 3.473 million inhabitants (2019 data) [ Europejski Urząd Statystyczny ], the incidence of COVID-19 varied highly from county to county (Table 4 ). During the study period, the number of COVID-19 cases Table 4 . Cumulative incidence of COVID-19 as of May 22, 2020 in the Greater Poland region by county (https://koronawirusunas.pl/wojewodztwo-wielkopolskie and https://stat.gov.pl/obszary-tematyczne/ludnosc/ludnosc/ludnosc-stan-i-strukturaludnosci-oraz-ruch-naturalny-w-przekroju-terytorialnym-stan-w-dniu-31-12-2019,6,27.html). Insert Table 4 Screening for COVID-19 at the GPCC J o u r n a l P r e -p r o o f To detect the presence of COVID-19 among radiotherapy patients, we targeted three main patient subgroups for screening. The primary target for qRT-PCR testing were patients admitted for chemoradiotherapy (mainly those with head and neck cancer) as these patients were expected to be hospitalised for several weeks and it was essential to minimise the risk of infecting other patients or staff. These patients underwent screening tests on their first arrival or admission (due to repeated treatments) to the hospital. The second group comprised patients staying at hotels/hostels located near the hospital. In this group, testing was considered necessary because most of these patients were expected to spend substantial time at the hospital (daily visits to receive radiotherapy treatments). The third group consisted of patients residing in the region who received daily radiotherapy on an outpatient basis. For this group, the main precautionary measures included a careful check at the main entrance to the hospital for any sign of infection, which included questions about the presence of possible COVID-19 symptoms and a body temperature check. Pulse oximetry was performed in some patients, with random qRT-PCR testing as well. Anti-SARS-CoV-2 immunoglobulin (IgM and IgG) testing was also performed. Starting on March 15, 2020 precautionary measures were introduced for departmental staff (nurses, technicians, physicians and administrative staff). One measure was to divide the staff into two groups with separate shifts. Another measure was to limit the number of patients scheduled for radiotherapy (two patients per hour). All hospital staff (n=1200) also underwent PCR testing for COVID-19 infection, and anti-SARS-CoV-2 immunoglobulin (IgM and IgG) testing (repeated regularly). Table 5 shows the distribution of staff members by professional groups. Table 5 . Results of genetic qRT-PCR from nasopharyngeal swab samples and antibodies from blood serum. Abbreviations: PCR -polymerase chain reaction, IgM, IgG: immunoglobulin type M, G. Insert Table 5 Precautionary measures implemented in the radiation oncology department Due to the size (in terms of number of employees) of the GPCC and its coverage area, the institution has a total of four radiotherapy departments, two located in the same hospital in Poznan and two others sites located in Kalisz and Pila. The first precautionary measure, taken on March 15, was the creation of separate areas for patients, including separate entrances with control posts. In addition, no new patients were scheduled for treatment during the week of March 15-20 in order to prepare for the implementation of these measures. Some hospital staff members were advised to stay at home, particularly these whose presence could be spared when precautionary measures were newly tested and those who could performed distant work from home . Starting the week of March 23-28, the department working J o u r n a l P r e -p r o o f hours were extended and shifts introduced to minimize the number of patients in the department at any one time. A limit of two patients/hour on the linear accelerators was introduced. The use of surgical masks was mandatory for all outpatients. inpatients were excepted from this obligation (tested on admittance to the hospital and therefore considered COVID19 free). In the following weeks, the department staff was provided with visors and the treatment rooms were equipped with thermometers to check the patients' body temperature in cases with suspected symptoms of infection. A brief questionnaire was introduced to assess the patients' health status and possible contact with individuals positive for COVID-19, and about visits to known disease "hot spots" (e.g., the counties of Krotoszyn and Kalisz). Every week thereafter, we reviewed the case mix and status of treated patients based on radiotherapy accepting new patients who met newly elaborated national and international radiotherapy and COVID-19 guidelines. 8, 16 The main aim of this observational study was to assess impact of safety measures implemented at our hospital to prevent the spread of COVID-19 on the performance of our radiation oncology department. Specifically, we assessed the impact of these measures on the number of patients who received radiotherapy on a daily and weekly basis during the study period. We observed a substantial decrease in the number of patients undergoing daily radiotherapy treatment from 301 per day (pre-epidemic) to a low of 190 in late April, a reduction of nearly 37%. However, these numbers began to rapidly increase in the following weeks, reaching 268 patients in the next few weeks. Similarly, in the pre-pandemic period, the mean number of weekly The Greater Poland region is among the largest in Poland and it is the second largest by area (29826.5 km²) and the third largest by population (3,367,016). In the year 2013, the annual incidence of cancer diagnoses in this region was 15,049 cases, with a mean of 289 new cancer cases and 139 deaths per week, which is a significantly greater number of deaths than caused by COVID-19. 15 In the context of a pandemic such as COVID-19, numerous factors must be cosidered when planning radiotherapy treatment. Clearly, a full workload is not possible due to staff shortages (nonoverlapping shifts, social leaves to attend children owing to pandemic social regulation) and the extended period of time required between consecutive patients (to minimize risks of disease spread amongst patients in waiting areas). In some patients, treatment can be safely postponed until the epidemic abates, or the hospital has implemented sufficient measures to allow for a larger caseload. In our sample, some patients decided to postpone treatment initiation for a short poriod. The precautionary measures implemented during the epidemic helped to keep the J o u r n a l P r e -p r o o f hospital and radiotherapy environment safe. Similar approach and observations were reported in rapidly growing number of publications. 1, 2, 3, 4, 5, 6, 7 The precautionary measures taken at our centre had a major impact on radiotherapy treatment. As Table 2 shows, fewer new patients received treatment during the study period compared to the weekly average for the early period of 2020 (before COVID 19 empidemia). Interestingly, patient numbers were, at least initially, primarily affected by national restrictions, which were introduced on March 15 (see Table 1 ). The precautionary measures introduced at our hospital started the following week. The weekly number of new patients did not recover pre-epidemic levels until May 4-8, which was the 8 th week after the introduction of these extraordinary measures at the GPCC. These figures reflect the improvement in the epidemic in the Greater Poland province, as shown in Figure 3b ). At the same time, the daily number of new COVID-19 cases for the whole Poland continued to rise (a wide plateau rather than a peak). We believe that the combination of practical and psychological adjustments to the new situation and safety measures amongst both staff and patients created a path to bring the department's performance rapidly back to the pre-epidemic period. Although there were two counties (Kalisz and Krotoszyn) with a high incidence of COVID-19 cases in the Greater Poland region, this did not materially raise the risk of COVID-19 spread because the number of patients from these counties treated with radiotherapy at the GPCC in Poznan was limited. The patients from these two hot spots in fact used to choose the satellite radiotherapy department in Kalisz. The current situation reflects the establishment of this satellite in 2017 on demand of patients organisations who opted for shorter than to Poznan distance from their domiciles to radiotherapy service. 17 , 18 , 19 In radiotherapy department in Kalisz social distancing and other measures could be more effectively introduced because this satellite department is much less crowded by patients and visitors. Noteworthy, most of the staff live in or near Poznan (city or county), where the incidence of COVID-19 was relatively low (< one new case/per day). For practical reason, we believe that it is more reasonable to assess the prevalence of COVID-19 in the regions where staff and patients live, rather than evaluating data for whole country of Poland. Treatment initiation for certain patients was temporarily suspended, however, as radiotherapy cannot be postponed indefinitely, therefore, once all necessary precautionary measures were put in place, the number of patients treated with radiotherapy gradually increased, as shown in Tables 1 and 2 . Although the number of patients treated daily have not yet reached the pre-pandemic levels (now 268 vs. 301), the trend is clear, confirmed by the number of patients initiating radiotherapy each week. In the last two weeks of the study period, the numbers significantly exceeded the pre-epidemic weekly average of 102.4. Therefore, we expect to return to pre-epidemic performance of the radiotherapy department in the very near future. The number of patients treated with radiotherapy during the study period decreased due to precautionary measures, as well as to the patients' own decisions to postpone radiotherapy. After five weeks, the number of radiotherapy treatments began to increase. The precautionary measures were effective and we did not detect any spread of COVID-19 among staff or patients in the radiotherapy departments. Letter from Italy: First practical indications for radiation therapy departments during COVID-19 outbreak Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement Therapy During the COVID-19 Pandemic: An ASTRO-ESTRO Consensus Statement. International Journaln of Radiation Oncology International Guidelines on Radiation Therapy for Breast Cancer During the COVID-19 Pandemic International expert consensus statement regarding radiotherapy treatment options for rectal cancer during the COVID 19 pandemic. 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