Two months of radiation oncology in the heart of Italian “red zone” during COVID-19 pandemic: paving a safe path over thin ice

Our Department is equipped with a treatment area with four linacs (two Elekta Synergy®, a tomotherapy equipment -Accuray Radixact®- and a Cyberknife®). Of note, Cyberknife® was recently installed and therefore its workload was already limited due to the ongoing process of implementation. Other facilities include an inpatient ward with 22 beds, a Day-Hospital with dedicated rooms for visits and administration of systemic therapies and a brachitherapy unit. Coping with COVID-19 required a profound reorganization with the aim to continue treatment administration. All the personnel was required to wear appropriate personal protective equipment (PPE): surgical masks and gloves through the whole shift and further protections (including FFP-2/3 respirators, waterproof gowns and cuff, face-shield or goggles and shoe-cover) in case of direct contact with suspect or RT-PCR positive patients. Staff members that reported direct contacts with positive or suspect cases or manifested fever or respiratory symptoms were monitored with repeated RT-PCR tests for SARS-Cov-2 on naso-pharyngeal swab.

Patients on active treatment underwent SARS-Cov-2 screening according to the same criteria; they were also guided with detailed instructions regarding social and hygienic rules and required to wear surgical masks and sanitize their hands when accessing the Department. Since the beginning of March, all the people accessing the hospital were screened for body temperature. In addition, we established a day time phone counseling service for cancer patients seeking medical advice; the attending physician was also responsible of the internal triage procedure, run in a dedicated room to evaluate the subjects with suggestive symptoms.

The treatment priority for each indication was evaluated on the characteristics of the patient and the disease, following general principles [5, 6] that were tailored on a case by case basis. Priority was given to treatments with curative intent and which effectiveness could be significantly affected by delay. All the procedures that could be deferred without an outcome impairment were postponed. Prescription of palliative radiotherapy was shifted when possible towards modulation of analgesic or systemic treatment. Scheduled follow-up visits were replaced by telephone interviews whenever possible: reports of imaging and laboratory tests were transmitted by e-mail or fax or retrieved from our hospital’s archiving system, examined and compared to previous evaluations by a physician that afterwards contacted the patient to ascertain his conditions and list a new appointment.

Radiation treatment of positive or symptomatic patients, accordingly to their clinical conditions, was performed on a dedicated linear accelerator (Synergy® 2), at the end of the shift to avoid contacts with other people, using the appropriate PPE and carefully sanitizing the room after each treatment.

Our ward went through a progressive transformation: at first some rooms with assigned nurses and facilities were arranged for isolation, as no rooms in COVID-19 dedicated wards were available during the epidemic peak. In fact, despite five wards of our Hospital were reallocated with this purpose, they were completely occupied due to the inflow of hundreds of patients. Subsequently, the increasing number of positive patients determined a complete conversion of our ward into a “COVID-ward”. At peak, seven positive subjects occupied our rooms, while other patients necessitating hospitalization were transferred to other “clean” wards. Additional preventive measures were implemented: swabs were performed periodically to all our staff and to every patient requiring hospitalization before admission; visits from patients’ relatives were forbidden. Since April 17 our ward returned “COVID-free”, a condition maintained up to date (June 06).

The enforcement of the above mentioned procedures resulted in a relatively limited reduction the overall workload of our four linear accelerators. The number of radiotherapy sessions provided each day is represented in Table 1 and Fig. 1a: the maximum decrease of total treatment number reached 17% and later contracted to 11%. The accelerator dedicated to the treatment of COVID-19 positive or suspect patients suffered a somewhat greater decrease (about 20%) due to time consuming sanitizing procedures that approximately doubled the duration of each session. Conversely, planning of new treatments faced a remarkable reduction (about 50%) throughout the whole month of March due to postponement of deferrable treatments and the need to avoid overcrowding of the waiting rooms. The relative reduction of brachytherapy treatments was mainly due to the deferral of treatment of low risk prostate cancer, while integrated treatments were granted. The administration of systemic treatment did not suffer a significant decrease, with a stable number of about 40–50 weekly accesses and periodic slight deflections unrelated to COVID-19, mainly due to logistical reasons and different treatments’ duration (Table 1, Fig. 1b). Scheduled follow-up visits were postponed or processed through telemedicine as stated above. An almost complete switch towards this modality allowed to maintain an overall stable number of follow up evaluations, as highlighted in Table 1.

Several of our patients considered discontinuation of ongoing life-saving treatments, frightened that hospital accesses could expose them to contagion: ten patients actually refused to start their treatment on the planned date, while no ongoing treatment was stopped for patient’s decision.

Characteristics of the impact of COVID-19 on our personnel are summarized in Table 2 and Fig. 1c. Our staff during the index period included a total of 87 professionals: 15 radiation oncologists, (of whom 5 temporarily employed), 17 radiation oncology trainees, 27 nurses, 22 radiation therapists and 6 physicists (4 full time and 2 part-time assigned to our Department). Nine symptomatic subjects received a positive naso-pharyngeal swab assay for SARS-Cov-2, three tested positive while asymptomatic and seven displayed a distinctive clinical presentation with negative RT-PCR. It has to be noted that all the positive cases among our staff were reported between 2nd and 17th of March. Infection rate was 13.7% among the total staff, with comparable numbers for radiation oncologists, trainees, day-hospital nurses and radiation therapists. No cases were identified within physicists, while 33.3% of ward nurses tested positive. Symptoms were mild and managed with household isolation in almost all cases, with only our ward head-nurse requiring hospitalization for severe pneumonia. A relative shortage of personnel was evident from the second week of March to the first third of April. This required a temporary reallocation to our inpatient ward of three nurses from our day-hospital and of two nurses from the Oncology Department.

Of the 23 patients on active treatment with a suggestive clinical presentation, 13 tested positive and 10 negative for RT-PCR assay. Considering the index period (February 24 to April 24), 402 patients underwent active treatment at our Center, of whom 324 were administered radiotherapy or radio-chemotherapy and 78 only systemic treatments. Therefore, the infection rate among patients receiving active treatment was 3.23% and the mortality rate was 1.24% (5 deaths). Characteristics of the positive patients are outlined in Table 3 and Table 4. Median age was 69.7 years and the large majority of patients were male (84.6%), active or former smokers (84.6%) with an Eastern Cooperative Oncology Group Performance Status (ECOG-PS) of 0–1 (84.6%). The most common cancer type was Non-Small Cell Lung Cancer (NSCLC), totaling 61.5% of cases, followed by Head and Neck Squamous Cell Carcinoma (15.4%); 84.6% were stage III-IV. Almost all the subjects bore comorbidities, with 38.5% presenting three or more, mostly represented by cardiovascular diseases. Timeline of confirmed infections is illustrated in Fig. 1d. Remarkably, 12 of the 13 first positive tests were collected before March 24 and 4 of the 5 deaths occurred within March 16. While two of the deceased were on palliative treatment and already in bad general conditions (ECOG-PS 3), the other three were in initially fair conditions and receiving radical treatments for locally advanced disease. Of the other positive patients, six carried on radiotherapy (in two cases with hypofractionation of the remaining dose) without a break; a single treatment was definitively halted before the planned dose and one underwent a prolonged stop (due to admission to another hospital) and restarted RT 45 days later after dose replanning. Of the 10 patients with suggestive symptoms and a swab negative for SARS-Cov-2, two continued radiotherapy without interruption, three restarted it after a short delay (median of 4 days) and two were admitted to other hospitals with consequent prolonged discontinuation (over 30 days) that will require a new treatment planning; two adjuvant chemotherapy cycles have also been postponed. Suggestive imaging findings were identified on chest X-ray of COVID-19 positive patients in 84.6% of the cases and in all the chest CT-scans performed. All the positive cases were periodically evaluated also by the colleagues of infectious disease and anesthesiology departments and the majority was treated off-label with hydroxychloroquine (84.6%), antiviral drugs (84.6%) and azythromicin (69.2%); three patients also received tocilizumab (23.1%). Six patients (46.2%) developed severe disease, defined as necessity of high-flow supplemental oxygen. Supplemental oxygen was administered to 84.6% of patients and Continuous-Positive-Airway-Pressure to one patient. None of our patients was offered invasive ventilation, due to the absence of indication attributable to prognosis and general conditions in two cases and in three cases also due to the overwhelmingly high number of patients treated at our hospital Intensive Care Unit during the outbreak peak, with consequent lack of available facilities. Six patients were discharged after full clinical recovery and negative RT-PCR on a naso-pharyngeal swab and two were transferred to other institutions at symptoms resolution, although still positive.