COVID-19 safe and fully operational radiotherapy: An AIRO survey depicting the Italian landscape at the dawn of phase 2
2020; Elsevier BV; Volume: 155; Linguagem: Inglês
10.1016/j.radonc.2020.09.049
ISSN1879-0887
AutoresBarbara Alicja Jereczek‐Fossa, Matteo Pepa, Mattia Zaffaroni, Giulia Marvaso, Alessio Bruni, Michela Buglione, Gianpiero Catalano, Andrea Riccardo Filippi, Pierfrancesco Franco, Maria Antonietta Gambacorta, Domenico Genovesi, Giuseppe Iatì, Alessandro Magli, L. Marafioti, Icro Meattini, Anna Merlotti, Marcello Mignogna, Daniela Musio, Roberto Pacelli, Stefano Pergolizzi, Vincenzo Tombolini, Marco Trovò, Maria Cristina Leonardi, Umberto Ricardi, Stefano Maria Magrini, Renzo Corvò, Vittorio Donato,
Tópico(s)Advances in Oncology and Radiotherapy
Resumo•Italy has been slowly reopening after a 10 week lockdown following COVID-19 outbreak.•A survey was administered to Italian RT departments to depict the current scenario.•In P1, RT departments managed to contain contagion with modest workload reduction.•All safety measures, maintained in P2, allowed RT departments to restore activities.•Reorganization of activities will be crucial to prevent the second wave of pandemic. Italy was the first European country heavily involved in the COrona VIrus Disease 19 (COVID-19) pandemic [[1]Lancia A. et al.Radiotherapy in the era of COVID-19.Expert Rev Anticancer Ther. 2020; 1–3https://doi.org/10.1080/14737140.2020.1785290Crossref Scopus (15) Google Scholar], with 294,932 cases and more than 35,000 deaths as of 18th September 2020 [[2]COVID-19 Virus Pandemic – Worldometer. https://www.worldometers.info/coronavirus/. Accessed the 18th September 2020.Google Scholar]. Despite the severity of the pandemic in the so-called Italian phase (P) 1 (18th March–3rd May 2020), radiation therapy (RT) facilities in the country managed to efficiently reorganised themselves to maintain a high standard of care while minimising the risk of contagion for patients and staff [[3]Jereczek-fossa B.A. et al.COVID-19 outbreak and cancer radiotherapy disruption in Italy: Survey endorsed by the Italian Association of Radiotherapy and Clinical Oncology (AIRO).Radiother Oncol. 2020; 149: 89-93Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar]. The safety measures adopted in the country had a positive impact on the epidemiological situation and allowed the authorities to relax the restrictions and introduce, on the 3rd May 2020, the so-called P2 (4th May 2020–today). The present study, which represents the natural evolution of a previous investigation conducted in the middle of P1[[3]Jereczek-fossa B.A. et al.COVID-19 outbreak and cancer radiotherapy disruption in Italy: Survey endorsed by the Italian Association of Radiotherapy and Clinical Oncology (AIRO).Radiother Oncol. 2020; 149: 89-93Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar], aims to query the directors of Italian RT centres, through an online questionnaire, about the approach and measures undertaken during P2 of the COVID-19 pandemic to restore the normal workload and revert to a new normality. The survey (Text of Survey, Supplementary Materials) was sent to 177 Directors of RT facilities, members of the Italian Association of Radiotherapy and Clinical Oncology (AIRO), between the 10th of June and the 13th of July 2020. Eighty-nine anonymous questionnaires (response rate 50%) were received from 18 different Italian regions (Fig., Supplementary Materials S1) within the permitted timeframe. Fifty centres (57.2%) reported modifications in their therapeutic activity both during P1 and P2. Therapeutic and outpatient activity reorganisation between P1 and P2 is summarised in Table 1. As far as clinical activities are concerned, during P1, all the responders but 3 (3.3%) reported a reduction inferior to 30% (62, 70%) or no reduction at all (24, 27%). Transitioning from P1 to P2, 35 (39%) centres reported workload increase, 22 (25%) a complete restart of the activity and 26 (29%) no variation, while only 6 facilities (7%) reported a decrease of activity. Triage procedures put in place during P1 remained active in all facilities during P2 to limit the contagion. Analogously, with regards to admitted patients, most measures adopted during P1 were maintained during P2 (surgical masks, 89 (100%); gloves, 13 (15%); hydro-alcoholic solution prior to entry 59 (66%); interpersonal distancing, 85 (96%)). In P2 a marked increase in the supply of all PPE was registered, especially for FFP2 and FFP3 (from 49.6% to 64% and from 9.6% to 13.5%, respectively, for the radiation oncologists). Meetings were allowed as per usual in 6 (7%) centres, with restrictions (i.e. interpersonal distancing) in 68 (76%), and in remote settings in 37 (42%). Remote working solutions for non-medical staff was maintained in the transition from P1 to P2 in 37 (42%) centres, and an additional 7% (6) of centres also enforced this working modality for radiation oncologists. In P2 a drop in the quarantined personnel was registered, with 80 (90%) of the centres registering no staff in quarantine against 50 (56%) centres during P1. Six and two centres registered 1 and 2 unit of quarantined staff respectively during P2. A single COVID-19 related fatality was reported among the personnel. Thirty-one centres (35%) reported positive or suspect cases among staff. In particular, 15/231 (6.5%) radiation oncologists, 23/302 (7.6%) RT technicians, 13/97 (13%) nurses, 1/49 (2%) administrative units and 2/101 (2%) physicists were tested positive. Thirty-nine (44%) centres reported COVID-19 positive cases among patients both before the start of RT and during treatment in P1 or P2. Out of these, 29 centres discontinued treatment of all positive cases, five proceeded with treatment for asymptomatic patients, and three continued RT for asymptomatic patients excluding chest tumour patients. For patients with a documented contact with a positive subject, the majority of the RT facilities requested a swab (25/48 52.1%) while 9/48 (18.8%) decided for a temporary interruption of the treatment. Fourteen centres instead opted for continuing the treatment, with (10/48, 20.8%) or without (4, 8.3%) extra precautions.Table 1Summary of activity reorganisation in Italian RT departments during Phase 1 and Phase 2 and trend between the two phases.Therapeutic activity reorganisationPhase 1 (18th March–3rd May 2020)Phase 2 (4th May 2020–today)Trend125 respondersN (%)89 respondersN (%)↓No substantial modification39 (31.2)No substantial modification respect to Phase 139 (43.8)↑Procrastinating treatment on a case-by-case basis46 (36.8)Postponed treatments (Phase 1) were re-evaluated on a case-by-case basis41 (46.1)–Optimising home cures of symptomatic patients17 (13.6)Palliative indications have been reallocated as in the pre-COVID-19 period24 (27.0)–Keeping only curative treatments otherwise not procrastinable14 (11.2)Keeping only curative treatments otherwise not procrastinable2 (2.2)↓Favouring of short-term treatments (hypofractionation)51 (40.8)Favouring hypofractionation even when weakly recommended14 (15.7)↓Favouring hypofractionation only when strongly recommended34 (38.2)↓Ongoing treatments interruption for particularly fragile patients5 (0.04)Treatments that had been discontinued were resumed13 (14.6)–Outpatient activity reorganisationPhase 1 (18th March–3rd May 2020)Phase 2 (4th May 2020–today)125 RespondersN (%)89 respondersN (%)No substantial change9 (0.07)No changes since no modification have been introduced during Phase 112 (13.5)↑↑↑Ordinary check-ups have been cancelled80 (64.0)Ordinary check-ups have been reinstated as normal69 (77.5)–Ordinary check-ups remain cancelled9 (10.1)↓First visits have been cancelled2 (0.02)First visits have been restarted11 (12.4)–Telematic consultations activated for cancelled visits54 (43.2)Telematic consultation for cancelled visits15 (16.9)↓List of abbreviations: COVID-19: Coronavirus disease 19; N: number of centres.NB. P1 results refer to the previously published work (Jereczek-Fossa BA, Pepa M, Marvaso G, et al. COVID-19 outbreak and cancer radiotherapy disruption in Italy: Survey endorsed by the Italian Association of Radiotherapy and Clinical Oncology (AIRO) Radiother Oncol. 2020;149:89–93. doi:https://doi.org//10.1016/j.radonc.2020.04.061). P2 results, instead, were collected in the context of the current investigation. Open table in a new tab List of abbreviations: COVID-19: Coronavirus disease 19; N: number of centres. NB. P1 results refer to the previously published work (Jereczek-Fossa BA, Pepa M, Marvaso G, et al. COVID-19 outbreak and cancer radiotherapy disruption in Italy: Survey endorsed by the Italian Association of Radiotherapy and Clinical Oncology (AIRO) Radiother Oncol. 2020;149:89–93. doi:https://doi.org//10.1016/j.radonc.2020.04.061). P2 results, instead, were collected in the context of the current investigation. The previous investigation [[3]Jereczek-fossa B.A. et al.COVID-19 outbreak and cancer radiotherapy disruption in Italy: Survey endorsed by the Italian Association of Radiotherapy and Clinical Oncology (AIRO).Radiother Oncol. 2020; 149: 89-93Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar] revealed that the prime focus of RT centres during P1 was to guarantee the continuity and the safety of the treatments for patients with high-risk conditions, while minimising undue risk for cases for which care can be safely deferred. Thanks to all the adopted measures to limit contagion among staff and patients, the pandemic effect on the Italian RT centres during P1 was, ultimately, modest, with most centres (55, 61.8%) reporting no reduction or a decrease in clinical activity not higher than 10%. Therefore, the average reduction of clinical activities in Italy turned out to be much less marked than that of Europe (38% centres reporting a reduction <80%) and US (84% centres reporting a reduction <80%) [[4]Slotman B.J. et al.Effect of COVID-19 pandemic on practice in European Radiation Oncology Centers.Radiother Oncol. 2020; 150: 40-42https://doi.org/10.1016/j.radonc.2020.06.007Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar]. The preventive measures put in place remained virtually unchanged during the transition from P1 to P2. This was reflected by the proportion of centres registering positive cases which dropped down from 43.8% in P1 to 10.1% in P2, and in the maximum reported number of positive staff cases per centre, which decreased from 18 to 2. The reduction of registered daily cases is imputable to the strict safety measures adopted and not to the decrease in number of treated patients. On the contrary, with the advent of P2, RT Directors globally reported a progressive realignment with the pre COVID-19 era workload for both outpatient and clinical activities, with a partial or complete reactivation of the previously interrupted or postponed treatments, also thanks to the several guidelines published to help clinicians coping with the novel pandemic scenario [5Alterio D. et al.Head and neck cancer radiotherapy amid COVID-19 pandemic: Report from Milan, Italy.Head Neck. 2020; : 1-9Google Scholar, 6Coles C.E. et al.International Guidelines on Radiation Therapy for Breast Cancer during the COVID-19 pandemic.Clin Oncol. 2020; 32: 279-281Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar, 7De Azambuja E. et al.ESMO Management and treatment adapted recommendations in the COVID-19 era: Breast Cancer.ESMO Open. 2020; 5: 1-12Abstract Full Text Full Text PDF Scopus (73) Google Scholar, 8Han K. et al.Management of gynecologic cancer: Choosing radiotherapy wisely by 3 Southern Ontario academic centers during the COVID-19 pandemic.Radiother Oncol. 2020; 151: 15-16Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 9Siavashpour Z. Taghizadeh-Hesary F. Rakhsha A. Recommendations on management of locally advanced rectal cancer during the COVID-19 pandemic: an Iranian consensus.J Gastrointest Cancer. 2020; 51Crossref PubMed Scopus (19) Google Scholar, 10Catanese S. Pentheroudakis G. Douillard J.Y. Lordick F. ESMO Management and treatment adapted recommendations in the COVID-19 era: pancreatic cancer.ESMO Open. 2020; 5Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 11Guckenberger M. et al.Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement.Radiother Oncol. 2020; 146: 223-229Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar, 12Liao Z. et al.Optimizing lung cancer radiation treatment worldwide in COVID-19 outbreak.Lung Cancer. 2020; 146: 230-235Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 13Thomson D.J. 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; https://doi.org/10.1016/j.ijrobp.2020.04.016Abstract Full Text Full Text PDF Scopus (145) Google Scholar, 14Passaro A. et al.ESMO Management and treatment adapted recommendations in the COVID-19 era: Lung cancer.ESMO Open. 2020; 5Abstract Full Text Full Text PDF Scopus (96) Google Scholar, 15Magrini S.M. et al.Letter to the Editor regarding ESTRO-ASTRO guidelines on lung cancer radiotherapy during COVID-19 pandemic.Radiother Oncol. 2020; 147Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 16De Felice F. Polimeni A. Valentini V. The impact of Coronavirus (COVID-19) on head and neck cancer patients' care.Radiother Oncol. 2020; 147: 84-85Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 17Vavassori A. et al.Practical indications for management of patients candidate to Interventional and Intraoperative Radiotherapy (Brachytherapy, IORT) during COVID-19 pandemic – A document endorsed by AIRO (Italian Association of Radiotherapy and Clinical Oncology) Interventional Radiotherapy Working Group.Radiother Oncol. 2020; 149: 73-77Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar]. Therefore, the present survey demonstrated how the planned progressive return to a novel routine during P2 has been attained by most Italian RT centres, maintaining high safety standards against a possible new spread of the infection and registering a lower number of positives cases among both patients and health professionals despite the resumption of a pre COVID-19 era workload. Such reorganisation will be crucial in prevention of the potentially detrimental impact of a possible second wave of pandemic on the society and health system. The institution of authors BAJF, MP, MZ, GM and MCL (IEO, European Institute of Oncology IRCCS, Milan) is partially supported by the Italian Ministry of Health with Ricerca Corrente and 5 × 1000 funds. MZ was supported by a research grant from Accuray Inc. entitled "Data collection and analysis of Tomotherapy and CyberKnife breast clinical studies, breast physics studies and prostate study". The sponsors did not play any role in the study design, collection, analysis and interpretation of data, nor in the writing of the manuscript, nor in the decision to submit the manuscript for publication. The authors wish to thank Lars Johannes Isaksson, MSc for the English revision of the manuscript. The authors wish to acknowledge all the Italian RT Directors who participated in the study. All the responders agreed for the publication of the results of the survey. Those who accepted to be acknowledged in the present work are listed in the Acknowledgments, Supplementary Materials. None.
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