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 Table of Contents  
Year : 2021  |  Volume : 12  |  Issue : 2  |  Page : 77-81

Severe acute respiratory syndrome-coronavirus-2 (COVID-19) infection and its impact on cancer patients receiving radiation therapy: Prevalence, protection, and clinical effects

Department of Medicine, Radiotherapy Section, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra, India

Date of Submission01-Oct-2020
Date of Acceptance28-Oct-2020
Date of Web Publication21-Apr-2021

Correspondence Address:
Mr. Umbarkar Prakash
Department of Medicine, Radiotherapy Section, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrcr.jrcr_52_20

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Introduction: COVID-19 illness caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus has been declared a pandemic by the World Health Organization in March 2020. It had an overwhelming effect on health-care delivery in India. We report the 5 months, April–September 2020, experience in our radiotherapy (RT) department. Methods: Since April–September 2020, we registered 184 cancer patients with various site diseases for RT/chemoradiation treatment for curative/palliative therapy. Preregistration and weekly once during treatment period all underwent throat/nasopharynx swab testing with reverse transcription polymerase chain reaction. Dedicated infection prophylaxis was carried for patients and staff. Results: Of the 184 patients, 10.9% (20/184) swab results were positive for SARS-CoV-2. With appropriate COVID-19 care and quarantine, 18 patients completed the planned RT. Two died with COVID-19 infection illness and progressive locoregional cancer. We observed no excess acute RT/chemoradiation effects in this group due to infection. Conclusions: Our 5-month experience in this COVID-19 pandemic period reveals that RT treatment, COVID-19 care, and quarantine can be done with dedicated infection protective measures.

Keywords: COVID-19, radiotherapy, severe acute respiratory syndrome-coronavirus-2

How to cite this article:
Venkatesan K, Vivek J A, Sudesh D, Prakash U, Bajpai R, Kabre R, Hinduja R, Alurkar P, Naidu S, Chauhan K, Shinde S, Parmar N, Jejurkar A, Kamble P, Ullagaddi S, Jadhav O, Tawde M, Nambiar J, Rohekar R, Goraksha P, Dharia R. Severe acute respiratory syndrome-coronavirus-2 (COVID-19) infection and its impact on cancer patients receiving radiation therapy: Prevalence, protection, and clinical effects. J Radiat Cancer Res 2021;12:77-81

How to cite this URL:
Venkatesan K, Vivek J A, Sudesh D, Prakash U, Bajpai R, Kabre R, Hinduja R, Alurkar P, Naidu S, Chauhan K, Shinde S, Parmar N, Jejurkar A, Kamble P, Ullagaddi S, Jadhav O, Tawde M, Nambiar J, Rohekar R, Goraksha P, Dharia R. Severe acute respiratory syndrome-coronavirus-2 (COVID-19) infection and its impact on cancer patients receiving radiation therapy: Prevalence, protection, and clinical effects. J Radiat Cancer Res [serial online] 2021 [cited 2021 Jul 28];12:77-81. Available from: https://www.journalrcr.org/text.asp?2021/12/2/77/314253

  Introduction Top

COVID-19 illness caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus infection is characterized by droplet transmission in humans. Cancer patients and age above 60 years have been identified as risk factors in contacting the infection.[1] It was found to be associated with high burden of severity in patients with lung cancer along with their smoking status and presence of chronic obstructive pulmonary disease.[2]

This prospective report from a tertiary health center presents the demographics, diagnosis, comorbidities, and tolerance to radiotherapy (RT)/chemoradiation in COVID-19-positive patients. Furthermore, patient and RT staff protective measures carried out, have been presented in this paper.

  Materials and Methods Top

COVID-19 Tests, Patient/Staff Protection, Radiotherapy Plan, and Treatment Procedures

Following our hospital guidelines, we initiated COVID-19 swab testing for SARS-CoV-2 on April 10, 2020. When a cancer patient was registered for RT planning simulation CT scan, they need to come with COVID-19 swab reverse transcription-polymerase chain reaction (RT-PCR) test report which should be negative. During the RT treatment course, patients were advised weekly once COVID-19 swab test if the treatment period extends for more than 1 week. This was one of the recommendations from Perrino Hospital, Brindisi, Italy.[3] The COVID-19 swab from patient's throat/nasal/nasopharyngeal region was analyzed with RT-PCR test. Any patient who tested positive after registration and during the treatment period were subjected to COVID-19 care treatment and quarantine for 17 days and during this time, they did not report for RT.

All RT staffs during the working hours were covered in proper personal protection equipment (PPE), which included headcover, eye goggles, visor face shield, 3-ply surgical face mask/N95 face mask, whole-body operation theater dress cover, hand gloves, and shoe cover. The daily staff-patient interaction was carried out through the window, which had Perspex sheet cover. All the staffs were taught to maintain a minimum of 3 feet physical distance from each other and from the patient. Weekly twice the department was fumigated.

Since April 2020, RT technologists were on duty once in 3–4 days, thereby reducing the chances of exposure to infection. Due to complete city lockdown, our hospital had made arrangements to provide proper social/physical distance, maintaining transport from home to office and return for the workers.

On day 1 after registration, appropriate immobilization was prepared for the treatment region followed by axial computed tomography (CT) scan with the patient having a face mask except for the head-and-neck cancer patients. The brain and pelvic tumor patients also had magnetic resonance imaging (MRI) done and fusion CT-MRI images were used for volume contour and RT planning. Radiation dose plan was either three-dimensional conformal radiotherapy or intensity-modulated radiation therapy (IMRT) (volumetric modulated arc therapy [VMAT]-arc plan). More than any other site head and neck poses the greatest chances of infection between the COVID-19 suspect patient and the RT service provider.[4] From May 2020, the additional safety measure of protection for staff by use of face mask for patient simulation and daily RT treatment even in head-and-neck cancer patient was implemented [Figure 1] and the plan was made such that the bolus effect when not needed was avoided on lips, nose, and cheek [Figure 2].
Figure 1: Head-and-neck cancer patient wearing a face mask while receiving radiotherapy

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Figure 2: Radiotherapy treatment beam avoiding the bolus effect on lips, nose, and cheek

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RT was delivered in linear accelerator with 6 MV X-rays. All patients had daily online kV X-ray image/cone-beam CT scan done in linear accelerator. This daily online imaging for every treatment setup enabled the technologists to spend minimal time with the patient inside the linear accelerator room and was of great help in proper alignment of the field center to the RT beam plan. The total dose range was from 8 Gy to 70 Gy. It was 8 Gy for the ALL patient for craniospinal cerebrospinal fluid (CSF) region before bone marrow transplant. The dose per fraction was 1.6–2 Gy and weekly five fractions were delivered from Monday to Friday. NCCN 2019 guidelines were followed for oncological care consisting of RT/chemoradiation.

All patients were assessed for acute reactions to treatment at least twice a week during the RT course. Symptomatic medications were prescribed for acute RT effects. All RT completed patients have been followed till September 2020.

This study is as per the ethical guidelines of the hospital.

  Results Top

Over the 5-month period between April 10, 2020, and September 10, 2020, 184 patients with cancer diagnosis involving various sites registered for RT treatment. Out of a total of 584 COVID-19 swab RT-PCR tests, which were done, 20 were positive for SARS-CoV-2. That is, 20 out of 184 patients, 10.9%, developed SARS-CoV-2 infection and the patient details are in [Table 1].
Table 1: Characteristics of COVID-19 swab positive patients

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In these 20 COVID-19 swab positive patients, there were 12 females and 8 males. The median age was 47 years. Thirteen patients were <60 years of age. Comorbidities, single or multiple (hypertension, diabetes mellitus, bronchial asthma, chronic kidney disease, and ischemic heart disease), were present in 8. The primary cancer sites were: breast 5 (includes one treated for brain metastasis), head and neck 6, lymphoma/leukemia 3, uterine cervix 3, brain 2, and urinary bladder 1. Seventeen were treated as outpatient and three as inpatient.

Of these 20 patients, 3 after CT scan simulation for RT planning became positive before start of RT. The other 17 patients became positive for COVID-19 swab test during RT course. Only one patient, with ALL, had fever as a symptom when the COVID-19 swab test was positive. None of the other 19 patients had any COVID-19 illness symptoms on the day the swab was positive or 14 days before that.

After COVID-19 diagnosis, eight needed in-patient treatment. Two had locally advanced tumor, one with thalamic glioma and the other, a case of carcinoma bladder with progressive pelvic mass with uremia. Both died in hospital with COVID-19 disease. The patient with ALL was treated in intensive care unit (ICU) with antiviral medications, oxygen and had a stormy course. He recovered fully well and completed the RT course. Five patients, three with head-and-neck cancer, 1 with NHL of the iliac bone, and 1 patient with brain metastasis, following hospital admission, were treated with antiviral medication and symptomatic therapy. No ICU care was needed. Following recovery, they reported to complete RT.

The remaining 12 patients had only home care management as the COVID-19 disease symptoms were nil to minimal. Following the quarantine period, they completed the planned RT schedule.

In 18 patients who have completed the treatment, there were no excess acute RT effects of added COVID-19 infection till the date of the last follow-up. However, the infection-related quarantine did lead to prolongation of RT overall treatment time. Ten patients had RT time dose gap correction done [Table 1]. All the four breast cancer patients treated to breast/chest wall with or without nodal RT had only a maximum of G-2 skin reaction. None had moist skin reaction. In the six head-and-neck cancer patients, four developed Grade 2 mucositis and needed nonsteroidal anti-inflammatory drugs. The other two had only Grade 1 mucositis. All maintained good oral intake. None required feeding tube for nutrition. The Grade 2 glioma patient treated with RT and temozolomide tolerated the treatment well without any features of increased intracranial tension and blood counts were normal. The other six with RT to para-aortic region/pelvis/sacrum-ilium/CSF completed the RT without any significant adverse effects.

In the short follow-up period till September 2020, none of the cancer patients with adjuvant RT had recurrent tumor. All the patients with radical RT/chemoradiation achieved either partial or complete response to treatment. The palliative RT in larynx tumor leads to excellent symptomatic improvement. The brain metastasis patient and lymphoma group, post-RT, are yet to report for follow-up to assess the response. The ALL patient after RT went on for bone marrow transplant preparation.

  Discussion Top

Diagnosis and management of cancer patients should not be compromised during the infectious disease pandemic. RT treatment requires the patient to report daily to the RT center for a median of 4 weeks. Commonly, the patients are outpatients and report from various parts of city, which can sometimes be high infection zones. SARS-CoV-2 particles might remain viable for up to 72 h have implications for both patient and staff safety.[5] This brings in the concept of enhanced and adequate protection measures to reduce the infection both to the patient and to RT staff.

Social/physical distancing of RT staff and with patients has been advised to reduce the infection chances. This we did by reducing the patient load in the treatment machine and also made shift duty[6] for all RT staff which led to less crowding in the department. PPE provision to all the staffs along with Perspex covered windows for staff-patient interaction provides a major protective effort for infection prevention. In Massachusetts, USA, implementation of universal masking for health care workers reduced the infection rate significantly from 14.7% before mask implementation to 11.5%.[7] Complete daily history documentation and vital parameters check-up reduced the chances of infected patients being handled by the staff.

To identify the possible infection in patients, Portaluri et al., from Italy, suggested weekly COVID-19 swab tests in patients on RT. Implementing this, we identified 10.9% of our patients to be infected. However, nearly all except one were asymptomatic for COVID-19 illness.

Applying the existing technology like daily portal kV/CBCT online imaging by the technologists for patient alignment to RT reduces their exposure time with the patient inside the treatment room. This procedure we implemented in May 2020. Medical physicists chipped in with their plan of IMRT-VMAT, avoiding the RT beam through the face mask and this greatly added the protection to the RT technologists by treating the head and neck cancer patients with mask covering the face.

The safety of cancer treatment for the patients in the pandemic time was reported from the Institute of Cancer and Genomic Sciences, UK, where 800 patients from March to April 2020 with a diagnosis of cancer and symptomatic COVID-19 were analyzed. The mortality rate was 28%. This was related to advancing age, male gender, and presence of hypertension and cardiovascular disease. Cancer directed treatment like RT did not increase mortality risk.[8] In our group 20 cancer patients, 18 completed the planned RT but two with advanced progressive malignancy, died of tumor progression and COVID-19 infection and illness.

From Henri Mondor Breast Center, France, Grellier et al.[9] observed COVID-19 infection pneumonitis in a breast cancer patient in the incidentally treated lung area during breast RT. At the time of their reporting, she was still in oxygen-dependent situation. In the four breast cancer patients in our study, all were asymptomatic and had no infection features clinically or had any X-ray findings. All four completed the planned RT course without any untoward side effects.

The authors from Zhongnan Hospital, Wuhan, China, opined that the potential for infection was associated with recurrent hospital visit.[10] Recurrent hospital visit for a median of 20 days in 4 weeks our series is a part of RT treatment. However with proper patient and staff safety measures, we were able to limit the infection rate to 10.9%. However, for the two with progressive disease who died, all the others have recovered fully.

  Conclusions Top

During the 5-month period of April–September 2020, 10.9% of patients reporting for RT became positive for SARS-CoV-2 infection. Thirteen were <60 years of age. Except one with ALL who had a fever, none of the other patients had any COVID-19 illness-related signs or symptoms before they tested positive for SARS-CoV-2. In 18 patients who have completed teleradiation, there were no increased RT acute effects because of SARS-CoV-2 infection.

COVID-19 infection prevention with enhanced protection for the RT staff evolved in the months of April and May 2020. This included the shift duty, complete PPE, Perspex shielded windows for interaction, appropriate physical distancing, and infection identification with weekly COVID-19 tests. The protection measures were reinforced with daily online imaging for quick patient positioning and alignment in linear accelerator and treating all patients including head-and-neck cancers with face masks.

Our RT health-care delivery in this 5-month pandemic time reveals that with proper safety and protection, there was no compromise in appropriate radiation treatment to cancer patients.

We dedicate this report to all our patients who in spite of their cancer illness followed the hospital guidelines for COVID-19 testing and personal protection during this period.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Yu J, Ouyang W, Chuo ML Xie C. SARS-CoV-2 transmission in patients with cancer at a tertiary care hospital. JAMA Oncol 2020;6:1108-10.  Back to cited text no. 1
Luo J, Rizvi H, Preeshagul IR, Egger JV, Hoyos D, Bandlamudi C, et al. COVID-19 in patients with lung cancer. Ann Oncol 2020;31:1386-96.  Back to cited text no. 2
Portaluri M, Bambace S, Tramacere F, Errico A, Carbone S, Portaluri T. Staff and patient protection in radiation oncology departments during coronavirus disease 2019 (COVID-19) pandemic. Adv Radiat Oncol 2020;5:628-30.  Back to cited text no. 3
Yanagihara TK, Holland RE, Chera B. Practical challenges of mask-to-mask encounters with patients with head and neck cancers amid the coronavirus disease 2019 pandemic. Adv Radiat Oncol 2020;5:651-5.  Back to cited text no. 4
Al-Shamsi HO, Alhazzani W, Alhuraiji A, Coomes EA, Chemaly RF, Almuhanna M, et al. A practical approach to the management of cancer patients during the novel coronavirus disease 2019 (COVID-19) pandemic: An international collaborative group. Oncologist 2020;25:e936-45.  Back to cited text no. 5
Combs SE, Belka C, Niyazi M, Corradini S, Pigorsch S, Wilkens J, et al. First statement on preparation for the COVID-19 pandemic in large German Speaking University-based radiation oncology departments. Radiat Oncol 2020;15:74.  Back to cited text no. 6
Wang X, Ferro EG, Zhou G, Hashimoto D, Bhatt DL. Association between universal masking in a health care system and SARS-CoV-2 positivity among health care workers. JAMA 2020;324:703-4.  Back to cited text no. 7
Lee LY, Cazier JB, Angelis V, Arnold R, Bisht V, Campton NA, et al. COVID-19 mortality in patients with cancer on chemotherapy or other anticancer treatments: A prospective cohort study. Lancet 2020;395:1919-26.  Back to cited text no. 8
Grellier N, Hadhri A, Bendavid J, Adou M, Demory A, Bouchereau S, et al. Regional lymph node irradiations in breast cancer may worsen lung damage in Coronavirus disease 2019 positive patients. Adv Radiat Oncol 2020;5:722-6.  Back to cited text no. 9
Chua ML, Yu J, Xie C. Letters: Comment and response. JAMA Oncol 2020;6:1472-3.  Back to cited text no. 10


  [Figure 1], [Figure 2]

  [Table 1]


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