Optimizing Cancer Hospital Services in the Era of COVID-19 Pandemic

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Musab Riaz http://orcid.org/0000-0002-5679-7878 Muhammad Tayyab Babar http://orcid.org/0000-0002-3736-5076 Khalida Khurshid http://orcid.org/0000-0003-0015-0204 Attia Gul Muhammad Mubashar Hussain


The public sector cancer hospitals in Pakistan adopted a resource constrained approach to optimize cancer care delivery to their patients owing to the challenges imposed by COVID-19 pandemic. The cancer patients are immune-deficient, with lymphopenia and neutropenia, either due to the disease process or treatment induced (chemotherapy or radiotherapy). This makes them more vulnerable to all sorts of infections including COVID-19. The smart lockdown approach and transport restrictions enforced by the government remained very effective in controlling the spread of COVID-19, however these brought numerous logistic hurdles both to the cancer patients as well as to the cancer care providers. To prevent overcrowding at the workplace and maintain social distancing, the entire hospital staff was put on staggered duties and patients’ appointments were limited and curtailed.  A triage was set at hospital entry point where COVID-19 risk scoring was carried out to filter out patients as well as hospital staff suspected of COVID-19. A pass “COVID-19 risk score” of less than 3 was set to allow entry into the hospital. Awareness posters were displayed at hospital entry point, reception, registration, and waiting areas to guide patients and public about COVID-19 and the importance of adopting the preventive measures such as wearing of facemasks, hand sanitation and social distancing. The education and training of hospital staff regarding COVID-19 prevention, infection control, sanitization and disinfection of hospital building and equipment, donning and doffing of personnel protective equipment (PPEs) was carried out side by side. The cancer care services in nuclear medicine department were curtailed. All non-urgent nuclear medicine scans and aerosol generating procedures such as lung ventilation scan, cardiac stress testing and I-131 nuclear medicine therapy were cancelled or delayed. Alternate testing measures and other supportive therapies were prescribed, and patients were counseled to remain in contact with the hospital through teleconsultation.  In oncology department all indoor admissions were closed and patients were put on faster “day-care metronomic chemotherapy regimens” or oral maintenance therapies. In radiotherapy department radiotherapy start (RT-Start) prioritization was adopted, after a detailed peer review of each individual patient keeping in mind the urgent or emergent clinical state of the patient without compromising the treatment outcome.  During the COVID-19 pandemic, out of the 2091 cancer patients who underwent radiation treatment 27.6% were treated under priority-1 (RT-start within a week), 29.3% were treated under priority-2 (RT-start between 1-4 weeks) and 43.1% were treated under priority-3 (RT-start after 4 weeks). The radiotherapy workload volume was reduced by changing the standard of care radiation treatment protocols to quicker “hypofractionantion protocols” with similar treatment outcome, approved for pandemic situations by national and international radiation oncology societies. We found that this multifaceted optimization applied at various levels in our hospital helped in mitigating COVID-19 spread to the cancer patients along with continued and uninterrupted delivery of services by the hospital, during the era of COVID-19 pandemic.

Keywords: Cancer Hospitals, COVID-10, Pandemic, Optimization, Metronomic Chemotherapy, Radiotherapy, Prioritization, Nuclear Medicine

Article Details

How to Cite
RIAZ, Musab et al. Optimizing Cancer Hospital Services in the Era of COVID-19 Pandemic. Medical Research Archives, [S.l.], v. 10, n. 10, oct. 2022. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/3144>. Date accessed: 19 june 2024. doi: https://doi.org/10.18103/mra.v10i10.3144.
Review Articles


1. Cancer Hospitals. Paec.gov.pk. https://paec.gov.pk/Medical/. Published 2022. Accessed August 11, 2022.
2. Cheng S, Chang Y, Fan Chiang Y et al. First case of Coronavirus Disease 2019 (COVID-19) pneumonia in Taiwan. Journal of the Formosan Medical Association. 2020;119(3):747-751. doi:10.1016/j.jfma.2020.02.007
3. Cucinotta D, Vanelli M. WHO Declares COVID-19 a Pandemic. Acta Biomed. 2020;91(1):157-160. Published 2020 Mar 19. doi:10.23750/abm.v91i1.9397
4. Kalinke U, Barouch DH, Rizzi R, et al. Clinical development and approval of COVID-19 vaccines. Expert Rev Vaccines. 2022;21(5):609-619. doi:10.1080/14760584.2022.2042257
5. Khan K, Bhatti W. Pakistan reports first coronavirus case in Karachi, raising infected toll to two. Thenews.com.pk. https://www.thenews.com.pk/latest/620148-pakistan-confirms-first-case-of-coronations. Published 2022. Accessed August 11, 2022.
6. Coronavirus updates, March 18: Latest news on the coronavirus outbreak from Pakistan and around the world. Geo.tv. https://www.geo.tv/latest/277853-coronavirus-updates-march-18-latest-news-on-the-coronavirus-outbreak-from-pakistan-and-around-the-world. Published 2022. Accessed August 11, 2022.
7. Hadden J. Immunodeficiency and cancer: prospects for correction. Int Immunopharmacol. 2003;3(8):1061-1071. doi:10.1016/s1567-5769(03)00060-2
8. Sahu KK, Jindal V, Siddiqui AD. Managing COVID-19 in Patients With Cancer: A Double Blow for Oncologists. JCO Oncol Pract. 2020;16(5):223-225. doi:10.1200/OP.20.00167
9. Ménétrier-Caux C, Ray-Coquard I, Blay J, Caux C. Lymphopenia in Cancer Patients and its Effects on Response to Immunotherapy: an opportunity for combination with Cytokines?. J Immunother Cancer. 2019;7(1). doi:10.1186/s40425-019-0549-5
10. Chen F, Ma L, Wang Q, et al. Chemotherapy is a risk factor of lymphopenia before adjuvant radiotherapy in breast cancer. Cancer Rep (Hoboken). 2022;5(7):e1525. doi:10.1002/cnr2.1525
11. Neutropenia and Nadir. CDCF PCI. https://www.preventcancerinfections.org/health-tip-sheet/neutropenia-and-nadir. Published 2022. Accessed August 11, 2022.
12. Ellsworth S. Field size effects on the risk and severity of treatment-induced lymphopenia in patients undergoing radiation therapy for solid tumors. Adv Radiat Oncol. 2018;3(4):512-519. doi:10.1016/j.adro.2018.08.014
13. Portaluri M, Barba MC, Musio D, Tramacere F, Pati F, Bambace S. Hypofractionation in COVID-19 radiotherapy: A mix of evidence based medicine and of opportunities. Radiother Oncol. 2020;150:191-194. doi:10.1016/j.radonc.2020.06.036
14. COVID-19: Operational guidance for maintaining essential health services during an outbreak Interim guidance 25 March 2020. Available at: https://apps.who.int/iris/bitstream/handle/10665/331561/WHO-2019-nCoV-essential_health_services-2020.1-eng.pdf?sequence=1&isAllowed=y. Published 2022. Accessed August 11, 2022.
15. Maintaining essential health services: operational guidance for the COVID-19 context, interim guidance, 1 June 2020. Who.int. https://www.who.int/publications/i/item/WHO-2019-nCoV-essential_health_services-2020.2. Published 2022. Accessed August 11, 2022.
16. Burki TK. Cancer guidelines during the COVID-19 pandemic. Lancet Oncol. 2020;21(5):629-630. doi:10.1016/S1470-2045(20)30217-5
17. Kamran K, Ali A. Challenges and Strategies for Pakistan in the Third Wave of COVID-19: A Mini Review. Front Public Health. 2021;9. doi:10.3389/fpubh.2021.690820
18. COVID-19 Pandemic: Guidelines for Ethical Healthcare Decision-Making in Pakistan. Storage.covid.gov.pk. https://storage.covid.gov.pk/new_guidelines/01June2020_Guidelines_for_Ethical_Healthcare_Decision-Making_in_Pakistan.pdf. Published 2022. Accessed August 11, 2022.
19. Kucewicz-Czech E, Damps M. Triage during the COVID-19 pandemic. Anaesthesiol Intensive Ther. 2020;52(4):312-315. doi:10.5114/ait.2020.100564
20. COVID-19 Guidance on Social Distancing at Work. Occupational Safety and Health Administration (OSHA) USA. Available at: https://www.osha.gov/sites/default/files/publications/OSHA4027.pdf. Published 2020. Accessed August 11, 2022.
21. Awada M, Lucas G, Becerik-Gerber B, Roll S. Working from home during the COVID-19 pandemic: Impact on office worker productivity and work experience. Work. 2021;69(4):1171-1189. doi:10.3233/WOR-210301
22. Ortega R, Gonzalez M, Nozari A, Canelli R. Personal Protective Equipment and Covid-19. N Engl J Med. 2020;382(26):e105. doi:10.1056/NEJMvcm2014809
23. Malik S, Riaz M. Living with COVID-19 pandemic – Emerging challenges for ultrasound physicians and their suggested solution. Journal of Rawalpindi Medical College. 2020;24(Supp-1):99-107. doi:10.37939/jrmc.v24isupp-1.1414
24. Czernin J, Fanti S, Meyer PT, et al. Nuclear Medicine Operations in the Times of COVID-19: Strategies, Precautions, and Experiences. J Nucl Med. 2020;61(5):626-629. doi:10.2967/jnumed.120.245738
25. Shaik S, Mahalingam A, Palanisamy M, Kalita P. Comprehensive review on medical waste incineration. International Journal of Global Warming. 2022;27(1):16. doi:10.1504/ijgw.2022.122793
26. Conesa JC. Nuclear Medicine in the Covid-19 pandemic. Medicina Nuclear en la pandemia por Covid-19. Rev Esp Med Nucl Imagen Mol (Engl Ed). 2020;39(3):138-139. doi:10.1016/j.remn.2020.05.001
27. Skali H, Murthy V, Al-Mallah M et al. Guidance and Best Practices for Nuclear Cardiology Laboratories During the COVID-19 Pandemic. Circulation: Cardiovascular Imaging. 2020;13(9). doi:10.1161/circimaging.120.011761
28. Freudenberg LS, Paez D, Giammarile F, et al. Global Impact of COVID-19 on Nuclear Medicine Departments: An International Survey in April 2020. J Nucl Med. 2020;61(9):1278-1283. doi:10.2967/jnumed.120.249821
29. Ain HQU, Tahir MJ, Waheed S, Ahmad S, Ullah I, Yousaf Z. Teleradiology in COVID-19: A Sustainable Innovative Solution. Acad Radiol. 2021;28(9):1325-1326. doi:10.1016/j.acra.2021.06.020
30. Shirke MM, Shaikh SA, Harky A. Implications of Telemedicine in Oncology during the COVID-19 Pandemic. Acta Biomed. 2020;91(3):e2020022. Published 2020 Sep 7. doi:10.23750/abm.v91i3.9849
31. Leung MST, Lin SG, Chow J, Harky A. COVID-19 and Oncology: Service transformation during pandemic. Cancer Med. 2020;9(19):7161-7171. doi:10.1002/cam4.3384
32. Baheti D. Should All Patients Admitted to Hospitals Be Tested for COVID-19? – The Wire Science. Available at: https://science.thewire.in/health/hospitals-covid-19-testing/. Published 2022. Accessed August 11, 2022.
33. Fedele P, Sanna V, Fancellu A, Marino A, Calvani N, Cinieri S. De-escalating cancer treatments during COVID 19 pandemic: Is metronomic chemotherapy a reasonable option?. Crit Rev Oncol Hematol. 2021;157:103148. doi:10.1016/j.critrevonc.2020.103148
34. Cazzaniga M, Cordani N, Capici S, Cogliati V, Riva F, Cerrito M. Metronomic Chemotherapy. Cancers (Basel). 2021;13(9):2236. doi:10.3390/cancers13092236
35. Teckie S, Andrews JZ, Chen WC, et al. Impact of the COVID-19 Pandemic Surge on Radiation Treatment: Report From a Multicenter New York Area Institution. JCO Oncol Pract. 2021;17(9):e1270-e1277. doi:10.1200/OP.20.00619
36. Damen PJJ, Kroese TE, van Hillegersberg R, et al. The Influence of Severe Radiation-Induced Lymphopenia on Overall Survival in Solid Tumors: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys. 2021;111(4):936-948. doi:10.1016/j.ijrobp.2021.07.1695
37. Slotman B, Lievens Y, Poortmans P et al. Effect of COVID-19 pandemic on practice in European radiation oncology centers. Radiotherapy and Oncology. 2020;150:40-42. doi:10.1016/j.radonc.2020.06.007
38. COVID-19 Recommendations and Information - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO). Available at:https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/Clinical-Guidance. Published 2022. Accessed August 11, 2022.
39. Amaoui B, Semghouli S, Benjaafar N. Organization of a radiotherapy service during the COVID-19 epidemic: Experience of Regional Center of Oncology of Agadir, Morocco. Radiography (Lond). 2020;26(4):e312-e314. doi:10.1016/j.radi.2020.06.008
40. Baskar R, Lee KA, Yeo R, Yeoh KW. Cancer and radiation therapy: current advances and future directions. Int J Med Sci. 2012;9(3):193-199. doi:10.7150/ijms.3635
41. Simcock R, Thomas TV, Estes C, et al. COVID-19: Global radiation oncology's targeted response for pandemic preparedness. Clin Transl Radiat Oncol. 2020;22:55-68. Published 2020 Mar 24. doi:10.1016/j.ctro.2020.03.009
42. COVID-19 Recommendations and Information - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO). ASTRO. https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/Clinical-Guidance. Published 2022. Accessed August 12, 2022.
43. Thomson D, Johansen J. Practice Recommendations for Risk-Adapted Head and Neck Cancer Radiation Therapy During the COVID-19 Pandemic: An ASTRO-ESTRO Consensus Statement. International Journal of Radiation Oncology*Biology*Physics. 2020;107(4):618-627. doi:10.1016/j.ijrobp.2020.04.016
44. Mallick I, Goyal L. Prioritizing Delivery of Cancer Treatment During a COVID-19 Lockdown: The Experience of a Clinical Oncology Service in India. JCO Glob Oncol. 2021;(7):99-107. doi:10.1200/go.20.00433
45. PSCO – Pakistan Society of Clinical Oncology. Psco.com.pk. https://psco.com.pk/. Published 2016. Accessed August 12, 2022.
46. ESTRO - European Society of Therapeutic Radiation Oncology. Estro.org. https://www.estro.org/. Published 2022. Accessed August 12, 2022.
47. ASTRO - American Society of Therapeutic Radiation Oncology. ASTRO. https://www.astro.org/. Published 2022. Accessed August 12, 2022.
48. Paez D, Fanti S. COVID-19 pandemic: guidance for nuclear medicine departments. Eur J Nucl Med Mol Imaging. 2020;47(7):1615-1619. doi:10.1007/s00259-020-04825-8
49. Vigne J, Manrique A, Mouet A, Le Hello S, Agostini D. Nuclear cardiology in the COVID-19 pandemic era. Arch Cardiovasc Dis. 2020;113(6-7):374-377. doi:10.1016/j.acvd.2020.05.003
50. 6. Mitra S, Simson D. Treatment Delay during Radiotherapy of Cancer Patients due to COVID-19 Pandemic. Asian Pacific Journal of Cancer Prevention. 2022;23(7):2415-2420. doi:10.31557/apjcp.2022.23.7.2415