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Figure.  Radiotherapy Caseload per Day During the Coronavirus Disease 2019 Outbreak
Radiotherapy Caseload per Day During the Coronavirus Disease 2019 Outbreak

Influence of public health measures on the daily number of patients undergoing radiotherapy at the Zhongnan Hospital of Wuhan University.

Table.  Clinical and Treatment Characteristics of the Study Patients
Clinical and Treatment Characteristics of the Study Patients
1.
Kwong  DL, Sham  JS, Chua  DT, Choy  DT, Au  GK, Wu  PM.  The effect of interruptions and prolonged treatment time in radiotherapy for nasopharyngeal carcinoma.   Int J Radiat Oncol Biol Phys. 1997;39(3):703-710. doi:10.1016/S0360-3016(97)00339-8PubMedGoogle ScholarCrossref
2.
Bleicher  RJ.  Timing and delays in breast cancer evaluation and treatment.   Ann Surg Oncol. 2018;25(10):2829-2838. doi:10.1245/s10434-018-6615-2PubMedGoogle ScholarCrossref
3.
Yu  J, Ouyang  W, Chua  MLK, Xie  C.  SARS-CoV-2 transmission in patients with cancer at a tertiary care hospital in Wuhan, China.   JAMA Oncol. Published online March 25, 2020. doi:10.1001/jamaoncol.2020.0980PubMedGoogle Scholar
4.
Li  Q, Guan  X, Wu  P,  et al.  Early transmission dynamics in Wuhan, China, of novel coronavirus–infected pneumonia.   N Engl J Med. 2020;382(13):1199-1207. doi:10.1056/NEJMoa2001316PubMedGoogle ScholarCrossref
5.
Song  J-Y, Yun  J-G, Noh  J-Y, Cheong  H-J, Kim  W-J.  Covid-19 in South Korea: challenges of subclinical manifestations.   N Engl J Med. 2020;382(19):1858-1859. doi:10.1056/NEJMc2001801PubMedGoogle ScholarCrossref
6.
Pan  A, Liu  L, Wang  C,  et al.  Association of public health interventions with the epidemiology of the COVID-19 outbreak in Wuhan, China.   JAMA. 2020;323(19):1-9. doi:10.1001/jama.2020.6130PubMedGoogle ScholarCrossref
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    Research Letter
    July 30, 2020

    Outcomes in Radiotherapy-Treated Patients With Cancer During the COVID-19 Outbreak in Wuhan, China

    Author Affiliations
    • 1Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, China
    • 2Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, Wuhan, China
    • 3Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China
    • 4Division of Radiation Oncology, Division of Medical Sciences, National Cancer Centre Singapore, Singapore
    • 5Oncology Academic Clinical Programme, Duke–National University of Singapore Medical School, National University of Singapore, Singapore
    JAMA Oncol. Published online July 30, 2020. doi:10.1001/jamaoncol.2020.2783

    Several health care services have been affected by the novel coronavirus disease 2019 (COVID-19) pandemic. A delay in diagnosis and treatment can be detrimental to patients with cancer.1,2 However, patients with cancer are also at risk for COVID-19 because of immunosuppressive treatments and recurrent visits to the hospital.3 In this article, we report preliminary outcomes in 209 patients who underwent radiotherapy at the Zhongnan Hospital of Wuhan University (ZHWU) during the COVID-19 outbreak in the city of Wuhan, China.

    Methods

    All patients who were treated at the Department of Medical and Radiation Oncology, ZHWU, from January 20 to March 5, 2020, were included. Public health measures implemented during the study period included city lockdown (January 23, 2020), cordon sanitaire, traffic restriction, social distancing, and home confinement. We analyzed patient demographics as well as clinical and treatment parameters. Survival status of all patients was updated as of March 12, 2020.

    This study was approved by the ZHWU institutional review board (No. 2020041) with waiver of informed consent for the use of aggregated, anonymized patient data.

    Results

    The Table summarizes the clinical characteristics of 209 patients and their treatment details. Median (interquartile range) age of the patients was 55 (48-64) years; 104 patients (49.8%) were men, and 105 (50.2%) were women. Most patients had thoracic cancer (n = 80 [38.3%], including lung, breast, and esophageal cancers), head and neck cancer (n = 53 [25.4%]), or gastrointestinal or gynecological cancer (n = 54 [25.8%]). Of the patients, 99 (47.4%) received adjuvant radiotherapy, whereas 57 (27.3%) and 53 (25.3%) underwent radical and palliative radiotherapy, respectively; 67 patients (32.1%) received concurrent chemoradiotherapy. All patients had already begun treatment prior to the study start date.

    Unfortunately, 112 patients (53.6%) were unable to return for radiotherapy after the lockdown. Among the 67 patients receiving chemoradiotherapy, 3 (4.5%) had completed treatment and 62 (92.5%) discontinued treatment (58 could not return, and 4 discontinued by the physician’s choice); only 2 patients (3.0%) resumed chemoradiotherapy. Before the lockdown, the mean (range) number of patients per day was 188 (160-209). However, these numbers dropped sharply after the date of lockdown and declined with each subsequent week (mean [range] number of patients per day, 12 [2-66]) (Figure).

    We recorded only 1 case (0.5%) of confirmed severe acute respiratory syndrome coronavirus 2 infection during the study period. Although 70 patients (33.5%) had a history of contact with this patient, none of them developed clinical symptoms of COVID-19. Of these 70 patients, 52 (74.2%) were unable to resume radiotherapy after the lockdown, while 18 (25.8%) continued radiotherapy without delay. All patients were alive as of March 12, 2020.

    Discussion

    To date, more than 10 000 000 humans have been diagnosed as having COVID-19. This disease is highly infectious, since both asymptomatic and symptomatic individuals can transmit the virus.4,5 Extensive public health measures that are focused on physical distancing and tight containment have been implemented. In the city of Wuhan, China, such measures were effective in limiting virus transmission and reducing daily new COVID-19 cases across all age groups.6 However, there are concerns that these public health measures will affect the delivery of other health care services.

    In this article, we share our experience with the COVID-19 lockdown and the delivery of radiotherapy in patients with cancer at ZHWU in Wuhan, China. Caseloads were substantially reduced (a 10-fold drop after lockdown). More than half of the patients in this case series were unable to return to the city for treatment, which is a consequence of the massive human migration (Chunyun) for the Spring Festival that preceded the lockdown. Additionally, physicians were conservative in resuming chemoradiotherapy. Long-term follow-up data may reveal detrimental ramifications of treatment interruption on the survival of these patients with cancer.

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    Article Information

    Accepted for Publication: May 15, 2020.

    Published Online: July 30, 2020. doi:10.1001/jamaoncol.2020.2783

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Xie C et al. JAMA Oncology.

    Corresponding Authors: Conghua Xie, MD, PhD, Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, 169 Donghu Rd, Wuhan 430071, China (chxie_65@whu.edu.cn); Melvin L. K. Chua, MBBS, PhD, Division of Radiation Oncology, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore 169610 (melvin.chua.l.k@singhealth.com.sg).

    Author Contributions: Drs Xie and Chua had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. They are co-senior authors. Drs Xie, Wang, and Liu are co-first authors who contributed equally to this work.

    Concept and design: Xie, Wang, Liu, Bao, Chua.

    Acquisition, analysis, or interpretation of data: Xie, Wang, Bao, Yu, Zhong, Chua.

    Drafting of the manuscript: Xie, Wang, Liu, Bao, Chua.

    Critical revision of the manuscript for important intellectual content: Xie, Wang, Yu, Zhong.

    Statistical analysis: Wang, Bao, Chua.

    Obtained funding: Xie.

    Administrative, technical, or material support: Xie, Wang, Yu, Zhong, Chua.

    Supervision: Xie, Liu, Chua.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: Dr Chua is supported by a National Medical Research Council Clinician-Scientist Award (grant NMRC/CSA/0027/2018). Dr Xie is supported by the Health Commission of Hubei Province Scientific Research Project (grant WJ2019H002), the Health Commission of Hubei Province Medical Leading Talent Project, Fundamental Research Funds for the Central Universities (grants 2042018kf1037 and 2042019kf0329), the Medical Science Advancement Program (Basic Medical Sciences) of Wuhan University (grant TFJC2018005), and the Zhongnan Hospital of Wuhan University Science, Technology, and Innovation Seed Fund (grants znpy2017049 and znpy2018070). This research was also supported by the National Research Foundation Clinical Research Programme grant (NRF-CRP17-2017-05).

    Role of the Funders: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: We thank all of the patients as well as the front-line healthcare professionals who are involved in patient care during this pandemic. We also thank Professor Xinghuan Wang, MD, PhD, for providing administrative support and his thoughtful comments on the manuscript. No compensation was received for these contributions.

    References
    1.
    Kwong  DL, Sham  JS, Chua  DT, Choy  DT, Au  GK, Wu  PM.  The effect of interruptions and prolonged treatment time in radiotherapy for nasopharyngeal carcinoma.   Int J Radiat Oncol Biol Phys. 1997;39(3):703-710. doi:10.1016/S0360-3016(97)00339-8PubMedGoogle ScholarCrossref
    2.
    Bleicher  RJ.  Timing and delays in breast cancer evaluation and treatment.   Ann Surg Oncol. 2018;25(10):2829-2838. doi:10.1245/s10434-018-6615-2PubMedGoogle ScholarCrossref
    3.
    Yu  J, Ouyang  W, Chua  MLK, Xie  C.  SARS-CoV-2 transmission in patients with cancer at a tertiary care hospital in Wuhan, China.   JAMA Oncol. Published online March 25, 2020. doi:10.1001/jamaoncol.2020.0980PubMedGoogle Scholar
    4.
    Li  Q, Guan  X, Wu  P,  et al.  Early transmission dynamics in Wuhan, China, of novel coronavirus–infected pneumonia.   N Engl J Med. 2020;382(13):1199-1207. doi:10.1056/NEJMoa2001316PubMedGoogle ScholarCrossref
    5.
    Song  J-Y, Yun  J-G, Noh  J-Y, Cheong  H-J, Kim  W-J.  Covid-19 in South Korea: challenges of subclinical manifestations.   N Engl J Med. 2020;382(19):1858-1859. doi:10.1056/NEJMc2001801PubMedGoogle ScholarCrossref
    6.
    Pan  A, Liu  L, Wang  C,  et al.  Association of public health interventions with the epidemiology of the COVID-19 outbreak in Wuhan, China.   JAMA. 2020;323(19):1-9. doi:10.1001/jama.2020.6130PubMedGoogle ScholarCrossref
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