key: cord-1046350-nq9z5jax
authors: Doll, Corinne M.; Wakefield, Daniel V.; Ringash, Jolie; Ingledew, Paris-Ann; Dawson, Laura A.; Eichler, Thomas; Schwartz, David S.
title: Impact of the COVID-19 Pandemic on Canadian Radiation Oncology Practices
date: 2022-03-19
journal: Int J Radiat Oncol Biol Phys
DOI: 10.1016/j.ijrobp.2022.03.017
sha: 65768d0391d0b1791ae0594630ee7216a6c92051
doc_id: 1046350
cord_uid: nq9z5jax

Purpose: To survey Canadian radiation oncology (RO) practice leaders to determine the impact of the COVID-19 pandemic on radiation services and patient and staff issues in the early phase of the pandemic and one year later. Materials and Methods: The RO leader (Department or Division Head) from every Canadian cancer center with radiation services was identified. Two surveys were circulated to the identified leader via email from the CARO central office, utilizing the SurveyMonkey® survey tool: the first closed in June 2020 and the second (expanded) survey in June 2021, representing two points in time of the COVID-19 pandemic. Questions included patient volume, service interruptions and delays, and changes in scheduling and virtual/telemedicine utilization. Additional questions were included in the follow-up survey to determine further impacts on disease presentation, volume, vaccination and access, and personnel issues. Results: Virtual/telemedicine was widely adopted early in the pandemic and continued to be a common technique to communicate/connect with patients. Although many centers were deferring/delaying certain disease sites early in the pandemic, this was not as prevalent one year later. Reduced cancer screening and patients presenting with more advanced disease were concerns documented in the 2021 survey. A high level of concern regarding stress amongst health care professionals was identified. Conclusions: Canadian RO centers have faced numerous challenges during the COVID-19 pandemic but continued to provide timely and essential cancer care for patients with cancer. Future evaluation of RO center practices will be important to continue to document and address the impact of the COVID-19 pandemic on issues relevant to RO leaders, patients and staff.

To determine the impact of COVID-19 on radiation oncology (RO) practice, the American Society for Radiation Oncology (ASTRO) and the European Society for Radiotherapy and Oncology (ESTRO) sequentially surveyed physician leaders (1) (2) (3) (4) .

The Canadian Association of Radiation Oncology (CARO) was invited by ASTRO to participate in this sequential survey, to query Canadian centers' practice responses and challenges related to the COVID-19 pandemic, and to document the changes from the early part of the pandemic to one year later. 4 The RO leader (Department or Division Head) from every Canadian cancer center with radiation services was identified from the CARO directory and verified with the CARO Board. The questionnaire was based on the developed ASTRO surveys (1, 4) 

Forty-six RO physician leaders (Department or Division Heads) representing 48 cancer centers (2 are leaders for 2 separate centers) in each of the 10 Canadian provinces were sent the electronic survey. Response rates were 18/46 (39.1%) for the first, and 26/46 (56.5%) for the second survey. Survey completion rate (answering every question on the survey) was 83% for the first and 100% for the second survey. In the first survey, all centers reported providing radiation therapy treatment services to patients; 5 all but one center in the second survey reported continuing radiation therapy treatment services to patients throughout the pandemic, with one closure of a satellite/regional center.

Regarding new patient scheduling, in the first survey, 47.1% reported deferring some new consultation visits (including benign diseases), whereas in the later survey, respondents reported 7.7% deferred in the prior 2 months, and 3.8% during May/June 2021. All centers incorporated virtual/telemedicine visits into their practices: telephone visits in 100%; computer-based visits in 65.4% and video-link visits in 34.6%. For 58.8% of responding centers, virtual/telemedicine was new to their center's practice in 2020.

In the follow-up survey, which included additional questions about the impact of the pandemic on various issues, 80% of respondents noted fewer patients receiving cancer screening; 61.5% (16/26) indicated patients presented to their center/practice with more advanced disease compared to prior to the pandemic. In the earlier survey, 12/17 (70.6%) of respondents reported a decline in patient treatment volume, mainly due to fewer referrals (90% of respondents). In the second survey, patient volumes remained reduced (57.7% of respondents) in 2020 compared to 2019, with 80% of respondents attributing this to fewer referrals and/or delays/deferrals of treatment for certain 6 diseases. In the first survey, almost half (7/15) of respondents estimated there was a 11-20% decrease in patient treatment numbers, whereas in the second survey the most common estimate of decrease in patient volume was 1-10% (53.3% of respondents), with 11-20% mentioned by 26.7% of respondents. 

Details on the impact of COVID on various staff roles are shown in Figure 3 . Reduction due to COVID-19-related self-isolation/quarantine (not COVID-positive) was high (80.8%), and 46.2% of respondents reported reduction due to staff COVID-19 illness.

Other impacts on staff numbers included family care responsibilities due to COVID-19 (65.4%) and staff transfer to other clinical areas (46.2%). The most affected staff positions were nursing and radiation therapists.

When leaders were queried about their COVID-related concerns for their colleagues, the most common response was well-being of health professionals (24/26, 92.3%), followed by burnout (22/26, 84.6%) and work/life balance (21/26, 80.8%), Figure 4 .

This is the first survey to document the impact of COVID-19 over time from a Canadian RO leadership perspective. Canadian cancer centers and RO leaders, in collaboration with multidisciplinary colleagues, have had to make major adjustments in response to the pandemic, including development and implementation of processes and protocols to protect patients and staff, pivoting to telemedicine from in-person encounters for most tumor sites, and deferring and delaying visits and treatments for certain disease sites.

There was an overall reduction in radiotherapy deferrals in the later versus the earlier part of the pandemic, but to some degree patients were still being deferred one year later. The most dramatic example of this was low risk prostate cancer; 60% of centers were deferring RT in the early part of the pandemic, which decreased to just over 9% in the most recent survey. This was very similar to the ESTRO survey, which reported 62% of centers deferring treatment for patients with low-risk prostate cancer in the early pandemic, decreasing to 8% the one-year follow-up survey (2, 3), but less than what was reported in the early pandemic 2020 ASTRO survey (88%; decreasing to 12.8%) (1, 4) .

The shift to virtual care came early in the pandemic and remained a model of care

delivery one year later. In Canada, many centers rapidly adopted virtual care to 8 maintain patient consultations and follow-up, and to limit patient exposure to busy hospital environments. This high uptake of virtual care was also noted in the ASTRO and ESTRO surveys, with 74% and 72% incorporating telemedicine for follow-up visits/surveillance, respectively (1, 2) .

This study demonstrated a perceived impact on screening, with 80% of respondents noting a change in cancer screening. Cancino et al similarly documented the impact of COVID-19 on cancer screening (6) . It is estimated that because of COVID-19, screenings for cancers of the breast, colon, and cervix dropped by 94%, 86%, and 94%

between January 20, 2020, and April 21, 2020, respectively (7). Concerningly, all three follow-up surveys indicated that patients presented with more advanced disease (CARO 61.5%, ASTRO 65.5%, and ESTRO 71%) than before the pandemic. It will take considerable time for the cancer system to re-adjust, and this may ultimately impact the quality of patient care and outcomes (8, 9) .

There were considerable stresses related to the pandemic on health professionals, with RO leaders reporting extremely high concern for their colleagues regarding well-being, burnout, and work/life balance issues. Rising rates of stress and burnout amongst oncology physicians have been previously documented (10) , and it is deeply concerning that there may be further repercussions and impacts in this specialized workforce as a result of the pandemic. 9 Limitations of this survey-based study must be stated. Given that this was a retrospective survey involving one leader per center, responder recall or awareness bias is possible, and there was no ability to cross-reference responses. Responses were anonymized, thus comparisons between province or region could not be performed. The timing of the survey distribution was slightly different than the ASTRO and ESTRO surveys, making direct comparisons challenging. However, with a relatively robust response rate (particularly for the 2021 survey, which had a 56% response rate and 100% of received surveys fully completed) and the specific identification of the cancer center's RO leader for participation in the survey, it was felt that their responses would most likely represent the practice patterns and response of the center to COVID-19 issues.

In summary, this study aimed to compare responses related to the COVID-19 pandemic over two time points, focusing on RO practices and operations, patient care, and personnel issues. Generally, there were similar issues identified within Canadian RO practices as noted in the ASTRO and ESTRO communities. The identification of patterns related to pandemic response between international cancer care centers is important and meaningful to document to guide and optimize the long-term response and recovery from this global pandemic, particularly as COVID-19 will continue to impact cancer care resources over the longer term. 

Initial impact and operational responses to the COVID-19 pandemic by American radiation oncology practices

Effect of COVID-19 pandemic on practice in European radiation oncology

European radiation oncology after one year of COVID-19 pandemic

Variable impact of the COVID-19 pandemic on US radiation oncology practices

Innovations in the ethical review of healthrelated quality improvement and research: the Alberta Research Ethics Community Consensus Initiative (ARECCI)

The impact of COVID-19 on cancer screening: challenges and opportunities

Preventive cancer screenings during COVID-19 pandemic. Epic Health Research Network 2020

Impact of the early phase of the COVID pandemic on cancer treatment delivery and the quality of cancer care: a scoping review and conceptual model

Delay in cancer screening and diagnosis during the COVID-19 pandemic: What is the cost?

Prevalence and workplace drivers of burnout in cancer care physicians in Ontario