Contingency plans... (COVID-19 thread)

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taserlaser said:
To answer your question about testing, I don't think it changes it. If they are incubating, they may have too low of a viral level even with PCR, and it may be a false negative.
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This is also happening in our hospital too.
The son of a patient tested positive 2 days after he was attending the first consultation of his father.
The colleague of mine who carried out the consultation was not wearing any protective equipment since that happened over 3 weeks ago, when rules were not so strict.
After the son was tested positive my colleague was allowed to work (but had to wear a mask for 10 days), was not tested (since he never developed symptoms) and most probably got away with it.

There seems to be a small window of opportunity for the tests to come back positive and if you test too early or too late you are going to miss it.
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taserlaser said:
As for our current health care system, our interactions qualify as 'high risk' and are unlikely to change. But because so many people were exposed, occupational health is going to do a detailed followup with each person to detail exposure and then reassess. Even between my post one trainee has been re-cleared for work.

To answer your question about testing, I don't think it changes it. If they are incubating, they may have too low of a viral level even with PCR, and it may be a false negative.
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we are doing two tests if 'high risk' suspicion
 
Need antibody testing in the worst way. Hopefully if test positive, plan to travel and stay in expensive hotels on the cheap.
 
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Another possible contingency arose yesterday...

What if one of our "competitors" in town has to shut down radiation treatment services because their technicians or MDs are ill or need to be quarantined. Flying technicians or locum doctors are an option but if this happens at a large scale in different clinics at the same time they may not be available.
And not every flying technician or locum doctor may be able to relocate that easily at times like this (family issues) plus working in a clinic where technicians or doctors got sick, may mean that you may also become sick down the road, thus making the idea less appealing.

This is especially a contingency for larger centers, which may need additional capacity to treat patients of smaller private practices with a few technicians and physicians, which may need to shut down.
The less staff you have, the higher the chance to have to shut down if people start getting ill.
 
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Had a couple early stage breast patients where a f/u surgery has been cancelled.... boosting a +margin to a higher dose in one and treating high tangents in another who can't get her f/u sentinel done after excisional bx of an early stage er+ tumor

www.npr.org

As Coronavirus Strains Hospitals, Cancer Patients Face Treatment Delays, Uncertainty

Hospitals are being forced to delay or cancel certain medical procedures so they can focus resources on treatment of COVID-19, disrupting ongoing care for people with other serious illnesses.
www.npr.org www.npr.org
 
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Basically all but emergency surgeries have been cancelled here. 2 residents redeployed (well, q, the other is self isolating from exposure), and we are checking our policies with the semi likely anticipation RO staff will be called.
 
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My urorads competitors still going strong!
 
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RadOncDoc21 said:
My urorads competitors still going strong!
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Hypofractionate!

Here's an ad:
"Don't wanna come in for 8 weeks for your radiation treatment and catch corona? We deliver the same treatment in 4 weeks!"
 
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Gfunk6 said:
I can name that tune in 5 days!
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1586304565410.png


Ad in airplane magazine 10 years ago
 
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Perhaps it’s been discussed here already (threads are so dang long now it’s impossible to follow) - should we be advocating for our therapists to be getting N95’s just as a standard for all patients (not just covid positive)?
 
Haybrant said:
Perhaps it’s been discussed here already (threads are so dang long now it’s impossible to follow) - should we be advocating for our therapists to be getting N95’s just as a standard for all patients (not just covid positive)?
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We’ve been using surgical masks as of this week.
 
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seper said:
Or waiting until Mon to see what happens.
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I call that the "weekend filter". Those who are dead by Monday are the ones you did not have to treat on Friday evening as an "emergency procedure".
 
Haybrant said:
Perhaps it’s been discussed here already (threads are so dang long now it’s impossible to follow) - should we be advocating for our therapists to be getting N95’s just as a standard for all patients (not just covid positive)?
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There is no clear data that a N95 is necessary or that will protect you better than a standard sugical mask, unless you are doing things that will produce aerosols.
So unless you are (still) doing ABC for breast/lung or your therapists have to use an aspirator for a H&N-patient before they put him on the treatment couch, surgical masks (Type IIR) are fine.
 
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I don't know about anyone else but in the Covid era, rad onc is one of the few fields at my institution that has not changed all that much. Sure, we are doing more hypo-fx, more telemed f/us, and I am working from home on my academic days... but still doing radiation oncology. My clinic looks quieter, but my volumes have not decreased much (if at all). This while many of my friends in other specialities are sitting on the sidelines because elective procedures have been cancelled, or have been re-purpoused to work in the ED, on the floor, or in an ICU. I am personally grateful that I still get to do what I love, even in the midst of all of this.
 
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Lamount said:
I don't know about anyone else but in the Covid era, rad onc is one of the few fields at my institution that has not changed all that much. Sure, we are doing more hypo-fx, more telemed f/us, and I am working from home on my academic days... but still doing radiation oncology. My clinic looks quieter, but my volumes have not decreased much (if at all). This while many of my friends in other specialities are sitting on the sidelines because elective procedures have been cancelled, or have been re-purpoused to work in the ED, on the floor, or in an ICU. I am personally grateful that I still get to do what I love, even in the midst of all of this.
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it may get a bit quieter in the coming weeks, as diagnostic procedures come to a standstill, and less people coming into the health care system with symptoms leading to diagnoses, due to fear of leaving the house. I think there is a 4-6 week lag effect

for me, this is the first week I have felt like there are less consults. i think it's starting
 
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Agreed. There was always going to be some delay from when screening mammography, colonoscopy, PSA stopped being drawn, and when they would be ordinarily be scheduled to see us.
 
Our volumes will drop. Well-incentivized surgeons will start operating, out of desperation, on marginal cases, that usually go to XRT first. E.g. a known stage IIIA lung cancer or advanced laryngeal tumors.


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seper said:
Our volumes will drop. Well-incentivized surgeons will start operating, out of desperation, on marginal cases, that usually go to XRT first. E.g. a known stage IIIA lung cancer or advanced laryngeal tumors.


Sent from my iPhone using SDN mobile
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It’s like the Wild West where I’m at. Some docs are being extra aggressive doing everything, while others have closed shop all together.
 
seper said:
Our volumes will drop. Well-incentivized surgeons will start operating, out of desperation, on marginal cases, that usually go to XRT first. E.g. a known stage IIIA lung cancer or advanced laryngeal tumors.


Sent from my iPhone using SDN mobile
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And then send for post op. So it may end up being delayed
 
We are seeing decreasing numbers on referrals in the past couple of weeks.
Dropping numbers in:
- newly discovered prostate cancer (urologists don't do biopsies for elevated PSA now)
- postoperative breast cancer (some surgeries seem to be scheduled for later, patients getting AHT in the mean time)
- some borderline palliative cases (the casual bone metastasis that doesn't cause pain, but looks quite big on the CT and the med onc thinks would be prudent to treat)
- benign cases
 
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It could have been a wonderful week. ..

Yet, we now have our first COVID case on beam. It's a head&neck case, he is halfway through treatment.

We cannot stop now or shorten the course. We need to keep on treating.

Have a nice week, all of you.
 
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Palex80 said:
It could have been a wonderful week. ..

Yet, we now have our first COVID case on beam. It's a head&neck case, he is halfway through treatment.

We cannot stop now or shorten the course. We need to keep on treating.

Have a nice week, all of you.
Click to expand...

I think it’s safe to say it’s inevitable. Projections have this strain lasting until August and without a vaccine this will likely return in the fall/winter. I’m hoping by that time, we all would have gained some sort of humoral/innate immunity... if we haven’t died yet!

Sorry to hear, let us know how you treated him.
 
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My hospital has now made policy to start COVID testing all new chemotherapy and radiation patients. Chemo patients will get tested once per cycle and radiation patients will get tested once per treatment course.
 
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metallica81788 said:
My hospital has now made policy to start COVID testing all new chemotherapy and radiation patients. Chemo patients will get tested once per cycle and radiation patients will get tested once per treatment course.
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i would prefer it especially since we are being exposed to each other every day, would be nice to know if a patient has it or not and not find out after fraction 17.
 
Palex80 said:
It could have been a wonderful week. ..

Yet, we now have our first COVID case on beam. It's a head&neck case, he is halfway through treatment.

We cannot stop now or shorten the course. We need to keep on treating.

Have a nice week, all of you.
Click to expand...

Hang in there, Palex!

Going with the last treatment of the day, terminal clean afterwards? How are therapists doing PPE? N95/mask/gown/face shield/hair coverage? How are you doing (or going to do) OTVs?

Any other steps you're taking? You're the first person I know actually treating a positive patient despite all the immediate theorizing that happened when this all began.

Is your department taking any quarantining/risk-analysis steps for those patient interacted with prior to knowing COVID status?
 
metallica81788 said:
My hospital has now made policy to start COVID testing all new chemotherapy and radiation patients. Chemo patients will get tested once per cycle and radiation patients will get tested once per treatment course.
Click to expand...

This is an interesting concept. Are you aware of any references in case our center wanted to adopt a similar policy?
 
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theradiator said:
This is an interesting concept. Are you aware of any references in case our center wanted to adopt a similar policy?
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Nothing incredibly groundbreaking but this is what my hospital leadership sent out. Of note, I am at a "satellite" a few hours away of a hospital based in a city that has had a rough time with COVID so far. They are doing a drive-thru testing setup for infusion and radiation patients near our cancer center.

Resources and References:
Rationale:

SARS-CoV-2 Transmission in Patients With Cancer

In a retrospective case study of coronavirus disease 2019 (COVID-19) in hospitals within Wuhan, China, which will appear in Annals of Oncology, researchers found that patients with cancer demonstrated deteriorating conditions and poor outcomes from the COVID-19 infection.

Given these findings, it is recommended that patients with cancer receiving anti-tumor treatments should have vigorous screening for COVID-19 infection and should avoid treatments causing immunosuppression or have their dosages decreased in case of COVID-19 co-infection. However, delaying anti-tumor treatments cannot be recommended according to the researchers.

“[Patients with cancer] should receive anti-tumor treatment in the setting of vigorous screening for COVID-19, including chest CT scan and nucleic acid testing, and the same should be extended to their companions. Treatment strategies likely to cause immunosuppression should be avoided or have dosages decreased, and patients who are generally in poor condition should not receive such treatments,” the authors wrote. “In addition, at least 7 days prior to anti-tumor treatment, [patients with cancer] should stay in the observation ward and in isolation from other patients. Stronger personal protection, including protection mechanisms for their families should be made for [patients with cancer].”

National Guidance:

  • Generalized
COVID-19 Patient Care Information
  • Heme Malignancies
COVID-19 Resources
 
evilbooyaa said:
Hang in there, Palex!

Going with the last treatment of the day, terminal clean afterwards? How are therapists doing PPE? N95/mask/gown/face shield/hair coverage? How are you doing (or going to do) OTVs?

Any other steps you're taking? You're the first person I know actually treating a positive patient despite all the immediate theorizing that happened when this all began.

Is your department taking any quarantining/risk-analysis steps for those patient interacted with prior to knowing COVID status?
Click to expand...

I'm in a community hospital-based practice in a hotspot. We have had to treat a COVID positive patient. Per discussion with our infection control department, we are treating him as the last patient of the day with terminal clean afterwards. Therapists are in bunny suits, face shields, N95 with surgical mask covering (to reuse the N95), and hair covering. I'm doing my OTVs in the vault 6 ft away.
 
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metallica81788 said:
Nothing incredibly groundbreaking but this is what my hospital leadership sent out. Of note, I am at a "satellite" a few hours away of a hospital based in a city that has had a rough time with COVID so far. They are doing a drive-thru testing setup for infusion and radiation patients near our cancer center.

Resources and References:
Rationale:

SARS-CoV-2 Transmission in Patients With Cancer

In a retrospective case study of coronavirus disease 2019 (COVID-19) in hospitals within Wuhan, China, which will appear in Annals of Oncology, researchers found that patients with cancer demonstrated deteriorating conditions and poor outcomes from the COVID-19 infection.

Given these findings, it is recommended that patients with cancer receiving anti-tumor treatments should have vigorous screening for COVID-19 infection and should avoid treatments causing immunosuppression or have their dosages decreased in case of COVID-19 co-infection. However, delaying anti-tumor treatments cannot be recommended according to the researchers.

“[Patients with cancer] should receive anti-tumor treatment in the setting of vigorous screening for COVID-19, including chest CT scan and nucleic acid testing, and the same should be extended to their companions. Treatment strategies likely to cause immunosuppression should be avoided or have dosages decreased, and patients who are generally in poor condition should not receive such treatments,” the authors wrote. “In addition, at least 7 days prior to anti-tumor treatment, [patients with cancer] should stay in the observation ward and in isolation from other patients. Stronger personal protection, including protection mechanisms for their families should be made for [patients with cancer].”

National Guidance:

  • Generalized
COVID-19 Patient Care Information
  • Heme Malignancies
COVID-19 Resources
Click to expand...

Thank you super helpful. SDN come for the biryani stay for actionable information!
 
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evilbooyaa said:
Hang in there, Palex!

Going with the last treatment of the day, terminal clean afterwards? How are therapists doing PPE? N95/mask/gown/face shield/hair coverage? How are you doing (or going to do) OTVs?

Any other steps you're taking? You're the first person I know actually treating a positive patient despite all the immediate theorizing that happened when this all began.

Is your department taking any quarantining/risk-analysis steps for those patient interacted with prior to knowing COVID status?
Click to expand...

We are treating him as the last patient at late hours in the least used of 3 LINACs.

Patient is being brought with the bed into the LINAC vault and is allowed to go over to the LINAC couch for treatment and back to the bed.

FFP3 mask, gown, face shield, hair covered, gloves for anyone going into the vault.
Two therapists go into the vault fully dressed and one stays at the console. They have to take off all PPE before walking out the vault and dress up again outside the vault before going back in, once the beam is off.

Any weekly appointments with the physician are done inside the LINAC vault.
No in-between stops. All surfaces where the bed has been driven through are being wiped as well as the treatment room after treatment. We received a special mobile air filter machine that runs when he is there. Cleaning the room and waiting until the desinfectant has fully acted takes around 3 hours.

And the therapists have to wipe the mask really clean after each treatment, which brought up the issue how to do that without losing the markings on the mask... ;) Someone suggested putting it into the microwave oven, but I don't think it will fit in there... :happy: :happy: :happy:



We do not undertake any special measures for screening patients or co-workers that have interacted with the patient the past week.
We are actually kind of lucky that he developed symptoms over the weekend and not during the working days of the week.
It was the longer Easter weekend and the last interaction with the patient took place on Thursday, 48 hours prior to any symptoms.
Which does not mean that we were "safe" on Thursday, since he could have been contagious without symptoms, but it does decrease a bit the chance of it happening. It seems that he started coughing on Saturday and got tested on Sunday.
 
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Palex80 said:
We are treating him as the last patient at late hours in the least used of 3 LINACs.

Patient is being brought with the bed into the LINAC vault and is allowed to go over to the LINAC couch for treatment and back to the bed.

FFP3 mask, gown, face shield, hair covered, gloves for anyone going into the vault.
Two therapists go into the vault fully dressed and one stays at the console. They have to take off all PPE before walking out the vault and dress up again outside the vault before going back in, once the beam is off.

Any weekly appointments with the physician are done inside the LINAC vault.
No in-between stops. All surfaces where the bed has been driven through are being wiped as well as the treatment room after treatment. We received a special mobile air filter machine that runs when he is there. Cleaning the room and waiting until the desinfectant has fully acted takes around 3 hours.

And the therapists have to wipe the mask really clean after each treatment, which brought up the issue how to do that without losing the markings on the mask... ;) Someone suggested putting it into the microwave oven, but I don't think it will fit in there... :happy: :happy: :happy:



We do not undertake any special measures for screening patients or co-workers that have interacted with the patient the past week.
We are actually kind of lucky that he developed symptoms over the weekend and not during the working days of the week.
It was the longer Easter weekend and the last interaction with the patient took place on Thursday, 48 hours prior to any symptoms.
Which does not mean that we were "safe" on Thursday, since he could have been contagious without symptoms, but it does decrease a bit the chance of it happening. It seems that he started coughing on Saturday and go tested on Sunday.
Click to expand...

Thank you for this.
 
E80E3BE1-F330-4149-8400-7A47B6976FBF.jpeg

Some great research from China!
 
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RadsWFA1900 said:
Reading the principles page says it can be considered if ebrt would be a medical or social hardship.
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I don't think the passage page has been updated. That verbiage was still there in the old guidelines when SBRT was not "checked" for unfavorable intermediate and high risk prostate cancer.
 
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Gfunk6 said:
I don't think the passage page has been updated. That verbiage was still there in the old guidelines when SBRT was not "checked" for unfavorable intermediate and high risk prostate cancer.
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This is true because I remember seeing this for one of my guys with transportation issues who was also undergoing dialysis. SBRT was the only reasonable option for him. He is actually doing very well, 2 yrs out, no biochemical failure or side effects from his treatment.
 
Hormones alone? Is 40 Gy of radiation adding anything to GS 9, PSA 30 cancer?

RadOncDoc21 said:
This is true because I remember seeing this for one of my guys with transportation issues who was also undergoing dialysis. SBRT was the only reasonable option for him. He is actually doing very well, 2 yrs out, no biochemical failure or side effects from his treatment.
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