The radiation oncology department has seven physicians and four physicists. The hospital has three linear accelerators (LINACS), a simulator, and a brachytherapy system for intracavitary treatment. It is the one of the busiest cancer facilities in Nepal, with cancer patients visiting from all over the country. I interact with patients from remote parts of Nepal, some of whom have to travel 16-20 hours by bus, after having trekked for one or two days. I am always eager to chat with them, as I myself come from a remote village in far-west Nepal. For patients from my region, it takes on average 18 hours by bus to reach the cancer hospital.
Tirthraj Adhikari (far right) and colleagues commission a cobalt-60 radiotherapy system during the pandemic. Courtesy of Tirthraj Adhikari.
During treatments, I noticed that -- due to a lack of screening and diagnosis -- patients would present in the late stages of their disease. The major factor is poverty. When someone in a remote village feels sick, they usually visit the pharmacy and buy medicine without prescriptions from physicians. This makes them feel well for some time, but after a while the problems return. After several such attempts, the patient becomes seriously ill and decides to visit the hospital. Unfortunately, by this time the cancer has reached a late stage and treatment becomes difficult.
The patients may have to undergo major surgery, but they cannot afford the cost. If they can afford surgery, they cannot afford radiotherapy, which is expensive. It is sad that for many patients who need treatment with a complex radiotherapy technique, we have to shift to a simple technique just because of the cost. For example, one patient with head and neck cancer was a candidate for volumetric-modulated arc therapy (VMAT), but we treated him using cobalt-60 radiotherapy because it is relatively inexpensive.
During this period, I created treatment plans for about 230 patients. Most of these were cobalt-60, 2D and 3D conformal radiotherapy (CRT) plans for head and neck, cervix, and breast cancers. In addition, I created a few intensity-modulated radiotherapy (IMRT) and VMAT treatment plans for prostate and esophageal cancers, as well as brachytherapy plans for cervical cancer. I remember that I created more plans for palliative than curative cases.
In addition to the treatment planning, I was involved in quality assurance and quality control in the department. Every day, I'd commute to the hospital early in the morning, do the daily quality assurance of the LINACS, and make the CT simulator and brachytherapy machine ready for treatment and simulation. At our department, frequent problems with the machines arise during treatment delivery. I was engaged in troubleshooting of the LINACS and CT simulator with senior physicists in the department.
Impact of COVID-19
The first COVID-19 patient in Nepal was identified in early February. He had flown from Wuhan in China to Nepal, and he soon recovered. Then the government declared us a corona-free state, while cases were growing in China, Italy, the rest of Europe, and then the U.S. However, in March a girl who fled from Qatar to Nepal was diagnosed with COVID-19, and cases grew over time. The government then imposed a lockdown to prevent transmission to the community. This harshly affected all patients, including cancer patients.
As we did not have personal protective equipment (PPE) in our department, the hospital stopped treatments for three days the first time. Treatments soon resumed, but some patients had already left the hospital, as there was uncertainty about when treatments would restart and difficulties with accommodation. Those patients who were living in the hospital wards and in the hospital periphery received the remaining fractions of their radiation treatments. But some patients had already traveled more than 600 km to their home.
Under normal conditions, the department used to treat 180-200 patients per day. But with lockdown, the number of patients declined rapidly, to 30-40 patients per day. This happened first because it was difficult for patients to travel to the hospital -- the lockdown meant there was no public transport and travel by ambulances was not affordable. Second, hospital personnel were afraid to touch or take care of patients without having PPE. During the first period of prolonged lockdown, around 30 patients who were having radiotherapy died at their homes.
After four months of lockdown, the hospital resumed normal activity and our department started to treat normally again. Patients who survived the lockdown came back to the hospital for their remaining treatments. For us, it was difficult to decide whether to treat patients with plans created four months earlier. Some patients had resimulation after changes in their diagnosis and plans were re-created for them. For those who had already received some radiation fractions, the gap was calculated and dose was managed accordingly.
Following a spike in COVID-19-infected patients, the government imposed a second lockdown from the middle of August. At the time, some hospital personnel were also infected, though fortunately none in our department. Treatment was stopped, again for some days, with the same problems; it was a high risk for us to treat patients without proper PPE and testing. We demanded mandatory polymerase chain reaction (PCR) tests for patients and their visitors to keep ourselves safe. Then the treatments resumed, but with fewer patients than under normal conditions.
A patient from Bardiya, a district of West Nepal, had started treatment in February. His head and neck cancer was being treated by 3D CRT. With three fractions remaining, his treatment was impeded because of the pandemic, and he was not able to resume treatment due to the ongoing pandemic. He contacted me recently saying that he had difficulty breathing. I suggested that he visit the department soon for follow-up. But in the meantime, the government had imposed the second lockdown. I am wondering how he will manage to travel 600 km. Cancer patients in Nepal have been affected miserably by this pandemic.
This pandemic has adversely affected everyone's lives. To keep myself physically active, I do regular yoga in the morning, wearing a mask, and I walk in the evening, maintaining physical distance.
In addition to the usual departmental clinical tasks, I used to talk with seniors, physicians, and technicians about treatments, innovations, politics, and science-economics. During lockdown, I followed more than 80 national and international webinars. In addition, I composed articles in my native language about nuclear laws in Nepal, radiation protection, cancer radiotherapy, managing errors in radiation therapy, the importance of radiation dosimetry in cancer care, and the increasing needs of the public cancer hospital in Nepal. I also prepared a proposal to establish a cancer hospital in my region, where there is no cancer center and people have to travel at least 16 hours to the nearest cancer hospital.
To engage myself, I have taken 25 online/remote training courses during the pandemic, covering themes including radiation protection, nuclear safety, radiotherapy safety, image-guided radiation therapy, and stereotactic radiosurgery. To stay updated, keep myself safe from COVID-19 infection, and answer people's questions, I took 10 online training courses from the World Health Organization. With this training, I gained confidence in how to deal with the virus.
Finally, I attended the 2020 virtual meeting of the American Association of Physicists in Medicine (AAPM) and the Canadian Organization of Medical Physicists (COMP). It was possible to attend this conference because a friend of mine from the U.S. paid the registration fee for me. Because of the time difference between Nepal and the U.S., I stayed up the whole night to follow the presentations.
Being a fresher, I have never felt nervous in dealing with radiation treatment during the pandemic, despite the risks. We continue to treat cancer patients with limited protective resources from COVID-19. But because of pandemic, I have had plenty of time to learn and implement ideas and techniques that I learned while abroad. I personally took this pandemic as an opportunity -- keeping myself busy by learning and teaching others remotely. Nobody knows what will happen tomorrow, so it's wise to prepare yourself to face any unpredicted situation.
Tirthraj Adhikari is a radiation oncology physicist at the BP Koirala Memorial Cancer Hospital in Nepal. This blog was edited by Tami Freeman, online editor for Physics World.
© IOP Publishing Limited. Republished with permission from Physics World, a website that helps scientists working in academic and industrial research stay up to date with the latest breakthroughs in physics and interdisciplinary science.