Response letter: Letter to the editor regarding Wei W et al.: ''Experience of the Hubei cancer hospital in Wuhan, China".

To the Editor

Merlotti and colleagues wrote a letter [1] on our manuscript in which we described the multiple measures for patient and staff COVID-19 protection and prevention at the Hubei Cancer Hospital in Wuhan, China in early 2020 at the start of the COVID-19 pandemic. We concluded that they raised three questions and discussion points: Firstly, Merlotti et al. thought that the main reason that a large proportion of cancer patients did not receive necessary radiation treatment was the two-team staff schedule put in place. Secondly, they pointed out that the chest CT required for inpatient admission and for the accompanying caregivers to enter treatment areas seemed unreasonable and unwarranted. Lastly, for patients exhibiting COVID-19 symptoms after admission, they questioned our policy of transfer or single-occupancy isolation for 14 days and asked if that also applied to patients under treatment.

Regarding the first point of patient volume drop, we just want to reiterate that, as described in our original manuscript [2], the main reasons were patient-perceived risks of infection and the traffic control implemented during the lockdown. Needless to say that nowadays the entire world is aware of the great health risks posed by COVID-19. The pandemic has caused not only extraordinary public health concerns but also tremendous psychological distress [3]. In the early months of the outbreak when much was still unknown about the disease fatality and transmission pathways, the panic was especially greater. In the first month of the outbreak, there were 16,500 confirmed cases, 360 fatalities, and over 20,000 suspected cases in China, with the vast majority of them concentrated in the city of Wuhan. Qian Y et al. reported [4] that 85% of cancer patients and 91% of their family expressed fear of becoming COVID-19 infected. Therefore, during the early months of the outbreak and the peak of the epidemic in Wuhan, most of cancer patients chose to stay at home rather than go to the hospital to receive cancer treatments, unless the tumor symptoms cannot be tolerated. In addition, as the only oncology specific hospital in Wuhan, our hospital regularly treats not only cancer patients living inside Wuhan city, but also many cancer patients in outside Wuhan city. Soon after the outbreak, the central Chinese government activated Level Ⅰ health emergency responses in Wuhan and Wuhan was under lockdown on January 23, 2020. According to Wang et al have reported that over one-third of cancer patients could not continue cancer treatments due to inconveniences (e.g., transport) caused by COVID-19 [5]. Therefore, the patient volume drop seen at our hospital in February to early March was also due to the traffic control which prevented patients living outside of Wuhan from coming to our hospital and leading these patients to choose nearby hospitals for treatment. As the same reasons as we have experienced, the number of patients receiving radiotherapy in Zhongnan hospital in Wuhan has also significantly decreased (a 10-fold drop after lockdown) [6].

Regarding the second point of requiring chest CT, we maintain that it was deemed helpful to improve COVID-19 detection sensitivity and put in place in accordance with the national health guideline. Real-time reverse transcription polymerase chain reaction (RT-PCR) of viral nucleic acid, which possesses a high specificity but a poor sensitivity, is regarded as the reference standard as COVID-19 diagnosis; however, half of the patients were diagnosed as COVID-19 without fever in the early stage [7], and even with negative nucleic acid tests at first few times [8]. Some studies have emphasized the importance of chest computed tomography (CT) examination in COVID-19 patients with false negative RT-PCR results [9], [10], and reported a CT sensitivity of 98% [7]. According to the diagnosis and treatment program (6th version) published by the National Health Commission of the People’s Republic of China at the time discussed in the original manuscript [11], CT examination was one of the diagnostic criteria for COVID-19. Therefore, the chest CT examination was required for inpatient admission and the accompanying caregivers to enter treatment areas to help make an early diagnosis of COVID-19 during the peak of the epidemic in Wuhan. Since the epidemic got under control in Wuhan, the requirement of chest CT testing has been lifted for inpatient admission.

Finally, for patients exhibiting COVID-19 symptoms after admission, our policy was to transfer the patient to a COVID-19 hospital or to observe in single-occupancy isolation for 14 days. While in isolation, these patients were treated only with COVID-19 care. Any antitumor therapy, including radiotherapy, was discontinued until their symptoms improved and the isolation was removed. For interrupted radiotherapy in such cases, our general departmental practice guideline was to add one additional fraction for each 3-day interruption, although this manner of prescription modification is ultimately up to the discretion of the attending radiation oncologist on a case-by-case basis. We recognize that there could be detriments for curative treatments due to prolonged interruptions. Yet in the early months of the COVID-19 pandemic, the strict prevention measures we took were effective in preventing the patient and staff infection and ensured the smooth and uninterrupted operation of our center in the epicenter Wuhan when it was hit by the virus with unprecedented intensity.

COVID-19 pandemic undoubtedly affected everyone across the world and changed how we go about our daily lives. Just as our personal practice varies from place to place and from time to time, our practice as cancer care professionals would also naturally stay fluid. With a common goal to provide quality cancer care to our patients and protect patients and staff from COVID-19 infection, we all try to optimize our practice based on the medical environment at the time and the prior experience of others, and in line with local governments’ regulations and recommendations.

Conflict of interest

None declared.