|Year : 2020 | Volume
| Issue : 2 | Page : 134-136
Conducting interdepartmental tele-joint clinic during the coronavirus disease 2019 pandemic in a tertiary cancer care center
Kajari Bhattacharya1, Suyash Kulkarni2, Amit Janu2, Anand Jadhav3, Sudhir Nair4, Amit Joshi5, Navin Khattry6, Sudeep Gupta6, Nitin Sudhakar Shetty1
1 Department of Radiology, ACTREC, Tata Memorial Centre, Navi Mumbai, Maharashtra, India
2 Department of Radiology, Tata Memorial Hospital, Navi Mumbai, Maharashtra, India
3 Department of Information Technology, ACTREC, Tata Memorial Centre, Navi Mumbai, Maharashtra, India
4 Department of Head and Surgical Oncology, ACTREC, Tata Memorial Centre, Navi Mumbai, Maharashtra, India
5 Department of Medical Oncology, ACTREC, Tata Memorial Centre, Navi Mumbai, Maharashtra, India
6 ACTREC, Tata Memorial Centre, Navi Mumbai, Maharashtra, India
|Date of Submission||13-Nov-2020|
|Date of Acceptance||18-Nov-2020|
|Date of Web Publication||8-Dec-2020|
Nitin Sudhakar Shetty
Department of Radiology, ACTREC, Tata Memorial Centre, Kharghar, Navi Mumbai - 410 210, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: The coronavirus disease 2019 pandemic has posed numerous challenges to health care across the globe. Time is of the essence in cancer care to prevent disease progression. Materials and Methods: TrueConf ®, a local area network-based software, has been used for holding joint clinic meetings which are an essential part of cancer management at our hospital. Results: A total of 12 meetings were held over a period of 12 weeks where 42 patients were examined and their clinicoradiological evaluation was done. Further treatment decisions were made based on these joint clinics. Conclusion: TrueConf ® is an economical platform and easily implementable system, easing decision-making for critical cases, avoiding crowding in outpatient departments.
Keywords: Cancer care, coronavirus disease 2019, virtual joint clinic
|How to cite this article:|
Bhattacharya K, Kulkarni S, Janu A, Jadhav A, Nair S, Joshi A, Khattry N, Gupta S, Shetty NS. Conducting interdepartmental tele-joint clinic during the coronavirus disease 2019 pandemic in a tertiary cancer care center. J Head Neck Physicians Surg 2020;8:134-6
|How to cite this URL:|
Bhattacharya K, Kulkarni S, Janu A, Jadhav A, Nair S, Joshi A, Khattry N, Gupta S, Shetty NS. Conducting interdepartmental tele-joint clinic during the coronavirus disease 2019 pandemic in a tertiary cancer care center. J Head Neck Physicians Surg [serial online] 2020 [cited 2021 Apr 18];8:134-6. Available from: https://www.jhnps.org/text.asp?2020/8/2/134/302640
| Introduction|| |
The coronavirus disease 2019 (COVID-19) pandemic has imposed many unforeseen challenges on health-care systems across the world. An analog health system has proved to be inadequate during these exceptional circumstances and pushed us to discover digital systems. Telemedicine and virtualized treatment have become critical in providing health care during this pandemic. It is especially important in cancer patients, as in many cases, there is a need to find the balance between prevention of iatrogenic exposure of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to this often immunocompromised group during clinical visit and inadvertently decreasing life expectancy which, in these patients, depends on timely diagnosis and management. The professionals at Tata Memorial Centre have been indomitable in providing cancer management during this unprecedented challenge. We have devised a safe, reliable, economical, and easy-to-implement process of holding joint clinic meetings, which are the very essence of comprehensive cancer care and decision-making at a tertiary cancer center as this.
| Materials and Methods|| |
The joint clinic meetings were held between the departments of head-and-neck surgical oncology, radiology, medical oncology, and radiation oncology. Members of the team included two surgeons, two radiologists, one medical oncologist, and one surgical oncologist.
Time and place
The online meetings were conducted at ACTREC, Tata Memorial Centre, in the respective departments, with the patient being examined in the outpatient department (OPD) of head-and-neck surgical oncology. All precautions were taken while examining the patient starting the use of personal protective equipment including face shields and N95 masks to limiting the time of examination, keeping it as low as reasonably achievable. The clinics were arranged weekly once, every Wednesday between 2.00 pm and 3.00 pm. A total of 12 meetings were conducted between August 12, 2020, and October 27, 2020.
TrueConf® video conferencing software was used for these meetings. The system was installed in the respective departmental computers dedicated for these clinics. In the Department of Radiology, it was installed and integrated with a high-end viewer to display radiology cross-sectional images directly from picture archiving and communication system. Cameras were also attached with these systems to ensure transmission at all points. All these systems were connected via local area network (LAN), without the use of any external internet connection. The systems were installed and checked for any glitches by our information technology (IT) department. [Figure 1] demonstrates the plan of these virtual joint clinics.
|Figure 1: Schematic representation of the interdepartmental virtual joint clinic organized during coronavirus disease 2019 pandemic using local area network-based software (TrueConf)|
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| Results|| |
Over the course of these 12 meetings, a total of 42 patients (30 males and 12 females) between the age groups of 39 and 68 years were considered for these interdepartmental discussions after being examined in the head-and-neck surgical OPD, as they required decision-making based on their imaging features to plan further management for undergoing surgery, palliative therapy, or presurgical chemotherapy. Majority of these patients (30/42) suffered from oral cavity lesions, including buccal mucosa, tongue, alveolar, and palatal masses, with other patients presenting with laryngeal cancers (10/42) and pharyngeal masses (2/42).
The clinical findings were correlated with imaging findings. Important imaging findings that were discussed included extension of the lesion to the high infratemporal fossa, prezygomatic space, parotid space, bony erosion, perineural spread, and intracranial extension, which were assessed on imaging in oral cavity and nasopharyngeal lesions, with assessment of vascular involvement, exolaryngeal spread, and prevertebral fascia invasion assessed in laryngeal/hypopharyngeal lesions for assessment of operability.
In 8 out of these 42 cases, discussion of the radiological findings with the team of surgeons and medical and radiation oncologists helped in changing the course of management with 3 of these patients who were considered operable after the discussion and 5 patients considered inoperable. Further imaging with MRI was advised in 6 of the other 34 patients for evaluation of perineural spread, cartilage invasion, and prevertebral fascia invasion, after which decision regarding further management was decided in the next clinical meeting. [Figure 2] demonstrates a representative case where plan of management was changed after review in a joint clinic.
|Figure 2: (a) A patient being examined in Head-and-Neck Surgical Outpatient Department as seen from the Department of Radiology (inset). (b) Contrast-enhanced computed tomography axial image of the buccal region showing a large enhancing mass lesion arising from the left buccal mucosa and extending to involve the left retromolar trigone. (c) The high infratemporal fossa was not involved with the disease (not shown), but the patient was planned for neoadjuvant chemotherapy after imaging review showed edema and fat stranding extending till zygoma (arrow)|
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During the virtual joint clinic meetings, there were two instances of camera malfunction and one instance of speaker malfunction which was promptly resolved by the members from the IT department. No transmission-related problem was encountered. Visualization of radiological images was considered optimal by the clinicians. Similarly, good visualization of the lesion was agreed upon by the other three sites.
| Discussion|| |
Comprehensive cancer care and decision-making encompass the interaction between various departments, including the medical and surgical teams, radiology, and radiation oncology. During the pre-COVID era, joint clinics at our institution were conducted with representatives from these teams. However, conducting these meetings requires a gathering of doctors and the patient in close quarters and may potentially serve as an event leading to the spread of the SARS-CoV-2.
With the aim of continuing cancer care even in these adverse conditions, the Department of Radiology in association with Departments of Head-and-Neck Surgical Oncology and IT at ACTREC, Tata Memorial Centre, devised a unique yet cost-effective version of a virtual joint clinic which minimizes the crowding in the patient vicinity. TrueConf®, a LAN-dependent video conferencing platform, enabled us in conducting these joint clinics in a seamless manner. This LAN-based private network does not depend on internet connection, hence it is inherently safe from problems of low bandwidth and malware. As the server is maintained by a local administrator, troubleshooting is almost instantaneous. The audio, video, and textual data are encrypted and protected with data authentication.
The meetings were critical in deciding the course of management in 14 of the 42 patients discussed. In our experience, there was no lag in uploading high-quality radiology images across this server, as they were being viewed in the OPD. The transmission quality and resolution were appropriate to demonstrate small lesions, even in the oral cavity, which were well appreciated across this platform by the radiologists. Troubleshooting was performed in all three instances within a few minutes, and the meetings could be conducted without any significant loss of time.
As the world moves increasingly toward digital from analog and virtual from real, the ongoing pandemic has accelerated the process due to need to draw the balance between social distancing and continued professional health care, especially for our vulnerable populations. This necessitates the rapid expansion of telemedicine, along with the development of affordable yet effective platforms for interdepartmental communication to prevent any untoward delays in patient care. We are hereby using a free version of this software which has been provided for a year and can be used by 12 users simultaneously. However, we plan to expand this program to involve and connect all departments forming various disease management groups, who can virtually gather for these meetings.
As we make leaps in cancer care and telemedicine, these virtual joint clinics conducted at our institute pave the way for establishing this as a safe, economical, and sustainable alternative to crowded OPDs, which are assured to continue beyond this global health crisis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
This material has never been published and is not currently under evaluation in any other peer-reviewed publication.
The permission was taken from the Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
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[Figure 1], [Figure 2]