Correspondence
The future of Iran’s
health workforce
Iran has been hit by six waves of
COVID-19 infection since the outbreak
of COVID-19 was announced by
authorities in March, 2020. 1 The
unprecedented and unknown nature
of the disease gradually led to burnout
of the health workforce, particularly
among those health-care workers
who were directly involved in treating
patients with COVID-19. On one hand,
burnout was caused by the fast spread,
absence of treatment, and severe
health outcomes; on the other hand, it
was driven by persisting deficiencies in
the health-care system: inexperienced
staff working in an epidemic situation;
untrained new medical staff; scarcity
of equipment, drugs, and other vital
resources; low ratio of nurses and
doctors to hospital bed; inefficient rest
time; anxiety; inability of families to
accompany patients to hospital; rigid
and busy work shifts of the health
workforce; infected staff continuing to
deliver care; and absence of alternative
personnel for medical staff.2
The Iranian workforce experienced
a remarkable increase in the
emigration of nurses and physicians
to work in high-income countries
such as Germany, Italy, and Canada.3
During the first year of the COVID-19
pandemic, more than 3000 Iranian
physicians applied for immigration
to foreign countries. The rate of
immigration requests from nurses
has increased by 300% during the
pandemic.4 Those who remained in
the country have worked day and
night through multiple waves of
COVID-19, hoping for permanent
elimination of the virus and a better,
healthier future.
Authorities had to deploy support­
ive, incentivising, and educa­ tional
measures during the pandemic to
increase productivity of the health
workforce and reduce burnout,1,5 but
no major change was observed. Due
to severe resource constraints and
budget deficits, increasing the number
www.thelancet.com Vol 400 September 10, 2022
of medical personnel with short-term
contracts and volunteers has been
used by policy makers to maintain
the required number of workers and
control spiralling costs. Except for the
permanent staff and those with long-
term employment contracts, the rest
of the health workforce was recruited
in hospitals using various forms of
employment that did not ensure any
future job security, including 89-day
contracts and a volunteer workforce
with small payments.4 Moreover,
national laws needed to support
medical staff were only partially
implemented or not implemented at
all. The ratio of nurses and nurse aid
staff per hospital bed is approximately
0·8–1·0 per bed 6 (compared with
the standard of 3·0 nurses per bed
and 4·0 nurse aid staff per bed).7
Considering how seriously a nurse’s
heavy workload affects patients’ health
outcomes, the government must take
measures immediately to compensate
for the shortage of hospital staff.8
Although Iran seems stable and has
passed over the peak of the sixth wave
of COVID-19 infection, urgent action
is needed to maintain the health
of the workforce and ensure their
resilience, particularly in anticipation
of future outbreaks. Strengthening
the district health network in Iran, a
symbol of Iranian policy intervention
in the past four decades,9 promoting
home care services, and investing
in the development of telemedicine
have the potential to reduce the
health workforce’s workload. For
this purpose, different health system
levels within the Iran Ministry of
Health of Medical Education should be
coordinated closely at service delivery
and policy making levels.
We have no competing interests.
Leila Doshmangir, *Shabnam Iezadi,
Kamal Gholipour,
Vladimir Sergeevich Gordeev
sh.iezadi@gmail.com
Tabriz Health Services Management Research
Center, School of Management & Medical
Informatics (LD) and Social Determinants of Health
Research Center (LD, KG), Tabriz University of
Medical Sciences, Tabriz, Iran; Hospital
Management Research Center, Health Management
Research Institute, Iran University of Medical
Sciences, Tehran 1996713883, Iran (SI);
Department of Infectious Disease Epidemiology,
London School of Hygiene & Tropical Medicine,
London, UK (VSG)
1 Doshmangir L, Gholipour K, Gordeev VS. Policy
changes needed to address the mental health
impact of COVID-19 in Iran. Lancet Psychiatry
2022; 9: e35.
2 Adibe B. COVID-19 and clinician wellbeing:
challenges and opportunities.
Lancet Public Health 2021; 6: e141–42.
3 Shaffer FA, Rocco G, Stievano A. Nurse and
health professional migration during
COVID-19. Prof Inferm 2020; 73: 129–30.
4 Maleki M, Mardani A, Vaismoradi M. Insecure
employment contracts during the COVID-19
pandemic and the need for participation in
policy making. Int J Environ Res Public Health
2021; 18: 12548.
5 Mehta S, Machado F, Kwizera A, et al.
COVID-19: a heavy toll on health-care workers.
Lancet Respir Med 2021; 9: 226–28.
6 Barasteh S, Rassouli M, Karimirad MR, Ebadi A.
Future challenges of nursing in health system
of Iran. Front Public Health 2021; 9: 676160.
7 Novak P. Iran: one nurse per 25 patients.
Sept 10, 2021. https://irannewsupdate.com/
news/society/iran-one-nurse-per-25-patients/
(accessed Aug 19, 2022).
8 Aiken LH, Sloane DM, Bruyneel L, et al. Nurse
staffing and education and hospital mortality
in nine European countries: a retrospective
observational study. Lancet 2014;
383: 1824–30.
9 Doshmangir L, Moshiri E, Farzadfar F. Seven
decades of primary healthcare during various
development plans in Iran: a historical review.
Arch Iran Med 2020; 23: 338–52.
The addition of pelvic
lymph node treatment
to prostate bed salvage
radiotherapy
Alan Pollack and colleagues1 suggest
improved freedom from progression
and reduced distant metastasis for
patients with prostate cancer who
are treated with salvage prostate bed
radiotherapy (PBRT) and pelvic lymph
node radiotherapy (PLNRT) combined
with short-term androgen deprivation
therapy (ADT; trial group 3) when
compared with treatment with PBRT
alone (group 1) or PBRT combined
with short-term ADT (group 2). Submissions should be
made via our electronic
We commend the investigators for submission system at
completing this important clinical http://ees.elsevier.com/
multicentre trial. thelancet/
883
 Correspondence
However, which subgroups of
contemporary patients should receive
PLNRT and short-term ADT remains
unclear. Importantly, only about two-
thirds of patients enrolled in the SPPORT
trial1 underwent lymphadenectomy,
with a median of only six resected lymph
nodes. Moreover, prostate-specific
membrane antigen (PSMA) PET–CT
scans were not done before PBRT to
exclude the involvement of pelvic
lymph nodes.2,3 PSMA PET–CT is widely
used at early biochemical progression
of disease after PBRT, offering the
possibility of salvage radiotherapy
treatment for patients with isolated
pelvic lymph node recurrences. This
option is not applicable to groups 1 or 2
of the SPPORT trial owing to the use of
the Phoenix definition for biochemical
failures, which is not validated in the
postoperative setting.
We hypothesise that in adequately
surgically staged patients, in whom
more than ten lymph nodes were
sampled4 and no lymph node involve­
ment was determined histologically,
and with modern functional PSMA
PET-based imaging at baseline and in
the case of early biochemical recurrence
of disease after PBRT, elective radio­
therapy of the pelvic lymph nodes
might not improve relevant cancer
control endpoints.
We declare no competing interests.
*Pirus Ghadjar, Stefan A Koerber,
Tobias Hölscher, Stefan Höcht,
Thomas Wiegel
pirus.ghadjar@charite.de
Department of Radiation Oncology, Charité
Universitätsmedizin Berlin, Berlin 13353, Germany
(PG); Department of Radiation Oncology,
Heidelberg University Hospital, Heidelberg,
Germany (SAK); Department of Radiotherapy and
Radiation Oncology, Faculty of Medicine and
University Hospital Carl Gustav Carus, Technische
Universität Dresden, Dresden, Germany (TH);
Xcare Radiology, Nuclear Medicine and
Radiotherapy, Saarlouis, Germany (SH);
Department of Radiation Oncology, University
Hospital Ulm, Ulm, Germany (TW)
1 Pollack A, Karrison TG, Balogh AG, et al.
The addition of androgen deprivation therapy
and pelvic lymph node treatment to prostate
bed salvage radiotherapy (NRG Oncology/
RTOG 0534 SPPORT): an international,
multicentre, randomised phase 3 trial. Lancet
2022; 399: 1886–901.
884
2 Miksch J, Bottke D, Krohn T, et al. Interobserver
variability, detection rate, and lesion patterns
of 68Ga-PSMA-11-PET/CT in early-stage
biochemical recurrence of prostate cancer after
radical prostatectomy.
Eur J Nucl Med Mol Imaging 2020; 47: 2339–47.
3 Fendler WP, Calais J, Eiber M, et al. Assessment
of 68Ga-PSMA-11 PET accuracy in localizing
recurrent prostate cancer: a prospective single-
arm clinical trial. JAMA Oncol 2019; 5: 856–63.
4 Fossati N, Willemse PM, Van den Broeck T, et
al. The benefits and harms of different extents
of lymph node dissection during radical
prostatectomy for prostate cancer: a
systematic review. Eur Urol 2017; 72: 84–109.
We read the results of the SPPORT
trial with great interest.1 Patients were
randomly assigned to salvage prostate
bed radio­therapy (PBRT), PBRT plus
short-term androgen deprivation
therapy (ADT), or PBRT plus short-
term ADT plus pelvic lymph node
radiotherapy (PLNRT). With a median
follow-up of 8·2 years, the study
showed a benefit in terms of 5-year
freedom from progression rates of
adding short-term ADT and PLNRT to
PBRT.
According to guidelines from the
American Urological Association
(AUA), the biochemical recurrence
of prostate cancer after surgery is
defined as a detectable serum prostate-
specific antigen (PSA) concentration
of 0·2 ng/mL or higher, which is later
confirmed by a second measurement
of 0·2 ng/mL or higher.2 According to
the inclusion criteria,1 patients with
PSA concentrations of 0·1–2·0 ng/mL
were included. However, the freedom
from progression endpoint was
driven by the Phoenix definition,
which is used worldwide for follow-
up after definitive radiotherapy. We
are interested to know the reason for
using the Phoenix definition, as most
of the world uses the AUA definition
of biochemical recurrence in the
postoperative setting.
Two previous prospective studies
have shown a benefit in terms of
recurrence-free survival when ADT
is added to PBRT. 3,4 In SPPORT,
the addition of short-term ADT to
PBRT also improved freedom from
progression outcomes, as might be
www.thelancet.com Vol 400 September 10, 2022
expected; however, the rationale
underlying the benefit of PLNRT is
not clear. The role of PLNRT as salvage
therapy is still controversial for
patients with­out nodal involvement.
At least ten lymph nodes must be
removed to establish accurate staging
by lymph node dissection.5 However,
only a median of six lymph nodes
was removed,1 which is presumably
insufficient. PLNRT could have
benefitted patients with undissected
occult lymphatic metastases. On the
basis of these results, the application
of PLNRT—which is more toxic than
PBRT—might not be appropriate in
patients without nodal involvement.
Could the positive effect be related
to PLNRT possibly compensating for
inadequate lymph node dissection?
Additionally, for patients with
intermediate-risk prostate cancer
who receive definitive radiotherapy,
ADT is suggested for those classified
in the unfavourable group but not
for those classified in the favourable
group. From this perspective, we
think that a personalised treatment
approach that considers the Gleason
score and the PSA concentration at
recurrence is important in the decision
to apply ADT and PLNRT. In the
treatment of prostate cancer, it would
be logical to include groundbreaking
metabolic imaging methods in the risk
stratification of patients.
In conclusion, although the
results of SPPORT are valuable and
thought-provoking, clarification of
the aforementioned issues would
be helpful to better understand the
implications of the findings.
We declare no competing interests.
Alper Kahvecioglu, Melek Tugce Yilmaz,
*Pervin Hurmuz
pervin.hurmuz@hacettepe.edu.tr
Department of Radiation Oncology, Hacettepe
University Faculty of Medicine, Ankara 06100, Türkiye
1 Pollack A, Karrison TG, Balogh AG, et al.
The addition of androgen deprivation therapy
and pelvic lymph node treatment to prostate
bed salvage radiotherapy (NRG Oncology/
RTOG 0534 SPPORT): an international,
multicentre, randomised phase 3 trial. Lancet
2022; 399: 1886–901.