Cancer Care in times of COVID-19
Dr Krishnakumar Rathnam, Senior Consultant & Head, Dept of Medical Oncology, Meenakshi Misson Hospital and Research Centre, Madurai
Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, is a novel coronavirus first detected in Wuhan, China in December 2019 and has infected lakhs of people causing deaths in thousands across 186 countries including India. In India as the clock is ticking, the number of people diagnosed with COVID-19 infection in India is certainly increasing. As last statistics recorded during writing of this article the total number of Covid-19 cases in India has reached 1637, including 1466 active cases, while 133 people have been cured/discharged.
Effect of COVID-19 on cancer patients
As per the Report of the WHO-China Joint Mission on COVID-19, cancer patients (especially elderly, very young patients, patients with diabetes, hypertension, cardiovascular diseases and chronic respiratory illnesses) had an estimated 2-fold increased risk of COVID-19 than the general population. Early published reports from China on outcomes of cancer patients infected with COVID-19 indicated a 3.5 times higher risk of needing mechanical ventilation or ICU admission or dying compared with patients without cancer. Over and above, they become a potential source of infection to all their contacts and care givers; emphasizing the need for thorough education of COVID prevention to all cancer caregivers.
Preparedness by the oncology team – “Prevention better than cure”
Suggestions and guidelines have been drafted by various oncology societies across the globe from USA, Europe, China and in India also. “PREVENTION OF INFECTION” is the first step in any health care. The starting point to infection and environmental control of COVID 19 is triage of patients with respiratory symptoms so as to reduce exposure to other patients. Use of screening questionnaire for the detection of suspected coronavirus cases, masking of individuals at all entry points of the system, symptom screening of all patients, visitors and staff before entering the hospital is very crucial. Any symptomatic patients will be referred to the government health department for next level evaluation and COVID-19 testing and isolation if indicated. As Oncologists we are more attentive to detect coronavirus infection early, as any type of advanced cancer is at much higher risk of unfavourable outcomes.
Use the telephone and use telemedicine technology if available
We generally ensure that every cancer patient spends more time at home and less time out in the community. A telephonic appointment system and reinforcement of a strict “stay at home when ill” policy is key in preventing community spread of COVID-19. As oncologists we also communicate to our patients the right information regarding practice modifications during COVID-19 outbreaks.
Continuum Of Cancer Care For New And Existing Cancer Patients
The general thumb rules
Cancer patients can continue their treatment unless they are in close contact with someone with COVID-19 or presenting with symptoms of cough, shortness of breath, breathing difficulties or high temperature.
Cancer surgery and radiotherapy during the pandemic
Elective cancer surgeries can be rescheduled after weighing specific risks of the delay. Oncologists would decide to postpone or modify radiation therapy depending on the clinical situation. Emergency radiotherapy, however will be delivered by most oncologists with all precaution.
Cancer chemotherapy and COVID-19 pandemic
With lock down and paucity in transport facility, all measures to minimize risk of chemotherapy toxicity should be taken. This is done to make sure the cancer patient is not stranded at his home town sick, unattended and unable to reach us on time. Less toxic chemotherapy regimens with lesser hospital visits and oral chemotherapy regimens may minimize exposure of both patient and the caregiver to COVID-19 sources. Certain planned chemo schedules may be delayed, however patients requiring chemotherapy for day to day control of disease may continue their therapy under strict monitoring and adherence to COVID-19 prevention strategy. Planned allogeneic stem cell transplantation can be reasonably delayed particularly in a situation where the disease control can be achieved with alternate treatment methods. Patients can continue to take palliative care at their own place under guidance of telemedicine consultation. It is important that each patient understands that every decision to modify treatment is taken keeping in mind risk/benefit to the cancer patient who is a highly susceptible person to COVID-19.
Cancer screening and Follow up visits
All asymptomatic people are advised to postpone their planned cancer screening procedures and asymptomatic patients who have completed cancer treatment to postpone follow up visits till COVID-19 epidemic settles. However, these patients must be educated to contact health care providers in case of contact history or if having symptoms of COVID-19.
General measures to prevent COVID-19 spread among cancer patients
Cancer patients requiring hospitalization need to be protected from potential sources of COVID-19 infection. Institutions handling large volume in-patient cancer patients, pediatric cancer patients, leukemia patients on treatment, bone marrow transplant patients and hematology patients on immunosuppressive therapy should preferably isolate these patients from potential and proven COVID 19 patients. In such centres, COVID-19 patients be admitted in separate blocks well away from these high-risk groups. Patients, the treating team and patient care givers should be educated about appropriate preventive measures about social distancing practices and maintaining hygiene and how to break COVID-19 transmission. Home quarantine and government policies of “staying home” is to be respected and strictly adhered to, understanding the fact that government is acting in support of community health at large and it is our social responsibility as citizens of India.