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The COVID- 19 Pandemic has imposed on clinicians a scenario -never seen before – where accepted guidelines and treatment norms are challenged because of the tremendous strain on health care resources. Moreover, because of their systemic immunosuppressive state caused by the malignancy and anticancer treatments, such as chemotherapy, targeted therapy and immunotherapy, cancer patients are more susceptible to COVID-19. As a result, they have a higher incidence of life-threatening events such as severe pneumonia, acute respiratory distress syndrome & cytokine storm, causing multi-organ failure and death.
According to a WHO report, cancer patients have an estimated 2-fold increased risk of COVID-19 than the general population.
There are approximately 1.7 million cancer cases in India, with an incidence of one million. Around 7.5 lakh patients succumb to cancer every year. Cancer is a semi-emergency disease, and its treatment is time-bound. Patients are reluctant to come for treatment during the covid 19 pandemic. During the lockdown and post-lockdown, there is a backlog, and as a result, patients are presenting with advanced disease. At Apollo Cancer Centres, Breast Cancer Presentations, during and post lockdown have been predominantly locally advanced and metastatic diseases. This is true of other malignancies like lymphoma, where a lack of follow-up has progressed the disease.
The use of hospital resources such as PPE, with reduced appointments and staff, also plays an additional burden on the financial resources and needs to be managed efficiently. But with no Vaccine in sight and community spread, the only practical solution appears to be protecting healthcare workers and the vulnerable population in the community against Covid-19 infection and transmission, having treatment strategies that benefit while not harming the patient and offer them a realistic chance for survival.
Apollo Cancer Centres is a dedicated cancer hospital, and we don’t admit a diagnosed Covid-19 patient unless they have cancer and is in need of immediate attention. The problem of the Covid -19 infection is many mild symptomatic and asymptomatic infections, especially in the lower socio‑economic, densely populated areas and among individuals exposed to community mobility. Healthcare workers and caregivers like nurses and housekeeping staff live in densely populated areas in hostels with shared accommodation and shared modes of transport. Despite following a strict rotation of independent working teams, we have had to quarantine groups of nurses living in the hostels as they turned positive, leading to acute staff shortages.
RT PCR can be false negative as its detection depends on the viral load, and there are limitations to antibody testing. We only do symptomatic evaluation for Covid-19 and check for fever, cough & cold, loss of smell and taste for patients who come for diagnostic imaging. We have found lung changes due to Covid-19 in few (three) of our PET CT patients who were asymptomatic and also turned out to be RT PCR negative. With community spread, periodic antibody testing of serum IgM & IgG values as a marker for recent and past infection for health workers and caregivers might prove to be more relevant as a cheaper, less cumbersome alternative before vaccine-induced herd immunity sets in.
Online dispatch of reports has become the norm, and wherever feasible, teleconsultations are encouraged, reducing the need for hospital visits. However, we consider all patients as Covid -19 positive, and a strict protocol in the work-flow for a safe environment, sanitization of equipment, staff & maintaining social distance is followed.
Psychological support needs to be provided during these anxiety-provoking times of Covid-19 to patients and staff. Oncological patients are emotionally very vulnerable because of the nature of their disease and the side effects of treatment and feel stigmatized. This is addressed by using exclusive hot-lines, phone calls and teleconsultation and messaging services like WhatsApp and taking the help of our support and survivor groups for patients.
Oncological emergencies need to be handled differently as the risk versus benefit must be assessed on a case-by-case basis, and virtual tumour boards have been very useful. For example, gastrointestinal oncological emergencies due to tumour perforation or obstruction can be the first presentation needing emergent surgery despite the risk of morbidity.
Breast cancer surgery is a non-emergent situation and can be postponed. But the delay in diagnosis and start of treatment comes at a huge cost of morbidity as the lesions which would have been operable become locally advanced and can disseminate to metastasis.
In Hindu scriptures, Kalki, the tenth avatar, is astride a horse brandishing a sword, and it is, He who will close the ‘Kalpa’ or the cycle. The divine ‘Horseman’ can decide an individual’s fate. Pandemics are cyclical, and this is not the first, nor will it be the last. Cancer is a semi-emergency, and timely treatments affect the disease’s morbidity and outcome. But with the Pandemic having raged for close to a year, we have seen a surge in the severity of presentation in patients with oncological ailments. Our duty as health care workers is to try to cure, alleviate suffering – offer succor, and care for our patients carefully and safely.
- Apollo Cancer Centres has seen an inflow of patients presenting with advanced stages of cancer due to delayed consultations as they have been unwilling to come for check–ups during the pandemic, as is seen in the below cases:
- A 54-year-old lady was presented with a small lesion less than 1cm, seen only in ultrasound & contrast mammogram. The biopsy showed she had infiltrative ductal carcinoma and was ER PR positive. The patient did not want surgery during Covid 19 & was put on hormonal therapy after placing a marker clip. The patient did not want breast conservation as she was reluctant to have radiotherapy and had a mastectomy. Post op the patient has recovered well.
- Another patient had come in with locally advanced carcinoma stomach and which was being treated in another hospital. Upper GI endoscopy was performed which showed an ulcer proliferative growth in the greater curvature of the stomach extending up to pylorus. Biopsy showed a Moderately differentiated adenocarcinoma. The patient was started on chemotherapy, and after the required cycles the recent CT showed stable malignant wall thickening in distal body and pylorus of the stomach with mild regression in metastatic peri gastric, pyloric and mesenteric nodes.
- An 87-year-old lady with no co-morbidities, well preserved with good mental status, developed acute abdominal pain and high-grade fever for two days. The colonoscopy evaluation showed multiple diverticulosis in the sigmoid and stricture in descending colon at 40cm from the anal verge, and scope could not be passed beyond the stricture. Although the patient developed ascites due to dyselectrolytemia, the ascitic fluid cytology was negative for malignancy. The patient was discharged as she was comfortable, afebrile, and hemodynamically stable with ileostomy in situ.
- A female patient was presented with abdominal pain, no comorbidities with no family history of malignancy. She had complaints of sudden onset lower abdominal pain which settled with analgesics. CT showed a well-defined heterogeneously enhancing complex multiloculated ovarian mass with features of torsion and well-defined lesions in segments II and III of the liver suggest haemangioma. Post-surgery, her left ovary showed borderline Seromucinous tumour with no evidence of invasion while the right ovary showed benign Seromucinous Cystadenoma. She got discharged as no further treatment was necessary, 90% of patients with Seromucinous tumours present at stage 1 and had a good prognosis.
- Apollo Cancer Centres has seen an inflow of patients presenting with advanced stages of cancer due to delayed consultations as they have been unwilling to come for check–ups during the pandemic, as is seen in the below cases:
