Verified By April 15, 2022
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.