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Table of Contents
MUSINGS
Year : 2020  |  Volume : 3  |  Issue : 5  |  Page : 145-148

Advisory for cancer patients during the COVIDpandemic


1 MS Patel Cancer Centre and Shree Krishna Hospital and Research Centre, Karamsad, Gujarat, India
2 Department of Medicine, Armed Forces Medical College, Pune, Maharashtra, India
3 Department of Medical Oncology, Army Hospital Research and Referral, New Delhi, India
4 Regional Cancer Centre, PGIMER, Chandigarh, India
5 Department of Medical Oncology, Tata Medical Centre, Kolkata, West Bengal, India
6 Department of Surgical Oncology, Ivy Hospital, Mohali, Punjab, India
7 Department of Medical Oncology, Dr. BR Ambedkar Cancer Institute, Rotary Cancer Hospital, AIIMS, New Delhi, India
8 Department of Medical Oncology and Hematology, Asian Institute of Medical Sciences, Faridabad, Haryana, India

Date of Submission05-Apr-2020
Date of Decision06-Apr-2020
Date of Acceptance08-Apr-2020
Date of Web Publication25-Apr-2020

Correspondence Address:
Priyanka Srivastava
MS Patel Cancer Centre and Shree Krishna Hospital and Research Centre, Gokul Nagar, Karamsad - 388 325, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_125_20

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How to cite this article:
Srivastava P, Tilak T V, Patel A, Das CK, Biswas B, Mahindru S, Pramanik R, Ghosh J, Mehta P. Advisory for cancer patients during the COVIDpandemic. Cancer Res Stat Treat 2020;3, Suppl S1:145-8

How to cite this URL:
Srivastava P, Tilak T V, Patel A, Das CK, Biswas B, Mahindru S, Pramanik R, Ghosh J, Mehta P. Advisory for cancer patients during the COVIDpandemic. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jun 1];3, Suppl S1:145-8. Available from: http://www.crstonline.com/text.asp?2020/3/5/145/283295




  Novel Coronavirus Infectious Disease 2019 – Severe Acute Respiratory Syndrome Coronavirus-2: an Overview Top


The World Health Organization (WHO) defines a pandemic as a worldwide spread of new disease. So far, in modern human civilization, influenza pandemic in 1918 (popularly known as the Spanish Flu Epidemic) has been the deadliest event. It claimed around 50 million or more deaths, equivalent in proportion to 200 million in today's global population,[1] and it has stood as a morbid benchmark till now. The year 2020 is now witnessing another such pandemic. The growing pandemic of novel coronavirus infectious disease, i.e., COVID-19, is caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). It originated in Wuhan, China, in December 2019. After spreading through China over the last 4 months, it affected more than 180 countries, with 857,487 confirmed cases and 42,107 deaths globally till March 31, 2020. At present, it is assumed to be seeding more than two secondary cases for each primary infected case.[2]

On March 11, 2020, the WHO declared COVID-19 a global pandemic.[3] The postulated origin of the virus from RNA sequences closely resembles those of viruses that silently circulate in bats. Epidemiologic information implicates a bat origin virus infecting unidentified animal species that are being sold in China's live-animal markets. In our modern epidemic era, any disease occurring anywhere in the world can appear the next day in our neighbor's backyard. We have reached this point because of continuing increases in the human population, over-crowding, human movement around the globe, environmental alteration, and ecosystemic complexity related to human activities and creations.

Most people infected with the COVID-19 virus experience mild-to-moderate respiratory illness and recover without requiring any special treatment. Older people and those with underlying medical problems such as age more than 60 years, cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely to develop serious illness.[4]

The best way to prevent and slow down transmission is to be well informed about the COVID-19 virus, the disease it causes and how it spreads. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose, i.e., when an infected person coughs or sneezes, or from contact with bodily fluids. Hence, it is important that one also practices respiratory etiquette (for example, by coughing into a flexed elbow or hand before mouth during coughing, maintaining social distancing).


  Perspective on Effects of Lockdown on Cancer Patients Top


The Indian government announced the nationwide 3 weeks lockdown on March 24, 2020. This meant, every citizen must be strictly confined to their houses for a minimum of 21 days. Provision of essential services was exempted such as emergency health-care services, buying of household things, and bank cash transactions. Most of the private and much of the public healthcare delivery system through the outpatient departments (OPDs) remained closed. Only emergency services were to be operational. These measures were undertaken to “flatten the exponential growth curve” of the COVID-19 pandemic. This has translated into challenges for cancer patients in many ways.

Social issues

Lack of social support system for cancer patients especially the vulnerable ones who either live alone, are differently abled, and elderly, and access to daily needs such as groceries are emerging as challenges for this population.

Treatment issues

Non-urgent cancer-related surgeries have been deferred till the lock down period is over. This will translate into longer waiting periods for planned surgeries and potential risk of worsening stage of cancer.

Financial issues

Due to the lock down period, loss of incomen will translate into economic burden for cancer patients and their families.

Logistics issues

Due to the non-availability of public transport and difficulties with private transport, patients have faced great difficulties to reach hospitals. Some required to show necessary documents for need of travel to the concerned authorities during this period. Courier services which used to procure medicines and deliver laboratory specimens are defunct. Special investigation modalities such as positron emission tomography-computed tomography, magnetic resonance imaging, and radionuclide scans are difficult to access.

Medical care delivery

Routine OPDs remained closed in most of the hospitals. Inpatient care is restricted to oncologic emergencies. Chemotherapy in day-care continues in only some facilities. Radiation therapy delivery is operational in certain hospitals mostly for ongoing patients.


  Recommendations and Advisory for Cancer Patients and Their Caretakers Top


Various international cancer societies are updating their recommendations as more scientific knowledge about COVID-19 is becoming available. Certain general recommendations are as given below.

Patient education

Cancer patients receiving chemotherapy and radiotherapy are immunosuppressed and hence at two-fold higher risk of getting COVID-19 infections.[2],[5] Cancer patients once infected with COVID-19 have higher rates of complications such as intensive care unit admissions and higher mortality as compared to the general population. Hence, all patients should be aware of the symptoms of SARS-CoV-2 infection. Symptomatology of COVID-19 infection and red flags requiring urgent medical attention are:

  • Fever >100.4°F with cough
  • Shortness of breath
  • Travel history to COVID-19 areas
  • Possible exposure to COVID-19 patients or close contacts
  • Presence of new-onset diarrhea
  • Loss of smell sensation
  • General care and precautions.[6]


  1. Hand hygiene: Frequent hand washing with soap and water for at least 20-30 seconds using the six-step technique or hand sanitizer with at least 60% alcohol base. Avoid handshakes
  2. Social distancing: Avoid public gatherings and keep safe distance of at least 1 m between two people. Avoid nonessential outdoor activities and travel
  3. Avoid touching surfaces that might be contaminated
  4. Follow cough and sneeze etiquettes with use of the sleeve or tissue
  5. Careful disposal of used tissues
  6. Clean and disinfect surfaces which may be contaminated using household cleaning solutions with soap base
  7. Every person should use mask.[7] Mask type used should be surgical masks in case of patients and N95 masks in case of healthcare workers with close contact with COVID-19 patients.


Specific precautions

Various international cancer societies are updating their recommendations as more scientific knowledge about COVID-19 is becoming available.[8]


  For Newly Diagnosed Cancer Patients Top


  1. Patients are advised to ascertain availability of medical services and staff at cancer center
  2. Telemedicine services are being set up in most of the cancer centers. Their contact details including phone numbers and email IDs are being uploaded on the hospital website dashboard
  3. Individual cancer cases are discussed in a multidisciplinary tumor board. The risks and benefits of delivering urgent cancer care during the COVID-19 pandemic in a resource-restrained setting are also being considered in decision-making. The panel discussion is shared with the patient and an informed decision is taken by a treating oncologist. Every hospital/healthcare facility is developing their own standard operating procedure regarding anticancer treatment and other patient management decisions
  4. Screening tests for cancer patients for asymptomatic SARS-CoV-2 carrier or active viral disease may also influence the cancer treatment decision. They are done at the discretion of the treating oncologist
  5. Clinical trial enrolments of new subjects may not be available during this period, as local logistical challenges may hamper smooth conduct of the trial and safety of the patient. Central Drugs Safety and Control Organization has notified that for patients in clinical trials, protocol amendment, deviation, and modification in the procedure may be necessary due to unavoidable circumstances. In case of ongoing trials, the sponsor in coordination with the investigator and the respective ethics committee will decide whether to continue the trial or otherwise in the interest of the trial subjects.



  For Patients Who Are on Active Treatment Top


Outpatient department patients

  1. Patients being treated on predetermined fixed chemotherapy protocols should continue receiving their doses of medications as before, if benefit outweighs the risk for COVID-19
  2. Depending upon the type and stage of cancer, the oncologist would tailor treatment on an individual basis, with an informed decision process by patient(s) and caregiver
  3. Maintain adequate distance, personal protection, and proper/periodic sanitization in the OPD sitting area.


Inpatients/hospitalized patients

  1. Maintain adequate distance between patients
  2. Provision of mask to all admitted patients. Change of masks at prespecified intervals should be ensured, based on the guidelines and logistics
  3. Patients with fever and cough should be tested for SARS-CoV2 keeping a low threshold for testing. Isolate such patients immediately with high index of suspicion even before testing as per symptomatology
  4. Neutropenic patients should be managed in separate rooms with standard precautions
  5. Maintain adequate ventilation.



  For Patients With Planned and Emergency Surgeries Top


  1. There are no specific guidelines for SARS-CoV2 testing for surgery patients. Precautions in the form of adequate personal protective equipment (PPE) should be undertaken for all emergency surgeries
  2. Planned surgeries should be discussed in tumor boards and delayed wherever feasible. Consider nonoperative management if it is clinically appropriate for the patient
  3. Aerosol-generating procedures may not be completely avoidable. These should be done with full PPE
  4. The recommendations for laparoscopic or open surgery procedures are insufficient currently.



  Palliative Care Top


  1. Symptom control of the patients should be done as per the existing protocols
  2. The caregivers and families of patients can play an important role in providing the medication to the patients in these difficult times. With the help of telemedicine, the palliative care staff, general physician, or treating oncologist can guide the caregiver
  3. Video calls are encouraged to assess the clinical status of patients, thereby limiting the clinic visit or hospital visits
  4. Oral route should be preferred as much as possible to administer the symptom control medication. Where it is not feasible, subcutaneous, transdermal, or transmucosal routes may be resorted to.



  Surveillance of Cancer Survivors Top


  1. Patients should be educated on the use of regular medications. The visits for follow-up of asymptomatic patients should be staggered and delayed as much as clinically feasible. Telemedicine consultation is more useful for this group
  2. Every patient should be guided to ensure 1-month supply of medicines to avoid emergency hospital visit
  3. Importance of safety precautions in the form of social distancing, hand wash, and keeping away from people affected by fever, cough, or flu-like symptoms should be encouraged among the patients.



  Mental Health and Stress Management Top


Threat perception during the period of COVID-19 pandemic is mentally challenging for general population worldwide. Fear and anxiety are the added stress factors for cancer patients who frequently suffer secondary depression. Cancer patients are advised to:

  1. Stay informed and stick to trustworthy sources for information
  2. Stay connected with family and healthcare provider
  3. Take up relaxation practices to reduce anxiety and panic episodes
  4. Reach out to healthcare provider in case symptoms worsen.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
CDC. The Discovery and Reconstruction of the 1918 Pandemic Virus. Centre for Disease Control and Prevention 2019. Available from: https://www.cdc.gov/flu/pandemic-resources/reconstruction-1918-virus.html. [Last accessed on 2020 Apr 05].  Back to cited text no. 1
    
2.
Shankar A, Saini D, Roy S, Mosavi Jarrahi A, Chakraborty A, Bharti SJ, et al. Cancer care delivery challenges amidst coronavirus disease-19 (COVID-19) outbreak: Specific precautions for cancer patients and cancer care providers to prevent spread. Asian Pac J Cancer Prev 2020;21:569-73.  Back to cited text no. 2
    
3.
WHO Announces COVID-19 Outbreak a Pandemic; 2020. Available from: http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/news/news/2020/3/who-announces-covid-19-outbreak-a-pandemic. [Last accessed on 2020 Apr 05].  Back to cited text no. 3
    
4.
Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032. [Epub ahead of print].  Back to cited text no. 4
    
5.
Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21:335-337. doi: 10.1016/S1470-2045(20)30096-6. Epub 2020 Feb 14.  Back to cited text no. 5
    
6.
Mitigating the Spread of COVID-19 and Its Impact on Cancer - The ASCO Post. Available from: https://www.ascopost.com/news/march-2020/mitigating-the-spread-of-covid-19-and-its-impact-on-cancer/. [Last accessed on 2020 Apr 05].  Back to cited text no. 6
    
7.
Use of Cloth Face Covering to Help Slow the Spread of COVID 19. CS 316353B 04/04/2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/downloads/DIY-cloth-face-covering-instructions.pdf. [Last accessed on 2020 Apr 05].  Back to cited text no. 7
    
8.
COVID-19 Patient Care Information. ASCO; 2020. Available from: https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19. [Last accessed on 2020 Apr 05].  Back to cited text no. 8
    




 

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