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   Table of Contents - Current issue
Coverpage
April 2020
Volume 3 | Issue 5 (Supplement)
Page Nos. 1-152

Online since Saturday, April 25, 2020

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EDITORIALS  

Catch-22: COVID versus Cancer p. 1
Vanita Noronha, Vichitra Behel
DOI:10.4103/CRST.CRST_145_20  
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Chloroquine and hydroxychloroquine: Clutching at straws in the time of COVID-19? p. 3
Ullas Batra, Mansi Sharma, Pallavi Redhu
DOI:10.4103/CRST.CRST_147_20  
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ORIGINAL ARTICLE Top

The pattern of care in head-and-neck cancer: Comparison between before and during the COVID-19 pandemic p. 7
Vijay M Patil, Anne Srikanth, Vanita Noronha, Amit Joshi, Sachin Dhumal, Nandini Menon, Kumar Prabhash
DOI:10.4103/CRST.CRST_161_20  
Background: Coronavirus disease 2019 (COVID-19) has led to a redistribution of the medical resources. However, there are limited data on the treatment patterns in head-and-neck cancer during this pandemic. Therefore, this study was aimed at comparing the pattern of care in head-and-neck cancer before and during the pandemic. Methods: This was a retrospective study of patients visiting the adult medical head-and-neck cancer unit of our hospital, between February 01, 2020, and April 15, 2020. The patients were divided for analysis into three groups: pre-COVID (February 01, 2020–February 29, 2020), start-COVID (March 01, 2020–March 31, 2020), and established-COVID (April 01, 2020–April 15, 2020). The patient footfalls, baseline characteristics, and pattern of treatment during the three time periods were compared. A two-sided P = 0.05 was considered statistically significant. Results: The number of patients in the pre-COVID, start-COVID, and established-COVID time periods was 219, 281, and 57, respectively. The median number of footfalls per working day in the pre-COVID, start-COVID, and established-COVID time periods was 84 (interquartile range [IQR], 70.5–89), 47 (IQR, 41.25–57.75), and 24 (IQR, 22.5–28), respectively (P = 0.000). There was no difference in the tumor-related baseline characteristics. In patients receiving neoadjuvant chemotherapy, the proportion of patients receiving the three-drug regimen was lowest in the established-COVID period (29.3% vs. 35.9% vs. 7.7%, respectively; P = 0.000). There was no difference in the pattern of selection of concurrent radio-sensitizing agents (P = 0.779). In patients receiving palliative treatment, the proportion of those receiving oral metronomic chemotherapy was higher in the established-COVID period than that in the pre-COVID and start-COVID periods (47.4% vs. 34.3% vs. 69.2%, respectively; P = 0.192). Conclusion: The early trend suggests that the number of patients visiting the hospital has decreased during the COVID-19 pandemic. The treatment pattern during the pandemic may be different for palliative regimens and neoadjuvant chemotherapy regimens.
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INVITED COMMENTARY Top

COVID-19 in oncology settings Highly accessed article p. 13
Nitin Bansal, Abdul Ghafur
DOI:10.4103/CRST.CRST_92_20  
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REVIEW ARTICLES Top

COVID-19 and head and neck cancer treatment Highly accessed article p. 15
Vijay Patil, Vanita Noronha, Pankaj Chaturvedi, Kaustav Talapatra, Amit Joshi, Nandini Menon, Durgatosh Pandey, Kumar Prabhash
DOI:10.4103/CRST.CRST_135_20  
The coronavirus disease 2019 (COVID-19) pandemic is exponentially increasing, as are the risks of COVID-related complications and fatalities. Hence, health-care resources are being allocated for its management. Cancer treatment has taken a back seat in multiple countries due to resource scarcity and the risk of COVID-19-related complications. Head and neck cancer is no different. Probably, by the time COVID-related data get generated specifically for head and neck cancers, either the pandemic will be over, or it will be too late. Hence, there is an urgent need for guidance for head and neck cancer treatment in this situation. In this review article, we have provided evidence-based guidance for selecting the most appropriate therapy in the current pandemic situation.
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Systemic therapy for thoracic malignancies during the COVID-19 pandemic p. 29
Nandini Menon, Vanita Noronha, Amit Joshi, Vijay Patil, Kumar Prabhash
DOI:10.4103/CRST.CRST_110_20  
People with cancer are particularly vulnerable during this pandemic and are at high risk of developing a serious COVID-19-related illness. The data that are available suggest that patients with cancer, especially those who are undergoing treatment, are at a higher risk for severe COVID-19 infection and death. These patients need increased surveillance, screening, and better personal protection strategies. Patients with lung and esophageal cancers often require aggressive multidisciplinary treatment. In the era of the COVID-19 pandemic, we face new challenges in delivering systemic therapies (chemotherapy/targeted therapy/immunotherapy) to patients with thoracic malignancies. This review aims to highlight the common issues faced and measures that need to be taken to effectively deliver systemic therapy to patients with thoracic malignancies.
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Systemic therapy for breast cancer during SARS-CoV-2 pandemic p. 35
Santosh Kumar Chellapuram, Ajay Gogia
DOI:10.4103/CRST.CRST_118_20  
The global community is currently facing the unprecedented challenge of the coronavirus disease 2019 (COVID-19) pandemic. More than 1 million cases have been reported until now. Increased mortality is reported in patients who are older and have cancer and multiple comorbidities. Few retrospective analyses of COVID-19 in cancer patients showed a higher mortality of about 28.6%; additionally, severe events are more in patients who develop infection within 2 weeks of receiving anticancer treatment. Clinical data separately analyzing breast cancer patients are lacking. Until an effective drug/vaccine develops, the clinical management is supportive, and pandemic control lies in non-pharmacologic interventions such as social distancing, testing, tracing, isolation, and quarantine. These measures hinder the proper care of breast cancer patients in all the three domains of clinical care, education, and research. These desperate circumstances need desperate measures. In this review, we highlight the medical management of breast cancer during this pandemic. An adoptive strategy is the need of the hour to balance both cancer care and COVID-19 management.
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Management of patients with gynecological cancers during the COVID-19 pandemic p. 40
Sampada Dessai, Ankita Nachankar, Pritam Kataria, Anuja Abyankar
DOI:10.4103/CRST.CRST_124_20  
Coronavirus disease 2019 (COVID-19) pandemic is on the rise. There is an urgent need for triaging cancer patients for treatment. Gynecological malignancies require complicated surgical procedures, complex prolonged radiation techniques, and myelosuppressive chemotherapy. Therefore, judicious decision-making is required, balancing the risk of fatality because of COVID-19 infection with the benefit of therapy. The guidelines need to be tailored according to the local situation. These guidelines are specifically written with respect to the current situation in India. Some procedures are urgent, while some can be deferred. Surgeries for suspected ovarian cancer and early-stage cervical cancer are considered urgent. Surgeries for early-stage endometrium can be deferred for 4–6 weeks. Surgery for advanced ovarian cancer can be deferred by administering neoadjuvant chemotherapy. Chemoradiation for advanced-stage cervical cancer is considered urgent. Similarly, chemotherapy in gestational trophoblastic neoplasm, adjuvant chemotherapy for ovarian cancer, and neoadjuvant and concurrent chemotherapy for cervical cancer and germ cell tumor of the ovary is considered urgent. These guidelines will help us to provide effective treatment for gynecological cancers in the current situation.
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Coronavirus disease 2019 pandemic and its implications on triaging patients with brain tumors for surgery, radiotherapy, and chemotherapy p. 49
Rakesh Jalali, Jayant S Goda, Vijay Patil
DOI:10.4103/CRST.CRST_115_20  
The coronavirus disease 2019 pandemic has the potential to overwhelm the current health-care system in our country. The oncologists face a tricky question as to whom to prioritize treatment for. Postponing cancer treatments might be associated with some risk of compromised clinical outcomes. The risks need to be considered in light of the magnitude of potential benefits, the impact of delaying standard treatment on outcomes, and competing patient-centric and infrastructure priorities. Treatment decisions during the pandemic have to be triaged and prioritized based on the existing health-care facility and the fluidity of the situation. High-priority and urgent interventions include management of suspected high-grade glioma, primary central nervous system lymphoma, and round cell tumors. Low-priority interventions include management of low-grade glioma, benign tumors, and relapsed-refractory brain tumors. Similar to other cancers, the management of patients with brain tumors also needs to be adapted and prioritized; pragmatic patient treatment pathways need to be formalized without compromising the clinical outcomes and overburdening the health infrastructure. Health-care professionals dedicated to oversee the management of patients with brain tumors may have to triage referrals and modify the management of various brain tumors, as treatment pathways will differ from region to region and country to country based on the ground level situation. This document is an endeavor to provide a basic framework to triage and prioritize brain tumor patient management pathways. As the situation is rapidly evolving, we suggest a basic treatment guideline for these patients, which is simple to adopt.
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Management of hematological malignancies during the COVID-19 pandemic p. 54
Ashay Karpe, Sunila Nagvekar-Karpe
DOI:10.4103/CRST.CRST_123_20  
Coronavirus disease 2019 (COVID-19) caused by novel coronavirus, which is structurally related to the virus causing severe acute respiratory syndrome, has emerged as a global health problem. During this pandemic, treatment of oncology patients especially patients with hematological malignancies has many challenges. In the absence of definite guidelines for the management of hematological cancers, we should follow certain principles for better treatment delivery with precautions to prevent COVID-19 infection in this vulnerable population with the least compromise in patient outcome
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Treating hematolymphoid malignancies during COVID-19 in India: Challenges and potential approaches p. 59
Chepsy C Philip, Anup Joseph Devasia
DOI:10.4103/CRST.CRST_114_20  
The rapidity of both the geographical expansion and the sudden increase in the numbers of COVID-19 cases poses critical challenges to public health and has the potential to severely limit non COVID-19 medical care. With early reports from China & Italy suggesting that patients with hematolymphoid malignancies along with the other cancers are at the highest risk of severe infection compared to the normal population; it is a challenge on how to best manage such patients in India. There is a lack of reliable evidence and it is yet unclear as to what the best practices are with regards to patients with hematolymphoid malignancies in this time of crisis. We present a collection of best practices and guidance from literature search, society resources and communications with experts. Despite the unique and unprecedented nature of this challenge, our approach should reflect the principles of beneficence and non-maleficence as outlined in the Hippocratic oath.
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Repurposing valproate to prevent acute respiratory distress syndrome/acute lung injury in COVID-19: A review of immunomodulatory action p. 65
Prabhat Bhargava, Pankaj Panda, Vikas Ostwal, Anant Ramaswamy
DOI:10.4103/CRST.CRST_156_20  
The novel coronavirus disease 2019 (COVID-19) is reported to cause acute respiratory distress syndrome (ARDS) in 20%–40% of the hospitalized patients. The pathophysiology of ARDS caused by a viral infection is still unknown; however, a histopathological hallmark of ARDS is diffuse alveolar damage due to excessive inflammation of the lung tissue from the inflammatory mediators released by the local epithelial and endothelial cells. ARDS is caused when there is an excessive inflammatory response compared to the anti-inflammatory response to the viral agent. It is often associated with multiorgan failure and increased chances of mortality. Epigenetic changes are known to cause rapid changes in the gene expression, thereby increasing hyperinflammatory/anti-inflammatory responses. Valproate (VPA), a histone deacetylase inhibitor, has been shown to inhibit the production of the nuclear factor-κB (NF-κB), tumor necrosis factor-alpha, and interleukin-6 in human cells stimulated with lipopolysaccharide. VPA has also been shown to block the migration of macrophages through the inhibition of pro-inflammatory cytokines. VPA can promote the differentiation of T cells toward Th2/M2 rather than Th1/M1, and it also stimulates the generation of the regulatory T cells (Treg), thereby reducing the percentage of CD8+ T lymphocytes. However, the anti-inflammatory action of VPA could decrease the cytokine expression and suppress the effector T cells, thereby delaying the viral clearance. This delayed clearance of the virus could be taken care of by the proposed direct antiviral activity of VPA.
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GERIATRIC ONCOLOGY SECTION Top

Management of geriatric cancer patients during the COVID-19 pandemic p. 71
Rakesh Pinninti
DOI:10.4103/CRST.CRST_120_20  
Physiological vulnerabilities greatly impact the outcome of coronavirus disease 2019 (COVID-19) infection. The COVID-19 infection results in far more serious illness in patients with compromised physiological reserve (older patients, infants, and pregnant women) and in those with preexisting or poorly controlled comorbidities. The COVID-19 infection can be life-threatening in older patients with cancer, but there are no standard guidelines or individual hospital data regarding methods or policies implemented to guide clinicians. Evolving clinical experience suggests that cancer patients with COVID-19 have more serious complications, such as intensive care admission from severe pneumonia or sepsis and a greater case fatality rate. Cancer history portends the highest risk of serious events. Considering the evidence for a clear association for older age and higher levels of comorbidity with more severe COVID-19 symptoms and adverse outcomes, the concept of risk mitigation is highly relevant to older patients with cancer. Chronological age alone cannot be relied on to ascertain the true biological status of an individual, and a comprehensive geriatric assessment (CGA) provides a multidisciplinary diagnostic process that encompasses several objectively evaluable domains to reliably and objectively assess medical, psychosocial, and functional limitations. With formal assessment tools, previsit questionnaires and appropriate training can reduce this burden on the clinician performing the initial CGA. This would enhance overall capabilities in reliable use of recommendations regarding treatment for comorbidities, geriatric syndromes, supportive care, drug interactions, and toxicities. Routine use of CGA would mitigate most of the risks related to biological vulnerability. Measures to reduce hospital visits such as shorter radiotherapy fractionation and conversion of intravenous to oral systemic regimens can be considered. Proactive discussions regarding end-of-life and hospice care at isolation facilities should be discussed in the management of older patients with cancer and COVID-19 infection. Oncologists should make an extra effort to educate and provide additional guidance to help patients and caretakers making hard decisions regarding withholding anticancer treatment to mitigate the risk of viral infection.
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PATIENT/CAREGIVER CORNER Top

My COVID-19 experience p. 76
Noopur Raje
DOI:10.4103/CRST.CRST_144_20  
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Plucking up “C”ourage p. 78
Sushrita Padhee
DOI:10.4103/CRST.CRST_141_20  
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IMAGING SECTION Top

Imaging and COVID-19: Preparing the radiologist for the pandemic p. 80
Ankita Ahuja, Abhishek Mahajan
DOI:10.4103/CRST.CRST_134_20  
Diagnosing COVID-19 cases poses a challenge. The viral nucleic acid detection using real-time polymerase chain reaction (RT-PCR) remains the standard of reference. As the world is hit by this pandemic, the health resources are facing tremendous pressure. Though imaging has a role to play in the management of COVID-19, one must judiciously use the health and imaging resources which would take us a long way in combating this pandemic. In this article we will discuss the role of imaging in management of COVID-19 infection. Imaging guidelines are also given that will aid in precise communication with other health-care providers and efficient use of health resources.
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POETRY IN ONCOLOGY Top

Rendezvous with reality p. 86
Nivedita Chakrabarty
DOI:10.4103/CRST.CRST_133_20  
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RESIDENTS CORNER Top

Impact of the coronavirus disease 2019 pandemic on resident doctors in India p. 87
Ravi Jaiswal
DOI:10.4103/CRST.CRST_140_20  
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Blindness during the coronavirus outbreak Highly accessed article p. 90
Sunny Chi Lik Au
DOI:10.4103/CRST.CRST_60_20  
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Life and training in the time of corona p. 92
Sindhu Malapati, Sunny R. K. Singh
DOI:10.4103/CRST.CRST_153_20  
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MUSINGS Top

Into the past in the times of COVID pandemic p. 94
Pankaj Chaturvedi, Natarajan Ramalingam
DOI:10.4103/CRST.CRST_139_20  
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COPING with CORONA: A developing country perspective on managing children with cancer during COVID-19 pandemic p. 97
Megha Saroha, Nirmalya Roy Moulik
DOI:10.4103/CRST.CRST_131_20  
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Caring for patients with genitourinary cancer during the COVID pandemic p. 102
Swaratika Majumdar, Amit Joshi
DOI:10.4103/CRST.CRST_116_20  
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Management of cancer during the COVID pandemic: Treatment of gynecological malignancies p. 106
Alok Goel
DOI:10.4103/CRST.CRST_108_20  
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Intelligent adaptation to the changing surroundings amidst the COVID-19 pandemic for sarcomas and melanomas p. 110
Sharada Mailankody, Jyoti Bajpai
DOI:10.4103/CRST.CRST_132_20  
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Management of cancer during the COVID-19 pandemic: Practical suggestions for the radiation oncology departments p. 115
Anusheel Munshi, Khushboo Rastogi
DOI:10.4103/CRST.CRST_111_20  
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Surgical management of cancer during the COVID-19 pandemic p. 119
Amar Prem, Swapnil Patel, Esha Pai, Durgatosh Pandey
DOI:10.4103/CRST.CRST_112_20  
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Experience of treating head and neck cancers in government and private health-care systems during the COVID-19 pandemic: A viewpoint with summary of existing guidelines p. 123
Harsh Dhar, Sourav Datta
DOI:10.4103/CRST.CRST_143_20  
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Palliative care for advanced cancer patients in the COVID-19 pandemic: Challenges and adaptations p. 127
Pankaj Singhai, Krithika S Rao, Seema Rajesh Rao, Naveen Salins
DOI:10.4103/CRST.CRST_130_20  
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Impact of COVID-19 on oncology clinical trials: A “novel“ challenge p. 133
Vijayalakshmi Mathrudev, Supriya Goud, Sucheta More, Srushti Jain
DOI:10.4103/CRST.CRST_146_20  
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Coronavirus disease 2019 pandemic: Nursing challenges faced p. 136
Swapna Joshi
DOI:10.4103/CRST.CRST_148_20  
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COVID-19: Experience of a tertiary reference laboratory on the cusp of accurately testing 5500 samples and planning scalability p. 138
Niranjan Patil, Ashish Lad, Aparna Rajadhyaksha, Kirti Chadha, Pratiksha Chheda, Vishal Wadhwa, Alap Christy, Puneet Nigam, Nilesh Shah
DOI:10.4103/CRST.CRST_154_20  
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Social issues faced by cancer patients during the coronavirus (COVID-19) pandemic p. 141
Nirjari Viren Dalal
DOI:10.4103/CRST.CRST_109_20  
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Advisory for cancer patients during the COVIDpandemic p. 145
Priyanka Srivastava, T V. S. V. G. K. Tilak, Amol Patel, Chandan K Das, Bivas Biswas, Shubh Mahindru, Raja Pramanik, Joydeep Ghosh, Prashant Mehta
DOI:10.4103/CRST.CRST_125_20  
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LETTERS TO EDITOR Top

Immunotherapy during the COVID-19 pandemic p. 149
Vinay Mathew Thomas, Aju Mathew
DOI:10.4103/CRST.CRST_129_20  
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Impact of COVID-19 outbreak on peripheral cancer clinic services p. 150
Ravikant Singh, Rohit Ishan
DOI:10.4103/CRST.CRST_121_20  
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