|Year : 2020 | Volume
| Issue : 4 | Page : 683-691
Impact of the coronavirus disease 2019 pandemic on cancer care delivery: A single-center retrospective study
Avinash Pandey1, Mala Rani2, Neelam Chandra2, Mridula Pandey2, Ravindra Singh2, Kanchan Monalisa2, Umesh Yadav2, Shivkant Singh2
1 Department of Medical Oncology, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Medical Oncology, State Cancer Institute, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
|Date of Submission||01-Sep-2020|
|Date of Decision||15-Sep-2020|
|Date of Acceptance||08-Oct-2020|
|Date of Web Publication||25-Dec-2020|
Department of Medical Oncology, All India Institute of Medical Sciences, Patna, Bihar
Source of Support: None, Conflict of Interest: None
Background: The coronavirus disease 2019 (COVID-19) pandemic and the resultant nationwide lockdown have adversely affected all the aspects of human life, including the access to health-care facilities. However, there is currently a lack of information on the impact of this pandemic on the delivery of routine cancer care.
Objectives: In this study, we aimed to evaluate the changes in the number of patients in the day care chemotherapy (DCC) unit and outpatient department (OPD) because of the nationwide COVID-19 lockdown.
Materials and Methods: This retrospective audit was conducted at the Department of Medical Oncology of the Indira Gandhi Institute of Medical Sciences in Patna, India. The demographic details and data related to the diagnosis and type and frequency of chemotherapy delivered in the DCC between February 1, 2020, and July 31, 2020, were retrieved. Patient numbers were recorded. Descriptive statistics, odds ratio, Chi-squared test, and Student's t-test were used to assess the changes in the pattern of DCC and OPD patient numbers because of the imposition of a nationwide lockdown on March 24, 2020. The Pearson correlation coefficient was used to assess the correlation between the number of COVID-19 cases and the number of patients visiting the DCC and OPD.
Results: A total of 3192 DCCs and 8209 OPD visits were recorded in 126 working days. The median age of the patients was 47 years (interquartile range [34–58]). Cancers of the breast (17%) and gall bladder (15%) were the most common cancers receiving chemotherapy. There was a significant decrease in the number of DCCs delivered after the imposition of the COVID-19 lockdown (mean, 21.97 [±9.7]) compared to pre-lockdown period (mean, 33.30 [±11.4]), (t = 4.11, P = 0.001). Similarly, there was a significant decrease in the number of OPD visits after the imposition of the lockdown (mean, 47.13 [±18.8]) compared to the pre-lockdown period (mean, 89.91 [±30.0]), (t = 7.09, P = 0.001). The odds of receiving weekly chemotherapy over non-weekly regimes significantly decreased after the imposition of the lockdown with an odds ratio of 0.52 (95% confidence interval, 0.36–0.75) and Chi-square value of 12.57(P = 0.001). The daily number of COVID-19 cases reported in the state and the number of patients visiting the OPD was found to be moderately positively correlated (Pearson correlation coefficient, r = 0.35, P = 0.001).
Conclusions: There was a significant decrease in the number of patients visiting the OPD and the number of chemotherapy cycles immediately after the imposition of lockdown. The number increased later despite a rise in the number of COVID-19 cases.
Keywords: Cancer care, chemotherapy, coronavirus disease 2019, day care, lockdown
|How to cite this article:|
Pandey A, Rani M, Chandra N, Pandey M, Singh R, Monalisa K, Yadav U, Singh S. Impact of the coronavirus disease 2019 pandemic on cancer care delivery: A single-center retrospective study. Cancer Res Stat Treat 2020;3:683-91
|How to cite this URL:|
Pandey A, Rani M, Chandra N, Pandey M, Singh R, Monalisa K, Yadav U, Singh S. Impact of the coronavirus disease 2019 pandemic on cancer care delivery: A single-center retrospective study. Cancer Res Stat Treat [serial online] 2020 [cited 2021 Jan 21];3:683-91. Available from: https://www.crstonline.com/text.asp?2020/3/4/683/304963
| Introduction|| |
On March 24, 2020, the Government of India announced a nationwide lockdown in view of the rapidly spreading coronavirus disease 2019 (COVID-19) pandemic. The lockdown was imposed in an attempt to “flatten the curve,” so as to delay the rise in the number of COVID-19 cases and buy some time to improve the health infrastructure and build COVID care facilities. Many apex multi-specialty hospitals, including a few cancer care delivery centers were designated as exclusive “COVID-19 facilities.” This rationing of services divested other illnesses including cancer of precious resources. The problem was further compounded by the intermittent disruption of care in running the facilities, whenever the patients or health-care workers turned COVID-positive.
The strict lockdown with stringent travel restrictions often led patients with cancer, especially those residing in the smaller towns and villages, to shun or delay opting for cancer care services. This was further aggravated by the concerns of getting infected with the novel coronavirus, loss of wages, poor means to travel, and reduction in the health-care workforce. This posed a serious threat of upstaging of cancer, disease progression, and worsening of symptoms including pain for patients who chose to stay home rather than avail therapy.
Our tertiary care hospital was declared a non-COVID healthcare facility, and cancer treatment was available all through the COVID-19 lockdown. In the absence of departments of pediatric oncology and hematology, the department of medical oncology is the single point of contact in our center for patients receiving chemotherapy, irrespective of their age, and the type (solid/hematological) of malignancy. Recently, several expert opinions and review articles have been published to rationalize and optimize cancer care delivery, that highlight the importance of risk stratification of patients in terms of urgency of treatment, delaying elective procedures, modifying chemotherapy to avoid toxicities, decreasing the frequency to reduce the number of hospital visits with minimal or no loss of overall efficacy and survival.,,, We had the unique opportunity to study the change in the number of patients receiving chemotherapy because of the COVID-19 lockdown. For this study, we conducted a retrospective audit with the objective to disprove the null hypothesis that there was no change in the number of patients receiving cancer-directed therapy before and after the COVID-19 lockdown. We report the first real-world experience of the impact of the COVID-19 pandemic on routine cancer care delivery across several malignancies, before, during, and after the lockdown in India.
| Materials and Methods|| |
General study details
This retrospective case audit was conducted in the Department of Medical Oncology of Indira Gandhi Institute of Medical Sciences, a tertiary regional cancer center, located in Patna in East India. The number of patients visiting the outpatient department (OPD) and subsequently receiving injectable chemotherapy in the day care chemotherapy (DCC) unit from February 1, 2020, to July 31, 2020, was recorded. During this period, the OPD and DCC services were available on all days of the week except for Saturday, Sunday, and national holidays. Informed consent was obtained from all participants to use their clinical data for publication purposes. The study was conducted according to the criteria mentioned in the International Conference on Harmonization Good Clinical Practices, Declaration of Helsinki, and guidelines established by the Indian Council of Medical Research. No funding was sought or received for this study. This was a retrospective audit, and as per the institutional policy, retrospective audits are exempted from obtaining the Institutional Ethics Committee approval.
All patients who received intravenous, intramuscular, or subcutaneous injectable chemotherapy, irrespective of their age and type of malignancy were considered eligible for this study. Additionally, patients receiving granulocyte colony-stimulating factor, hormonal preparations, bone-modifying agents, targeted therapy, and immunotherapy, with or without chemotherapy were also considered eligible provided these agents were delivered via the intravenous, intramuscular, or subcutaneous route. Patients receiving supportive care medications such as nonsteroidal anti-inflammatory drugs, opioids, antibiotics, anti-fungals, anti-emetics, crystalloids, colloids, and iron preparations alone without concomitant chemotherapy were excluded. Similarly, patients receiving oral chemotherapy or oral targeted therapy alone were not eligible for this study. Patients who underwent invasive procedures in the day care premises such as peripherally inserted central catheter insertion, flushing and dressing, ascitic or pleural effusion tapping, wound debridement, and dressing were also excluded from the study.
All registered patients fulfilling the selection criteria and who received injectable chemotherapy on any working day between February 1, 2020, and July 31, 2020, were included in the study. Data were collected from the records available in the DCC unit attached to the department of medical oncology. Demographic details, including age, sex, type of malignancy, chemotherapy frequency, names of chemotherapeutic drugs, and their doses, were retrieved and entered in a database. The number of patients visiting the Medical Oncology OPD during the aforementioned period was also obtained. The daily number of new COVID-19 cases detected in the normal population in the State of Bihar and its capital city, Patna, was obtained from the official website/twitter handle of the Bihar government for the aforementioned period.
Patient care and health-care worker protection during coronavirus disease 2019 pandemic
Our hospital was designated a non-COVID hospital by the State Government, and services including oncology care were functional and available throughout the study period. As per the Institutional Nodal Officer for COVID-19 and the Hospital Infection Control Committee (HICC), the day care and OPD services of the Department of Medical Oncology were designated as “moderate risk” following the Indian Council of Medical Research (ICMR) guidelines. While providing OPD consult and DCC services, strict compliance to the recommended level of personnel protection as prescribed by the ICMR advisory was ensured. All doctors in the OPD donned N95 masks, gloves, face shields, and head covers; the nursing staff delivering chemotherapy donned all of the above in addition to shoe covers, goggles, and overalls/gowns.
All health-care workers attended regular training workshops for COVID-19 prevention as per the recommendations of the Institutional Nodal Officer and HICC. They were made aware of the common signs and symptoms of COVID-19 and were instructed to report promptly in case of their appearance. On testing positive for COVID-19, the option for home/institutional quarantine or treatment, if symptomatic, was followed as per the ICMR guidelines. At the site of entry, health-care workers and patients/relatives were subjected to daily thermal screening. Only one able relative was allowed to accompany the patient to the OPD and DCC unit. All patients were asked to don N95 masks, whereas the relatives were instructed to wear at least a triple-layered mask. The practices of social distancing and frequent hand washing or using an alcohol-based hand sanitizer were encouraged.
Study scope, variables, and endpoints
I. The change in the number of patients opting for OPD and DCC services between February 1, 2020, and July 31, 2020, was recorded
II. The study period was divided into various phases as listed below and the change in the numbers of patients opting for OPD and DCC services during each of these phases was recorded:
- Pre-lockdown/routine/baseline (February 1, 2020–March 24, 2020)
- National lockdown Phase 1 (March 25, 2020–April 14, 2020)
- National lockdown Phase 2 (April 15, 2020–May 03, 2020)
- National lockdown Phase 3 (May 04, 2020–May 17, 2020)
- National lockdown Phase 4 (May 18, 2020–May 31, 2020)
- National unlock Phase 1 (June 01, 2020–June 30, 2020)
- National unlock Phase 2 (July 01, 2020–July 14, 2020)
- State lockdown Phase 1 (July 15, 2020–July 31, 2020).
III. Keeping the number of working days the same (36), the number of patients opting for OPD and DCC services in the pre-lockdown (February 1, 2020–March 24, 2020) and national lockdown (March 25, 2020–May 15, 2020) periods were compared. Additionally, the changes in the frequency or pattern of chemotherapy use were recorded, and the age group of patients and chemotherapy regimens used in the pre-lockdown and national lockdown periods were compared
IV. As the pandemic escalated with time, there was rise in the state- and district-wise COVID-19 cases in the general population. At the same time, the national and state governments gradually deescalated lockdown and relaxed the travel restrictions. Therefore, we also assessed a possible correlation between the number of patients availing cancer-related services at our center and the number of newly detected COVID-19 cases in the general population in the later months (May, June, and July 2020) of the pandemic
Sample size calculation was not done for this study, and all patients who fulfilled the eligibility criteria of the study within the specified time frame were included. Descriptive statistics, frequency distribution, tables, charts, and graphs were used to analyze the demographic, epidemiological, clinical, and treatment-related variables. Crosstabs, odds ratio, and Pearson's Chi-squared test were used to compare binomial categorical variables. To compare the means, the paired Student's t-test was used. As the data were parametric, the Pearson's correlation coefficient was used to find the direction and strength of association between the number of patients availing OPD/DCC services and the rise in COVID-19 cases. Similarly, simple linear regression method was used to assess the relationship, if any, between the above two variables. All of the above statistical analyses were performed using the SPSS software version 17.0 (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, version 17.0. Armonk, NY, USA).
| Results|| |
Demographic, clinical, and patient profile
Out of 3238 cases registered in the DCC unit of the Department of Medical Oncology between February 1, 2020, and July 31, 2020, 3192 (98.57%) were eligible for this study [Figure 1]. During this 6-month period, a total of 8209 OPD visits were registered over 126 working days. The median age of the patients receiving treatment in DCC unit was 47 years (interquartile range, 34–58) with a male-to-female ratio of 1:10. Breast cancer (17%) and gall bladder cancer (15.2%) were the most common malignancies seen. The once-in-3-weeks chemotherapy was the most commonly prescribed schedule, with 1990 cycles (62.4%). Majority of the patients (65.8%) were in the age group of 18–60 years. Chemotherapy with or without targeted therapy was the most common therapy received in the day care with 3000 cycles (93.9%) [Table 1].
|Figure 1: Flow diagram showing the number of cases who received various treatments in our medical oncology day care chemotherapy unit and the selection algorithm for cases that were enrolled in this study. NSAIDs: Nonsteroidal anti-inflammatory drugs|
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|Table 1: Demographic, disease, and treatment-related variables of patients who received injectable drugs/cycles between February 1, 2020 and July 31, 2020|
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Trends with respect to time and lockdown
Month-wise consecutive changes in the number of patients receiving therapy in the DCC unit are shown in [Table 2]. The demographic profile, including the age group and frequency of chemotherapy regimens delivered, varied between February and July 2020 [Table 2]. The median number of patients visiting the OPD and DCC unit dropped by 66.7% and 53.9%, respectively, immediately following the imposition of the nationwide lockdown [Table 3]. After a gradual recovery in the number of cases seen in the later months (May and June 2020) with a relaxation of travel restrictions and unlocking, the number of cases visiting the OPD and DCC unit plummeted again after July 15, 2020, due to the imposition of a statewide lockdown [Figure 2]a and [Figure 2]b.
|Table 2: Change in the age groups, frequency of drugs administered, and type of drugs between February 1, 2020 and July 31, 2020|
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|Table 3: Median number of cases in the outpatient department and day care chemotherapy unit in the various phases of national lockdown, unlocking, and state lockdown along with change from the baseline (pre-lockdown) values|
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|Figure 2: (a and b) Out-patient department (opd) and day care chemotherapy (DCC) trend between 1st february 2020 to 31st july 2020 in our medical oncology department|
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Comparison between pre-lockdown and lockdown periods
There was a significant decrease in the number of DCCs delivered during the national lockdown period (mean 21.97 [±9.7]) compared to the pre-lockdown period (mean 33.30 [±11.4], t = 4.11, P = 0.001). Similarly, there was a significant decrease in the number of OPD visits following the imposition of the national lockdown (mean 47.13 [±18.8]) compared to the pre-lockdown period (mean 89.91 [±30.0], t = 7.09, P = 0.001). Between the pre-lockdown and national lockdown periods, the number of once-a-week chemotherapy cycles dropped from 128 to 41 (68%), whereas the number of once-in-3-weeks cycles dropped from 703 to 469 (33%), suggesting a preference to switch to regimens with longer intervals.
The odds of receiving weekly chemotherapy over non-weekly regimens significantly decreased post the imposition of the nationwide lockdown, with an odds ratio of 0.52 (95% confidence interval [CI], 0.36–0.75) and a Chi-squared value of 12.57 (P = 0.001). Among patients who received paclitaxel alone or paclitaxel-based chemotherapy, the odds of receiving once-in-a-week paclitaxel over once-in-3-weeks paclitaxel decreased post the imposition of the lockdown with an odds ratio of 0.10 (95% CI, 0.03–0.29) and a Chi-squared value of 22.68 (P = 0.001). Among patients with colorectal cancer receiving once-in-2-weeks (FOLFOX/FOLFIRI) or once-in-3-weeks (CAPOX/CAPIRI) regimens, the odds of receiving the once-in-2-weeks regimen over the once-in-3-weeks regimen showed a non-significant decrease post the imposition of the lockdown, with an odds ratio of 0.58 (85% CI 0.23–1.45). Pediatric and older patients compared to adults had an odds ratio of 1.92 (95% CI, 0.86–1.60) and 0.93 (95% CI, 0.74–1.17), respectively, for receiving chemotherapy post lockdown versus pre lockdown which were not significant.
Change in the number of patients receiving anti-cancer treatment with the rise of coronavirus disease 2019 cases in the general population
Although the nationwide lockdown was imposed on March 24, 2020, in the state of Bihar, a rise in the number of COVID-19 cases was seen in late April and early May. As the number of COVID-19 cases continued to surge, gradual de-escalation, unlocking, and reduction in travel restrictions have been implemented in a graded manner [Figure 3]a and [Figure 3]b. The number of COVID-19 cases recorded daily in the state and the number of patients visiting the OPD were found to be moderately positively correlated by Pearson's correlation coefficient (r = 0.35, P = 0.001), no such correlation was observed for the city of Patna or for the number of patients visiting the DCC unit. Linear regression was used to access whether the rise in COVID-19 cases could predict a change in the number of patients visiting the OPD. The linear regression model was found to be significant with F = 12.39 (P = 0.001). The number of patients visiting the OPD could be predicted from the number of new COVID-19 cases in state using the following formula:
|Figure 3: (a and b) Daily new and cumulative COVID 19 cases detected in City (Patna, a and State (Bihar, b) where our institute in located with time|
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OPD cases = 1.724 × new COVID-19 cases – 6.704, R2 = 0.123.
| Discussion|| |
The COVID-19 pandemic and the efforts to curb its spread have affected routine cancer care delivery. Nationwide lockdown, travel restrictions, and the fear of getting infected with the novel coronavirus have caused treatment delays and reduction in the number of patients availing cancer-directed services. In our study, there was a significant decline in the number of OPD visits immediately following the imposition of lockdown (mean 47.13 [±18.8]) compared to the pre-lockdown period (mean 89.91 [±30.0], P = 0.001). Similarly, there was a decline in the number of DCCs delivered post the imposition of lockdown (mean 21.97 [±9.7]) compared to the pre-lockdown period (mean 33.30 [±11.4], P = 0.001). We also noticed a change in the pattern of prescription with a significant decrease in the once-in-a-week chemotherapy cycles as the pandemic progressed with an odds ratio of 0.52 (95% CI, 0.36–0.75) and Chi-squared value of 12.57 (P = 0.001). However, as the lockdown restrictions were relaxed, the number of patients in the OPD increased despite a rise in the COVID-19 cases in the community in the later months, suggesting the subduing of COVID-related concerns along with the manifestation of disease progression and implications of delay in cancer therapy.
A survey done on clinicians practicing gynecologic oncology reported a significant fall in patient volumes, especially in government hospitals after the imposition of the COVID-19 lockdown. An early analysis reported by Patil et al. showed a drop in the footfalls in a retrospective audit of the adult medical head neck cancer unit of an apex tertiary cancer hospital. The Indian Association of Surgical Oncology mandated routine COVID-19 testing before any surgery. Curative cancer surgeries were postponed if the patient was found to be COVID-19-positive, and the patient was referred for neoadjuvant chemotherapy, radiotherapy, hormonal therapy, or sometimes, best supportive care till viral clearance or recovery of health status.,, In another study by Chauhan et al. on patients receiving radiotherapy, the number of patients receiving radiotherapy significantly reduced after the imposition of lockdown. In our study, we present our real-world experience of running the OPD and DCC services during the COVID-19 pandemic over a period of 6 months. We observed a significant decline in patient numbers immediately post the imposition of lockdown. We also found a significant reduction in the prescriptions of once-in-a-week chemotherapy post the imposition of lockdown. Similar findings have been reported by previous studies, where single-fraction palliative radiotherapy emerged as a prominent choice over multi-fractionated regimes. This reflects the choice of the treating physicians to maintain efficacy while minimizing the patients' visit to clinic during the pandemic. A prospective study conducted on patients with cancer demonstrated their willingness to continue chemotherapy during the pandemic, as they perceived disease progression as a bigger threat than COVID-19. Our study substantiates their claim, as immediately after the lockdown restrictions were relaxed, our OPD patient numbers started rising despite a rise in the COVID-19 cases in the general population.
Delay or postponement of radiotherapy or systemic therapy affects the outcomes adversely in head-and-neck, colon, and breast cancers, especially in the curative setting.,, Moreover, patients diagnosed with acute leukemia, high-grade lymphoma, and metastatic germ cell tumor require urgent intervention with systemic therapy to prevent mortality. Several expert opinions and recommendations were issued regarding the approach to patients with cancer during the COVID-19 pandemic.,,,,, Guarded approach to systemic therapy with prompt intervention for urgent medical crisis and tumors with curative potential, while delay in palliative chemotherapy for cases with limited or questionable survival benefit was advocated in most. Our cancer center is a part of a tertiary government multispecialty hospital. During the lockdown, all patients were initially screened at the “flu center” and then referred to the OPD consult or chemotherapy, as practiced by another apex cancer center. However, we did not routinely test our patients for COVID-19 before the OPD consult or chemotherapy, unless they were symptomatic for COVID-19 as per the ICMR recommendation., None of our healthcare workers during the study period tested positive for COVID-19, reported sick, or remained absent. Neither the OPD nor the DCC services was interrupted on any working day during the study period.
We did not have patient details other than the number of patients who visited the OPD such as diagnosis, demographic and clinical factors, unlike having those for patients receiving chemotherapy in day care. Hence, data pertaining to the type of patients in the OPD, the type of cancer, oral chemotherapy done on OPD basis, or any change from intravenous to oral therapy during the lockdown were unavailable. We also did not have information on whether any maintenance chemotherapy, such as pemetrexed in lung cancer or 5-fluorouracil in colon cancer was halted, increased in frequency, or changed to oral therapy during the lockdown as this decision was often made in the OPD. We also do not have the information on any of our patients with cancer who might have tested positive for COVID-19 in any other center or a COVID-19 designated hospital, abandoned therapy, or died due to it. New patients otherwise eligible for curative surgeries or radiotherapy were directed to us for neoadjuvant chemotherapy or hormonal therapy as elective surgery was postponed during the lockdown. We do not have separate information on those cases. Moreover, the DCC register did not mentioned the stage and intent of therapy; hence, this information is missing in our analysis. As none of the asymptomatic health-care workers were tested for COVID-19, any asymptomatic disease or carrier state in them is unknown. As many of our patients braved travel restrictions during the lockdown and came from far off places, we did not deny them chemotherapy even if it was less urgent or for minimal symptomatic palliative benefit.
| Conclusions|| |
Nationwide lockdown imposed to curb the COVID-19 pandemic had a negative impact on cancer treatment a significant reduction in the number of patients receiving cancer-directed therapy. The pattern of chemotherapy prescriptions changed to longer interval and protracted courses to reduce the frequent patient visits. Withdrawal of travel restrictions later led to a rise in patient numbers for consultation despite a rise in the COVID-19 cases in the community.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]