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Table of Contents
EDITORIAL
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 793-795

Decline in the number of patients with cancer during the COVID-19 pandemic: A matter of concern or just a statistic?


Department of Medical Oncology, Tata Medical Center, Kolkata, West Bengal, India

Date of Submission19-Oct-2020
Date of Decision12-Nov-2020
Date of Acceptance21-Nov-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Joydeep Ghosh
Department of Medical Oncology, Tata Medical Center, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_332_20

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How to cite this article:
Ghosh J, Ganguly S. Decline in the number of patients with cancer during the COVID-19 pandemic: A matter of concern or just a statistic?. Cancer Res Stat Treat 2020;3:793-5

How to cite this URL:
Ghosh J, Ganguly S. Decline in the number of patients with cancer during the COVID-19 pandemic: A matter of concern or just a statistic?. Cancer Res Stat Treat [serial online] 2020 [cited 2021 Jan 20];3:793-5. Available from: https://www.crstonline.com/text.asp?2020/3/4/793/304999



The coronavirus disease 2019 (COVID-19) pandemic has caused a significant disruption and delay in the delivery of health-care services globally. Moreover, there have been reports of increased morbidity and mortality in patients with cancer.[1],[2],[3],[4] Multiple hospitals in India and across the world were designated as COVID-19 care centers, thus affecting routine clinical practice.[5] Besides this, the health-care workers started getting infected with the severe acute respiratory syndrome coronavirus 2, mandating quarantine for 2–3 weeks, further disrupting the health-care delivery system. There has been a flurry of publications from various organizations suggesting the various dos and don'ts during this pandemic. A large number of guidelines were published, purely based on expertise and personal opinion.[6],[7],[8] Very few studies were conducted to actually measure the losses in health-care delivery and patient footfalls. We congratulate Pandey et al., for their article on the impact of the COVID-19 pandemic on cancer care delivery in the current issue, which gives us an objective evidence of the actual impact of the pandemic on health-care delivery in oncology.[9] We critically analyze Pandey et al.'s study and discuss its important aspects in this editorial.

Pandey et al.'s study is a retrospective case audit from a regional tertiary cancer center in Patna, Bihar. To our knowledge, this is the first real-world evidence of the effect of the pandemic on cancer care from India. All patients who visited the outpatient department (OPD) and those who received injectable chemotherapy in the day care (DCC) between February and July 2020 were included in the analysis. Patients receiving supportive care medication were excluded. The number of patients availing the OPD and DCC facilities before and during the nationwide lockdown was compared. The authors also looked at the possible correlation between the number of patients coming to the OPD and the number of newly diagnosed COVID-19 cases in the general population in the later months. Standard statistical tests were applied, and a total of 3192 patients were included in this study. A total of 8290 OPD visits were registered during this period, and the most common cancer types were breast (17%) and gall bladder (15.2%). Once-in-3-weeks chemotherapy was reported to have been administered in 62.4% of the cases. The most common therapy received in the DCC was chemotherapy with or without targeted therapy (94%). The median number of patients visiting OPD and DCC dropped by 66.7% and 53.9%, respectively, post the imposition of the nationwide lockdown. After a gradual recovery in the number of cases during the later months, the numbers again dropped due to the imposition of a statewide lockdown. There was a statistically significant decline in the number of chemotherapies delivered during the lockdown versus the pre-lockdown period (mean, 22 vs. 33.3, P = 0.001). There was also a significant decline in the OPD visits during the lockdown (mean, 47.1 versus 89.9, P = 0.001). In addition, as a result of switching to regimens with longer intervals, the drop in the number of once-in-a-week chemotherapies delivered was more than that for the once-in-3-weeks regimens (68% versus 33%). With the implementation of unlocking and the resultant relaxation of the travel restrictions, the number of COVID-19 cases positively correlated with the number of patients visiting the OPD (P = 0.001). Overall, the authors concluded that the nationwide lockdown significantly reduced the OPD and DCC footfalls and significantly changed the pattern of chemotherapy by prompting the use of less intensive regimens.

However, there are certain limitations to this study. This is a retrospective audit, and hence, is liable to biases of various kinds. The authors have not clarified whether the drop in the footfalls could also have resulted from institutional restrictions imposed due to the lack of manpower. Further, patients receiving oral therapies were not included in the study. We believe that including these patients could have added more value, since a large chunk of the present-day targeted therapies are administered orally. Even capecitabine and uracil with tegafur/leucovorin are two of the very commonly used regimens which are orally administered and are being used in a large number of patients. As the authors' hospital is one of the major cancer centers in Patna, it serves a large number of districts. Therefore, we believe that the place of residence of the patients should have been taken into consideration during the analysis. We also believe that a comparison with the baseline data would have been extremely useful, especially to understand whether the decline in the numbers was solely due to the imposed travel restriction. The high prevalence of biliary tract cancers may explain the high numbers of gall bladder cancers in this study.[10] The authors have reported a drop in the use of the once-in-a-week regimens, but there could have been a preferential decline in the number of patients receiving the once-in-a-week regimens, which is in turn a form of bias. This is exemplified by the FOLFOX versus CAPOX regimens used in this study, where the odds of receiving the once-in-2-weeks regimen over the once-in-3-weeks regimen declined post the imposition of the lockdown, but the decline was not significant. Finally, the parallel rise in the number of patients during the latter part of the study clearly suggested that the patients did not want their chemotherapies to be delayed due to the fear of cancer progression. This aspect has also been dealt with in a prospective manner in another study on the perspective of patients during COVID-19.[11]

Since the inception of COVID-19 was absolutely unpredicted, a prospective scrutiny of the databases was not possible for any of the hospitals. Most hospitals were obviously occupied with the high case load for COVID-19. Like Pandey et al.'s center, many other centers have faced a decline in the patient numbers. In one study from India on the impact of COVID-19 on neurosurgical practice, the fall in the number of neurosurgical patients was evaluated using a questionnaire, and it was found to be 76.3% for the OPD and 70.6% for surgeries performed.[12],[13],[14] Similarly, Patil et al. and Chauhan et al. also reported a decline in the number of patients with cancer during the pandemic.[15],[16] Another study from the Netherlands reported a temporary halt in the national screening program for breast cancer resulting in fewer surgical procedures being performed during the pandemic.[17] A study by London et al. suggested a clear decline in all cancer-related encounters due to the pandemic.[18] Similarly, a study from Austria in patients with gynecological malignancies showed a slight increase in the newly diagnosed cases in January and February 2020 compared to the corresponding months in 2019. Overall, it appears that this pandemic has significantly affected the patient numbers across all cancer types.

The pandemic is ongoing, but we have emerged through its worst phase. It is high time that the decisive authorities take prospective steps to analyze the impact of this pandemic on the country and devise strategies for the decentralization of cancer care. There should be a greater emphasis on receiving chemotherapy or targeted therapy at hospitals closer to the patients' place of residence, training the healthcare personnel for small intravenous injections and chemotherapies, sensitization of patients and their relatives to the safety of home-based or local-hospital-based care, making teleconsultation more accessible, and making chemotherapeutic drugs available at the local pharmacies. Another important aspect that needs to be prospectively evaluated is the effect of this decline in patient numbers on the outcomes of these unfortunate patients. If the outcomes are significantly poorer compared to those during the normal times, proactive measures must be implemented so that the patients are not deprived of timely cancer-directed therapy.



 
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Lee LY, Cazier JB, Angelis V, Arnold R, Bisht V, Campton NA, et al. COVID-19 mortality in patients with cancer on chemotherapy or other anticancer treatments: A prospective cohort study. Lancet 2020;395:1919-26.  Back to cited text no. 1
    
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