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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 829-830

Surge in pelvic and para.aortic nodal involvement in newly diagnosed cervical cancer patients during coronavirus disease 2019: A chance or imminent reality?


Department of Radiation Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India

Date of Submission27-Aug-2020
Date of Decision10-Sep-2020
Date of Acceptance23-Sep-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Deleep Kumar Gudipudi
Department of Radiation Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Road Number 10, Banjara Hills, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_281_20

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How to cite this article:
Selvaraj VK, Gudipudi DK. Surge in pelvic and para.aortic nodal involvement in newly diagnosed cervical cancer patients during coronavirus disease 2019: A chance or imminent reality?. Cancer Res Stat Treat 2020;3:829-30

How to cite this URL:
Selvaraj VK, Gudipudi DK. Surge in pelvic and para.aortic nodal involvement in newly diagnosed cervical cancer patients during coronavirus disease 2019: A chance or imminent reality?. Cancer Res Stat Treat [serial online] 2020 [cited 2021 Jan 26];3:829-30. Available from: https://www.crstonline.com/text.asp?2020/3/4/829/304962



Cervical cancer is one of the most commonly encountered malignancies in developing countries. According to GLOBOCAN 2018, it is the second most common cancer and the cause of cancer-related deaths among women in India.[1] India being a developing country, the early detection of cervical cancer is hampered due to financial constraints and the lack of adequate screening programs, trained personnel, and infrastructure.[2] Hence, the majority of cases present in the advanced stages with parametrial and vaginal involvement. However, regional involvement of the pelvic and para-aortic lymph nodes (FIGO Stage IIIC1/C2) at diagnosis is not as common as the local spread (FIGO Stage IIIA/B).

The first case of coronavirus disease 2019 (COVID-19) in India appeared toward the end of January 2020. Following this, the infection spread rapidly across the country over the next few months.[3] Therefore, a nationwide lockdown was imposed by the end of March 2020, and it continues to this date with some relaxations. There have been restrictions on the intra-and interstate public transportation, as a result of which patients from lower socioeconomic strata, who primarily depend on public transportation, were the most affected.[4] Moreover, the increasing number of COVID-19 cases and mortalities has instilled fear among the people. Therefore, despite having symptoms such as white discharge or vaginal bleeding, women are hesitant to seek medical advice or visit a hospital. These factors are expected to have a major impact on the long-term oncological outcomes in terms of cancer-related mortality in patients with cervical cancer.[5]

Although it is too early and premature to say that COVID-19 has affected oncology care, a spurious observation of increased pelvic and para-aortic lymph node involvement in newly diagnosed patients with cancer was made in our tertiary cancer center in southern India. This observation encouraged us to analyze the clinical records of patients with cervical cancer treated in the Department of Radiation Oncology before and during the lockdown, namely January–March 2020 and April–June 2020, respectively. On retrospective analysis, we observed a significant decrease in the number of newly treated patients with cervical cancer and an increase in the number of patients with FIGO Stage IIIC disease during the April–June 2020 period. Compared to the pre-lockdown period, there was a 14% reduction in the number of newly diagnosed patients with cervical cancer receiving radiation during the lockdown period (95 cases pre-lockdown vs. 82 cases during the lockdown). The incidence of pelvic and para-aortic lymph nodal disease as diagnosed by magnetic resonance imaging (MRI) was 33% (27 patients) and 11% (9 patients), respectively, during the lockdown period as opposed to 20% (19 patients) and 6.3% (6 patients), respectively, in the pre-lockdown period. Thus, an increase of 13% in Stage IIIC1 disease and 4.7% in Stage IIIC2 disease was observed during the lockdown period.

This observation of increased pelvic and para-aortic lymph node spread in the newly diagnosed cases of cervical cancer could be perceived either as a good or bad sign. Moreover, the observation could simply be attributed to a bias or the chance that a greater number of patients with FIGO Stage IIIC disease came for treatment to our hospital during the lockdown period. If the observation is based on chance, a positive aspect of it would be the effective detection of lymph nodal disease with an MRI scan leading to appropriate radiation treatment fields and better local control. However, there also exists the possibility that patients have been presenting to the hospital with a significant delay due to COVID-19, causing the progression of disease to nodal stations. In that case, if the pandemic continues for a few more months, we may end up seeing a greater number of patients with advanced-stage diseases, unless patients resort to COVID-19 precautions and seek early treatment. Thus, if the symptoms continue to be neglected, then apart from wreaking havoc on the social and financial status of patients with cervical cancer, COVID-19 will also have serious implications on their oncological outcomes.

In conclusion, we would like to suggest that extreme caution must be exercised while evaluating patients with cervical cancer during the COVID-19 era and increased efforts must be made to evaluate the lymph nodal status properly. In small cancer centers in rural and urban areas, where the availability of MRI or positron emission tomography/computed tomography (CT) scans is limited, a minimum of CT scan or laparoscopic lymph nodal sampling should be done in every patient before treatment initiation, even in those with FIGO Stage II disease. Disease staging and designing radiation treatment fields based on the clinical or ultrasound findings alone should be avoided during and immediately after the COVID-19 era to prevent the mismanagement of newly diagnosed patients with cervical cancer. However, further studies with larger sample size are warranted to test this hypothesis; we are planning to conduct one such study after a few months. The sole purpose of writing this article now is to make oncology professionals, policymakers, and patients with cancer vigilant about taking health-related decisions amid this pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.  Back to cited text no. 1
    
2.
Bobdey S, Sathwara J, Jain A, Balasubramaniam G. Burden of cervical cancer and role of screening in India. Indian J Med Paediatr Oncol 2016;37:278-85.  Back to cited text no. 2
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3.
Pande P, Sharma P, Goyal D, Kulkarni T, Rane S, Mahajan A. COVID-19: A review of the ongoing pandemic. Cancer Res Stat Treat 2020;3:221-3.  Back to cited text no. 3
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Dalal NV. Social issues faced by cancer patients during the coronavirus (COVID-19) pandemic. Cancer Res Stat Treat 2020;3:141-4.  Back to cited text no. 4
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Dessai S, Nachankar A, Kataria P, Abyankar A. Management of patients with gynecological cancers during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3:40-8.  Back to cited text no. 5
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