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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 37-43

Impact of COVID-19 lockdown on patients with cancer in North Bihar, India: A phone-based survey


1 Department of Community Medicine, Homi Bhabha Cancer Hospital and Research Centre, Muzaffarpur, Bihar, India
2 Department of Obstetrics and Gynecology, Homi Bhabha Cancer Hospital and Research Centre, Muzaffarpur, Bihar, India
3 Department of Preventive Oncology, Homi Bhabha Cancer Hospital and Research Centre, Muzaffarpur, Bihar, India

Date of Submission06-Nov-2020
Date of Decision10-Jan-2021
Date of Acceptance04-Mar-2021
Date of Web Publication26-Mar-2021

Correspondence Address:
Chanda Rai
C/O Dr Bikash Kumar, Daudpur Kothi, Laxmi Chowk, Muzaffarpur - 842 003, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_349_20

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  Abstract 


Background: In India, the coronavirus disease-2019 (COVID-19) outbreak led to an extensive lockdown, leaving the other time-sensitive medical conditions, such as cancer unaddressed. Patients with cancer are extremely vulnerable to infections owing to their already immunocompromised status and the need for prolonged treatment.
Objectives: We aimed to study the impact of the COVID-19 lockdown on the utilization of health-care services by patients with cancer in the Muzaffarpur district of North Bihar, India.
Materials and Methods: This descriptive, cross-sectional study was conducted at a preventive oncology clinic in the Muzaffarpur district of North Bihar in India. All consecutive patients registered in the population-based cancer registry of Muzaffarpur were telephonically contacted between April 15, 2020, and May 7, 2020, during the first phase of the nationwide lockdown. The patients were asked questions related to their disease, treatment status, and impact of the lockdown on their treatment. Detailed responses were recorded and analyzed.
Results: The study comprised 210 patients of which majority were women (62.9%) and aged more than 40 years (77.1%). A total of 162 (77%) patients were found to be affected by the lockdown, of which 137 (65.4%) missed their scheduled visits, 1 (0.5%) missed surgery, 1 (0.5%) missed chemotherapy, and 24 (11.4%) could not get the prescribed drugs. Most patients who missed their scheduled appointments were aged more than 60 years, women, inhabitants of rural areas, with multiple comorbidities, or belonged to the lower middle-income economic strata. About 70% of the patients faced transportation issues, and 55% experienced financial problems during the lockdown.
Conclusion: The lockdown led to difficulties in accessing cancer care in almost 80% of the patients with cancer. This suggests the need for strategic planning of health-care services for patients with cancer during the current pandemic, by means of telemedicine consultation, home-based palliative care services, and ensuring the availibility of essential cancer drugs.

Keywords: Cancer and COVID-19, COVID-19, pandemic, SARS-CoV-2, lockdown


How to cite this article:
Singh R, Rai C, Ishan R. Impact of COVID-19 lockdown on patients with cancer in North Bihar, India: A phone-based survey. Cancer Res Stat Treat 2021;4:37-43

How to cite this URL:
Singh R, Rai C, Ishan R. Impact of COVID-19 lockdown on patients with cancer in North Bihar, India: A phone-based survey. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Apr 23];4:37-43. Available from: https://www.crstonline.com/text.asp?2021/4/1/37/312087




  Introduction Top


The ongoing coronavirus disease-2019 (COVID-19) pandemic has proven challenging for the health-care systems all over the world.[1] As per the World Health Organization data, globally, there have been 102.58 million cases and 2.22 million deaths due to COVID-19.[2] India alone reported 10.83 million cases and 155,018 deaths due to COVID-19.[3]

The Indian health-care system is grappling with the ever-increasing load of COVID-19 patients. This has affected the delivery of health care to patients with other serious illnesses like cancer. The GLOBOCAN 2018 data from India reported that more than 1.1 million new cases of cancer were diagnosed every year, and 0.78 million cancer deaths occurred annually.[4] Patients with cancer have been at the receiving end of the COVID-19 crisis because of the overburdening of hospitals across India, where prioritizing patients with COVID-19 has become the need of the hour. The COVID-19 pandemic led to an extensive lockdown in many countries including India, as a measure to contain its spread. During the nationwide lockdown in India, most of the hospitals had to suspend their routine outpatient department (OPD) services.[5] Transportation facilities were curtailed, and hence, patients with cancer had no means to travel during the lockdown.[6]

Bihar is a state in Northern India with the lowest per capita gross domestic product in the country[7] and is home to a large number of migrant daily wage workers who lost their jobs during the lockdown and had to return. Cancer centers in Bihar that provide quality care include the All India Institute of Medical Sciences, Indira Gandhi Institute of Medical Sciences, and Mahavir Cancer Hospital. However, these centers are located in the capital city of Patna, which is situated 100 km away from our peripheral outreach cancer clinic located in the Muzaffarpur district of Bihar. Muzaffarpur has a population of over 5 million and is characterized by poor health infrastructure. It is one of the 115 aspirational districts identified from 28 states in India, marked by poor socioeconomic indicators.[8]

Recently, several articles have outlined the measures taken by various tertiary cancer care centers to tackle the COVID-19 situation.[9],[10] We reported our findings from a study conducted at our peripheral outreach center in Muzaffarpur, in which we assessed the impact of the pandemic on peripheral health-care services.[11] Likewise, studies have been conducted to assess the impact of the lockdown on dispensing radiotherapy and chemotherapy services in cancer care centers in Patna.[12],[13] However, there is relatively little information about the impact of the pandemic on access to cancer care from the patients' perspective. Therefore, in this study, we aimed to examine the health-care challenges faced by patients with cancer frequenting our preventive oncology clinic amid the COVID-19 lockdown.


  Materials and Methods Top


General study details

This cross-sectional, descriptive study was conducted in the OPD of the preventive oncology clinic in the Muzaffarpur district in Bihar, a grant-in-aid institute under the Department of Atomic Energy of the Government of India. The study was conducted between April 15, 2020, and May 7, 2020. As our study was questionnaire-based and did not involve any direct intervention, approval of the Institutional Ethics Committee was not required. Verbal consent was obtained from all participants before administering the questionnaire. For participants aged <18 years, verbal consent was obtained from their parent or legal guardian. The study was conducted in accordance with the ethical principles laid down in the Declaration of Helsinki.

Participants

The preventive oncology department maintains a population-based cancer registry (PBCR) that collects, classifies, and stores a detailed record of all the patients with cancer in the Muzaffarpur district. These data are eventually recorded in the National Cancer Registry. The PBCR records all new cases in a defined population with an emphasis on epidemiology and public health along with providing information on cancer incidence and mortality. The PBCR of Muzaffarpur became functional in September 2018.

The PBCR of Muzaffarpur was the primary source for selecting eligible participants for this study. The PBCR data for the years 2018 and 2019 were reviewed, and all consecutive patients with cancer who were willing to participate in the study were enrolled. Patients who did not respond, those whose phone numbers were not available or were invalid, and patients who were dead were excluded from the study.

Variables

Our primary objective was to assess the effect of the COVID-19 lockdown on the treatment of patients with cancer. Our secondary objective was to evaluate the different factors that hindered the utilization of cancer care services by the patients during this period.

Study methodology

A phone-based survey was conducted during the first phase of the lockdown. A phone-based survey was opted for to prevent the patients from visiting our center during the pandemic. A standard, open-ended questionnaire was prepared that comprised 14 questions related to the patients' characteristics, type of cancer, their current and past treatment status, impact of the lockdown on their follow-up appointments, treatment, and surgery, or any other problems they may have faced during the lockdown that affected their treatment.

Our team of surveyors was trained for a week to conduct telephonic surveys for patients with cancer. Patients were called sequentially on their registered mobile numbers based on their enrollment in the PBCR. Those who did not answer the call even after three attempts were considered non-responders. The questionnaire was verbally administered either in Hindi or the local language. The questions were mostly answered by the patients themselves, but at times, they were assisted by their family members or caregivers. For children aged <16 years, questions were answered by the children with help from their parents. The responses were then recorded by the surveyors in either English or Hindi language.

Statistics

A formal sample size calculation was not performed, and all consecutive patients fulfilling the eligibility criteria were enrolled in the study. The information collected in the study was entered into Microsoft Excel. Qualitative variables were compared using the Chi-square test or Fisher's exact test. Descriptive data were described as percentages, and the relationship between nominal variables was calculated using the Pearson's Chi-square test. P ≤ 0.05 was considered statistically significant. Data were analyzed using the Statistical Package for the Social Sciences (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp).


  Results Top


A total of 567 patients were contacted, of which 176 did not respond and 181 were reported deceased. Thus, a total of 210 patients were eligible for the final analysis [Figure 1]. [Table 1] summarizes the various sociodemographic details, clinical characteristics, and treatment status of the patients. It was observed that 20 (9.5%) patients had stopped the prescribed allopathic treatment completely and resorted to alternative forms of medicine like homeopathy or ayurveda.
Figure 1: Flowchart for patient enrollment in the study

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Table 1: Sociodemographic and clinical profile of the patients included in the study

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A total of 137 (65.2%) patients reported that they had missed their scheduled hospital visits, of which 38 had completed their treatment and were on regular follow-up. A total of 24 (11.4%) patients were not able to procure the oral chemotherapeutic drugs prescribed either due to financial stress (8/24), travel restrictions (6/24), or both (10/24) [Figure 2].
Figure 2: Impact of coronavirus disease-2019 lockdown on patients with cancer

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Altogether, 28 patients were receiving active chemotherapy, of which 1 male patient who had recently been diagnosed with gallbladder cancer missed his scheduled chemotherapy and a female patient with cervical carcinoma missed her chemoradiation appointment.

The social and clinical details of patients who missed their follow-up appointments on account of the imposed lockdown are elaborated in [Table 2]. Majority of the patients who had difficulty visiting the hospital were aged more than 60 years, women, inhabitants of rural areas, had multiple comorbidities, or belonged to the lower middle-income strata. Thus, age, sex, place of residence, presence of comorbidities, and economic status were found to be significantly associated with the ability to visit the hospital amid the lockdown. Although the disease stage was not found to be significantly associated with the ability to visit the hospital amid the lockdown, it is important to note that out of 16 patients with a terminal illness, 13 complained of difficulty in visiting the hospital.
Table 2: Characteristics of patients who missed their follow-up

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The clinical symptoms that the participants experienced during the lockdown are listed in [Table 3]. Pain was reported by 72 (34.3%) patients, whereas 104 (49.5%) had no complaints.
Table 3: Symptoms experienced by patients with cancer during lockdown (n=210)

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Transportation and financial problems were experienced by 71% and 55% of the patients, respectively [Figure 3] and [Figure 4]. The different types of patients with cancer who had to miss their scheduled clinical visits and those who could not procure essential cancer drugs during the lockdown are highlighted in [Figure 1S] and [Figure 2S], respectively.
Figure 3: Proportion of patients facing transportation issues

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Figure 4: Proportion of patients facing financial problems

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  Discussion Top


In our study, we found that 65.2% of the patients had to miss their scheduled hospital visits and 47.1% were unable to complete their treatment. This forced non-compliance to therapy could affect the patient outcomes and lead to upstaging of various cancers, thus having serious repercussions for patients with cancer. Pandey et al. in their study on adult patients with cancer living in the rural areas observed a delay of more than 6 months in the diagnosis of breast and genitourinary malignancies and 3 months in the diagnosis of gallbladder, lung, and hematological malignancies due to the pandemic.[14] A delay in the diagnostic workup and treatment of breast carcinomas is likely to upstage the disease and shorten the survival of patients, thereby increasing the overall morbidity and mortality.[15] A study from Taiwan reported that patients who received treatment within 30 days of diagnosis had better overall survival than those who received treatment after 30 days from diagnosis.[16]

Similarly, studies have shown that delaying surgery in patients with gastrointestinal malignancies for more than 30 days can adversely affect the prognosis.[17] Shen et al. emphasized that delaying treatment in patients with cervical cancers lowered their 1- to 5-year survival rates and shortened the mean survival time.[18] Studies conducted at cancer centers in Patna, India, have shown a decline in the number of patients with cancer who were scheduled for radiotherapy and chemotherapy during the pandemic.[12],[13] This was attributed to the curtailment of public transportation facilities and financial difficulties faced by the patients during the lockdown;[12],[13] We have reported similar findings in our study. In addition, we observed that a large proportion of patients in our cohort were not able to procure the drugs prescribed to them, including oral chemotherapeutic drugs and pain-alleviating medications. This was largely due to the unavailability of drugs and the patients' financial constraints. An unplanned break in anticancer therapy can severely worsen the patients' health status and hence is a matter of concern. Our study also showed that the lockdown had inequitable effects on patients with different sociodemographic backgrounds and particularly affected those who were aged more than 60, female patients, those hailing from rural areas, and those with a low socioeconomic status.

Out of eight patients with gallbladder cancer, six were affected by the lockdown. Five of them who had completed their treatment missed their scheduled follow-up appointments, and one patient with a recently diagnosed disease had to defer surgery. Gallbladder cancer is one of the most common cancers in Bihar and a major public health problem.[19],[20] The mean overall survival of patients with gallbladder cancer is 6 months, with a 5-year survival rate of 5%.[21] The rapid progression of gallbladder cancer and delayed diagnosis are the reasons for increased mortality in these patients.[22] The fact that some patients miss their scheduled surgery despite the knowledge about their poor prognosis is concerning. Saini et al.'s study highlights the overburdening of hospitals due to COVID-19 and how it has affected health-care delivery to patients with cancer whose outcomes are negatively impacted.[23] The fact that the pandemic has led to a decrease in cancer screening and diagnosis and hampered the treatment, thus increasing the overall mortality, is corroborated in another study by Moujaess et al.[24]

At our center, we started with reaching out to patients registered within our OPD through phone calls and asking them about the problems they faced, while simultaneously arranging for telemedicine sessions with the Tata Memorial Centre in Mumbai, India. We strove hard to provide the required medications to some of the patients with the help of various pharmaceutical agencies and non-governmental organizations. Despite having just started the preventive oncology clinic, we tried to address all the oncology problems to the best of our capacity.

Our study may have been limited by a selection bias. Patients who did not respond could be the ones who lived in remote places with poor network connectivity, and their situation may have been substantially different from that captured in our survey. Second, ours was a single-center study, so the results cannot be extrapolated to the entire population of Bihar or India. Since only 7.5% of the patients in our study had a terminal illness, the cohort might not have been representative of the entire cancer burden in the state of Bihar. Our sample size was limited as our study period was restricted to the lockdown phase. In addition, the study assessed self-reported health status and health-seeking behavior of the patients, and therefore, there is a possibility of a reporting bias. Moreover, information regarding the cancer stage could not be obtained telephonically, and hence, was not reported in our study.


  Conclusion Top


Our study shows that patients with cancer had to face several hardships to avail cancer treatment during the COVID-19 pandemic and the ensuing lockdown. The entire shift of focus to COVID-19 management has left voids in other areas of health-care, including cancer care. Therefore, there is a need to strategize protocols for the safe delivery of care to all the patients with cancer, without compromising its quality.

Acknowledgment

Our team would like to thank Dr. Nishant Kumar and Mr. Gaurav Raj for their assistance in the statistical analysis of data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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