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Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 315-320

Impact of the COVID-19 pandemic on patients with cancer and cancer survivors: A narrative review


1 Medical Education Unit Coordinator and Member of the Institute Research Council, Council, Sri Balaji Vidyapeeth – Deemed to be University, Ammapettai, Nellikuppam, Chengalpet District, Tamil Nadu, India
2 Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Sri Balaji Vidyapeeth – Deemed to be University, Ammapettai, Nellikuppam, Chengalpet District, Tamil Nadu, India

Date of Submission15-May-2021
Date of Decision27-May-2021
Date of Acceptance07-Jun-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Saurabh RamBihariLal Shrivastava
Professor, Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Sri Balaji Vidyapeeth (SBV) – Deemed to be University, Thiruporur - Guduvancherry Main Road, Ammapettai, Nellikuppam, Chengalpet District - 603108, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/crst.crst_109_21

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  Abstract 


The coronavirus disease-2019 (COVID-19) pandemic has impacted the healthcare system. Patients with cancer have been severely affected by the pandemic and have not been able to utilize the required healthcare services in a timely manner. This review is aimed at assessing the clinical and psychological impact of the COVID-19 pandemic on patients with cancer and cancer survivors. A comprehensive literature search was performed for this review in the PubMed database and Google Scholar database using the keywords, “COVID-19,” “cancer,” and “impact” in the title. Of a total of 30 relevant studies, 27 articles were included in the review. In addition, the World Health Organization website was extensively searched for relevant information. For patients with cancer who are affected by COVID-19, it has been advocated that post recovery from COVID-19, the therapeutic management of cancer should resume at the earliest to minimize cancer-related mortality. The COVID-19 pandemic has caused massive disruptions in the prevention, screening, diagnosis, and management of cancer. Therefore, minimizing the effect of the COVID-19 infection and improving the healthcare services offered to the patients with cancer by strengthening the healthcare system is the need of the hour.

Keywords: Cancer, coronavirus disease-2019 pandemic, World Health Organization, coronavirus, SARS-CoV-2


How to cite this article:
Shrivastava SR, Shrivastava PS. Impact of the COVID-19 pandemic on patients with cancer and cancer survivors: A narrative review. Cancer Res Stat Treat 2021;4:315-20

How to cite this URL:
Shrivastava SR, Shrivastava PS. Impact of the COVID-19 pandemic on patients with cancer and cancer survivors: A narrative review. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Jul 24];4:315-20. Available from: https://www.crstonline.com/text.asp?2021/4/2/315/320156




  Introduction Top


The coronavirus disease-2019 (COVID-19) outbreak that started as a cluster of cases of pneumonia of unknown etiology in the Wuhan city of China, was declared a public health emergency of international concern on January 30, 2020. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was later identified to be the causative agent for COVID-19.[1] Considering the constant rise in the number of people infected with SARS-CoV-2 and the rapid global transmission of the disease, the World Health Organization declared COVID-19 to be a pandemic on March 11, 2020.[2] The COVID-19 pandemic has significantly impacted the healthcare system and quality of life of the general population. As of May 11, 2021, a total of >157 million cases and 3.27 million deaths due to COVID-19 have been reported, with America and South-East Asia being the most affected.[3] The global case fatality rate has been estimated to be 2.1%, with the infection being reported across 222 nations and territories.[3]

On the other hand, cancer has been reported to be the second most common cause of death globally, and >10 million deaths occurred across the world in the year 2020 due to cancer and its associated complications.[3] Global estimates suggest that breast (2.26 million cases) and lung (2.21 million cases) cancers were the most common cancer types reported in 2020.[4] The findings from six population-based cancer registries across India revealed that lung and oral cancers were the most frequent types of cancer among men, while breast and cervix uteri cancers were the commonest among women.[5]

It is important to note that more than two-thirds of the deaths due to cancer have been reported from the low- and middle-income countries.[4] Even though the occurrence of serious microbiological infections in patients with cancer is not unusual, infection with SARS-CoV-2 in these patients has been associated with high mortality.[6],[7] Considering the impact of COVID-19 on the management of different diseases and health conditions, it is imperative to understand the consequences of SARS-CoV-2 infection in patients with cancer and cancer survivors. This review is aimed at assessing the clinical and psychological impact of COVID-19 on patients with cancer and cancer survivors, the challenges faced by patients with cancer during the pandemic, and the effect on their overall quality of life. In addition, we aimed to provide insights into the measures to be taken for the protection of patients with cancer against COVID-19, the role of COVID-19 vaccination in cancer survivors, and the implications for practice and research.


  Methods Top


An extensive literature search was performed to identify relevant research articles on COVID-19 and cancer published between January 2020 and March 2021. The search was done in the PubMed and Google Scholar databases, and the World Health Organization website. The databases were searched using the keywords, “COVID-19,” “cancer,” and “impact” in the title (viz. COVID-19 [ti] AND cancer [ti]; COVID-19 [ti] AND impact [ti]; COVID-19 [ti] AND vaccine [ti]). We excluded non-English language articles and articles for which the full-text version was not available. A total of 30 relevant articles were identified and screened for eligibility, of which 27 articles were finally selected based on their relevance to the current review [Figure 1].
Figure 1: Flowchart for selection of studies for inclusion in the review on the impact of coronavirus disease-2019 on patients with cancer and cancer survivors

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  Coronavirus Disease-2019 and Cancer Top


The unprecedented COVID-19 pandemic has profoundly affected all the patients with cancer by changing the dynamics of patient care and disrupting the delivery of routine essential healthcare services.[6] The immunocompromised state of the patients with cancer due to the use of anticancer drugs or the disease itself significantly enhances the risk of infection with SARS-CoV-2 in these patients as compared to the general population.[6] Furthermore, there is a higher risk of complications resulting from the infection, which can lead to alterations in the line of management, delay in treatment, or increase in the rate of hospitalization.[6],[8]

A study on Chinese patients with cancer revealed that they have a definite risk of developing more severe forms of the COVID-19 disease and the chances of requiring mechanical ventilation or admission to the intensive care unit and mortality were 3.5 times higher among patients with cancer when compared to those without.[9] On a similar note, another study from China reported that cancer was one of the conditions that could augment the risk of the development of serious forms of COVID-19.[9],[10]


  Issues Faced by Coronavirus Disease-2019-Positive Patients with Cancer Top


Cancer is often preceded by exposure to or presence of one or more predisposing factors, such as tobacco use, obesity, conditions involving the circulatory and respiratory systems, diabetes, etc. Infection with SARS-CoV-2 in people with comorbidities significantly increases their potential risk of development of a complication or severe forms of COVID-19.[6],[8] The simultaneous presence of these predisposing factors with COVID-19 makes it extremely challenging for the treating physicians to produce a favorable outcome, especially if the patients present to the hospital in the advanced stage of the disease.[6],[8] The detection of COVID-19 in patients with cancer results in the forced modification of the management of cancer (deferment of a surgical intervention, delay in the administration of immunosuppressive anticancer drugs, changes in the radiotherapy regimen, etc.,) that eventually influences the disease outcomes.[11],[12]

We must realize that other than cancer management challenges, COVID-19 infection has significantly impacted the psychosocial (social, financial, and emotional) well-being of the patients and their caregivers. There has been a significant rise in the incidence of anxiety, stress, and depression among these patients with many people having a fear of the infection.[13],[14] In addition, the presence of financial burden, issues with the accommodation of caregivers, transportation concerns with lockdown being imposed, shortage or uncertainty about the medications, masks, and other hygiene products are prevalent.[13],[14] Furthermore, the problem of the emergence of antimicrobial resistance among cancer patients can also be expected to rise further, if we continue the practice of indiscriminate usage of antibiotics.[15]

As a result of the ongoing COVID-19 pandemic, patients with cancer have not been able to utilize the required healthcare services in a timely manner.[11] The findings of a retrospective study done in the adult head and neck cancer department of a cancer specialty hospital in Mumbai revealed that the number of patients visiting the hospital reduced from 219 (pre-COVID period) to 57 (established-COVID time periods).[16] The findings of another retrospective study done in a tertiary care cancer center over a 5 months' period depicted that there was a decline of 10.5% among female patients who were planned for radiotherapy.[17] A retrospective study done in the medical oncology department of an Indian institute reported that there was a statistically significant decline in the number of outpatient department visits and chemotherapy cycles during the period of lockdown imposed to contain the COVID-19 pandemic.[18] Furthermore, the findings of a descriptive and cross-sectional phone-based survey showed that >65% cancer patients missed their scheduled visits, while close to 12% could not get the required medications.[19]


  Coronavirus Disease-2019 and Cancer Survivors Top


In cancer, survivorship refers to the different dimensions of the health and well-being of a person who has been diagnosed with cancer from the time of diagnosis till the end of their lives. The findings of different studies suggest that owing to the COVID-19 pandemic, various healthcare services have been restricted. Thus, the restaging imaging scans have been either postponed or canceled, endoscopy and other surveillance interventions have been delayed, and the delivery of rehabilitative services like physiotherapy and occupational therapy for lymphedema management has been significantly delayed.[11],[17],[18] Moreover, COVID-19 has also affected the strategies that have been implemented for fertility preservation, including oocyte and embryo cryopreservation among females, and sperm cryopreservation among males.[20]

As most of the available healthcare resources such as hospital beds, workforce, equipment, consumables, and laboratory infrastructure have been diverted towards the containment of the COVID-19 pandemic, the strategies aimed at cancer prevention, screening, diagnosis, and treatment have been significantly affected.[21],[22] The restrictions imposed for curtailing the spread of COVID-19 have significantly limited the timely detection of new cancers, thereby increasing the risk of progression of the disease to advanced stages. In addition, the treatment of patients with cancer has been interrupted, which can adversely impact the disease prognosis.[12],[21],[22]

In order to maintain social distancing, fewer patients are admitted to hospital wards, which has led to a decline in the number of patients with cancer who can utilize the healthcare facilities.[12],[21] It has been more than a year since COVID-19 was declared a pandemic, and it seems unlikely that the healthcare system will return to the way it was in the pre-COVID-19 era in the near future.[21],[22],[23] Only time will reveal the real impact of the COVID-19 pandemic on mortality due to cancer and the quality of life of cancer survivors.


  Psychological Concerns of Cancer Survivors and Their Caregivers Top


The COVID-19 pandemic has become a source of multiple psychological concerns in the general population. This has been attributed to home confinement, isolation of COVID-19-positive individuals and their contacts for 2 weeks after the detection of infection, fear, and anxiety associated with the novel disease, unemployment due to closure of workplaces, and propagation of myths and misconceptions about the infection.[6],[10] Similarly, healthcare personnel have been exposed to a lot of stress related to the increased workload, shortage of personal protective equipment, and a constant fear of acquiring the infection. Even the caregivers of patients with cancer who are infected with SARS-CoV-2 experience considerable psychological stress as they are not allowed to see the patients and are often concerned about the outcome of the disease.[6],[11],[12],[21],[24],[25]

In an online questionnaire-based cross-sectional study on patients with breast cancer in the United Kingdom, it was reported that the respondents had COVID-19-related emotional vulnerability to a significant extent, and there was an increase in the incidence of anxiety and depression.[26] Another institution-based, cross-sectional survey performed among patients with cancer, caregivers, and healthcare professionals in Singapore during the lockdown period revealed that 66% of the patients and close to 73% of the caregivers had immense fear about the rapid spread of the COVID-19 pandemic.[27] Moreover, the study participants highlighted different psychological concerns like the fear of dying alone, being anxious about cancer and COVID-19, and a higher incidence of burnouts among healthcare professionals.[27] Therefore, the need of the hour is to promptly implement accessible interventions to develop emotional resilience among patients with cancer.[26],[27]

Thus, there is an immense need to extend psychological assistance to everyone, and once again, the onus lies on the frontline healthcare professionals. Therefore, it would be ideal to use the services of a multidisciplinary team to help people tackle their emotional stress.[21] The family members of patients with cancer who are affected by COVID-19 should be encouraged to speak with the patient through telephone or video calls to raise their morale. In addition, the domiciliary follow-up of isolated patients with cancer through telephone or video consultation or in person can be proposed.


  Protection of Coronavirus Disease-2019-Negative Patients with Cancer Top


It is extremely important to protect the patients with cancer who are hospitalized for their treatment from COVID-19. Therefore, it is advised that these COVID-19-negative patients with cancer should be admitted to a non-COVID-19 facility, as this significantly reduces the potential risk of acquiring the infection.[9],[22] In addition, the standard preventive measures such as frequent hand washing, use of face masks, respiratory hygiene, disinfection of surfaces, periodic disinfection of toilets, and physical distancing should be strictly adhered to.[28] It is also important to ensure the safety of the healthcare personnel.[11],[12],[21]


  Role of Coronavirus Disease-2019 Vaccination in Patients with Cancer and Cancer Survivors Top


As vaccines against COVID-19 have been made available by different pharmaceutical companies in the past 4–5 months, it becomes our utmost priority to vaccinate cancer survivors.[29],[30] The COVID-19 vaccines including Covishield, Covaxin, Pfizer-BioNTech vaccine, Moderna vaccine, Johnson and Johnson (Janssen) vaccine, etc., should be taken by patients with cancer and cancer survivors. In fact, the current National Comprehensive Cancer Network guidelines recommend that all patients with solid tumors, including those who are receiving cytotoxic chemotherapy, targeted therapy or immunotherapy, and those on radiation should get the vaccine as soon as it is available.[31] Further, patients who are scheduled for surgery should also get vaccinated, but should separate the vaccine administration date and the surgery by a few days. Patients with hematologic malignancies who are receiving intensive myelosuppressive therapies like induction therapy for acute myelogenous leukemia should receive the COVID-19 vaccine once the absolute neutrophil count has recovered; all other patients with hematologic malignancies and marrow failure syndromes should receive the vaccine when available. Patients undergoing transplantation (autologous or allogeneic) and patients receiving cellular therapy (e.g. CAR-T cell) should receive the COVID-19 vaccine 3 months or later post-transplant or cellular therapy.[31]

It is essential for the policymakers to develop a strategic plan to ensure that all patients with cancer and cancer survivors are immunized on priority.[29],[30] The available vaccines can significantly reduce the risk of infection with SARS-CoV-2, thus indirectly reducing the potential aggravation of the disease or development of complications among cancer survivors.[30]

However, the main concern has been the effectiveness of the vaccine in patients with cancer who tend to have a weak immune system (due to the ongoing chemotherapy or radiotherapy or stem cell or bone marrow transplantation).[29],[30]


  Implications for Clinical Practice Top


Upon recovery from COVID-19, it has been advocated that the therapeutic management of cancer should resume at the earliest to minimize the risk of cancer-related mortality. In the absence of availability of an effective drug against COVID-19, it is necessary that all the standard prevention strategies be strengthened. Treatment guidelines for COVID-19-positive patients with cancer are being formulated by the different national cancer organizations as more evidence is emerging. Currently, the best approach for the management of COVID-19-positive patients with cancer and cancer survivors is to extend psychological support to the patients and their caregivers, to provide them with updated information regarding the disease, and to continue the standard cancer-directed therapy uninterrupted.


  Implications for Research Top


There is an immense need to intensify research activities to ensure better outcomes for COVID-19-positive patients with cancer and cancer survivors. Not all anticancer drugs are immunosuppressive. Given the increased vulnerability of patients with cancer to develop COVID-19, it is essential to identify anticancer drugs that do not cause immunosuppression. Moreover, there is a need to develop standard protocols for the treatment of different types of cancer and specific guidelines for the use of chemotherapy and radiotherapy in various settings. There is also a need to assess the prognosis of SARS-CoV-2 infection among cancer survivors with or without the presence of predisposing factors, and this will require large-scale multicentric studies.


  Conclusion Top


The COVID-19 pandemic has caused massive disruptions in the prevention, screening, diagnosis, and management of cancer. Therefore, minimizing the effect of the COVID-19 infection and improving the healthcare services offered to the patients with cancer by strengthening the healthcare system is the need of the hour.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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