|LETTERS TO THE EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 218-220
Caring of cancer patients during COVID-19: A real-life challenge
Shreya Das Adhikari1, Nitin Gupta2, Atul Sharma3, S V S Deo4, Sushma Bhatnagar1
1 Department of Oncoanaesthesia and Palliative Medicine, Dr Bhim Rao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
2 Department of Infectious Diseases, Kasturba Medical College, Manipal, Karnataka, India
3 Department of Medical Oncology, Dr Bhim Rao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
4 Department of Surgical Oncology, Dr Bhim Rao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||16-Apr-2020|
|Date of Decision||28-Apr-2020|
|Date of Acceptance||28-Apr-2020|
|Date of Web Publication||17-May-2020|
Department of Oncoanaesthesia and Palliative Medicine, Dr Bhim Rao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Adhikari SD, Gupta N, Sharma A, Deo S V, Bhatnagar S. Caring of cancer patients during COVID-19: A real-life challenge. Indian J Cancer 2020;57:218-20
As the first report of this disease in late 2019, COVID-19 has engulfed almost entire world in a very short period. Patients with cancer are a vulnerable group of the population who need frequent visits to healthcare settings. Given the susceptibility of cancer patients to develop a severe infection, their presence at hospitals should be minimized. At the same time, they need to be provided with the best possible care. Hospitals around the world have been burdened with an increasing influx of COVID-19 patients. According to a study of 1590 COVID-19 cases from China, a total of 1% patients had a history of cancer, which seems to be higher than the average incidence of cancer (0.29%) in the overall Chinese population. However, whether this is due to increased susceptibility of cancer patients to acquire the infection or because they are more likely to be in contact with COVID positive patients due to their frequent hospital visits, needs to be evaluated. It also appears that patients with cancer are more likely to develop complications compared to those without. This is evidenced by studies from China, Italy, France, and the United States of America.,, Similar observations were noticed in patients with influenza.
In a country with low resources and overburdened healthcare system, we need to make difficult decisions in our daily practice about how and when to provide cancer treatment. We propose solutions that may be suitable for our country using recent recommendations from prominent international bodies.
- Screening for patients: Entry points into the facilities should be separate for cancer patients and staff and strictly managed as per resource settings. All cancer patients should be asked the following screening questions so that patients with suspected COVID-19 can be identified: (1) Do you have symptoms such as fever, new-onset cough, expectoration, difficulty breathing, myalgia, chills, rhinorrhoea or unexplained diarrhoea? (2) Did you have any known contact with a confirmed COVID-19 individual? (3) Do you have any history of travel in the last few months? Those patients with positive answers to any of these questions should be tested immediately. Following cancer-related risk factor should be looked for patients “at risk ”: Patients on active chemotherapy/radical radiotherapy/immunotherapy, patients with hematological malignancies, hematopoietic stem cell transplant recipients (in last 6 months)
- Medical management: Patients requiring chemotherapy can be stratified according to the risk and benefit. Patients with the lowest risk and highest benefit should get the priority. Wherever possible, regimens that are less resource-intensive should be used. Outpatient consultations for cancer patients who do not need active management should be avoided to reduce hospital contact. All screening, surveillance and protocol-based diagnostic procedures can be rescheduled for later dates. Outstation patients can be provided with a written interim plan of management and can be relocated to their local cancer centres on an individual basis. In dire circumstances accommodations, for patients can be earmarked in nearby guesthouses or “dharamshalas ”. Telemedicine, with the help of telephone or digital messaging/conferencing services, would be beneficial. All treatments beyond the first-line therapy with expected modest efficacy (unless there are compelling clinical reasons) can be delayed. Telecommunication will also be useful to monitor the diseases with slow progression. Brief remote regulated check-ins should be initiated to ensure that patients on maintenance therapies have sufficient drug supplies and provide instructions on when they should call their provider
Group activities/sessions should be postponed or conducted over video call. Minimize or delay the opening of new cancer clinical trials. Limit or hold patients' accrual in ongoing trials requiring extra procedures (decision to be taken after a multi-team discussion) as compared with clinical practice. Caregivers should not be allowed to stay with patients unless they are of extremes of age or with disabilities. This is necessary to minimize exposures. Video calls through smartphones with family members can be beneficial for emotional support of the patients. Ensure proper documentation for stay allowance with adequate protective gear for caregivers. Suspected and positive cases should be kept in separate cubicles.
- Surgical management: Elective surgical cases with a high likelihood of postoperative intensive care unit (ICU) or ventilator utilization should be delayed considering the risk of infection and need of these resources for patients with COVID-19. All aerosol-generating procedures (e.g., endoscopy, procedure related to airways, intubation) should ideally be done in negative pressure rooms. A dedicated operating theatre should be kept to take care of suspected or confirmed COVID-19 patients with cancer, in case of emergency. Only life-threatening procedures should be performed in suspected or confirmed patients. All anaesthesia providers who are at the highest risk of contracting the virus should be trained in proper donning and doffing of Personal protective equipment (PPE). Simulation exercises for correct methods of intubation and operative procedures are beneficial. American College of Surgeons (ACS) and the Society of Surgical Oncology (SSO) recommend a strategy where the hospital is divided into different phases according to the COVID-19 burden on the respective hospital should be guided by the survivorship within the next 3 months, few days or few hours. Guidelines on how to manage individual cancers has been recently updated by SSO and ACS,
- Radical radiotherapy or chemoradiotherapy with curative intent can be initiated in patients with rapidly proliferating tumors, especially when treatment has already been started. In aggressive tumours, where the residual disease is left after surgery, postoperative radiotherapy can be given. For less aggressive tumours, radical radiotherapy can be initiated if it is the first-line treatment done with curative intent. Palliative radiotherapy can be done if it reduces the usage of other treatment modalities. In COVID-19 positive patients, radiotherapy should be deferred until the patients become negative and asymptomatic
- Palliative care: Palliation is an ethical obligation, and we should strive for reasonable symptom control and comfort care for cancer patients in a pandemic. Ensure adequate medications are available to patients as repeated trips to hospital pharmacy is not desired. Our institute shifted from prescribing opioid medications from our strict 2 weeks policy to 1-month policy. We are practising telemedicine to monitor opioid use
- Hospital infection control (HIC): HIC is the cornerstone in preventing nosocomial outbreaks of COVID-19 in cancer patients and therefore, it must be reinforced. Arrangements for the adequate supply of PPE along with earmarked donning and doffing area should be made with proper disinfection and biomedical waste management. This should be coupled with regular training for healthcare workers on the proper use of PPE. PPE allotment and management of the patients should be done as per the institutional guidelines. Whenever patients are suspected with COVID-19, (e.g., respiratory symptoms) use of PPE is advised, especially if aerosol-generating procedure done. Surgical masks and handwashing with alcohol-based hand rub should be provided to all cancer patients at the entrance and wards.
The COVID-19 pandemic has presented unique challenges and learning opportunities for cancer centres. The future trajectory of this pandemic is uncertain, and we must continue to prepare for its widespread impact.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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