Cancer Care in India during COVID-19
Cancer care even prior to the Covid-19 outbreak was a large battle for any cancer fighter and their family. The COVID-19 pandemic has changed everyone’s life for better and as well as worse. There have been countless challenges while battling the pandemic, of which, one vital has been treatment for any disease including management of cancer patients.
Today, on the 25th of September, COVID-19 has led to 92920 deaths out of the 5823060 cases (mortality of 1.5%). In 2014, 491,598 people died in out of 2,820,179 cases. That is an alarming 17% mortality rate.
We are blessed in many ways that health care technology today is advanced enough (such as telemedicine or oral chemo) that many cancer fighters can get treatment without hospital visits or going to cancer centers. However, those in later stages, or recently detected cases need to go to hospital for diagnosis and treatment. Unfortunately, cancer patients have a lower immune system which makes them higher risk to catch viruses.
Cancer Care and Treatment of Cancer Guidelines in India
The following points are from the guideline from the Indian Medical Association of Surgical Oncology:
- Cancer Surgeries, if planned, must be simple and short and with low morbidity with minimal blood loss.
- Priorities Surgeries with high chances of cure when given early treatment.
- Avoid surgery with doubtful benefits and for poor prognostic diseases.
- Avoid surgical time and manpower associated with extensive surgery like micro vascular reconstruction, laparoscopic lengthy procedures, breast reconstruction, major Liver & Oesophageal Resections etc.
- Biopsies: being the 1st step in confirming the diagnosis, and being a minor procedure, should be considered early. Management decisions can be based on these reports.
Here are the guidelines by cancer type:
- ER,PR positive patients can be delayed with Neoadjuvant hormonal therapy.
- Locally advanced cases may be offered neoadjuvant chemotherapy if they are Hormone Receptor negative.
- Very early cancers can be delayed till crises subsides.
- Surgery may be justified inpoor responders to Neo-adjuvant treatment or where Chemotherapy and Hormone therapy are not an option (eg elderly ER negative patient), or Malignant Phylloides, sarcomas
- Emergencies like Stridor, bleeds, dysphagia need to be treated appropriately. Procedures like Tracheostomy, Carotid Artery ligation, Endoscopic NG tube insertion/ stenting need to be considered in such cases.
- Advanced and palliative patients should be counselled to remain at home with minimal therapy ensuring adequate symptomatic medical treatment.
- Surgeries when done should be simple involving minimal manpower and material. Cosmetic reconstruction can be delayed.
- T1, T2 lesions can be operated with minimal hospitalisation.
- Cases which have equivalent results with radiation should be given.
- Anyone who is a candidate for neoadjuvant therapy must be dealt with accordingly.
- Slow cancers like Thyroid, Parotid, Basal cell Carcinoma can be delayed.
- However, Thyroid cancers which are locally aggressive and has local invasion or airway compression should be taken up for early surgery.
- Uncontrolled Hyperparathyroidism may also be a candidate for early surgery.
- It is prudent to avoid surgery which is likely to require ventilators for long periods and can have high risks of chest complications.
- Esophagus cancers are preferably given Neo-adjuvant radiotherapy and or chemotherapy and those who have already completed Neo-adjuvant treatment, surgery can be delayed for another 3 weeks.
- Lung cancers are mostly inoperable and get Non-surgical treatments like Chemotherapy, Radiotherapy, Targeted therapy. A multidisciplinary decision should be taken after full work up to rationalise surgery versus Non-surgical Neo-adjuvant treatment in Stage I-III Cancers.
- Thymomas are mostly slow growing and can be delayed. Metastatic resections are preferably deferred.
Upper GI, Hepatopancreatico biliary Cancers
- All obstruction, bleeding and perforations need to be operated on without delay. Neo-adjuvant Chemotherapy should be considered in Gastric malignancies.
- Stenting can be done in patients with Oesophageal stricture or gastric outlet obstruction in advanced cases for palliation.
- Complex Cases like Whipples and Segmental Liver resections should preferably be done only at high volume Centrein otherwise uncomplicated cases.
- Surgeries for Gallbladder cancer should be done sooner rather than later for its aggressive nature.
- RFA may be considered to treat small HCCs and Colo-rectal Liver metastases (upto 3 cms). For larger lesions, systemic therapy should be considered.
- Embolization may be also be considered for treating HCC.
- GIST can be treated with neo-adjuvant TKIs unless they are bleeding actively which will necessitate surgery.
- Treatment for PNET, IPMN, etc. can be delayed.
- Rectum cases will preferably be radiated preoperatively. Surgery can be planned 8- 12 wks. after completion of RT patients. In obstruction lesion a stoma has to be considered.
- Colonic obstructions, bleeding and impending perforation should be relieved early with a resection/ stoma. Definitive surgery may be delayed by Endoluminal stenting for obstructing lesion.
- Neo-adjuvant chemotherapy may be considered for locally advanced colonic cancers.
- Colectomies should be done early as delay may significantly affect the outcome.
- Low grade sarcomas (eg Low grade Retro-peritoneal Liposarcoma) can be deferred therapy.
- Those cases which need Radiation and Chemotherapy, are preferably given in the Neo-adjuvant setting especially in the extremities.
- Aggressive malignant sarcomas are to be operatedupon without much of delay.
- Select young patients who can undergo surgery with minimal morbidity. Prefer early discharge with Telephonic support.
- Renal cancers are relatively slow growing and can be delayed for 2- 3 weeks, unless associated with any complications or bleeding.
- Surgery may be deferred unless the patient is having uncontrolled symptoms in Pheochromocytomas/ Paragangliomas/ Cushings.
- Simple procedures to be done on day care basis. RPLND to be delayed or avoided in favour of chemotherapy. Elective groin dissections to be delayed.
- Early surgery should be considered in Stage I & II. Neo-adjuvant therapy should be considered in Stage III.
Peritoneal surface malignancy / Ovarian Cancer
- Consider Chemotherapy for all fresh cases.
Those who are responding to chemotherapy may be further delayed with additional chemotherapy.
- Those due for surgery or those not responding to chemotherapy must be delayed by minimum 2 weeks. Those with surgical complications like obstructions need to be operated immediately.
- Avoid extensive surgical therapy. Trade off better survival with minimal therapy possible as per your acumen.
Pre malignant cases should avoid therapy for now.
Learn more about how other parts of the world is dealing with cancer in the COVID-19 era here.
Guides for Patients on Cancer Care
Note: The above mentioned points are from the guideline released in March and April 2020. Please consult your doctor for the most updated guidelines and regulations. All information is subject to change without notice and information may not be up to date. The opinions and views in blogs on this website are from their author(s) may not be representative of Positive Biosciences Ltd.
- IASO Covid-19/Curfew Guidelines – 25th March
- The COVID-19 pandemic and the Tata Memorial Centre response
- Caring of cancer patients during COVID-19: A real-life challenge
Special Contributor: The Onco Clinic
Our thanks for contributing information and edits for this article to our partner The Onco Clinic. Based in Gurugram, Haryana The Onco Clinic is an emerging institute focused on high-quality and affordable care for cancer patients.