|Year : 2020 | Volume
| Issue : 3 | Page : 213-216
Cancer care and COVID-19 pandemic: An experience from cancer center in North-East India
Amal Chandra Kataki1, Manigreeva Krishnatreya2
1 Department of Gynaecological Oncology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
2 Department of Cancer Epidemiology and Biostatistics, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
|Date of Submission||06-Jun-2020|
|Date of Decision||18-Jun-2020|
|Date of Acceptance||30-Jun-2020|
|Date of Web Publication||10-Jul-2020|
Dr. Manigreeva Krishnatreya
Room 3, OPD Building, Dr. B Borooah Cancer Institute, Guwahati - 781 016, Assam
Source of Support: None, Conflict of Interest: None
Providing continued cancer care during lockdown for a pandemic is a big challenge. There are several issues like lack of public transport, facilities for lodging as most of cancer patients undergoing radiation and chemotherapy are treated on day care basis, maintaining physical distancing in otherwise crowded government hospital, and safety of healthcare workers. We present here a brief report of the challenges and measures undertaken by a tertiary care cancer center in the North East India. Further, we also describe the pattern of cancer and consequent care of cancer patients' pre and post lockdown.
Keywords: Cancer, care, COVID-19, North-east India, pandemic
|How to cite this article:|
Kataki AC, Krishnatreya M. Cancer care and COVID-19 pandemic: An experience from cancer center in North-East India. Curr Med Issues 2020;18:213-6
| Introduction|| |
Balancing the risk of coronavirus disease 2019 (COVID-19) for patients with cancer and safety of health-care workers and at the same time continue to provide cancer-directed treatment is a tremendous challenge for health-care administrators. The pandemic has meant a transformation of many aspects of cancer care. A study has shown a higher risk of case fatality due to Covid-19 in cancer patients. Furthermore, it is now established that older people are more vulnerable, with underlying health conditions such as chronic respiratory, cardiovascular or chronic kidney disease, diabetes, active cancer, and other severe chronic illnesses. There is added concern for cancer patients getting infected with COVID-19, along with the existing cancer itself. For a cancer patient, it is worth-taking risk of the treatment, because COVID-19 might not kill him or her, but cancer surely will if not treated. Studies with large patient population and with prospective study designs are warranted to further explore the risk factors and severe events in COVID-19-infected cancer patients.
Our tertiary care cancer center caters to cancer patients from the seven North-eastern states of India with a combined population of 45 million. Every year around 14,000 new cancer patients are registered, and 70,000 patients visit the hospital for check-ups and continuation of treatment. The various surgical divisions of the hospital perform 1500 major surgeries and around 3500 patients are taken up for radiotherapy each year. Around 25,000 chemotherapy cycles are administered in a year. The institute has five tele-therapy units and five-operating rooms.
| Strategies For Continuing Cancer Care During The Pandemic|| |
On March 16, 2020, our institute initiated noncontact thermal screening of all patients and their attendants. In addition, hand sanitization was made mandatory at the time of entry. A single point of entry was created for everyone coming to the institute and also to residential quarters inside the hospital campus. Furthermore, we collected the history of travel to high-risk places or “hot spots” as designated by the Government notification at that time and any contact history of all patients and their attendants coming to the hospital. Only one person per patient was allowed, and for critically ill patients, more than one person was allowed entry. We prepared by acquiring personal-protection equipment (PPE)/N95 masks for doctors and health-care workers of the institute. A COVID-19 task force has been created to monitor. The task force's role was to supervise on a daily-basis noncontact thermal screening area, for reducing overcrowding, hospital preparedness, and disinfection. A two-bedded febrile clinic was set up near noncontact thermal screening area, where any patient with fever was triaged and examined separately. Once it is clinically established by the attending doctor that patient with fever was without influenza-like illness (ILI) and no contact history, and then, the patient was allowed in the routine outdoor or indoor patient area. Eight patients with fever and ILI were sent for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) real time-polymerase chain reactions (RT-PCR) test at designated testing center in the Guwahati Medical College and Hospital, and two patients were tested positive for SARS-CoV-2. However, both the positive patients were asymptomatic, and interestingly, all febrile patients were tested negative for COVID-19. A four-bedded isolation ward has been established in the indoor patient admission area and any patient during his/her hospital stay develops fever and ILI is then immediately shifted to the isolation ward.
Duty roster for hospital staff was prepared. On every shift, a third of the staff, including doctors and other ancillary staff, was posted on a week basis followed by off duty for a week. His was done to ensure, if any hospital staff is exposed to Covid-19-positive patient, he or she can be kept off the duty roster and stay home quarantine for 2 weeks. One of the resident doctor developed fever with cough, and the doctor was sent on self-quarantine at home for 14 days. Fortunately, the resident was tested negative for SARS-CoV-2 RT-PCR test. We allowed doctors and staff over 60 years of age, with comorbidities such as diabetes and heart disease to go on paid leave.
To reduce nonessential hospital visits, we identified two groups of patients. One group, newly diagnosed cancer patients that will require treatment by surgery, chemotherapy, and/or radiotherapy, and patients with “active disease” that were already undergoing treatment. The second group consisted of patients who had completed treatment or those who had the disease under control and requires only periodic check-up at our institute. During the lockdown, many patients were stranded at home due to the closure of public transport, and hence, could not come to the institute for their routine checkup. On March 31, 2020, a control room was established to reach out to the second group of cancer patients by telephonic consultation. In this regard, 65 doctors of the institute were pressed into action for providing teleconsultation to over 5000 cancer patients. Many patients were also connected through institute's social networking sites and a dedicated helpline number. We encouraged the second group of patients to pay visit to local hospital or district hospitals. Furthermore, this small gesture of empathy helped to foster doctor–patient relationship and improve patient's satisfaction at this hour of humanitarian crisis. Similarly, a helpline number was launched, and this phone number was published by MyGov Assam (Government of Assam) in its social media handles (https://twitter.com/mygovassam/status/1245544420130189313) for wider dissemination to the public. In addition, director of the hospital spelled out dos and don'ts for cancer patients at home and people in general amid the current lockdown due to COVID-19 pandemic through MyGov Assam social media account. Our hospital also reached out to many cancer patients through our social media handles of Twitter and Facebook.
Because of the lockdown, all adjacent hotels and other hospitality services were also closed down. One major advantage for our hospital was to have three guest houses inside the hospital premises, which could accommodate 105 patients and their attendants during this period. Another advantage was residential quarters for hospital staff, including nurses, office staff, and ward attendants, which ensured seamless travel by the staff for duty without depending on public transport. For staff not residing in hospital quarter, we arranged hospital vehicles for transport to hospital and back home. This was a huge challenge to meet for bringing 20–30 staffs from various localities of the city. Large cancer center had to tie up with state transport corporation for bringing large number of hospital staff. Two social workers were pressed to create the database of staff, their locations in the city, and assign vehicles for the purpose. Furthermore, in view of closure of eateries in and around the hospital, arrangement was made for the free distribution of lunch and dinner to all outdoor patients and attendants with the help of various nongovernmental organizations.
| Challenges in Lockdown|| |
There were many challenges in fighting COVID-19 and cancer together in a lockdown scenario. Number one issue was accessibility. Because of the public transport closure, many patients are unable to come to the hospital to get diagnosis and start the cancer treatment. It was seen that, ambulances were charging exorbitant prices for ferrying these patients from their home to hospital and back. Hence, our doctors ensured that all investigations and tumor board decisions are fast tracked, so that patients can complete most of pretreatment work up in a single hospital visit. The management of the institute also ensured that not a single patient is turned down of their right to the treatment. Most patients hail from families engaged in the unorganized sector, and due to the lockdown, they were affected economically. However, the management of the hospital ensured that Government schemes such as Atal Amrit Abhiyan and Ayushman Bharat continue to function without any hindrance, as this would greatly offer succor to cancer patients during the time of financial hardship due to the lockdown. Another big challenge for cancer patients during the lockdown will be up staging of their cancer, for example, a patient at Stage II will move to Stage III or Stage IV due to delay by few weeks or more in the diagnosis and start of treatment, and surely that would have adverse outcomes to standard treatment.
| Cancer Patient Management Prelockdown And Postlockdown Period|| |
Many non-COVID hospitals were reluctant to take up new patients ranging from heart disease, kidney problems, diabetes, asthma, cancer, and even minor ailments in fear of acquiring Sars-CoV-2 infection. As far as various clinical services are concerned during the lockdown, we continued to offer all services same as before. The management of the institute compared the hospital statistics of 31 working days before lockdown, i.e., from February 18, 2020, to March, 24, 2020, (Period I) and 31 working days during the lockdown period till March 25, 2020–May 01, 2020 (Period II). The overall findings are presented on [Table 1]. In the previous 31 working days (Period I), the footfall of patients was 5963. However, during the Period II, the footfall of patients was reduced by 50% to 3079. In contrast, in a premier cancer center of the country, there was 65% reduction in new patient registration from 200 to 70 per day. Similarly, there was a drop of 56% during the Period II for new cancer patients that underwent radiotherapy from 330 to 147. As general precaution physical distancing in the waiting area was strictly ensured, mold of each patient was separately kept, and all technicians worked by wearing N95 masks, face shield, and double-layered gloves. As special precaution, after radiotherapy to each patient with tracheostomy or feeding tube, the contact surfaces of patient with the machine was sprayed with 70% alcohol sanitizer. There was a reduction in the number of chemotherapy cycles from 2500 to 1461. All chemotherapy cycles during the Period-II were curative or radical only, and palliative chemotherapy was deferred. There was a massive drop of 74% in the number of routine surgeries performed; however, there was a significant increase in the number of emergency surgeries. Emergency surgeries were performed using full PPEs by doctors and nurses, and tests for SARS-CoV-2 were done before routine surgeries. Two asymptomatic COVID-19 patients were detected due to routine testing before schedule surgery. The number of day care emergencies rose by more than four times from 60 patients in the 31 Period I to 236 patients during Period II. The number of new admission also increased from 983 in Period I to 1058 during Period II.
|Table 1: It shows the hospital statistics of patients during two time periods|
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We also examined the pattern of gender, age group distribution [Table 2], and presentation of sites of new cancer patients registered during both the periods. There was marginal increase of 3% of men reporting to the institute during the two lockdown periods and a corresponding decline in women patients reporting. There were no significant changes in reporting of various age-groups, and in fact, there was no major decline of patients above 60 years of age registering for the treatment.
|Table 2: It shows the gender and age group distribution of new cancer patients in two time periods|
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An interesting finding was that, in women, patients with gall bladder cancer reported the highest number of new patient registration (17.4%) in Period II as shown on [Figure 1]. Similarly, in men, gall bladder cancer patients were in the leading site of cancer at patient registration (5.3%) [Figure 1]. This could be attributed to the severity of the disease or illness which was prioritized for hospital presentation and referral to the institute, as patients with gall bladder cancer are mostly presented in advanced stages and patients are in moribund conditions.
|Figure 1: It shows the five leading cancers at patient registration during Period I and Period II.|
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| Conclusion|| |
Facilities of campus guest houses and residential quarters for hospital staff and support from nongovernmental organization are essential for continuing cancer care services during pandemics in a lockdown scenario. The use of social media and tele-consultations are crucial to connect with patients and improve patient satisfaction. It is highly probable that, cancer patients with moderate-severe symptoms will present to hospitals despite an ongoing pandemic. However, large proportion of cancer patients in early stages with lesser symptoms will not present to hospital for the diagnosis and further treatment during a lockdown, and this will result in stage migration to higher stages once the lockdown is lifted. Furthermore, cancer hospitals should prepare for rising number of day care emergencies during a lockdown.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]