Dr. Suneel Mattoo
SARS CoV-2 has taken a toll on the whole world with more than 19 lakh active cases in India and 11,000 active cases in our J&K alone. The rising burden of screening, patient management, quarantine and vaccination coupled with a shortage of health care staff and doctors has led to a state of crisis at many places. Many major hospitals have turned into Covid centers and this has affected the patients suffering other diseases in various ways. While some have not been able to turn to health centers and hospitals timely due to intermittent lockdowns, others have preferred to remain confined to their homes and suffer in silence due to fear factor.
People with new onset cancers or those on treatment are currently suffering a major “Covid blow” as cancers do not wait for the pandemic to be over. Many health care professionals have started to notice more advanced, neglected and difficult to treat cancers in their clinics and the same is expected to get reflected in future cancer registries. This silent effect of the pandemic is currently being overlooked and hence, one can imagine that the current mortality rate being reported due to direct effect of Covid is just tip of the iceberg.
Breast cancer is the leading cancer in Indian women. According to National Cancer Institute data, more than 13 lakh new breast cancer cases are being diagnosed every year. Every 4 minutes, one woman gets diagnosed with breast cancer and every 13 minutes, one woman dies of it in India. These alarming statistics call for newer strategies for breast cancer management during the pandemic.
Diagnosis of cancer is a high priority exercise. Any suspicious lesion must undergo biopsy to establish a diagnosis even during Covid era to prevent delayed diagnosis of an aggressive cancer. A non-cancerous lesion can then simply be followed.
Not all breast cancers deserve the same degree of priority during the pandemic. It is imperative and humane to treat such patients first who have large and advanced cancers, those which are bleeding or have a foul-smelling disease. Such patients should not be denied admission and urgent treatment must be provided at any cost as it can be potentially lethal for the patient. Those patients who have already been operated upon and present with a complication also deserve priority treatment as we are bound by laws of the state and ethics of the human society.On the other hand, surgery for low-risk cancers like ductal carcinoma in situ can definitely be deferred in a difficult situation without any potential negative outcome on patient’s life.
The treating physician should be aware and discuss alternative initial treatments like hormonal therapy and radiation therapy in low-risk breast cancers with his patients when the local cases of Covid-19 are overwhelming.
It would be prudent to mention here that the outcome of breast cancer depends largely on its biological characteristics. Patients with a risk of poorer outcome like triple negative breast cancer (TNBC), HER-2 positive disease, axillary node positive disease or those who have completed their chemotherapy need to be operated within 6-8 weeks as further delay could potentially lead to poorer outcomes.
There are two major modalities of breast cancer treatment- mastectomy and breast conservation surgery. Even during these times, breast conservation surgery can be performed, and mastectomy can be avoided. However, complex procedures with a major potential for complications should be avoided to reduce the duration of hospital stay. Breast reconstructions after mastectomy should similarly be delayed till the intensity of pandemic subsides.
Abbreviated schedules of radiotherapy may be employed by radiotherapists to decrease hospital visits which can reduce the burden on health care services and the chances of contracting the virus by a cancer-afflicted patient. In low-risk cancers, radiotherapy may even be avoided depending upon local scenario.
Patients of breast cancer need to come for many follow up visits. These can be curtailed to a great extent by arranging consultations via telemedicine. It is heartening to know that even our State has taken some baby initiatives in this regard and specialist consultations are available on just a phone call. Specialists from private sector should also be involved to provide care as it is the moral duty of one and all to fight in this war.
Unfortunately, there is poor awareness of health issues among the masses and hence, the onus of decision making in most cases in India lies with the physician. So, the physician can find himself in a really difficult situation at times due to lack of Indian data and guidelines, but principle of informed consent and beneficence must be followed even in the times of pandemic to save one’s face in this era of litigations.
Many international societies have published guidelines of management of breast cancers during these trying times and the time is ripe to form some locally adaptable guidelines suited to needs of Indian patients rather than imposing a blanket ban on all elective cases, which has been the scenario in most hospitals in India where Covid cases are rising fast. Not all people afford to visit major cancer centers and most of them are managed in medical college hospitals with local expertise. This calls upon the Government and health policy formulators to be more sensitive to their risk adapted needs and develop a policy to handle such issues during the pandemic so that none is left to die for want of the care they aptly deserve.
(The author is Consultant Breast and Endocrine Surgeon)
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