Dr Kirti Bushan
As is implied in the name COVID-19, ‘CO’ stands for ‘corona,’ ‘VI’ for ‘virus,’ and ‘D’ for disease, and 19 represents the year of its occurrence. Coronavirus or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a single stranded RNA virus, first emerged in Wuhan, Hubei province, China in December 2019 and rapidly circled the globe.
It has posed enormous health, economic, environmental and social challenges to the entire human population. Till now there is no report of any clinically approved antiviral drugs or vaccines effective against COVID-19.
COVID CHALLENGES TO CANCER CARE
The Covid-19 lethality combined with lockdown has scrambled health care delivery in cancer centres. Firstly it has led to disruption of routine clinical practice by shutting down out patient departments and operation theatres when a patient or staff tested positive. Secondly ,it has created fear in health workers that they may contract infection themselves and pass it on to loved ones and family members. Thirdly our lacunas in health system got exposed – lack of adequate infrastructure, human resources and serious supply-chain disruptions. Fourthly rapidly changing guidelines has created confusion and and at times resulted in patient care and safety being compromised.
Deferring timely treatment during lockdown has moved a lot of patients from the curative to palliative stage . Cancer in India is also a socioeconomic challenge. Scare to travel plus increased out-of-pocket expense related to accommodation, food, medicines during lockdowns has compromised their access to treatment in quality institutions. Both these scenarios may adversely affect long-term survivals and possibly lead to worse outcomes. Moreover backlog will result in post lockdown overburden on cancer institutions and patients seeking financial assistance will be more due to loss of livelihood.
SOLUTION – MULTIPRONGED APPROACH
Although a pandemic leads to disruptions in every aspect of life, it doesn’t necessarily mean that treatment of other diseases like cancer has to come to a standstill. We as Indians need not press pessimistic button because recovery rates are better inspite of increased infection rates . We are better understanding and adapting to current circumstances. Our last 6 months experiences have shown that by setting patient and treatment friendly guidelines, standard hospital protocols , various preemptive measures and implementing technological solutions to overcome conventional challenges, good outcome can be achieved in treatment of cancer patients. Understanding clinical spectrum of covid infection, identifying high risk cancer group, providing basic health education, treatment prioritisation and minimisation of hospital exposure by hospital administrative and treatment related modifications by treating physicians are keys to success.
CLINICAL SPECTRUM
This virus is highly infectious and can be transmitted through coughing, sneezing, respiratory droplets or aerosols. These aerosols enter the respiratory system during inhalation via nose or mouth. The clinical spectrum ranges from asymptomatic carriers to symptomatic (80%) with mild symptoms and signs of acute respiratory illness such as fever, cough, fatigue, shortness of breath, to severe disease (15%) like pneumonia and 5% progress to respiratory failure and septic shock requiring intensive care.
IDENTIFYING HIGH RISK CANCER PATIENTS
Available data indicate that active cancer patients with old age or with underlying comorbidities such as chronic respiratory, cardio-vascular or chronic kidney or liver disease, diabetes, are more vulnerable. Patients at risk are those receiving chemotherapy, or who have received chemotherapy in the last 3 months , people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppressive drugs
CANCER PATIENT CATEGORISATION AND PRIORITISATION
In order to minimise hospital burden and exposure to cancer patients , ESMO divided cancer patients in 3 categories – high, medium and low priority group . High priority patients are active cancer patients with early disease and high chance of cure requiring surgery, chemotherapy or radiotherapy. It also includes patients with acute life threatening emergencies. Medium priority patient’s situation is non-critical but delay beyond 6 weeks could potentially impact overall outcome . Low priority patient’s condition is stable enough that services can be delayed for the duration of the COVID-19 pandemic and/or the intervention is non-priority based on the magnitude of benefit. Thus patients with potentially curable disease who could substantially benefit from treatment are given high priority for hospital admissions as compared to patients who were being treated with palliative intent or for those expected to have marginal benefit.
BASIC HEALTH EDUCATION
It is mandatory to provide basic health education to all cancer patients regarding precautions to be taken in this covid era. To minimise risk of contracting disease , they must adher to “SMS formula”- S for social distancing, M for masks and S for sanitisation. Avoiding crowded places and maintain social distance of at least 1 meter (3 feet) from people who have issues of cough or are sneezing. They must wear PPE or N95 mask, cap, glouse and face shield during hospital visits. Hand wash by soap water or by sanitisers containing atleast 60% alcohol or soap water frequently for at least 20 seconds thoroughly is warranted. Use your non-dominant hand while accessing the doorknobs and handles in hospitals , as these are frequently touched by many people. One must avoid touching own eyes, nose, and mouth during stay in hospital. There should be no contact with friends and relatives with COVID-19 symptoms or living in endemic zones. Remember to sanitise each time one touch a surface as Covid 19 strain can stay on surfaces for a few hours to days. It is better to disinfect your belongings as they are frequently touched, such as phones, car keys, pen etc .one must practice respiratory hygiene while coughing or sneezing. if you have fever, cough, and difficulty breathing, please seek medical advice early without any hesitation.
HOSPITAL MEASURES
All cancer patients at the time of admission in hospital need to have report of high resolution CT scan of chest ( not more than 48hrs duration, otherwise repeat) and negative SARS CoV-2 RNA detection by RT-PCR (not more than 5 days duration otherwise repeat).The hospital administration must completely segregate covid and non covid patients in hospital by providing separate pathways , beds and attending staff to minimise risk. In order to regulate access to the cancer hospitals and departments inside , establish checkpoint areas for screening and early detection of potentially infectious persons. Clinical staff responsible for the checkpoint area should be trained and wear PPE. Social distancing markers on the floors, walls and furniture to help everyone maintain 6 feet of distance. Make it sure policy of “SMS formula” is adhered to by patients. There should be frequent cleaning of high-touch surfaces like elevator buttons, chairs, clinic rooms and restrooms. A limited visitor policy is mandatory and alternate options like video call or phone call to connect with loved patients must be promoted. Outpatient visits for cancer patients should be reduced to the safest and most feasible level without jeopardising patient care by avoiding unnecessary meetings.
TREATMENT MODIFICATIONS
There is enough evidence to suggest that that all supra major surgeries can be done safely and outcome depends on proper patient selection, proper planning and availability of all tools required. Minimising and rotating OT staff and limiting daily routine surgeries has benefitted. We have been doing routine cancer surgeries in our institution even during peak time and our results have encouraged us to continue thanks to strict protocols and patient cooperation.
Current evidence supports that without compromising oncological principles, chemotherapy regimens can be adapted in many cases to minimise treatment duration and hospital visits. Some of the measures include switching from intravenous (i.v.) to oral therapy; preferring i.v. regimens with shorter duration and long intervals, conservative doses to avoid immunosuppression and monitoring at home with blood tests by local labs or home visits. Also prefer telephonic or web-technology contacts for consultation and prescription renewal.
The radiation treatment can be given with emphasis to shorten duration wherever feasible. Discuss shorter/accelerated or hypo-fractionated radiation schemes with radiation oncologists. In patients with suspected or confirmed SARS-CoV-2 infection radiotherapy can be either withheld, or continue as long as their disease is mild and the radiation facility has measures in place that prevent potential spread to other patients and staff. On the other hand, in cases with significant viral symptoms, treatment should be halted and resumed only after patient recovery
TIPS FOR CANCER PATIENTS TO FIGHT COVID
1. SET YOUR GOALS – make a proper routine and set your short term goals on daily basis and achieve them . this will keep you busy. Focus on a new habit like writing or learning music or cooking. It helps in preventing the mind from going astray.
2. DON’T SKIP ON EXERCISE – Regular, moderate excercises for atleast 30 to 45 minutes per day depending on stamina is advised .It helps improve metabolism which improves immunity and also releases chemicals called endorphins which elevate mood and improve mental health. There are several You tube channels and apps to help you exercise at home. Physical activity does not always mean a particular set of exercises for a defined duration. We should indulge in any activity which keeps us sharp and at the same time not lead to too much of exertion
3. STAY HYDRATED – Drink up to 8-10 glasses of water every day, to stay hydrated. Hydration will help flush out the toxins from the body and lower the chances of flu. Other alternatives include juices made of citrus fruits and coconut water, to beat the heat.
4. DESTRESS YOURSELF – prolonged period of staying indoors has its adverse effect on on your mental wellbeing and immunity. One must practice meditation and yoga, one must avoid smoking, alcohol and other addictive substances. We must avoid overload of information on covid virus through whats up videos, you tubes and other means of social connectedness which create negativity.
5. BOOST YOUR IMMUNE SYSTEM BY PROPER DIET – The better option is to focus on coronavirus prevention. Boost your immune system with a low carb and protein rich diet with regular consumption of green vegetables (broccoli, spinach) , mushrooms, tomatoes; fruits rich in beta carotene, ascorbic acid, magnesium, minerals ; & other essential vitamins like vitamin B12 with methylcobalamin, Vitamin C, D and E. Supplements to boost your immune system include zinc, elderberry, turmeric, garlic, ginger, gooseberries(amla), omega 3 and 6 fatty acids, herbs like basil leaves and black cumin.
6. DON’T COMPROMISE ON SLEEP – Good snooze time for 7-8 hours is the best way to help your body build immunity; lesser sleep will leave you tired and impair your brain activity. The lack of sleep will prevent the body from resting and this will impair other bodily functions that will have a direct impact on your immunity.
7. TRAVELLING- Avoid all kinds of non-essential travels. Most Covid 19 positive cases are imported cases, which later spread to the communities.
Apart from maintaining a healthy lifestyle and taking supplements, the Indian health ministry is also suggesting few organic and natural ways to practise as preventive measures to fight COVID-19. The Ministry of AYUSH has recommended the following self-care guidelines as preventive measures and to boost immunity with special reference to respiratory health.
* Drink warm water throughout the day.
* Practice Meditation, Yogasana, and Pranayama.
* Increase the intake of Turmeric, Cumin, Coriander and garlic.
* Drink herbal tea or decoction of Holy basil, Cinnamon, Black pepper, Dry Ginger and Raisin.
* Avoid sugar and replace it with jaggery if needed.
* Apply Ghee (clarified butter), Sesame oil, or Coconut oil in both the nostrils to keep the nostrils clean.
* Inhale steam with Mint leaves and Caraway seeds.
While the battle against the Covid-19 pandemic is fought by our health care workers, we can do our bit by limiting our exposure to the virus by staying indoors, social distancing, eating healthy, hydrating and following basic hygiene protocol. Cancer hospitals need to continue to provide cancer care while also managing patients with cancer and COVID-19 so that adverse cancer outcomes due to denied or delayed cancer care do not become a bigger problem than pandemic-related morbidity and mortality.Top of Form
(The author is Consultant Surgical Oncologist Lilawati, Nanavati, Raheja Fortis , Global, Sushrut and Asian Cancer Institute Mumbai)
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