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How COVID-19 has redefined hospital practices for oncologists

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If cancer has not and will not stop for the pandemic, can oncologists stop, asks Dr Rakesh Reddy Boya, Senior Medical Oncologist, Mahatma Gandhi Cancer Hospital & Research Institute, Vizag. He reviews the changes oncologists made to hospital practices to deal with the pandemic, some in line with guidelines and some with logic and reason.

He also urges patients not to ignore any symptoms and not to delay speaking to a specialist if they suspect cancer. As the fear of visiting a hospital should not come in the way of cancer treatment, he suggests patients should use tele-consultation to reach out to doctors as he warns that early-stage cancer (stage 1 or 2) can progress to late-stage disease, becoming incurable, if prompt action is not taken.

The COVID-19 pandemic has claimed a lot of lives. It has not only redefined the way we live, but for us oncologists, it has also redefined the way we treat our patients with cancer.

Cancer patients are known to be at higher risk of infection and mortality from COVID-19 due to immune suppression caused by the cancer itself and also its treatment. Various treatment modalities, like say chemotherapy, are likely to decrease immunity of patients making them susceptible to getting infected and suffer from more severe forms of COVID. This created a sense of panic, both among patients and treating doctors.

Guidelines were issued by many international bodies (ASCO, ESMO, etc) which outlined how to go about cancer treatment during the COVID-19 pandemic.

What we oncologists found was that the actual scenario at ground level was much more different. A lot of cancer treatment got delayed. Not just palliative chemotherapy or supportive care, but curative treatment as well. In these cases, COVID-19 may or may not have killed the patient, but cancer has certainly done so. Without timely initiation of treatment most cancers are fatal. Some like leukaemias and aggressive lymphomas are fatal within months. These are the conditions which otherwise have high cure rates with proper treatment.

The reasons for poor outcomes in cancer patients in the COVID-19 situation are manifold. Patients were unable to find transport to reach a specialised cancer center (which in India, tend to be centered in few urban locations) due to lockdown.

Diagnostics and drugs have gotten delayed because of transport and logistics issues. Patients faced huge financial burden due to loss of revenue during the lockdown, which had an impact on ability to bear treatment cost. These are some of the factors which have restricted oncologists from delivering cancer treatment to patients.

The situation in the hospital itself is far from conducive to do the work that we oncologists are accustomed to do. We made several changes to hospital practices to deal with the pandemic, some in line with guidelines and some with logic and reason.

We asked follow-up patients who have completed treatment to connect through online consultations. We advised change of chemotherapy protocols to regimens with less potential for bone marrow suppression to preserve immunity of patients. We advocated for avoidance of elective surgeries and prolonged regimens of radiotherapy.

Treatment for cancers with high potential for cure were given the highest priority, though delivering care for leukemia became very difficult with drying up of blood banks. Despite that we managed to treat a good number of these patients and performed bone marrow transplants too.

The idea is to balance the risk of exposure to COVID-19 with the risk of progression of disease. Each case today must be looked at individualistically and we oncologists have to customise the treatment to suit the situation.

We urge patients not to ignore any symptoms and not to delay speaking to a specialist if they suspect cancer. The fear of visiting a hospital should not come in the way of cancer treatment. Patients should use tele-consultation to reach out to doctors. Early-stage cancer (stage 1 or 2) can progress to late-stage disease, becoming incurable, if prompt action is not taken.

COVID-19 is here to stay and both patients and doctors alike just have to get used to the new normal.  For both oncologists and patients alike the new normal requires taking extra precautions. These precautions include the basic ones like wearing personal protective equipment and maintaining adequate distancing between people.

Hospitals should prioritise creating a triage area to identify patients with features of COVID-19 before they enter into the main hospital area and creating teams among hospital staff to work in shifts (say, weekly).

Lastly, despite the precautions, infection among health care workers is rampant and oncologists are not left untouched in this regard. Taking care of one’s own health has somehow taken a backseat in caring for the patients. Taking back infection to vulnerable people at home, elderly with comorbid conditions, very young children etc has been a source of great stress apart from the fear of contracting the disease oneself.

As oncologists we are used to dealing with tough situations, but the COVID-19 pandemic has added so many additional challenges. Despite the extremely difficult and trying circumstances that prevail, oncologists should make their health a priority, and also focus on mental health. The right kind of mental health support can help build resilience, giving us doctors the ability and confidence to manage the stress created by the COVID-19 pandemic.

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