A young woman in her forties was recently brought to my OPD on a wheelchair. Depressed and dim she was gazing at me thoughtfully; perhaps with an amplified hope that she would pull through the ailment she was suffering from.
On asking why she was on a wheelchair, the five attendants holding her wheelchair with their eyes brimmed with tears, said in one voice: "Doctor please do something, she cannot stand or walk as there is no power in her legs for last 20 days. We could not bring her here (SKIMS) because of lockdown and Coronovirus threat".
While taking history of her illness, it became clear that the patient had noticed a small lump in her breast in the last week of February this year. It was the Covid scare which deterred the family to get the patient examined in a hospital till June 15.
After examining and going through the investigations, I found the patent had cancer of Breast stage IV. If she could have got diagnosed in the month of February in stage 1, chances of cure were more than 90 percent. Now she has thrown "metastasis" to spine because of which she has lost power and will never be able to walk or even stand of her own. The chances of cure are now less than 50 percent.
There would be hundreds of cases like this where disease might have progressed and the attendants in view of the coronavirus threat would have hesitated to consult a doctor.
The rapid drop in cancer diagnosis amid COVID-19 pandemic is a huge cause for concern. There are hundreds of cancer patients who did not undergo treatment or test or follow up screening as a direct consequence of the disruption due to corona virus in the last three months. The drop in the attendance of patients can be justified by the fact that in March last year 361 cancer patients were registered at cancer centre of SKIMS while as in March this year only 198 patients got registered. Similarly in the month of May last year 418 patients were registered and this year in May only 230 patients got registered.
Though the cancer Centre at SKIMS was running smoothly with adequate availability of faculty, resident and other para medical staff, panic and threat of coronavirus infection coupled with lockdown stopped patients from going to hospitals. This all resulted in major delay in the diagnosis and treatment of cancer patients.
The unprecedented burden of covid-19 on health systems worldwide has devastating implications for cancer care. Firstly, patients with cancer remain more vulnerable to worse outcomes from the infection. Secondly, diagnosis get delayed as the diagnosis services have been reduced or suspended in many countries. In Jammu and Kashmir the same happened which made attendants scary of getting exposed to the risk of COVID hence were reluctant in getting their patient to the hospital health care services. Thirdly, treatment pathways were altered or reduced to minimize the potential exposure of the cancer patients with the infection during surgery, chemotherapy and or radiotherapy.
The referral of patients with cancer by primary care physicians had reduced by over 70 percent in April-May in many countries of the world. At our center in SKIMS, the referral, from districts and other private institutions, reduced by more than 80 percent in April–May. It is worth to mention here that department of Radiation Oncology in particular and other departments managing cancer patients in general continued their services undisrupted throughout the pandemic lockdown.
More than 100 patients were receiving radiation therapy at SKIMS daily during lockdown period. Radiotherapy has always had a major role in cancer both as a curative and as a palliative therapy. This role has expanded with COVID-19, as radiation therapy was used to replace or to delay other treatment modalities with higher infection risk like surgery, chemotherapy. Since follow up is very important for cancer patients after treatment is over, in order to detect early recurrence, progression of disease or complications. There was reduction in the number of follow up patients by more than 90 percent in the month of April-May. Though during this period, radiation oncology department provided telephonic consultation to patients, but in actual conversation and examination is more accurate and essential.
There will be a growing backlog of delayed diagnosis as patients with advanced disease will rush to hospitals as the lockdown will goes. Unfortunately, it seems, coronavirus will not leave us soon. The UK Coronavirus Cancer Monitoring Project found that patients, who were treated with chemotherapy, immunotherapy, targeted therapy, hormonal therapy and/or radiation therapy had no significant effect on morbidity /mortality in COVID 19 positive patients.
I am of the opinion that withholding effective treatment for a cancer patient because of pandemic fear, leads to real risk of increasing cancer morbidity and mortality; perhaps much more than COVID-19 itself. We should not forget that early detection, early referral and early treatment can cure a cancer patient. In conclusion, I think awareness is needed so that patients would come forward for treatment without any fear of getting coronavirus infection. Covid can be prevented by following the instructions and guidelines, which come from time to time, but progression of cancer cannot be.
Dr. Nazir Ahmad Khan is Professor, Department of Radiation Oncology, SKIMS Srinagar