Caring for cancer and chronic diseases during a pandemic

Suman Devi, a pancreatic cancer patient, waited on the footpath outside the All India Institute of Medical Sciences as her husband queued up for charity food nearby. Devi’s ongoing treatment at the Delhi hospital brought them here from small town Bareilley in Uttar Pradesh but a nationwide lockdown on 25 March 2020 hindered their travel back home.

Devi is among hundreds of other critically ill patients who spent days living on the footpath waiting for their turn for treatment and food before being shifted to quarantine facilities. Getting an appointment with doctors for most of these patients has been difficult as healthcare professionals get diverted to COVID-19 wards.

Kenyan national Agnes Kiminza suffering from breast cancer has been stuck in Bengaluru for days after her last radiation therapy ended. She and many others from her country – regular visitors to private hospitals in India for treatment – are living in inexpensive hotels with skeletal facilities, waiting for air travel restrictions to lift so that they can go back home.

As the COVID-19 pandemic begins to put more pressure on healthcare facilities in India, uncertainty grips people suffering from other critical illnesses — cancer, diabetes, chronic lung and kidney diseases, liver disease, cardiovascular diseases, morbid obesity, HIV and high blood pressure. Their anxiety is compounded by the fact that these diseases make them more vulnerable to the novel coronavirus infection than healthy people.

A study from Wuhan in China shows that cancer patients, with compromised immunity, are at greater risks of viral infection than ones without cancer¹. Elderly with cancer are also more likely to end up in ventilators or die due to the viral infection². For India, where, 1.45 million new cancer cases are reported every year³, this is a matter of concern.

The official number of people infected in India with the novel coronavirus had gone past 20,000 in the third week of April 2020. Three cancer patients at the Delhi State Cancer Institute Hospital were recently found to be carrying the virus, contracting it from infected healthcare workers.

"Just because a lot of resources are being put into COVID-19, we don’t want a rebound of other diseases – we need to be extra cautious about that," says Anant bhan, a visiting professor in the Department of Community Medicine, Yenepoya Medical College, Mangaluru. "Of course, we need to ensure that we are adequately resourcing for a COVID-19 response but not at the cost of basic services at a minimum quality level."

Crisis time cancer care

Oncologists are struggling to protect and treat cancer patients amidst the pandemic. Manju Sengar, an oncologist from the Tata Memorial Centre in Mumbai says home care givers need to be educated on how to control the spread of COVID-19 with basic hand hygiene, physical distancing and cough etiquette. “Cancer patients should be screened for COVID-19 symptoms such as fever, sore throat, cough and difficulty in breathing,” she said in a National Cancer Grid Initiative webinar recently.

Sengar says oncologists should delay extensive surgeries. Instead, they could prioritise surgeries for rapidly proliferating and life-threatening brain tumours. Decisions on chemotherapy should also be taken cautiously. “It is better to switch to oral anticancer drugs,” Sengar points out. Steroid use should be limited and doctors should try to manage patients using a single anticancer agent or fewer drugs, she says.

A set of guidelines⁴ for managing cancer patients drawn up by international researchers suggests that oncologists could postpone, discontinue or modify radiation therapy. Some patients may be given the option of home infusion of chemotherapy to minimise the risks of infection. Stem cell therapy for cancer patients can be reasonably delayed during the COVID-19 crisis, the researchrs say.

“Certain cancers, such as acute leukemia, could be life threatening, if not treated early,” says Kolkata-based haemato-oncologist Prantar Chakrabarti. “If the patient is young, has a chance of getting cured and does not have significant comorbidities, we administer chemotherapy – that’s the standard protocol Indian hematologists are using,” he says. All such patients are screened for COVID 19 before therapy. Those with low grade malignancies are being requested not to visit the hospitals and avail home or day care based treatments as much as possible.

For people with less aggressive cancer, physial distancing is the way out. “Such cancer patients should avoid overcrowded facilities at a hospital and seek medical advice remotely using mobile phones,” Sengar says.

However, patients are also concerned about what would happen if they stop, delay or switch cancer treatment. “Many of them are asking for tele-consultations, but that is not practically possible,” says Abhishek Shankar, an oncologist from the Lady Hardinge Medical College in New Delhi. Consultations, he points out, are based on tests to assess their condition and progress of the disease, chemotherapy and radiotherapy, every week, especially for aggressive types of cancer.

The novel coronavirus can survive outside the human body⁵ in aerosols and surfaces for limited time. This raises the possibility that people, including cancer patients, may acquire the virus by touching contaminated surfaces. According to WHO, besides basic hand hygiene, cancer care providers should wear clean sterile, protective personal equipment. They should follow safe waste disposal procedures and sterilisation of equipment. There should be separate rooms for admitting suspected COVID-19 cancer patients or keep at least one meter distance between beds in an isolation ward, the guidelines say.

Diabetics and Covid-19

Diabetes has emerged as one of major risk factors responsible for increased mortality due to COVID-19. In India, often called the world’s diabetes capital, the lockdown has meant less exercise, increased snacking and decreased availability of glucose-lowering drugs for patients. These factors may shoot up blood glucose and blood pressure.

“To make up for the lack of exercise, I walk in a long corridor or rooftop of my house,” says Sudip De Sarkar, a 68-year-old diabetic patient from Kolkata. “I avoid snacking, carefully choose a non-diabetic diet, monitor my blood glucose levels using a sugar-testing machine and send the data to my physician through WhatsApp,” he adds.

During lockdown, telemedicine may prove useful for the management of patients with chronic diseases such as diabetes, a study in India says. Diabetics could connect with the physicians through messaging apps or video calls on chat platforms, the study suggests6.

“More than 90% of people living with diabetes in India suffer from type-2 diabetes (T2DM), which is primarily a lifestyle disorder,” says Satinath Mukhopadhyay, a diabetologist from the Institute of Post Graduate Medical Education and Research in Kolkata. T2DM is all about self-management and self-care, and telemedicine may be effective, he says.

“Besides training patients how to self-monitor blood glucose, telemedicine can be used to train them to recognise and treat glucose-lowering episodes on their own,” says Deep Dutta, a diabetologist from the Seth Sukhlal Karnani Memorial Hospital in Kolkata.

A person with type-1 diabetes may develop diabetic ketoacidosis, a life-threatening problem when the body starts breaking down fat at a rate that is much too fast with the liver making a huge amount of blood sugar. “Telemedicine is not suitable for such patients because they need hospital care, adequate intravenous hydration and modulation of insulin therapy,” Dutta adds. Telemedicine is also difficult for the elderly or uneducated without technical skills.

The critically ill

Patients suffering from asthma, cardiovascular diseases and HIV are also highly vulnerable to COVID-19 infection. People with moderate to severe asthma may be at higher risk of getting very sick from COVID-19 since it can affect the respiratory tract (nose, throat, lungs), cause an asthma attack, and possibly lead to pneumonia and acute respiratory disease.

Analysis shows that people with chronic obstructive pulmonary disease (COPD) are associated with a significant, over five-fold higher risk of severe COVID-19 infection⁷.

Like other viral illnesses such as the flu, COVID-19 can make it harder for heart to work. Persistent immune activation in predisposed patients, such as the elderly and those with cardiovascular risk, can lead to secretion of specific immune molecules, leading to multi-organ failure. Inflammation, particularly in the muscular layer of the heart, can result in myocarditis, heart failure, cardiac arrhythmias, acute coronary syndrome and sudden death⁸.

HIV patients with a low count of CD4 cells, a type of white blood cells which trigger immune response, are at a higher risk of getting very sick from COVID-19. Patients receiving standard anti‐HIV drug might not have increased risk for COVID‐19⁹.

The bottom line is that we are all at risk, says Shankar. “To suppress and control the epidemic, we must isolate, test, treat and trace. If this is not adopted, transmission chains can continue at a low level and then resurface once the lockdown period is over,” he adds.

[Nature India's latest coverage on the novel coronavirus and COVID-19 pandemic here . More updates on the global crisis here .]

References

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2. Liang, W. et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet. Oncol.(2020)Doi:10.1016/S1470-2045(20)30096-6

3. Sengar, M. et al. Medical oncology in India: workload, infrastructure, and delivery of care. Indian. J. Med. Paediatr. Oncol.40, 121-127 (2019)

4. Shankar, A. et al. Cancer care delivery challenges amidst coronavirus disease – 19 (COVID-19) outbreak: specific precautions for cancer patients and cancer care providers to prevent spread. Asian. Pac. J. Cancer. Prev. 21, 569-573 (2020)

5. Doremalen, N. et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N. Engl. J. Med.382,1564-1567(2020)

6. Ghosh, A. et al. Telemedicine for diabetes care in India during COVID19 pandemic and national lockdown period: guidelines for physicians. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 14, 273-276 (2020)

7. Lippi, G. et al. Chronic obstructive pulmonary disease is associated with severe coronavirus disease 2019 (COVID-19) Respir. Med. (2020)Doi:10.1061/j.rmed.2020.105941

8. Liu, P. P. et al. The science underlying COVID-19: implications for the cardiovascular system. Circulation. (2020)Doi:10.1161/CIRCULATIONAHA.120.047549

9. Joob, B. et al. SARS-CoV-2 and HIV. J. Med. Virol. (2020)Doi:10.1002/jmv.25782

10. Wang, M. et al. International expansion of a novel SARS-CoV-2 mutant. J. Virol.(2020)Doi: 10.1128/JVI.00567-20