Decision making in Cancer Care amidst the COVID-19 Pandemic

A blog from Dr Abhishek Shankar, a front-line oncologist in Delhi.

I have been a practicing oncologist in India since 2009 and have faced many adverse situations along the way. I have been fortunate to be supported and mentored by my teachers, senior and junior colleagues who have helped me find solutions to most of the daily problems we face on the cancer ward. In India, like in most developing nations, cancer is still a dreaded mortal disease. What keeps us going are our small victories which inspire us to continue making positive, incremental strides in cancer care in India. I cannot deny though that there have been several times where I have cried for my patients.

However, nothing I have previously experienced has prepared us for what has happened since the first case of COVID-19 detected in Wuhan, China in December, 2019. The disease has now reached 196 countries and is conservatively estimated to have infected more than eight hundred thousand people with an associated death toll of more than forty-two thousand patients (as of 1 April 2020). The virus has heavily burdened the health system in all the affected countries with normal service just not possible. Where this leaves the already sick and vulnerable is a cost we are just starting to count.

In my practice we are fighting a new type of war, with new battle fronts opening up every day. We have never washed our hands or poured sanitizers on like this before. We are scared of each other, maintaining a distance of at least 1 meter and calling it social distancing. We cannot relax as no one knows what will happen in the next few days, months or year. It’s scary and it’s surreal for us oncologists, and of course it’s even worse for many of our patients.

My cancer patients are in a confused state of mind with apprehensions related to diagnosis, treatment and follow up. The already high levels of cancer related anxiety and distress have been further aggravated by a situation where clinicians do not know what are the best choices to make for their patients. The choices we have are bleak, potentially expose our vulnerable patients to the disease or expose them to the risk of disease recurrence, progression to higher stage or loss of life due to inability to access the system.

Many of our patients who have recently been diagnosed with cancer or who have symptoms of cancer and are waiting a diagnosis, are stuck in limbo inside their houses because of the lock down imposed by the government to prevent community transmission.

One such patient in limbo was diagnosed with stage 3 breast cancer the same day the government announced the lockdown (Janta Curfew). Her biopsy samples were unable to be processed and she is desperate for information on when treatment can begin. She is naturally fearful that her disease will progress but as her oncologist I can offer little in the way of concrete reassurance because I do not know when I can get her results. For my patient her normal coping mechanisms such as seeing friends, accessing the countryside or walking to deal with stress are also not available.

I have another patient who is on dialysis and has other co-morbidities and is suspected to have breast cancer. The PET-CT showed wide spread dissemination of disease and I had requested a biopsy to plan treatment. However, with the evidence clear that elderly people with co-morbidities are most at risk from severe respiratory disease, as a clinician I am unclear about the next line of management to be adopted. We need guidelines. Quickly.
As an oncologist I have faced helplessness before, but not on this scale. Even when the pandemic is over, the scars left by the decision to ‘treat or not to treat’ will be left on us psychologically and on the bodies of our patients.

Oncologists must come together now to think critically and prepare guidelines for dealing with cancer patients during the time of health emergencies and how to manage cancers in elderly patients as they are more prone to adverse outcomes.

According to the American Society of Clinical Oncology (ASCO), “To date, there is no supporting evidence to delay, withhold, or change chemotherapy, target therapy or immunotherapy in cancer patients. Therefore, routinely withholding critical anticancer or immunosuppressive therapy is not recommended.”

ASCO recommends that oncologists must make treatment decisions by considering each individual as well other factors like cancer stage, chemotherapy type and the risk of cancer recurrence, if treatment is delayed or changed.

But patients are understandably nervous. It is a very difficult decision for both patients and oncologists to continue immunosuppressive cancer treatment during the COVID-19 outbreak. Patients are asking, “what will happen to me and my disease, if I stop, delay or switch my cancer treatment? What might happen to me if I don’t?”

Furthermore, we have no clarity about a positive COVID-19 diagnosis and decision making regarding anticancer treatment. Can anticancer treatment be delivered during quarantine or should patients wait until they’ve recovered to resume chemotherapy? The answer is yet unclear.

In India, all patients planned for anticancer treatment must be tested for COVID-19 irrespective of symptoms or contact history before compromising their immune system. This is eminently sensible, but testing kits are not readily available.

Apart from treating the disease, doctors are also fighting the myths and misinformation spreading through digital and print media to cancer patients. No one is immune from this misinformation.

A good friend, the author, actress and cancer survivor Manisha Koirala, called me in a state of anxiety after reading misleading messages on WhatsApp. The spread of incorrect information is causing trauma and distress in vulnerable populations and adding to the heavy psychological burden of this disease for those who can least afford it. The WHO are the definitive source of information on the disease and I would urge everyone to use their resources.

We will have to adopt WHO recommended isolate, test, treat and trace strategy. If this is not adopted, transmission chains can continue at a low level and then resurface once physical distancing measures are lifted, which will be the worst outcome for all.

Abhishek Shankar, MD is an Assistant Professor in the Department of Radiation Oncology at Lady Hardinge Medical College & SSK Hospital, Delhi, India. He has worked at All India Institute of Medical Sciences, Delhi from 2012-2019 in different capacities i.e. Resident, Research Fellow, and Faculty. He is a NCI Cancer Prevention Fellow and recipient of many National and International awards. He is a Member and Chair of many National and International Committees. His areas of clinical and research interests include community based cancer prevention, quality of life issues in cancer patients, cancer screening, global oncology, cancer policy, cancer management in resource-limited settings, tobacco control and smoking cessation, and familial and high risk cancers.