By Dr Bhawna Sirohi, MBBS, FRCP, Director, Medical Oncology, Max Healthcare, National Capital Region, India.

In these exceptional times every cancer patient is stressed and anxious and has one question on their minds – will my treatment be compromised by COVID-19? The sad reality is that COVID-19 is already impacting cancer diagnostics and treatment.

As doctors we have to balance risks versus benefits on a daily basis. Right now, for many of our patients, given the risks associated with the infection in the immune-compromised, those with co-morbidities and with advanced age, it would be sensible in the short-term to delay any treatments that will compromise the immune system further. 

Given that none of us knows how long the risks from COVID -19 are going to last, I am going to discuss some practical considerations here that we need to be doing in the short term.

For cancer patients undergoing active treatment there are numerous issues that need to be addressed individually with a shared decision-making model between the patient, family and the oncologist.

Do’s for all patients

• 1. Have a detailed discussion on the phone with your oncologist about the risks versus the benefits of ongoing treatment as this has to be tailored for every patient.
• 2. Transmission occurs typically if there is sustained exposure to the virus and there is lack of personal protection/ hand hygiene. Hand hygiene must be followed rigorously by you and your caregiver. Hand washing should be done for 20 seconds. Gloves or sanitiser are NOT a substitute for hand washing. If using a sanitiser, use one with at least 60% alcohol.
• 3. Can any hospital visits be deferred; can any procedures be carried out at home?
• 4. If you have to go to the hospital, do not take more than one caregiver with you.
• 5. Fever, dry cough, fatigue and muscle aches are signs of COVID-19 infection but are also normal side effects of some cancer treatments. If you have these, talk to your oncologist before going to the hospital.
• 6. Once wider COVID-19 testing is available - if it is possible to get the test done at home, consider this rather than going to the hospital.
• 7. The early evidence  indicates that cancer patients have a higher risk of contacting COVID-19 than others, so practice social distancing, hand hygiene and wear protective clothing if you do have to attend hospital. Once you come back home, have a shower and have the clothes cleaned separately.

Do’s for hospitals and cancer specialists

• 1.As doctors we need to be counselling and talking to patients about the impact of what changes to treatments mean for them as an individual in the short term. We cannot measure what impact these decisions will have on mid and long-term outcomes.
• 2. We have no formal clinical or ethical guidelines here, so we have to proactively practice pragmatic, exceptional medicine. Ask yourself the following questions:
  a. Is it possible to avoid radiotherapy or chemotherapy, especially in solid tumours where the benefit is small?
  b. If needed, can treatment be delayed?
  c. If needed now, can we shorten the duration of treatment or even consider oral or long-spaced out interval treatment? Maintenance chemotherapy can be interrupted for a short duration based on each individual’s risk factors.
  d. It would also be wise to delay bone marrow transplants and consider an alternate strategy as these are usually done in remission.
  e. Given that governments globally are trying to deal with the shortage of ventilators we must ask ourselves are we justified in continuing with complex cancer surgery which require admission to critical care units for prolonged periods of time?
• 3. Be aware that social distancing will have a negative impact on the mental health of our patients as they will have lesser contact with friends, family and support groups. Consider doing support group meetings via platforms like Zoom if possible. We have already started this.
• 4. Virtual consults by telephone or video calls are likely the norm for the next few months to minimise hospital visits. Routine follow-ups should be postponed till we know more.
• 5. Patients on oral medicines need their doses replenished with longer prescriptions of 3-4 months. Face to face consults will still be necessary for those without smart phones or wifi. Subsequent monthly reviews can be done over the telephone.
• 6. We need to consider having conversations about a good death with dignity and quality of life with all of our patients (not just those in Stage IV). Ventilated patients may be unable to speak. ‘Do not resuscitate’ orders which are legal in most western countries are not legal in India, so it is all the more important that patient wishes are documented clearly in their own words. It is critical to communicate that ‘Do not resuscitate’ does not mean do not treat.
• 7. Discuss if it is required to test potential donors for COVID-19 though we know there is no blood transmission.
• 8. Stop all routine cancer screening for the next 3-4 months or longer.

For the doctor’s personal protection

• 1. The psychological impact of all this on us as oncologists is also going to be immense. We are all in uncharted territory here. Our patients many times become our family and friends. The bond is often life-long and unique. We are the privileged few to experience this but this is going to add to the toll on us and we need to look after each other.
• 2. Protect your family (leave shoes outside the house, disinfect the car everyday while going and coming, leave wallets, phone cases in car, hand washing at every step of the way, dispose of clothes separately). This has to become part of our daily routine for the next few months or maybe longer.
• 3. Wearing of protective masks, gloves, gowns, disinfecting all surfaces, hand hygiene after each and every patient, social distancing are to be practiced routinely. 
• 4. Every day brings on a new restriction. No meetings, no handshakes, no conferences, no domestic or international travel, no travel across borders – this must be respected.

It is quite possible that we may end up under treating a few patients which may compromise cancer outcomes in the long run, but this must be weighed against the clear threat from the COVID-19 which may also increase deaths short-term. To try and improve 5 or 10 year survival outcomes marginally and to ignore the real risk of dying now due to COVID-19 is impractical.

This is upsetting for all of us but we have to make the best of the unique situation we are currently in and make exception-based medicine our guide rather than be hamstrung by evidence-based medicine.

Let us exercise self control, be smart and practical and stay safe!

References: Liang et al, Lancet oncology 2020; 21: 3 : 335-37