These are unprecedented times, we are living in with an outbreak of a novel coronavirus,
also known as severe acute respiratory syndrome coronavirus 2 (CoV-2), or CoV Disease
19 (COVID-19). By April 20th, as per the World Health Organization Data, COVID-19
as a pandemic has caused 2,407,414 cases, and 165,073 confirmed deaths in 213 different
countries worldwide.
Elderly patients and those with comorbid illnesses with COVID-19 infection have poor
outcomes. Cancer patients are immunosuppressed, and at an increased risk of COVID-19
infection and have worse outcomes as compared to the general population. The mortality
rate of COVID-19 among oncology patients is about 20%.[1] Young oncologists are guided by the national and international cancer societies
through guidelines that are adapted during this pandemic for the safety of patients
and physicians.[2],[3] Patients with active cancer therapy including chemotherapy, immunotherapy, radiotherapy,
and surgery are at a higher risk as compared to cancer survivors.[4] Patients are not only worried about disease courses due to the lack of transport,
inaccessibility to the hospital, and shortage of medications but also about the transmission
of the virus to their relatives, friends, and caregivers. It is a challenging situation,
as cancer patients are in a vulnerable situation, and physicians have to make difficult
decisions due to the uncertainty. The number of registered cases of COVID-19 in Italy
was 162,488 as of April 14th, the third highest globally behind the United States
and Spain, according to the data of Istituto Superiore di Sanità. As Italy's death
toll passed 18,279 on April 10th, the Italian government announced the lockdown to
be extended until early May. The deaths included more than 17,000 frontline health-care
workers, who were in this war against the Novel Corona Virus. The Italian health-care
system, known as Servizio Sanitario Nazionale, provided an immediate, efficient, and
effective solution to this crisis. It is increasing intensive care unit capacity and
recruiting doctors, nurses, and medical staff for the emergency CoV task force, which
included retired doctors, medical graduates, and residents. Embracing the Hippocratic
Oath, over 7000 retired doctors came to fight against this deadly virus. Standing
by and watching are impossible for those who face pain every day, even if they are
recent medical school graduates. They were all ready to go in the frontline fight
against COVID, where the need is greatest, learning daily, as this crisis is a new
experience even for specialists with 20 years of experience. Unfortunately, the number
of doctors who have died of COVID-19 infection reached 121 as on April 15, 2020, according
to the Italian doctors' federation Federazione Nazionale degli Ordini dei Medici Chirurghi
e Degli Odontoiatri. The reasons include a shortage of personal protective equipment
(PPE) and the lack of COVID-19 diagnostic kits.
The Italian Association of Medical Oncology (AIOM) with the boards of Academic Oncologists
(COMU) and Oncology Unit Director (CIPOMO) suggested recommendations on cancer care
during the COVID-19 crisis. The recommendations include delaying cancer treatments
based on clinical status, prognosis, and tumor characteristics and reducing follow-up
visits using online consultations to assess the patient's status. Many oncological
institutions in Italy offer online psychological counseling services, as patients
find it difficult to cope up during the lockdown and to reduce the patient visits
to the hospital. Teleconferencing is a gamechanger in healthcare as tablets and smartphones
connect patients with their loved ones. People of Italy had supported the health-care
workers and staff in the COVID-19 fight.
As on April 20, 2020, the number of COVID-19-positive patients in India was 17,357,
of which 13,938 were active, 2859 patients had recovered, and 560 had succumbed. The
trends of COVID-19 in India were different as compared to the developed world. The
reasons are still to be explored retrospectively. Several hypotheses include different
strains of COVID-19 in different countries, the presence of malaria as an endemic
disease, and universal Bacillus Calmette–Guérin vaccination in India. The Indian government
has chosen to lockdown the entire country from March 20th to prevent the spread. Cancer
care in India continued with great difficulty despite the lockdown affecting the transport.
Guidelines both in general and for specific cancers were published by cancer societies
in India such as Indian Society of Medical and Pediatric Oncology and Indian Cooperative
Oncology Network, for the efficient utilization of resources in these challenging
times and how to modulate practices balancing the risk–benefit ratio due to COVID
infection and cancer-directed therapy. The key takeaways include weighing the risks
and benefits of palliative chemotherapy against the risk of COVID infection, postponing
nonurgent appointments, following up such patients with telemedicine, and decision
to use antiangiogenic therapies and immunotherapy on a case-by-case basis. Medical
education, including oncology updates was affected severely. Thankfully, several webinars
and live online classes conducted by the editorial staff of the Indian Journal of
Medical and Pediatric Oncology helped students to keep up with the continuing oncology
updates. Several doctors and medical staff, including oncologists, got infected in
the process of delivering care to COVID-19 positive patients and treating asymptomatic
patients who had come for treatment. However, the fight is still on and being continued
by thousands of doctors, despite the saddening death of some colleague doctors due
to COVID infection. The reasons include the lack of PPE and limited testing. However,
now the government has approved testing in private laboratories for COVID-19, allowing
more testing in all suspected cases, asymptomatic high-risk contacts of a confirmed
case, and all symptomatic health-care workers.[5] The main breakthrough that happened in the light of the pandemic in India is the
introduction of telemedicine guidelines by the Health Ministry of India. This move
was taken in the light of restriction of movement of patients making routine clinical
visits difficult, and most importantly to decongest health-care system. This is particularly
useful for patients who are on follow-up after the completion of treatment.
Empathy in cancer care has always been the backbone of the patient–physician communication,
practicing which has been a challenge with masks on the face, and PPE masking the
facial expressions. As oncologists, we have to support our patients more than ever
by showing smiles through our eyes. The society also needs to be empathetic about
health-care personal who are risking their own and their loved ones' lives in these
difficult times to help the patients. Indian doctors have to face and fight just more
than COVID pandemic that is ignorance and apathy of some people in the society. There
were several reports of assaults on doctors, residents throughout the country, with
the wrong impression that they are carriers of this virus. They were forcefully evicted
from the rented houses and are boycotted in many housing societies. Doctors were stoned
and had to shed blood when they went door to door for contact tracing. In Tamil Nadu,
doctors who died of COVID-19 infection were refused burial by the general public,
fearing the spread of CoV.[6]
In Italy, where one of the highest numbers of cases was reported, there was no assault
on health-care workers. However, despite the pessimistic instances in India, the determination
of cancer patients and the iron will of oncologists to care for patients resulted
in the continuum of cancer care. One instance I faced was a 25-year-old young female
who drove 800 km for her mother's treatment, chemotherapy for locally advanced breast
cancer, clearing through 28 police check posts in the lockdown from the interior village
in Uttarakhand. Another 65-year-old gentleman pedaled 140 km with his wife tied to
his back, to prevent her from falling down, to reach Jawaharlal Institute of Postgraduate
Medical Education and Research, Puducherry, for chemotherapy. Such heartwarming tales
keep us inspired and continue cancer care during this deadly pandemic.
Learning to live with uncertainty during the COVID-19 crisis is the only way at this
point. Compulsory quarantine with social distancing has disrupted daily life, but
technology has helped people to connect worldwide. The coming months will pose further
challenges in this crucial fight. Empathy and patient-centered care for health-care
professionals are vital in these uncertain times. We shall never forget, this too,
shall pass.
