Keywords Cancer surgery - cancer treatment - chemotherapy - COVID-19 pandemic - radiotherapy
Introduction
The coronavirus disease 2019 (COVID-19) pandemic has deemed it necessary for clinicians
to view patient treatment guidelines in the context of the danger of hospital-acquired
COVID infection. Elective surgeries and procedures have been postponed and only emergency
and lifesaving procedures are carried out.
Cancer treatment places different challenges in front of oncologists because delay
in therapy can result in progression of cancer with worsening of outcome.[1 ]
The first patient of COVID in Pune, Maharashtra, India, was detected on March 9, 2020.
Thereafter, the number of patients in Pune district and Maharashtra state kept on
increasing exponentially, and hence, Pune has been labeled as a hotspot for COVID
infection [Figure 1]a ],[Figure 1]b ],[Figure 1]c ]. The Government of India announced a nationwide lockdown on March 24, 2020, which
was extended in different phases. At the time of writing this article, India was in
its 5th phase of lockdown, from June 1, to June 30. We present a cohort study of cancer
patients treated at our tertiary care designated COVID hospital.
Figure 1: (a) COVID-19 hotspots in India (Source: Wionews.com), (b) prevalence of
COVID-19 in the state of Maharashtra, with Pune being a hotspot (Source: Wikipedia),
(c) rising COVID‑19 patients in Pune (Source: COVID‑19 India.org)
Aims and objectives
Our aim has been to study the change and delay in the management of cancer patients
in this pandemic and lockdown situation. We have studied the comorbidity profile and
complications in these patients and evaluated symptomatic patients for COVID infection
in the study period and the follow-up period till June 15.
Subjects and Methods
This was a cohort study in which we evaluated patients receiving cancer treatment
in our hospital during the period of March 20, 2020 – May 31, 2020. They were further
followed up till June 15, 2020, considering the incubation period for COVID-19 infection.
The institutional ethics committee approved this study.
All newly registered patients who underwent cancer surgery, chemotherapy, radiotherapy,
or palliative care in our hospital during the study period were included in the study.
Those patients who were already receiving treatment for cancer were also included.
Cancer patients who were only on supportive care treatment were excluded from the
study.
Consent was obtained from the patients included in the study. Information gathered
for this study included patient demographics, comorbidity profile, delay in starting
treatment, complications, and COVID-19 infection and related morbidity in patients.
Delay was defined as any delay in initiating planned treatment of >7 days.
The required data were obtained from the patients, treating doctors, and electronic
medical records of the hospital.
Microsoft Excel Version 22019 16.0.6742.2048 (Microsoft Corporation, Redmond, Washington,
USA) and IBM SPSS Statistics for Windows version V26 (IBM Corp., Armonk, N.Y., USA)
were used for data recording and analysis. Chi-square test was used to rule out any
difference between the mortality during the study period and the mortality during
the preceding 2 months.
Results
A total of 940 patients underwent cancer care at our hospital. Out of these, 864 patients
who underwent surgery, chemotherapy, or radiation were included for analysis [Figure 2 ].
Figure 2: Participants’ flowchart
Patient characteristics regarding demographics and comorbidities are mentioned in
[Table 1 ]. The follow-up period was 15–78 days, with a median of 37 days.
Table 1
Demographics and other details
Variable
Number of patients
Sex
Male
353
Female
511
Age (years)
<20
65
21-40
103
41-60
398
>60
298
Comorbidity
Diabetes mellitus
161
Ischemic heart disease
34
Hypertension
71
Bronchial asthma
11
Obesity
86
Delay due to the COVID pandemic (n =109/864; 12.61%)
Surgery
11
Chemotherapy
75
Radiotherapy
23
Change in treatment in view of the pandemic (n =84/864; 9.72%)
Surgery
1
Chemotherapy
46
Radiotherapy
37
Deaths during the study period (n =21/864; 2.43%)
Surgery
0
Chemotherapy
16
Radiotherapy
5
Hospital visits (each admission/radiation fraction is counted as one visit)
Surgery
122
Chemotherapy
1888
Radiation
3498
Total
5508
Deaths in patients undergoing cancer treatment during January-February 2020 (2.24%)
26 (out of 1157 patients)
One hundred and ten patients underwent 122 surgeries, out of which 102 were major
and 20 were minor surgeries. The median hospital stay was 4 days, with a range of
1–22 days. None of the surgical complications seen fitted into the profile of COVID-19
infection.
Six hundred and fifty-eight patients received chemotherapy [Table 2 ], and a total of 1888 cycles were administered during the study period. Bone marrow
transplant was done in 11 patients. Two hundred and five patients received radiotherapy
[Table 3 ] during the study period, and 3498 fractions were administered. Information regarding
delay in initiating treatment and complications during cancer therapy is given in
[Table 1 ] and [Figure 3]a ],[Figure 3]b ],[Figure 3]c ].
Figure 3: (a) Surgery complications (n = 7, 6.36%), (b) chemotherapy complications (n = 129, 19.66%), (c) radiotherapy complications (n = 14, 6.82%)
Table 2
Cancer site/type in patients
Site/type
Number of patients
Cancer site/type in all patients (n =864)
Head and neck
111
Breast
236
Gastrointestinal
102
Gynecological
109
Urological
49
Lung
41
Central nervous system
9
Soft-tissue sarcomas
21
Lymphomas
87
Leukemias
68
Others
31
Surgical patients (n =110)
Head and neck
27
Breast
31
Gastrointestinal
14
Urological
15
Gynecological
10
Soft-tissue sarcomas
5
Others
8
Table 3
Intent of treatment
Intent
Number of patients
Chemotherapy (n =658)
Neoadjuvant
65
Definitive
160
Adjuvant
168
Palliative
222
Radiation (n =205)
Neoadjuvant
13
Definitive
19
Adjuvant
105
Palliative
68
Surgical treatment decision had to be modified only in 1/110 (0.9%) patient of rectal
cancer. She preferred surgery to neoadjuvant chemoradiotherapy because it required
a greater number of hospital visits. Similarly, in 46/658 patients (6.99%) undergoing
chemotherapy [Table 4 ] and in 37/205 (18.04%) patients undergoing radiotherapy [Table 5 ], treatment had to be modified in view of the pandemic situation.
Table 4
Chemotherapy modifications
Treatment modification in chemotherapy
Number of patients
Weekly to 3 weekly
27
Bi-weekly to 3 weekly
2
Change of drugs
15
Shifted to hormonal
2
Total (%)
46/658 (6.99)
Table 5
Radiotherapy modifications
Treatment modification in radiotherapy
Number of patients
Reduction in number of fractions
9
Reduction in number of brachytherapy fractions
8
Hypofractionation
16
Concurrent chemotherapy omitted
3
Only brachytherapy
1
Total (%)
37/205 (18.04)
Out of the 25 patients who had symptoms suggestive of COVID, 16 underwent reverse
transcription-polymerase chain reaction (RT-PCR) testing, as advised by the COVID
treatment team because they fitted into the clinical picture of the disease [Figure 4 ]. Of the three patients (3/864, 0.34%) who tested positive, one had mild symptoms,
while the other two (2/864, 0.23%) patients were suffering from advanced hemato-lymphoid
malignancies and succumbed to the infection.
Figure 4: Patients evaluated for COVID (n = 25, 2.89%)
In the 2 months preceding the pandemic, there were 1157 admissions in the oncology
department with 26 deaths (2.24%). The deaths in the study period are categorized
in [Figure 5 ]. There were 21 deaths (21/864, 2.43%) (P = 0.791), out of which two were attributed
to COVID. There was no statistically significant increase in mortality in the study
period. Chi-square test was used to rule out a difference in mortality during the
two periods.
Figure 5: Deaths during the study period (n = 21, 2.43%)
Discussion
In the current COVID pandemic in India, multispecialty hospitals play a huge role
in treating COVID patients. These hospitals must also continue treating patients with
other ailments during this period. Our hospital is an 800-bedded tertiary care hospital
with a fully functional oncology unit.
After the announcement of the nationwide lockdown, an embargo on elective surgical
procedures was imposed by the government in light of several reports of hospital-acquired
COVID infections in operated patients and reporting of worse outcomes and increased
mortality in COVID patients undergoing surgery.[2 ],[3 ] Consequent to this, a decision to defer elective surgeries, except surgical emergencies,
cancer surgeries, and cancer treatment, was taken. This viewpoint from the Indian
perspective, where the rise in COVID cases was still slow, was supported by guidelines
provided by one of the premier cancer institutes of the country.[4 ]
With a view to separate infectious patients from others, an entire building was designated
for COVID patients and another one for non-COVID patients.[5 ]
The following standard operating procedures (SOPs) were laid down to ensure that cancer
care delivery continued in the hospital without being affected by the pandemic situation:[5 ]
The number of relatives accompanying patients and outpatient visits was restricted
The two different buildings had separate outpatient departments, inpatient wards,
operating rooms, and radiology services designated for COVID and non-COVID patients
Access points to the hospital were limited and they were manned by health-care workers.
An effort was made to direct the flow of COVID-positive or suspected positive patients
in a specific manner after screening
Education of health-care workers, resident doctors, and managers about specific biosafety
precautions was carried out by lectures, simulations, and one-to-one meetings
Entrance to the chemotherapy day care was restricted, and the health-care workers
were educated about social distancing and sanitization
Use of specific modified personal protective equipment for managing all surgical patients
was made mandatory[5 ]
The radiotherapy department couch and headrest were sanitized after each use
Appropriate personal protective measures were adopted by the radiotherapy department
personnel
Appointments for radiotherapy were adequately spaced out to avoid overcrowding
Expedited management of surgical patients by liberal use of frozen section analysis
instead of paraffin section to minimize the time and visits required for a diagnosis.
Several meetings were held between the medical director and all oncologists. Some
changes in the management of common cancers according to recent guidelines issued
by various oncology societies were considered.[6 ] It was unanimously decided that the situation would be reviewed periodically and
any increased rate of COVID infection in these cancer patients would warrant a change
in strategy.
In accordance with the prevailing Indian Council for Medical Research guidelines,[7 ] a decision of not doing RT-PCR testing for all patients undergoing cancer treatment
was taken. This was contradictory to suggestions by certain authors who recommended
preoperative testing for all patients in light of hazardous postoperative complications
in COVID-positive patients undergoing surgery.[8 ]
In our series, very few patients required evaluation for COVID infection despite there
being multiple hospital visits (25/864, 2.893%). A scrupulous selection of patients
and careful peri-operative care has helped in having no COVID-related complications
or cross-infections in surgical patients. The incidence of COVID positivity in all
treated cancer patients was also very low (3/864, 0.34%) as compared to the other
series reported by Shrikhande et al.[9 ]
The incidence of complications in surgery and adverse events in chemotherapy and radiation
(150/864, 17.36%) was comparable to historical controls, and there was no unexpected
increase in this number due to the impact of pandemic-related events.
Only 109/864 (12.61%) patients had to suffer a delay for starting their cancer treatments
due to the pandemic situation. This was found in concordance with a similar study
by Ghosh et al. which mentioned that most patients in their study wanted to continue
chemotherapy despite the pandemic.[10 ]
Only a small percentage of patients (84/864, 9.72%) underwent a change in their treatment
plan. Most of these treatment plans were modified by the treating physician with a
view to minimize patients' exposure to the hospital system without deviating from
standard treatment guidelines.
Eleven bone marrow transplants were carried out without inflicting any additional
complications on these immunocompromised patients.
Twenty-one deaths (21/864, 2.43%) were reported in our study. This was comparable
to the number of deaths (26/1157, 2.24%) observed in a similar cohort of patients
treated in our hospital in the 2 months of January and February 2020. Only two deaths
were due to COVID infection in patients with advanced hematological malignancies.
Despite the presence of 363 comorbidity factors in 864 patients, there was no increased
susceptibility to infection.
During the study period, the number of COVID cases in the city, state, and our hospital
was rising exponentially [Figure 1]b ],[Figure 1]c ] and [Figure 6 ].
Figure 6: Weekly admissions of COVID-19 patients in our hospital during the study
period
Despite more than 5500 essential hospital visits in 864 patients during this period,
there was minimal incidence of COVID infection in the study patients.
This model of effective patient segregation, separation of treatment streams, and
judicious use of testing has resulted in minimal treatment delays or changes, is unlikely
to have an adverse impact on the outcome of cancer, and can be effectively employed
in a resource-limited setting in light of the pandemic. Possibly, the actual risk
of treating cancer patients in the COVID pandemic in a COVID hospital may be much
less that what has been estimated. A similar sentiment has been echoed in the correspondence
by Cai et al., with regard to mortality in COVID-positive patients undergoing surgery.[11 ]
Conclusion
We successfully delivered cancer treatment to patients in our DCH. Only 12.61% of
our patients reported a delay in treatment initiation due to the pandemic situation.
We modified the treatment plan for 8.72%. The percentage of adverse effects, symptomatic
COVID infection, and related mortality has been very low in our study. Thus, we would
like to conclude that cancer care - a semi-emergency in itself, can be continued with
due diligence even during this pandemic.
Strength of the study
We have reported our experience of treating cancer patients in a hospital which was
simultaneously managing COVID patients in an area which was a COVID hotspot. To the
best of our knowledge, such a combined study including surgery, chemotherapy, and
radiotherapy has not been reported in the recent COVID-related literature.
We continued to manage cancer patients in a COVID hospital, without any major compromise
in a pandemic situation, especially when the scientific and medical community was
leaning toward postponement and change in the treatment of most cancers.[1 ],[12 ] This speaks a lot about the preparedness of the hospital team as a whole, and it
can be attributed to diligent training, motivation, and setting up of SOPs for each
service.
Limitations
It can be argued that most of these patients have not been tested for COVID infection
unless they have had COVID-like symptoms or exposure to contacts. The clinical significance
of these asymptomatic undiagnosed carriers is not properly known. In this pandemic,
it is difficult to generate randomized data. In addition, there is no similar historical
precedent for comparison.
The effective management of COVID and cancer patients under a single roof was possible
because the graph of COVID patients in Pune and India is still on an upward curve
and the health-care systems are not yet overwhelmed with cases. Upcoming months may
present different challenges.
Generalizability
Cancer treatment cannot be postponed indefinitely due to the fear of disease progression
and worsening of outcomes. A judicious balance of continuing cancer treatment along
with management of the pandemic needs to be considered in a resource-limited country
like India, where tertiary care hospitals will have to take the initiative.
