Cancer Related Precautions in COVID 19 Pandemic Country Like India

Introduction

Coronavirus disease 2019 (COVID-19) is a respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus was identified as the cause of an outbreak of pneumonia of unknown cause in Wuhan City, Hubei Province, China, in December 2019 [1]. The outbreak was declared a public health emergency of international concern on 30 January 2020. On 11 February 2020, WHO announced a name for the new coronavirus disease COVID-19 and declared it a pandemic on 11 March 2020 [2].

As per WHO there are 4,62,684 cases globally and 20,834 death due to COVID-19 on 26 March 2020 [3]. Italy, Spain and United States of America are suffering majorly at present and number of confirmed cases and death due to coronavirus disease is rapidly increasing day by day and minute by minute.

India is facing the same problem and number of confirmed cases on 26 march 2020 is 647 and death is 13 [4]. In such situation health care and cancer care delivery Opinion system had affected much. Daily increase in number of cases and associated mortality has forced lockdown in various countries to check the spread of virus including India.

Cancer patients are immunocompromised and susceptible to have various secondary infections. This is because of direct effect of chemotherapy, radiation therapy, hormonal therapy, immunotherapy, stem cell transplantation, molecularly targeted drugs, diagnostic modalities of cancer and combined modality therapy. All these effects cause cancer related fatigue, cytokine releasing syndrome and cancer cachexia syndrome which further because decrease immunity and hence cause cancer patients to have secondary infections. In a pandemic of corona virus disease outbreak these infections can affect the cancer patients too. Reported a significantly higher incidence of severe events i.e. death or ICU admission requiring invasive ventilation among individuals with a cancer history than those without (39% vs. 8%; P = .0003), in 2,007 Chinese patients hospitalized with COVID-19 [5]. In this study cancer was present only in 18 cases and because of small sample size and other comorbidity association, findings are difficult to interpret. However, cancer history was present in only 18 patients, some of them were long term survivors while others had active disease. The smaller sample size and associated co-morbidities like diabetes, hypertension, liver disease and cardiovascular disease in cancer patients contributing to increase infection susceptibility, made the findings difficult to interpret.

General precautions pertaining to COVID-19 patients as such apply to cancer patients as well.

Primary Prevention

Avoid exposure to virus.

Use social distancing. (i.e., maintain a distance of at least 1 metre [3 feet]).

Hand hygiene Proper wash with soap and water for minimum 20 seconds. Alternative is alcohol-based sanitisers Avoid touching the eyes, nose, and mouth with unwashed hands.

Respiratory hygiene (i.e., cover mouth and nose when coughing or sneezing, discard tissue immediately in a closed bin, and wash hands) Medical advice in case of symptoms of fever, cough, sore throat, difficulty in breathing, gastrointestinal upset.Face cover by mask in case of symptomatic patients and in health care providers.

Chemotherapy

Case should be individualised and the patient should discuss with medical oncologist regarding outcome. hemotherapy in metastatic or palliative setting should be rescheduled. Single agent chemotherapy is preferred over double agent. Oral tablet chemotherapy is preferred over intravenous chemotherapy. Stem cell transplantation is to be deferred or rescheduled in pandemic COVID-19.  Immunotherapy modulation done only after discussion with medical oncologist. Proper precautions and safety measures are to be followed.

Radiotherapy

Radiation oncologist, technicians and other staff should take personal protective equipment. Sanitise the hands of patients and after proper travel history and case history the patient should be given radiation therapy. Concurrent chemotherapy means chemotherapy along with radiotherapy should be avoided. Entry and exit point of patient in machine chamber should be separate if possible. Routine OPD, follow up, direct and indirect laryngoscopy should be avoided. Type of radiation like ABC (Activated breath control), SBRT(stereotactic body radiation therapy) should be avoided. Thoracic radiation for breast, lung and head neck cancer is to be avoided. Complex radiation plans to be avoided, Patients should be categorised according to the risk category and patient with oncology emergency should be given priority. Normal fraction to hypofractionation can be done. In palliative setting single fractionation to be used and each case to be individualise according to radiation oncologist. A traveller pass should be given to each patient so that in lockdown situation, the patient should not suffer.

Alternative Treatment

In the panic situation among COVID-19 pandemic, all patients should be counselled carefully with positive attitude. Stress and the panic associated with the current situation will be more evident in the near future, so managing psychosocial wellbeing during this time is as important as managing physical health. The use of social media to be done to generate positivity among cancer patients. Cancer awareness and coronavirus protections should be done regularly. Yoga, meditation, exercises, music therapy, healthy eating habits, deep breathing and stress relieving exercises to be done on regular basis to enhance the immunity. All safety measures to be done to protect from COVID-19 infection.