Rakesh Chopra, MD
Kavita Yadav, BDS, MPH
Ravi Mehrotra, MD, DPhil, FRCPath
With the announcement of a complete nationwide lockdown on March 25, 2020, to prevent the spread of COVID-19, a lot of unprecedented events came into being in India. The National Health Mission reported a 69% reduction in measles, mumps, and rubella vaccination in children; a 21% reduction in institutional deliveries; a 50% reduction in clinic attendance for acute cardiac events; and a surprising 32% decrease in inpatient care for pulmonary conditions in March 2020 compared with March 2019.1
Cancer care wasn’t far behind, as nearly 70% of patients could not access life-saving surgeries and treatment. Chemotherapy treatments and follow-ups were postponed.2,3 Even private clinics in major Indian cities reported a nearly 50% decrease in patient footfall for cancer care and diabetes from the numbers they saw earlier.4 Overall cancer services declined by 50% in April and May, as compared with the same period the year before (data from leading private cancer hospitals across India).
“The fact that patients with cancer are more vulnerable to COVID-19 infection and its complications has resulted in new challenges in managing cancer care delivery systems.”— Rakesh Chopra, MD, and colleagues
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As for surgeries, only one-fifth of them were performed, compared with those performed in the corresponding period in 2019. And at least 51,100 life-saving cancer surgeries were cancelled in India from the end of March to the end of May.5 Failing to attend regular cancer care follow-up, not being able to attend the scheduled emergency surgeries, and not being able to reach home after chemotherapy were some of the common problems that resulted in the loss of life in certain cases.
New Challenges in Cancer Care
To top it off, the fact that patients with cancer are more vulnerable to COVID-19 infection and its complications6 has resulted in new challenges in managing cancer care delivery systems. Although restrictions were downscaled in a phased manner from June 2020, and hospitals such as Tata Memorial offered a ray of hope by operating 494 major cases in 5 weeks,7 there is still a huge backlog of patients with cancer who need urgent care.8
Apart from these oncology issues, even primary health care in rural areas took a hit, as most of the ground level health-care workers (eg, accredited social health activists) were directed toward pandemic care, leaving none for cancer-screening activities.9 Not only patients but even health-care managers (eg, hospitals, doctors, nurses) are finding it difficult to manage the situation that has arisen due to COVID-19.
“Apart from health-care management, one area that has suffered tremendously due to the infectious outbreak is cancer research.”— Rakesh Chopra, MD, and colleagues
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On the one hand, hospitals are struggling with the increased burden of patients with COVID-19, and, on the other hand, management of the backlog cases has created a mammoth task for them. Hospitals not only need to take precautionary measures (wearing personal protective equipment), but also need to follow minimalistic rules (eg, reducing the number of attendants with each patient, reducing the number of visitors for inpatients, and using online or telephonic routes for routine follow-up). They also need to protect the vulnerable forefront health-care providers, maintain supply chains, and conduct triaging of patients based on several categories. And while doing all these tasks, they need to protect the front-line health-care workers from COVID-19.
Impact on Cancer Research
Undoubtedly, patients with cancer and health-care workers need special attention during these trying times; however, calculating risk-benefit ratio considerations is becoming equally important. Apart from health-care management, one area that has suffered tremendously due to the infectious outbreak is cancer research.
The estimated decrease in cancer funding in India ranges from 5% to 100%, as many funding agencies have cancelled calls for funding. The private/charity sector is the worst hit, with an estimated decrease of more than 60% of its funding.10 This raises a serious concern for cancer researchers, and this debacle has the potential to topple many advancements in cancer research. With most conferences and official meetings happening online due to travel restriction, the chances of learning and physical interactions with experts have been reduced, if not vanished.
In contrast to these findings, overly ambitious announcements earlier in the year (eg, launching a coronavirus vaccine by August 15) presented a rather hazy picture of the future. We need a ray of hope to find that hidden silver lining in the COVID-19 pandemic. However, falling prey to overly positive news is also an area that needs to be addressed. Although all of us are trying to adjust to the new normal (heavy use of online tasks), only time will tell what extent of damage COVID-19 has caused in all spheres of the cancer care continuum familiar to us.
DISCLOSURE: Drs. Chopra, Yadav, and Mehrotra reported no conflicts of interest.
1. Cash R, Patel V: Has COVID-19 subverted global health? Lancet 395:1687-1688, 2020.
2. Sharma S: Cancer care takes a hit during lockdown. June 21, 2020. Available at https://www.hindustantimes.com/india-news/cancer-care-takes-a-hit-during-lockdown/story-9yIR9C2F6ZhRmyodjFdGRO.html. Accessed October 8, 2020.
3. Dhupkar A: Tata hospitals postpone chemotherapy and surgeries. March 22, 2020. Available at https://mumbaimirror.indiatimes.com/coronavirus/news/tata-hospitals-postpone-chemo-and-surgeries/articleshow/74754405.cms. Accessed October 8, 2020.
4. Sharma EK: How can India combat COVID-19’s collateral damage? August 31, 2020. Available at https://thewire.in/health/national-health-mission-covid-19-medicine-vaccine. Accessed October 8, 2020.
6. Liang W, Guan W, Chen R, et al: Cancer patients in SARS-CoV-2 infection: A nationwide analysis in China. Lancet Oncol 21:335-337, 2020.
7. The Hindu: Tata Memorial Hospital opens up window of hope for elective cancer surgeries. June 12, 2020. Available at https://www.medicalbuyer.co.in/tata-memorial-hospital-opens-up-window-of-hope-for-elective-cancer-surgeries/. Accessed October 8, 2020.
8. Neal RD, Nekhlyudov L, Wheatstone P, et al: Cancer care during and after the pandemic. BMJ 370:m2622, 2020.
9. Rukmini S: How COVID-19 response disrupted health services in rural India. April 27, 2020. Available at https://www.livemint.com/news/india/how-covid-19-response-disrupted-health-services-in-rural-india-11587713155817.html. Accessed October 8, 2020.
10. International Cancer Research Partnership: Project funding people map. Available at https://www.icrpartnership.org/map/people/215558. Accessed October 8, 2020.
Disclaimer: This commentary represents the views of the author and
may not necessarily reflect the views of ASCO or The ASCO Post.
Dr. Chopra is a medical oncologist working in multiple organizations in New Delhi and Gurugram. Dr. Yadav is a public health researcher at the Centre for Social Medicine and Community Health, Jawaharlal Nehru University. Dr. Mehrotra specializes inpreventive oncology and works for the Indian Council of Medical Research-Department of Health Research as Chief Executive Officer of the India Cancer Research Consortium.