Cancer Management in India during Covid-19

To rapidly communicate short reports of innovative responses to Covid-19 around the world, along with a range of current thinking on policy and strategy relevant to the pandemic, the Journal has initiated the Covid-19 Notes series.

The Covid-19 pandemic has created major dilemmas for providers in all areas of health care delivery, including cancer centers. The rapid spread of SARS-CoV-2, combined with an unprecedented, near-complete global lockdown, has laid bare the weaknesses in health systems. Lack of adequate health care infrastructure and human resources, serious supply-chain disruptions, and widespread fear among patients and health care workers have resulted in patient care and safety being compromised. Throughout the world, health systems have had to scramble together rapidly changing responses while relying on inadequate information and on models of disease spread that are based on multiple assumptions. The resulting rationing of care has left patients and physicians feeling frustrated and burned out. Several cancer centers drastically scaled back their services after preliminary reports from China showed that Covid-19 outcomes are significantly worse among patients with cancer.

At Tata Memorial Centre (India’s largest cancer center), despite having to scale back operations by about one third, we made the decision to continue providing cancer care using a proactive and multipronged approach (www.indianjcancer.com/preprintarticle.asp?id=281968), the components of which are summarized in Table 1. Some degree of scaling back was required to allow for physical distancing in clinics and because India’s lockdown prevented some patients and health care workers from being able to reach the hospital. We also established a staff-sparing strategy, which involved providing paid leave for at-risk employees and rotating remaining staff.

Table 1. Summary of Covid-19 Measures Taken at Tata Memorial Centre.

Administration

Creation of a core Covid-19 action group

Daily debriefings and formulation of action plans

Cancer care

Avoidance of complex surgeries likely to require multiple blood transfusions and prolonged intensive care unit stays

Use of hypofractionated regimens whenever possible (e.g., for breast, prostate, and lung cancers); provision of palliative radiotherapy in a single fraction or weekly regimens

Reduced use of myelosuppressive systemic therapy; conversion to oral agents when feasible; deferral when magnitude of benefit is marginal

Patient-directed

Establishment of “screening camps” outside the hospital to reduce patient visits

Stringent restriction of relatives and friends in outpatient clinics and inpatient wards

Use of teleconsults as a substitute for routine follow-up visits

Hospital preparedness

Establishment of standard operating procedures for cases of suspected or confirmed Covid-19 infection; use of simulation drills

Establishment of a fever clinic and creation of isolation wards

Employee-directed

Provision of paid leave for high-risk staff members (elderly people, people with multiple comorbidities or who are taking immunosuppressive agents, and pregnant people)

Rotation of staff to ensure a fallback option in case of mass quarantine

Provision of hospital buses to transport staff unable to reach work because of the transportation lockdown

Our de-escalation of services has been far less pronounced than the cuts made at similar cancer facilities globally. The decision not to cut routine services was based on two factors. First, because the government took early decisive action, SARS-CoV-2 has spread more slowly in India than in some other countries, and we are not yet seeing large numbers of hospitalizations for Covid-19 in Mumbai. More important, for a center that sees more than 70,000 new patients with cancer each year, even a slowdown in clinical services is likely to have a substantial impact on outcomes. Although cancer is often not immediately life threatening, treatment services are also not entirely elective, and delaying care can have serious adverse consequences.

The constraints created by the pandemic have required us to make some difficult choices, including those we made in drawing up prioritization criteria to guide treatment decisions. Patients with potentially curable disease who could substantially benefit from treatment are given high priority, whereas care for patients who were being treated with palliative intent, especially those for whom interventions are expected to have marginal benefit, is being deferred. Decisions about care for individual patients are made by balancing the risk that patients will contract Covid-19 because of exposures associated with cancer treatment — and their risk for complications if they do — with the benefits of receiving potentially lifesaving cancer treatment.

We have already learned a great deal from this pandemic. Being forced to quickly respond led to a radical overhauling of entrenched hospital systems and processes, which ultimately made our operations more efficient. The rapidly evolving nature of the pandemic meant that we needed the full and unconditional support of our large body of employees. We gained this support by establishing open electronic-communication channels and a process for shared decision making, despite circumstances that preclude face-to-face meetings. We were quick to share best practices and guidelines for cancer treatment during the pandemic with other hospitals in India by creating a series of webinars available through the National Cancer Grid, a network of cancer centers that includes our hospital (https://ncgeducation.in/course/view.php?id=37).

The decisions we had to make regarding triaging of patients for cancer treatment will undoubtedly be helpful when we establish a robust health technology assessment program, an essential tool in a country where public health care expenditures are low. Our previous work on the “Choosing Wisely India” campaign to outline low-value or harmful practices in cancer care (https://www.thelancet.com/article/S1470-2045(19)30092-0/fulltext) also facilitated our Covid-19 response. Countries that have not had high rates of death from Covid-19 could consider similar approaches that involve balancing pandemic control with providing continued cancer care.

This note was published on April 28, 2020, at NEJM.org.