The state of Maharashtra accounted for a third of the 151 000 cases of coronavirus disease 2019 (COVID-19) reported in India up to May 27, 2020. The pandemic has disrupted life in Mumbai, Maharashtra's capital, overwhelming its health-care facilities. The nationwide lockdown introduced to prevent spread of the virus has also had an impact on cancer care, since Mumbai is a major destination for cancer treatment for patients from other states. When the lockdown was announced on March 24, many such patients were unable to travel home from Mumbai after cancer treatment, while those scheduled for chemotherapy or surgery found it difficult to travel to Mumbai, as all modes of transportation were suspended. The situation was similar in Delhi, Chennai, and Bangalore, where large cancer hospitals are situated.
More than 1 million new cases of cancer are reported in India every year. Because most Government-run facilities are in big cities, people from rural areas often have to travel long distances for treatment and follow-up. At the beginning of the lockdown, the central Ministry of Health directed state Governments to keep running non-COVID-19-related essential health services, including cancer treatment and screening. However, few patients could access these services with no means of transport, and some hospitals, such as the Delhi State Cancer Institute, were forced to shut outpatient units following COVID-19 outbreaks among staff.
Clinical services in most cancer centres remained curtailed for most of the lockdown, and few new cases of cancer have been registered. “Since health care has been redirected to optimally manage the pandemic, routine clinical services including oncology have been relegated to second priority. Patients are finding it difficult to find transportation to reach health-care facilities. They are also scared of acquiring the infection in hospitals, not realising that cancer spread and the resultant poorer prognosis may be far more dangerous”, explained Ravi Mehrotra (Chief Executive Officer, India Cancer Research Consortium, New Delhi, India).
The Tata Memorial Hospital in Mumbai, however, continued to offer full services for patients who could access it during the lockdown period. “We planned early on and initiated precautionary measures like restricting the number of attendants with each patient, banning visitors for inpatients, using teleconsultation for routine follow-ups, protecting vulnerable staff, maintaining supply chains and so on. A ‘war room’ was set up for meticulous planning and execution of all this”, explained C S Pramesh (Director, Tata Memorial Hospital, Mumbai, India). The centre also modified its protocols to defer surgeries where outcomes would not be substantially affected by postponement, and modifying chemotherapy regimens to minimise the likelihood of complications. Their learnings were shared with members of India's National Cancer Grid and the City Cancer Challenge (Union for International Cancer Control, Geneva, Switzerland).
The delay in treatment or detection of new cases is likely to affect the cancer burden soon. A global modelling study on the impact of the COVID-19 pandemic on surgeries projected that 59·7% of cancer surgeries were postponed in India during the peak 12 weeks of disruption, translating to 51 100 postponed cancer surgeries.
“Delayed or postponed surgeries might result in tumours being upstaged and reaching the operation table at a later stage than they would have ordinarily. The delays might also move a lot of patients from the curative to palliative stage. Both these scenarios may adversely affect long-term survivals and possibly lead to worse outcomes”, commented Dhruv Ghosh, surgeon at Christian Medical College (Ludhiana, India) and member of the Global Surgery Research Collaborative at the University of Birmingham (Birmingham, UK).
Cancer in India is also a socioeconomic challenge. “Though treating hospitals are taking utmost care to best manage patients, increased out-of-pocket expense related to accommodation, food, medicines, and travel is an ongoing challenge which has accentuated during the lockdown”, said Yogendra Kumar Sapru of Cancer Patients Aid Association (Mumbai, India). “When the lockdown ends, there will be a backlog, and we expect a sharp increase in the number of patients seeking financial assistance for treatment as many people have lost their livelihoods”, he added.
Activities to promote cancer awareness and early diagnosis have also slowed down. On May 19, 2020, the Indian Government directed suspension of screening for oral cancers under the National Cancer Screening Programme, on the basis of risks associated with examination of the oral cavity.
Pramesh added, “cancer hospitals need to continue to provide cancer care while also managing patients with cancer and COVID-19 so that adverse cancer outcomes due to denied or delayed cancer care do not become a bigger problem than pandemic-related morbidity and mortality.”
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