Impact of Covid-19 on Cancer Care – Where Karkinos Healthcare makes a difference
By Dr. Yogesh Jain, Director, NCD
In the early months of 2020, the rampant and contagious spread of the original strain of SARS-CoV-2 virus causing the COVID-19 pandemic wreaked the world. It shattered healthcare systems across several countries and made normal functioning of hospitals tough. The fallout of prioritizing care for Covid-19 affected patients was consequentially felt on the management of other grave diseases. And like every other disease management, cancer care too bore a massive brunt.
Treatment of cancer and its prognosis are extremely time-sensitive. Apart from time being crucial, the access to the right screening, diagnosis, treatment, follow-up, and palliative care are essential to a positive outcome of the treatment. With the pandemic, cancer care was adversely affected in several ways. First, lockdowns and restrictions on movement during the pandemic combined with patients’ fear of contracting COVID-19 prevented patients from traveling to cancer centers for diagnosis, treatment, and follow-up, especially in the metropolitan centers like Mumbai, Delhi, Chennai and Bangalore.
Besides, several cancer centers were converted to COVID-19 care facilities with redeployment of hospital beds and staff, reducing the resources available for cancer care. This was further exacerbated by scarcity of personnel in hospitals due to infection, quarantine or as a conscious staff-sparing strategy. Frequently, oncologists resorted to modify treatment regimens to ameliorate the risk of an anticipated or feared increase in mortality from COVID-19 in their cancer patients.
Research-based facts on Covid-19’s impact on cancer
The results of a study done at 41 high volume cancer centers, as part of National Cancer Grid (NCG) in India, showed considerable reductions in the provision of oncology services in 2020 compared with the corresponding time period in 2019. The reduction was the largest for new patient registrations, outpatient services, hospital admissions, and major surgeries, and less marked for radiotherapy and palliative care.
The number of new patients registered decreased by 54%, patients who had follow-up visits decreased by 46%, hospital admissions had a 36 % reduction, outpatient chemotherapy decreased by 37%, the number of major surgeries decreased by 49% reduction, minor surgeries by 52%, patients accessing radiotherapy by 23%, pathological diagnostic tests by 38%, number of radiological diagnostic tests by 43%, and palliative care referrals by 29%. These reductions were even more marked between April and May, 2020. Cancer screening was stopped completely or was functioning at less than 25% of usual capacity at more than 70% of centers during these months. Reductions in the provision of oncology services were higher for centers in tier 1 cities (larger cities) than tier 2 and 3 cities (smaller cities).
Modeling studies showed that a general concern over COVID-19–related delays in peri-management of oncological patients, may lead to an increased loss of life and life-years linked to patient age and tumor type with reports of an overall 55% decrease in referrals, whereas the diagnostic yield increased from 2.9% in January to 8.06% in April. Diversion of beds and specialized spaces such as ICUs, staff such as physicians, nurses, surgeons, and pathologists as well as shortage of medicines and PPE led to the decline in resources available for all non-COVID care, of which oncology services were one of the main ones to suffer.
Dealing with the backlog
The NCG study (mentioned above) predicted that reductions in oncology services due to COVID-19 will lead to between 83,600 and 111,500 missed cancer diagnoses and between 98,650 and 131,500 excess cancer-related deaths over the next 5 years. Cancer cases increased by nearly 324% from 2017 to 2018 in India according to National Health Profile, 2019 data. However, a rise of only 29% in cancer cases was noticed from 2020 to 2021. This highlights a huge number of missed cases that will further increase the burden on the health care system in the coming years.
Specific risk of poorer outcomes has been observed for head and neck cancers. A study done in England showed a substantial increase in avoidable cancer-related deaths as a result of the impact of an ongoing pandemic on cancer care. The total additional years of life lost (YLL) across oral, breast, and colon cancer were estimated to be 59,204–63,229 years. Increased incidence of advanced-stage disease and increased cancer-related mortality have been noticed in CMC Vellore, a leading cancer care center in South India.
The lockdowns hampered travel for patients who needed chemotherapy or other day care treatments. This was a major setback for delivering quality treatment. Delays in cancer treatment are known to have a detrimental effect on cancer outcomes. Every month’s delay in accessing or starting treatment was found to result in 6–8% increased mortality for patients requiring surgery and substantially increased mortality in those requiring radiotherapy and chemotherapy for specific indications. Not only treatment delays and disruptions, lockdowns have seriously affected the wellness checks and self-screening procedures that have a serious impact on the early diagnosis of cancers.
Manageable second wave
The consequences of the first wave of Covid-19 in early 2020 in cancer care were unimaginable. In the second wave, cancer services did not suffer as much – chemotherapy, for instance, had resumed in August 2020 and continued through the second wave at the Tata Memorial Hospital, Mumbai and other hospitals. During the first wave, staff were downsized and many workers fell sick. In the second wave, hospital staff were able to work at full capacity because a significant proportion of health care staff were already vaccinated. Radiotherapy protocols were modified to deliver external radiation and brachytherapy in fewer sittings, such as in cervix cancer where schedules of 3 to 4 weeks were delivered in 3 sittings.
The National Cancer Grid (NCG) also intervened to make things better by a) increasing reliance on tele-consultations and reducing in-person consultations; b) implementation of enhanced infection prevention and control practices can potentially reduce the risk of other hospital-acquired infections; and c) segregating hospital set-up into COVID-19 and COVID-19-free areas.
Digital technology to the rescue
In the times of the pandemic, digital healthcare got a big boost and emerged as a second-best option to physical checks. Surely, some aspects of health care interaction can be done adequately through virtual mode, and should be practiced even in the post pandemic period to cut down unnecessary travel and expenses. But we need to ensure that we don’t end up unburdening the health systems and health professionals of the need to use physical examination for correct diagnosis and for best communication with the patients. Digital healthcare can’t be high tech and low touch, it has to be high tech and high touch!
In cancer care too, deployment of digital technology proved to be a good leveler. Karkinos Healthcare is addressing several problems associated with delivering ubiquitous cancer care by leveraging its digital oncology service delivery platform. The company’s proprietary distributed cancer care network envisages the use of digital technology and resource distribution to provide highest quality care closest to the patient’s home. Services which can be done at a community clinic or the first level hospital could also be empowered to provide many components of cancer care. Adoption of tele- and video-consulting facilities to reduce hospital visits and travel can help in decentralizing cancer care with a tiered care delivery model.
Treatment protocols finalized at tertiary cancer centers may be implemented in primary or secondary health centers closer to the homes of patients such as in L3 and L4 centers rather than expect patients to visit tertiary care centers like L1 and L2 centers. To aid this, access to medicines, especially essential chemotherapy and pain relief, could be improved by arranging for delivery of these drugs to the patient to ensure continued care. By using digital technology smartly, we need to develop guidelines based on the current evidence to reduce non-essential interventions, response assessment scans, follow-up and treatments with marginal magnitude of benefit. Karkinos Healthcare is working on all these areas to address the requirements with its digital oncology platform.
Karkinos Healthcare is also concerned about the adverse impact on learning systems in oncology care due to the Covid-19 pandemic. The company’s novel digital learning and simulation platforms offer the ability to limit in-person interactions and provide flexibility of access for all levels of cancer care providers from physicians, nurses and other cadres of ancillary care providers.
In the area of preventive medicine, Karkinos Healthcare is aware that a robust immune response to the vaccine may not happen in people with cancer. Hence, the company is proposing additional strategies, such as reduced intervals between doses, and booster shots for people with cancer who are either on active therapy or post therapy.
Research in cancer requires patient- and researcher-friendly clinical trial protocols designed in a way that can be easily implemented across different levels of care and not just at the tertiary level, and with meaningful clinical benefit to optimize resource utilization.
Overall, as we go ahead into the post pandemic period, we need to (1) ensure uninterrupted cancer treatment even when future waves of COVID or other disease epidemics come up (2) establish guidelines for the management of patients with cancer during pandemics (3) focus on assessment and management of patients with cancer who have been infected with COVID (4) develop strategies to implement appropriate modifications to screening programs; and (5) ensure the uninterrupted continuation of cancer education and research.