Thirty-five-year-old Priyadarshini, mother of two, from Guntur, diagnosed with breast cancer in January, 2020, was used to making the 400-odd kilometre journey by road, with family, to the Regional Cancer Institute at Adyar, Chennai for treatment.
The Regional Cancer Institute at Adyar, Chennai is a public charitable voluntary institute, of international repute, which was the first comprehensive cancer center of its kind in South India, established in 1954. The center provides the latest advances in cancer care treatment to all patients, with at least sixty percent of them receiving therapy at no cost or having to pay a nominal amount.
They had familiarised themselves and formed a trusted bond with the hospital and its doctors over the last 2.5 months. She was operated in January, and received the first cycle of chemotherapy in February; was due for the next, two weeks ago!
The Covid-19 pandemic provoked nationwide lockdown and resultant closed state borders has presented her with a dilemma as to how to get to her treating center across state borders. Anxiety fills her as she recalls the doctor’s advice and implications of unprescribed delays in treatment, that could translate into a detriment to her survival.
Priyadarshini is only one amongst the two million diagnosed cases of cancer over the last five years, in India. According to Globocan, approximately 1.1 million cases of cancer were newly diagnosed in India, in the year 2018 alone, and is estimated to rise to 1.9 million by year 2040! The recently imposed lockdown, has posed unfortunate road-blocks (pun intended) to cancer patients in the midst of treatment.
Most Indian patients who present to tertiary care centers for treatment, are already in advanced stages of the disease. The modest set-up of five regional cancer centers (RCC) in 1975, has now multiplied to 25 such centers spanning across the country; Yet, grossly inadequate for a population of 1.38 billion!
It is not uncommon, therefore, to see patients undertaking arduous journeys from one end of the country to another, for medical opinions; now, next-to-impossible, following the lockdown.
Many-a-patient is left fretting, with treatments suspended mid-way or indefinitely postponed. A similar predicament has befallen those travelling long distances within the state, to their treating hospital, owing to the temporary halt of public transport. When they do manage to reach a hospital however, other logistical challenges arise, such as temporary accommodation, procurement of food etc. Not to mention, a nagging fear of being incapacitated by the virus. Most hospitals have revised rules and now allow only one attendant per admitted patient, to avoid overcrowding, and maintain social distancing. A blessing to some, but a conundrum to many!
Mariselvan, diagnosed with lung cancer, would travel eleven hours by train, from the temple town of Tirunelveli to Chennai, for treatment. He was in the middle of radiation therapy, when the numbers of Covid-19 positive patients began rising in the country.
With lockdown initiated, he was now stuck in the stark hospital ward, amongst hordes of other patients, haunted by scores of uncertainties and mounting fear at his increased risk of contracting the virus. Recent data has demonstrated that cancer patients are increasingly susceptible to Covid-19 infection in view of their systemic immunocompromised state, caused by the cancer itself and associated treatments, have poorer outcomes.
Oncologists are in a quandary as to whether to offer treatments in the midst of the ongoing crisis, and render patients further immunosuppressed; but postponing the said therapies to the post-crisis period, might be inadvisable for many. It’s a very delicate balance.
As the saying goes, “damned if you do, damned if you don’t!” Cancer has a wide spectrum of presentations and symptomatology, ranging from mild, seemingly-harmless symptoms to outright emergencies.
In light of the present situation, various hospitals nationwide have temporarily halted regular functioning; attending only to emergencies; whilst concentrating on tackling grave unforeseen issues that have cropped up with the pandemic, such as procuring adequate PPEs for patients and health care personnel, setting-up specific wards and ICUs for Covid-19 positive patients, and segregating them from the unaffected population. One is now having to think twice before waltzing into the emergency room of a hospital, lest run the risk of getting infected!
In order to allay some of the inconveniences that are being faced by cancer patients in the current scenario, close collaboration with governing authorities is crucial; whether it be in allowing selective passage across borders to those patients with letters from treating hospitals, or earmarking ambulances to assist them in this regard. Whether to offer patients treatment or not has to be decided on a case-per-case basis, by the treating oncologist, after carefully assessing the risk-to-benefit ratio. Unprecedented situations call for unprecedented measures.
As per the WHO, Cancer is the second leading cause of death globally (6.2 million of the 9.6 million deaths in 2018, occurred in India). The economic impact of cancer is significant and steadily increasing.
In the present hour, the Covid-19 pandemic has the nation paralyzed. Fear and panic are predominant, as the knowledge of one’s mortality dawns. Awareness, rather than fear is paramount as people practice what is essential, to flatten the curve of the pandemic; regular hand-hygiene, social distancing and abide by the declared curfew.
One must realize, however, that long before Covid-19, Cancer is one of the diseases, amongst others, that has been responsible for millions of deaths annually; and it is also essential to ensure that these measures taken to tackle Covid-19 does not come in the way of the treatment for cancer patients, who can be greatly impacted by the slightest of delays.
In the long run, it might be prudent for the government to consider increasing the total healthcare expenditure, as a proportion of the GDP. The various RCCs distributed nation-wide, are still inadequate and inaccessible to many. Facilities offered in these centers, moreover, are not uniform throughout, and are in dire need of critical review and guided evolvement. Set-up of many more standardized cancer centers, with mindful geographical mapping and uniform treatment protocols, would go a long way in alleviating these concerns in the future.
(Authors are faculty in Department of Surgical Oncology, Adyar Cancer Institute, Chennai. Views expressed are personal.)
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