Facts to consider for cancer patients amid ongoing coronavirus pandemic (Comment)

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The world has been rattled by the ongoing coronavirus infection (COVID19) which started from the city of Wuhan, China somewhere in late 2019. So far, more than a million people have been infected worldwide — there have been over 50,000 deaths involving more than two hundred countries.

In 2018, WHO estimated almost 9.6 million deaths worldwide due to cancer (almost 1 in every 6 deaths). Many of these cancers require immediate attention and treatment. Delay in treatment is known to jeopardize treatment outcomes in most situations.
When the entire world is busy fighting the highly contagious virus , cancer patients are finding it difficult to understand and respond to this situation adequately. Even oncologists across the globe are in a fix due to lack of data of coronavirus infection and its implication on cancer patients.
Let us have a look at the common concerns at this moment and suggest some practical solutions with examples of some common cancers.
Q: What is the data specific to coronavirus infection in cancer patients?
A: Very less. Only one Chinese data with roughly 2,000 patients from 575 hospitals across 31 provinces is available at present. They identified 18 patients with a history of cancer. This rate is higher than their usual national cancer occurrence pattern suggesting slightly higher risk of cancer in patients being affected with coronavirus infection. Also, patients with cancer had more severe events. It is important to understand that no concrete conclusion can be drawn from only 18 patients’ data
Q: Are the symptoms of coronavirus infection same as in other patients?
A: As of now there is nothing to suggest that they are different. The common symptoms are fever, dry cough, sore throat, fatigue, breathing difficulty, diarrhoea etc. Severe infection can give rise to severe pneumonia like features.
Q: Which conditions make corona infection worse?
A: Few conditions make the situation worse. These include but are not limited to diabetes, heart disease, high blood pressure, immunosuppressed states (including cancer) etc.
Q: Can corona infection risk be more in cancer patients?
A: Scientists are learning new things about coronavirus infection. The only Chinese data suggests some increased risk but that is yet to be confirmed in larger population data.
Q: Why are cancer patients more at risk?
A: Few cancers and their spread to other organs reduce the body’s immunity. Different anticancer treatments like radiation, chemotherapy or immunotherapy can lead to immunosuppression. Few cancers require bone marrow transplant and they are at increased risk due to immunosuppressed state. Cancer can also be associated with anorexia, poor nutrition, cachexia which can reduce immunity further.
Q: Which cancers are at more risk?
A: There is no single answer to this question. However, few cancers like blood cancers (acute leukemia, chronic leukemia, lymphoma), cancers requiring bone marrow transplant; cancers requiring immunosuppressive chemotherapies, cancers requiring radiation to an area of the body involved in production of blood etc. are at more risk of severe complications from coronavirus infection. It is always important at this moment to ask your treating team of doctors about the risk of immunosuppression.
Q: Do all cancers require immunosuppressive therapies?
A: Perhaps no. However, it is impossible to answer in one single word or sentence. There might be some cancer and treatment which does not cause significant immunosuppression. Ask your physician to know if your cancer falls in that category or not.
Q: When will my immunity become normal once again?
A: Again, it is difficult to answer. Usually chemotherapies are given in a cyclical repetitive manner. During this time, immunity level also varies. Depending on the type and nature of this chemotherapy cycle, lowest immunity time also varies. Some treatments can cause prolonged immunosuppression. Please inquire with your caregiver regarding this and take necessary precautions.
Q: Should I start my treatment right now?
A: Starting and completing cancer treatment in a timely manner is important to maximize the benefits. Some cancers are less aggressive whereas others are more aggressive. For example, some prostate cancers are slowly growing and perhaps may not require immediate treatment. On the other hand, a breast cancer in a young woman or a lung cancer with aggressive nature or advanced stage may need immediate attention. Sometimes alternative treatment regime and schedule can reduce the frequency and number of hospital visits. This is applicable to both chemotherapy and radiation. Please discuss with your doctor regarding these alternative treatment approaches.
Q: I have almost completed my treatment. Is it safe to discontinue treatment in between?
A: It is not wise to stop treatment in between without discussing with your doctor.
Q: How can I increase my immunity?
A: There is no proven evidence that your immunity against coronavirus infection can be boosted by drugs or other things. Scientists are working on that. You can continue taking a healthy diet, continue your regular physical activities to keep yourself healthy and fit. Vitamin C, lemon, Ginger, Turmeric, Garlic etc. are as such good for health. However, it is important to understand that none of the above food or spices or herbs are effective in preventing or treating coronavirus infection. During treatment, you may be given colony stimulating factors to increase your blood cell counts. However, it is not proven if that gives protection against the corona virus or not.
Q: Is it safe to use public transport?
A: At this moment it is better to avoid all public transports. Use your personal transport if possible. However, if you at all need to use public transport, try to maintain physical distancing as much as possible. Use basic self-protection (like wearing a mask, avoiding people with symptoms of cold or cough or sick people etc.), carry your personal hand sanitizer and apply liberally when you touch any object or surface of the transport etc. Carry as minimum objects as possible.
Q: What precautions should I take?
A: Some basic precautions which are applicable to all, like:
* Wash your hands properly with soap water for 20-30 seconds. Do this as many times as possible, after every coughing or sneezing before touching anything else. If you cannot wash hands, you can also use alcohol-based hand rub (at least 60-70 per cent alcohol concentration
* Physical distancing of at least 1-2 meters
* Protect your face by covering with mask
* Do not touch your mouth, nose, eyes unnecessarily. If required, sanitize your hands before and after touching the surface. You can use a goggle to protect your eyes
* Sanitize your car steering or places where you touch with your hands
* Change your dress immediately after reaching home. Keep them in a safe place not to be touched by others for five or six hours before washing with soap or detergent. It is better not to shake the cloth as that may dislodge any droplets or virus in it. If possible, use one set of cloth for one day.
* Do not touch hospital surfaces unnecessarily like walls, side rails of staircase etc.
* Maintain shoe hygiene. Droplets can reach home by contaminated shoe as well. Keep outdoor shoes away and use a separate pair for home.
* Sanitize the places at home where people touch very commonly like calling bell, doorknob etc.
* If you are an in-patient, ask your health care provider to follow hand hygiene and other protective steps properly.
Q: Any special precautions if I am undergoing radiation?
A: Yes. Follow all the basic steps as outlined above. Additionally:
* Inside the radiation area you may need to change your dress. Be careful inside change room and avoid any source of infection
* Be careful when you are lying down on a simulation table or radiation treatment table. Ensure that proper sanitization was done before you entered the room.
* Ensure that staff delivering the treatment are following hand hygiene protocols.
* Ensure that the thermoplastic mask you are putting on is not contaminated by other’s mask.
* Sanitize your hands after your simulation or radiation delivery is over
* In any doubt, inquire with your radiation oncologist for the same.
* Discuss if a shorter course of treatment is useful without compromising the outcome for you.
Q: I am due for my routine follow up. Should I visit the hospital right now?
A: If you are not in an emergency situation and if it is a routine follow-up, you can discuss with your oncologist if an electronic discussion can be useful or not. You can talk over the phone or email your symptoms if any for understanding your need. It is better to avoid routine hospital visit at present.
Even after saying all these, please understand that this virus is very much new to the scientific community and facts related to cancer patients are very rare at present. All cancers are different, every patient is different from the other one, treatments are customized, and one size does not fit all. I strongly recommend you discuss in detail with your team of doctors whenever necessary.
(The author is Oncologist, Indraprastha Apollo Hospital, Delhi. He was previously Asst. Professor, National Cancer Institute, AIIMS Delhi. Views are personal)