Archives in Cancer Research

Statement of the Problem: Breast cancer is one of the most common cancers in women all over the world, with increasing incidences due to various reasons. These include greater awareness about the occurrence of breast cancer, early detection, increase in life-style and stress-related diseases, hormonal imbalances and diet. Operative treatment forms the mainstay of management along with chemotherapy and radiotherapy. The current COVID-19 pandemic is an eye opener for all the stakeholders in health-care sector. The inadequate health systems are currently overwhelmed by COVID-19, that other diseases like cancer have taken a back seat in most institutions. Breast cancer can spread further if surgical treatment is delayed in resectable tumors, resulting in increased morbidity and mortality. COVID testing must be done for patients posted for these surgeries. Complete asepsis must be maintained during patient handling and all procedures. In addition, regional anesthetic techniques must be utilized in all patients to reduce the stress response and anesthetic requirements. Conclusion & Significance: Breast cancer detection and management should not be delayed due to crisis due to COVID-19 pandemic. Such oncosurgeries must be done in dedicated non-COVID centers after requisite testing and taking adequate barrier precautions and asepsis. So far, no systematic reports are available regarding a higher incidence of COVID-19 or SARS-CoV2 asymptomatic infections in patients with cancer. Recent limited data from China, and more recently from Italy and the US, do however seem to confirm a higher risk.

Available data indicate that older people are more vulnerable, with underlying health conditions such as chronic respiratory, cardio-vascular or chronic kidney disease, diabetes, active cancer and more generally severe chronic diseases.

Therefore, during the COVID-19 pandemic, the Benefit/Risk ratio of cancer treatment may need to be reconsidered in certain patients.

Two groups of patients have been identified: “patients off therapy” (A) who have completed a treatment or have disease under control (off therapy); and patients under treatment (neoadjuvant or adjuvant curative treatment or treatment for metastatic disease) (B). Patients with “active disease” can be eligible for surgery, chemotherapy and/or radiotherapy, biological therapy, endocrine therapy and immunotherapy (either in the adjuvant or in in the metastatic setting). For all patients (A and B) it is mandatory to provide health education: a) Avoid crowded places; b) Wear PPE when you attend hospital for visits and treatments; c) Correctly wash your hands according to World Health Organization (WHO) indications; d) Do not have contacts with friends and relatives with COVID-19 symptoms or living in endemic zones; e) Guarantee social distancing with all people: protect yourself to protect others. For patients receiving active treatment (B), living in epidemic zones or not, hospitals should identify specific pathways in order to guarantee timing of treatment with curative intent and, when possible, also for patients with metastatic disease. Outpatient visits for cancer patients should be reduced to the safest and most feasible level without jeopardizing patient care. For patients receiving oral treatment for which monitoring can be done remotely, drug supply should be provided for at least 3 courses to reduce access to the hospital. Blood monitoring for those patients can be done in local labs close to home. We suggest implementation of telemedicine services. We advise to delay all follow-up visits. More intensive surveillance should be used during treatment for patients with lung cancer or who received previous lung surgery, and for older patients or those patients with other co morbidities. Intensive measures should be undertaken to avoid nosocomial spread. There should be strict and safe triaging procedures to assess any COVID-19 symptoms and the urgency and necessity of hospitalization. In order to regulate access to the “Cancer Hubs”, establish “checkpoint areas” screening for early detection of potentially infectious persons. Clinical staff responsible for the checkpoint area should be trained and wear PPE. Individuals who meet criteria for highly communicable diseases requiring isolation, such as novel COVID-19 or other emerging infections, must be placed in a private exam room as soon as possible, as per the infectious control guidance found on the WHO and CDC websites. They should be tested and transferred to COVID-19 dedicated areas.

Dr Uma Hariharan is a medical graduate (MBBS) from the Armed Forces Medical College, Pune, India (2000). She completed her post-graduation in Anesthesiology, Ganga Ram Institute of Postgraduate Medical Education & Research, New Delhi in 2007. She was felicitated with the “Best DNB Student Award” for overall excellence during her anesthesia training. She was conferred with the “Best Debater Award” for her talk on medical education on the “World Anesthesia Day” celebrations in Delhi, 2005. She won the “Best Paper Presentation Award” in the National Pain Conference held in Delhi, 2006. She also won the “Best Poster Presentation Award” at National ISA (Indian Society of Anesthesiologists) Delhi Conference in 2011. Dr Uma Hariharan is also a certified, ATLS faculty (Advanced Trauma Life Support, under the aegis of American College of Surgeons, USA) since 2011 and a NELS (National Emergency Life Support, conducted by the Ministry of Health and Family Welfare, Government of India) Instructor. In recognition of her achievements in the field of anaesthesiology, she has been conferred with the prestigious award of “FELLOW OF INDIAN COLLEGE OF ANAESTHESIOLOGISTS” (FICA) in the annual conference of the ‘Indian College of Anesthesiologists' in 2018. Her special areas of interests include pain management, transplant anesthesia and critical care.