Impact of Covid 19 on patient with chemotherapy

1. + C6: “CONCERN,COMBAT,CARE
CONTINUITY IN
PANDEMIC COVID 19 TIMES & CHOICE
AHEAD”
ORGANIZER: SANDRA SHROFF ROFEL COLLEGE OF
NURSING, VAPI
5TH INTERNATIONAL
WEBINAR
ON

2. SESSION-1
“CHEMOTHERAPY
DURING IMPACT
OF COVID 19”
Date:15-7-2020
By: Mallika Vhora
Principal – Muni Seva Ashram
College of Nursing , Goraj. Vadodara.

3. • To have quick look on
COVID-19.
• To know the consequences
of Covid-19 on cancer
patients.
• To discuss the impact of
Covid-19 on cancer patient
with chemotherapy.
OBJECTIVES:

4. • To have quick
look on COVID-19

5. INTRODUCTION
• A viral illness was reported in late December 2019 from Wuhan city of China
which was identified and designated “as novel coronavirus 2019-nCoV or
COVID – 19 OR SARS Cov 2.”
• World Health Organisation (WHO) declared COVID – 19 outbreaks as
pandemic on March 11, 2020.
• India reported its first positive case of COVID- 19 infection on January 30,
2020.
• As a preventive measure, a nationwide lockdown was announced by
honourable Prime Minister on March 24th, 2020.
• As a result of this, routine medical services were modified as per the advisory
issued by competent authorities from time to time.
• https://www.japi.org/w2f4d474/impact-of-covid19-pandemic-on-oncology-practices-
during-nationwide-lockdown-period-a-single-centre-experience-and-the-way-forward

6. • COVID-19 is a major health concern and can be devastating, especially
for the elderly.
• Although much is known about the mortality of the clinical disease,
much less is known about its pathobiology.
• Although details of the cellular responses to this virus are not known, a
probable course of events can be postulated based on past studies
with SARS-cov.
• A cellular biology perspective is useful in explaining the clinical
course by focusing on the areas of the respiratory tract that are
involved.
• Based on the cells that are likely infected, covid-19 can be divided into
three phases that correspond to different clinical stages of the disease
.

7. STAGE-1

8. viruses can be
detected by
nasal swabs
local propagation of the
virus with limited innate
immune response
Although low viral burden.
[Person is infectious]
Super spreaders can
identify.

9. STAGE-2

10. 11
Host innate immune
response responsible for
disease
80% of infected patient,
mild symptoms.
disease restricted to
upper & conducting
airways

11. STAGE-3

13. In Conclusion
NOTE

14. WHY DO SOME PEOPLE GET SO SICK, BUT
OTHERS ARE FINE?
• One of the most problematic features of SARS-CoV-2 infection is the
broad spectrum of disease, ranging from no symptoms to mild flu-like
symptoms,
• Anosmia, fever, nonproductive cough, dyspnea, and fatigue to acute
respiratory distress syndrome, the main cause of death.
• While multiple organs, including the heart, kidneys, liver, and
gastrointestinal tract, are injured.
• It remains to be resolved to what extent tissues are damaged by
infection, hypoxia, or the immune response.
• Complications may also involve the central nervous system, either by
direct infection or secondary damage.
• https://www.ccjm.org/content/early/2020/05/12/ccjm.87a.20047

15. 2. To know the
consequences
of Covid-19 on
cancer
patients.

16. As per the Authors of the Lancet Journal few
consequences of covid-19 in cancer patients are listed
below
1. Fear and insecurity of being infected by COVID-19
2. Risk of morbidity and mortality
3. Collateral Damage
4. Risk of developing complications
5. Interruption in drug supply
6. Chances of cancellation or postponement of cancer treatment and
surgeries
Etc.,

17. • Patients with cancer are a high-risk group in the COVID-19 pandemic.
• Already vulnerable to infection due to underlying illness and often immunosuppressed
status, and are at increased risk of developing severe complications from the virus,
including intensive care unit admission or even death.
• Moreover, for those who develop COVID-19, treatment of the disease were prioritized,
and further cancer therapy delayed.
• Patients with cancer in quarantined cities were unable to travel to appointments or
struggling to obtain essential medicines.
• The risk of interruptions in drug supply chains and consequent shortages exacerbated
this issue.
• Scheduled operations, some types of cancer treatment, and appointments were being
cancelled or postponed to prioritize hospital beds and care for those who are seriously ill
with COVID-19
https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(20)30175-3/fulltext

18. COLLATERAL DAMAGE: THE IMPACT ON OUTCOMES
FROM CANCER SURGERY
• For patients with cancer, delay of surgery has the real potential to
increase the likelihood of metastatic disease, with some patients'
tumors progressing from being curable (with near-normal life
expectancy) to non curable (with limited life expectancy).
https://www.annalsofoncology.org/article/S0923-7534(20)39825-2/fulltext

19. As per WHO:
• Non communicable diseases kill 41 million people each year,
equivalent to 71% of all deaths globally.
• Each year, 15 million people die from NCD between the ages of
30 and 69 years; more than 85% of these "premature" deaths
occur in low- and middle-income countries.
• This situation is of significant concern because people living
with NCDs are at higher risk of severe COVID-19-related illness
and death.

20. Conti.
.• In addition to that WHO reported that More than half (53%) of the
countries surveyed have partially or completely disrupted services for
NCD among which 42% are of cancer treatment. Reason behind that
was declaration of Covid-19 pandemic.
• And the most common reasons for discontinuing or reducing services
were cancellations of planned treatments, a decrease in public
transport available and a lack of staff because health workers had been
reassigned to support COVID19 services.
https://www.who.int/news-room/detail/01-06-2020-covid-19-
significantly-impacts-health-services-for-noncommunicable-diseases

21. As per Deepak Sundriyal- Assit Prof., Medical Oncology
Haematology, AIIMS: Uttarakhand
• COVID–19 pandemic has created a cosmopolitan risk of morbidity and mortality,
and it has become a double-edge sword for cancer patients as well as clinicians.
• On one end, cancer patients are more vulnerable to severe illness and death.
• He mentioned that Early reports from China stated that patients with malignancy
affected by COVID–19 had a fivefold risk of severe events (a composite endpoint
defined as the percentage of patients being admitted to the intensive care unit
requiring invasive ventilation, or death) as compared to patients without
malignancy.
• They also demonstrated poorer outcomes from COVID-19 in malignancy patients

22. Conti…
1 A possible role of increased susceptibility to COVID–19 infection played
by immunosuppression frequently seen in malignancy patients cannot be
negated.
2 On the other end, delaying malignancy treatment could lead to poorer
oncological outcomes.
Delaying cancer surgeries can lead to upstaging and some tumors could
lead to obstruction, perforation, risk of bleeding, organ failure or
metastasize.
Similarly, delaying neo-adjuvant and adjuvant chemotherapy could lead to
upstaging or relapse of the tumor.
Delaying palliative chemotherapy could lead to worsening of quality of life.

23. • In country like India dedicated centres providing cancer treatment are
in very limited numbers.
• Many patients travel from one state to another for the same.
• Evaluation and planning of treatment for a cancer patient is a lengthy
process and requires multi-modality inputs and multiple visits.
• Treatment itself is delivered in multiple steps and cycles.
• Regular follow up is an essential component of cancer care.
• It has to be kept in mind that curative intent treatment should not get
compromised

24. 3.To discuss the
impact of Covid-19
on cancer patient
with
chemotherapy

25. An article published in The Health World from The Economics Times
on April 21, 2020, 12:59 IST
• The author Aiman Khan mentioned that: At New Delhi At a time
when hospitals were busy dealing with the COVID-19
cases, cancer patients were facing immense hardships as their
treatments and surgeries have been postponed.
• Those who visited the hospital for the treatment during pandemic
were feeling helpless as they were stranded due to the
continuing lockdown.
• Ritiraj from Bihar said that his mother was undergoing treatment of
cancer and she was on chemotherapy. "However, chemotherapy
treatment could not planned due to lockdown and her treatment
may begin after the corona phase gets over. She was being given
only oral medicines

26. Dr Shyam Aggarwal, a cancer specialist in Gangaram hospital, said:
• "We cannot stop those who are undergoing chemotherapy, but we
can only give them oral medicine for some time."
• "We also suggesting chemotherapy patient to first go for COVID-19
test, because if one tests positive for coronavirus and we gave them
chemo then it will be harmful to the person," he said.
https://health.economictimes.indiatimes.com/news/diagnostics/delhi-cancer-patients-
facing-hardships-as-hospitals-are-busy-dealing-covid-19-cases/75266051

27. What if you skip chemotherapy during this lockdown? Merillife Blog
In the NEWS Meril life blogged that:
• Ideally, one should never skip any chemo procedure but if patients have
missed it due to this lockdown one can’t really do anything.
• So, normally up to 3 months, Patients can have altered treatment.
• If the gap increases more than 3 months, between 2 consecutive cycles
than the therapeutic benefits may lost in cancer patient .
• So in blog Meril life advised that be in touch with Onco- consultant and try
arranging at a nearby hospital as per his guidance.
https://www.merillife.com/blog/in-the-news/impact-of-covid-19-on-cancer-
patients

28. The impact on Chemotherapy patients
The impact of convid 19 Pandemic on chemotherapy
patients are been taken from few published articles in past
few months

29. 1. Mary Lloyd, with her family outside a cancer centre in Sydney on the first day of her
chemotherapy treatment.(ABC News)
• Mary says:(producer and Journalist of ABC news)
• “Last year I was diagnosed with breast cancer.
• I had it removed and am now enduring four months of chemotherapy to keep me cancer-free. I'm
seven weeks into my treatment and every time I receive a dose of the cancer-killing stuff, it also
knocks out part of my immune system.
• Last week, I picked up a viral throat infection from one of my kids and ended up at Sydney's St
Vincent's emergency department after the symptoms escalated worryingly. It was a real wake-up
call.
• If I'm to fight off a viral infection, it is my lymphocytes I'll be relying on.
• The normal range for a healthy person is a count between 1.5 and 4. When my blood was tested
halfway through my third chemo cycle, it showed my lymphocyte count had dropped to 0.6.
• A reading that low does not mean I have no immune system to rely on, but it does leave me genuinely
concerned that if I contract COVID-19 I might not be among the group who experience only mild
symptoms.
• I am by no means the only one with this worry.
https://www.abc.net.au/
news/2020-03-
15/cancer-chemo-and-
coronavirus-dont-be-
flippant-with-
covid19/12056582

30. As per the article published online in Lancet journal
(April 28)”
• COVID-19 outcomes in patients with cancer have resulted in the community being fearful of giving
effective anticancer treatments.
• These studies concluded that cancer patients are not only more susceptible to contracting the virus
compared with the general population, but also at risk of developing more severe sequelae.
• To clarify the relationship between cancer, anticancer treatments, and COVID-19, larger-scale
datasets are necessary.
Dai MY, Liu D,Liu M et al.Patients with cancer appear more vulnerable to SARS-CoV-2: a multi center study
during the COVID-19 outbreak.Cancer Discov. 2020; (published online April 28.)
DOI: 10.2139/ssrn.3558017
• https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31173-9/fulltext

31. • Cancer patients on chemotherapy often have to travel to a hospital, clinic or infusion center for
regular treatments.
• But those concerned about exposure to the coronavirus may have another option:
• Taking chemotherapy at home in pill or liquid form.
• Taking an oral medication instead of traveling to get an or injection or an infusion may seem like a
good option for a cancer patient who is in isolation or trying to avoid going out, but realize there are
some pitfalls.
• “While there may be an oral option for systemic anti-cancer drug delivery in certain clinical situations,
it is important that patients understand both differences in potential side effects as well as any
specific financial implication for them resulting from a change from systemic to oral treatment,”
says Maurie Markman, MD, President of Medicine & Science for Cancer Treatment Centers of
America® (CTCA).
Patient shifted to Oral chemotherapy

32. Here are some issues to consider with Oral
Chemotherapy(ACS)
• The chemotherapy required to treat your cancer may not be made in a pill or
liquid oral dosage
• Chemotherapy drugs may be very toxic, and bodily fluids may be, too, after
taking them.
• Some medications need to be stored carefully and may require to wear gloves
while handling.
• Patients should consider whether they can handle these medications safely
• Oral medications may cost more. Check on the cost of the medication and
whether it’s covered by insurance.
• Some medications have strict instructions on when they need to be taken.

33. • Chemotherapy drugs differ in the side effects they may cause. Some
patients may find it difficult to take pills they know will make them sick,
but they don’t tell their doctors.
• In many cases, medicines or supplements are required to deal with
side effects. The number of pills can be overwhelming, causing
patients to lose track of when or whether they have taken their pills.
• One should not skip treatments. If patient want to consider a switch
from infusion to an oral chemotherapy, it’s important that patient
maintain a treatment schedule until that switch is made. Again need to
Talk to oncologist about how to transition from one drug to another.

34. Negative impact on patients
• In U.K. news :Professor Gordon C Wishart, Chief Medical Officer at Check4Cancer says that:
delay in cancer diagnosis can lead to patients ultimately requiring more treatment and
having a worse prognosis and in certain cases, losing their chance of survival.
• Therefore, the longer that the coronavirus is allowed to reduce access to timely cancer
diagnosis and treatment, the greater the negative impact on patient outcomes.
• It is likely that this scenario will be similar for other common cancer types and many other
acute healthcare interventions that are currently being rationed or cancelled.
https://ecancer.org/en/news/17643-cancer-treatment-delays-could-increase-death-rates-due-
to-impact-of-covid-19-pandemic-on-uk-hospital-capacity

35. At the end take home message
• Every attempt should be made to consider oral therapy wherever feasible.
• Oral therapy may be advised for 2 or 3 cycles in a single visit with interval
evaluation done via teleconsultations or electronic means.
• Every attempt should be made to provide BSC at a patient’s home or a
nearby facility.
• This may require frequent teleconsultations with the patient’s caregiver and
family or local physician.
• A comprehensive discussion should be done with the patient’s caregiver in
this regard.

36. • Follow up visits in person should be limited and at longer intervals.
• Telemedicine or electronic communication should be emphasized if
patients general condition is fair and investigations do not suggest a
change in advice.
• Restrict the manpower of healthcare staff directly involved in patient care
to bare minimum.
• Needless to say, basic hygiene, the use of protective equipment, and social
distancing should be a norm.
japi.org/w2f4d474/impact-of-covid19-pandemic-on-oncology-practices-during-
nationwide-lockdown-period-a-single-centre-experience-and-the-way-forward