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Cancer Care at Stake in Low- & Middle-Income Countries

Balakrishnan, Vijay Shankar

doi: 10.1097/01.COT.0000749948.96214.8e
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Avinash Shankar, MD, a retired endocrinologist in New Delhi, India, was diagnosed with squamous cell carcinoma of the pyriform sinus in December 2018. Even cordectomy and postoperative radiotherapy did not help and, since March 2019, he was on palliative chemotherapy to which he was responding well—even showing partial response on PET-CT after 3 cycles. Shankar was due for PET-CT after completion of 5 cycles of chemotherapy in January 2020.

“Sixth cycle was not planned in view of toxicities, but he had urinary tract infection in February and was managed at home with antibiotics, analgesics, and antipyretics until mid-March,” said Abhishek Shankar, his son. When his father was ready for the next PET-CT and further prognosis, on March 24, 2020, the Prime Minister Narendra Modi announced the world's largest nationwide lockdown for COVID-19 management. A practicing radiologist at Lady Hardinge Medical College, New Delhi, India, Abhishek Shankar was able to clinically manage his father at home when the lockdown prompted rerouting health care services for “COVID hospitals.”

“When it was hard for me to see every day in our house where I was vigilant and observant about every inconvenience father has been facing, as a physician I am glad I was able to help. However, I am not sure about other cancer patients where most of them have limited access to resources than I do,” Abhishek Shankar noted.

Patients like Avinash Shankar are now more common to be seen worldwide. As of June 2020, per the survey of 155 countries by the World Health Organization, ministry of health staff working in the area of non-communicable diseases in 94 percent of the respondents were partially or fully reassigned to support COVID-19. About 42 percent reported partially or completely disrupted services for cancer treatment and over 50 percent reported a widespread postponement of public screening for breast and cervical cancers.

Reasons for reducing services were cancellations of planned treatments, less frequent public transport facilities, and shortage of health workers. In about 20 percent of the countries that reported disruptions, one of the main reasons for discontinuing services was shortage of medicines, diagnostics, and other care facilities. Though COVID impact on non-COVID care is global, the low- and middle-income countries (LMIC) are the hardest hit.

Many parts of Africa and the poorest regions of Brazil such as the Amazonia have high burden of cancer in these regions, and yet roiling poverty as well as lack of transportation added to the public fear of catching COVID has greatly reduced the number of people appearing for screening, diagnosis, and treatment in these countries.

“The northwest Brazil has been affected harder than the south in this regard since the public health system in Brazil is in imbalance across the country and is severely impacted in poorer regions,” said Leandro Colli, MD, PhD, Assistant Professor of Medical Oncology at University of São Paulo, Brazil. “That the government is not being transparent with the health data is making the situation worse,” he added.

Per a recent report, the average number of cancer diagnoses has plummeted considerably in all Brazilian regions since the start of the pandemic, say about 15,000 undiagnosed cases per month (Semin Oncol 2021; https://doi.org/10.1053/j.seminoncol.2020.12.002).

While in Africa, a continent that has already been through a growing cancer rates, compounding to the lack of personal protective equipment and facilities in many regions of the continent, the public fear was at the highest towards catching COVID and hence the cancer care was at severe stake.

“Because of these reasons, we are seeing significant drop in screening, diagnosis, and treatment for malignancies such as breast and cervical cancers,” said Prebo Barango, MSc, at WHO Afro, Harare, Zimbabwe. A recent report confirms that Africa, home for several low- and middle-income countries, has suffered worse cancer management amid the pandemic compared to higher income countries such as the U.K. and the U.S. (Science 2021; doi: 10.1126/science.abd1016).

Notwithstanding all these situations, selected countries including Zambia in Africa and India, have been adopting positive measures and telemedicine to manage at least a bit better. For instance, the Tata Memorial Hospital has been managing COVID-19 patients as well as cancer patients at the same time.

Another example is Japan. Though cancer has been known to be the leading cause of deaths in Japan, the Ministry of Health rerouted services to COVID management. In Tokyo, the COVID-19 lockdown was issued from April 7 to May 25, during which time the National Cancer Center Hospital (NCCH) was accepting COVID-19 patients, limiting the diagnosis and treatment of cancer patients.

“Cancer Screening Center at our hospital was completely closed; however, our endoscopy center limited to provide emergency endoscopy and diagnostic/treatment endoscopies,” said Takahisa Matsuda, MD, endoscopist at NCCH in Tokyo, Japan. “However, even in such a situation, we made an effort to continue to treat cancer patients as much as possible while paying attention to the risk of COVID-19 infection,” he added.

Whereas in India, telemedicine practices to manage difficult cases remotely and even administration of chemotherapy under tele-hand-holding came into the management of cancers (Cancer Treat Res Commun 2021; https://doi.org/10.1016/j.ctarc.2021.100313). However, Abhishek Shankar and colleagues are warning that India, like many other LMICs, is not prepared for a post-pandemic shock of cancer burden since the care nowadays and after the pandemic is expected to be a major challenge (Asia Pac J Oncol Nurs 2021; doi: 10.4103/apjon.apjon_57_20).

Though there is no apparent prioritization for cancer patients in India for vaccination against COVID-19, national guidelines suggest different timelines for people under various levels of cancer care in order for themselves to be free from COVID-19, if not cancers.

Vijay Shankar Balakrishnan is a contributing writer.

A Comparison Example From a Developed Country

According to the Cancer Research UK (CRUK), as of June 2020, around 2.3 million people in the U.K. were waiting for a cancer screening test following 11 weeks of lockdown across all the screening programs (breast, bowel, cervical); a third of cancer surgeons had to stop cancer surgeries completely; and as of mid-April around 126,000 patients were unable to participate in charity-funded clinical studies.

“Essentially what we need to do is to reinvigorate confidence in the health care system so that patients seek medical advice promptly, and GPs and primary health care workers feel safe and confident to see them and to refer them up to secondary and tertiary care in a safe and COVID-protective environment where they are less likely to acquire the infection in the nosocomial manner,” said Charles Swanton, FRS, FMedSci, FRCP, CRUK's Chief Physician.

However, recent numbers showed an 8 percent reduction in the number of patients starting treatment compared with January 2020. This is a bigger drop than in October-December 2020 (3-6% reductions), and the same as the fall in September 2020. Urgent suspected cancer referrals were around 2 percent up on previous year figures in November and December 2020, but then down by 2 percent in January 2021.

“Whilst it's positive that urgent referrals did not plummet as they did in the first wave, these January figures show that the pandemic continues to have a devastating impact on cancer patients,” said Michelle Mitchell, OBE, Cancer Research UK's Chief Executive. “Some patients faced cancellations to their cancer surgery, and this appears to be reflected in the figures.”

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