Understanding Cancer and Coronavirus - Dr Senthil Jagannathan Rajappa

Senior Consultant and Head, Dept. of Medical Oncology at BasavatarakamIndo American Cancer Hospital and Research Institute, Dr Senthil J Rajappa’s work has led him to become one of the best cancer-care doctors in town. He has been named Inspiring Oncologist 2020 by Economic Times, and last year he won the Clinical Excellence in Medical Oncology Award from the Indian Medical Association, Telangana State. Dr Senthil speaks to us about COVID-19 and its impact on oncology care in Telangana and India.

How much has cancer care been affected due to COVID-19 in India? What are some of the key consequences?
Like any other speciality in medicine, cancer care has been affected significantly. The biggest issue patients face at the moment is not being able to travel to hospitals for their treatment. Things are improving now, but the problem still continues. It has mainly affected surgeries; we have tried to reschedule surgeries for patients. We are also trying to prioritise and make sure that cancer care is not compromised. At the same time, we need to avoid overwhelming the systems that are now burdened in addition to treating COVID-19 cases.

The continuity of care for patients who are on active treatment has been interrupted, with patients missing their  appointments over the past couple of months.Some patients have worsened to a point where they have become non- salvageable, while others have been able to get back on track. According to what has been modelled in the Western world, all the missed diagnoses and treatments are likely to reflect in an increase in mortality in the years to come. We are also likely to face a similar situation.

Are there ways for these patients to cope with this issue?
Once the patient has missed the treatment, it’s missed forever, and one can’t do anything about it. Cancer is not a disease that’ll wait for you. For patients who are being treated with curative intent, delays are likely to compromise on the cure rates. If the cancer relapses and spreads to other parts, then the opportunity to cure it is lost. This is the group of most concern, and the situation is worrisome. The impact is likely to be less profound in patients with advanced cancers which are incurable, and the intent of therapy is comfort and prolongation of life.

As good cancer hospitals tend to be located in the cities, how can people from rural areas or small towns continue their treatments while following the protocols issued by the government?
The situation is beyond anyone’s control. We have tried to direct these patients to smaller centres near their towns where at least a part of their treatment can be delivered. There are many factors involved here. Certain treatments like radiation therapy cannot be done in smaller towns. These treatments require infrastructure and expertise and can’t be delivered remotely.

Since coronavirus primarily attacks the respiratory system, what precautions and measures should patients with lung cancer take? Are they more prone to the virus?
In terms of being prone to coronavirus, you, me, or a cancer patient are no different; we all are equally prone. The question is, if we contract the virus, are cancer patients more prone to suffer from complications? From that standpoint, cancer patients have a higher chance of developing complications secondary to infection. This is compounded by the fact that a significant proportion of cancer patients are elderly people who have diabetes, cardiac disease, hypertension, among other health issues. Some cancer patients are smokers too. All these factors are independently associated with a higher risk of complications and death from the infection.

The mortality seems to be higher in patients with lung cancer compared to other cancers. The diagnosis of COVID-19 in these patients can be difficult. There is a lot of overlap in symptoms and findings on an X-ray or CT- scan. Preexisting lung damage due to smoking can complicate this further. There is nothing specific they can do other than taking the universal precautions we talk about. 

Are cancer patients who come in for surgery tested for COVID-19? If they are asymptomatic and go through a surgery, can it lead to complications?
One of the things we need to do aggressively is to test, which we haven’t done so far in our country, particularly in Telangana.It is appropriate to test before doing any procedure in the hospital, since the patient who is an active case of COVID has a higher chance of procedure-related complications. It is also important to test so that adequate protection is taken by all healthcare workers, and the virus is not passed on to other patients and their caregivers.

In an ideal world, they should be tested first, but it is difficult to do this in reality. Facilities that are available in the city and state in general, do not provide adequately for testing. There are not enough labs, the turn around time is too slow, and sometimes the tests are unaffordable and beyond the reach of patients who generally come to trust hospitals like ours.

We do a chest CT scan in patients who are unable to get the COVID test done. If patients have some shadows that are suspicious of COVID, we postpone the procedure for a while unless it is an emergency. That’s the next best step to having a COVID test done.

Having a normal CT scan does not rule out the possibility of an asymptomatic COVID-19 infection. But this is the reality, and it’s important to explain this to the patient clearly before we put them through any procedure.

What should cancer patients do if they have COVID-19 symptoms?
Get in touch with a physician or specialist, and be aware that their chance of having complications is higher. The situation does not warrant hospitalization for everybody. From registry data in the West, about 60% of cancer patients can be very well managed at home, and others are likely to need hospitalization. Those who are admitted will be monitored as needed. But for those at home with the infection, they can keep in touch and provide updates. If we feel they need to be in the hospital, they can come in.

How is the oncology department coping with the waiting list for surgery and chemotherapy?
Fortunately, we don’t have a big waiting list. There are a few waiting for surgeries, but for chemotherapy and radiation therapy, there isn’t a waiting list in our facility. If you are on a waiting list and not able to get to the operating table, we always look at what else can be done in the interim. There are situations where we precede these surgeries with some chemotherapy and radiotherapy and make sure the cancer remains under control; the patient can have the surgery at the appropriate time, making sure the outcomes are not compromised. We need to determine who needs it immediately, and who can come back later, mostly depending on their stage of cancer. 

Can patients undergoing chemotherapy do anything to boost their immune systems during the pandemic?
Keep yourself active, practice yoga and meditation and maintain a healthy diet. Being active is an important part in keeping healthy. There is nothing different that they need to do. All the vitamins that are being promoted as immune-boosters are not backed by scientific evidence. Sleep adequately and stay positive.

Since most hospitals are full and no beds are available for coronavirus patients or those  with other health issues, what can be done to empower the hospitals?
That’s a problem everybody is concerned about. There is no one-stop solution, but I think it would be useful to have data about where and how many beds are available for COVID-19 or other patients. That way, people will know where to seek help when necessary. It’s imperative for us to find a bed or whatever is needed to take care of patients if they are already being treated at our facility. We have to juggle between our resources to find a place for them. It’s a challenge, but we need to go that extra mile for our patients so that we can help them. One of the things the government can do is empower hospitals to do the test, and to fast track certifying hospitals to be able to do so. This will help expedite patient care faster and better.

The lockdown is lifted, and the cases have increased. What do you feel can be done to contain the virus in our country?
I have a feeling that the pandemic won’t continue for too long and that everything will be restored to normal. It might become a little worse, but eventually it will end. However, if it continues, we will learn to live with it; hospitals and health systems will find innovative ways to deliver health care. Things will evolve in such a way that we will do as much as possible without making our patients go through hardships. And hopefully, the vaccine will come in another year or so. Herd immunity is something everybody talks about, but I am not too sure we are anywhere close to that

I think the vaccine will ultimately be the solution. Most people think nothing will happen to them, but eventually, it might. We need to keep hammering away that the best way to stop this is to ad here to universal prevention guidelines.      –Srivalli