In a country where a majority of patients are diagnosed in later stages of the disease, the outbreak is further hampering diagnosis and treatment.
By Dr Vedant Kabra
45 year old Ayesha (name changed), a resident of a small town in west Uttar Pradesh, first spotted a tiny painless lump in her breast in April this year. However, the COVID induced lockdown and a fear of catching the infection in healthcare settings prevented her from seeing a doctor. Even when the lockdown was lifted, her family was too scared to travel to Delhi to seek medical consultation. By the time she reached an Oncologist 4 months later, her aggressive cancer had already hit stage 3, diminishing chances of her survival.
Unfortunately, Ayesha is not a lone case of a seriously ill patient being deprived of timely treatment due to the coronavirus pandemic. While we will never be able to collate data of how many such patients suffered delayed diagnosis and treatment this year, it is evident that the number is significant. Patient attendance in Oncology OPDs fell significantly in the initial months of the pandemic. Number of new diagnoses continued to remain relatively low even several months after the total lockdown had been lifted.
Breast Cancer Now, a British charity organization, estimated that due to COVID 19 almost a million British women had missed a breast cancer screening appointment. This might have led to thousands of cancers going undetected. For a country like India where a majority of breast cancer diagnoses still happen in later stages of the disease, the COVID outbreak has further hampered diagnosis and treatment, and is likely to negatively impact survival rates from the disease.
Rising disease burden in India
Breast cancer is today the most common type of cancer in women and accounts for an estimated 28% of all cancers in Indian women. In fact, a woman is diagnosed with breast cancer every 4 minutes while a woman dies of this disease every 13 minutes in India. In 2018, breast cancer is estimated to have claimed as many as 87000 lives in India. The incidence of the disease has increased dramatically over the last 25 years due to multiple factors including increasing urbanization, adoption of unhealthy lifestyles (smoking, junk food etc), rise in obesity, drop in physical activity levels, delayed age of childbearing and reduced breastfeeding.
India also has a high mortality rate due to breast cancer because a majority of patients in India are still diagnosed in late stages of the disease and a significant proportion of patients
not being able to get appropriate treatment. Apart from low survival rates, another worrying trend is an increasing incidence of breast cancer in younger women – nearly half of the patients in urban India are less than 50 years of age.
Lack of awareness about symptoms, lack of screening program, taboo and embarrassment are main reasons behind delayed diagnosis as well as resultant high breast cancer mortality in India. Unfortunately, the prevailing situation due to a worldwide pandemic has impeded diagnosis and treatment of a number of non COVID diseases including breast cancer. Already a neglected subject, women’s health has further been relegated to the backburner as families delay medical consultation and avoid visiting healthcare facilities or undergoing regular disease screening.
Pandemic or not, do not put health issues on the backburner COVID 19 is a long term problem which is likely to stay with us in the near future.
While containing the pandemic and ensuring treatment of all infected must be a high priority, adequate policy measures also need to be taken to ensure that other serious diseases are not neglected in the process. Governments as well as healthcare providers both have a role to play in doing this. It is important to educate people about not neglecting their non-COVID health conditions and prevent interruptions in treatment modalities. It is equally important to ensure continuation of unimpeded non COVID services in hospitals while also inducing confidence among people about the safety of hospitals and OPDs.
Thanks to advanced diagnostic and treatment modalities, survival rates of breast cancer patients have increased significantly. While survival depends on a number of factors such as the type of cancer, stage at the time of diagnosis, quality of treatment, in the US it is estimated that up to 90% of women survive five years of diagnosis and 84% manage to survive 10 years 4 . However, in India, the survival rates remain abysmally low for reasons mentioned above. Increased awareness & health literacy, regular screening after 40 years of age, adoption of healthy and active lifestyle sans smoking or excessive drinking, timely and appropriate treatment can help improve survival rates in India as well.
New age technologies can help navigate the COVID pandemic
Adoption of new age technologically advanced methods further help improve quality of life of patients by Surgical treatment of breast cancer does not mean removal of the whole of the breast in all patients; it is possible to offer breast conservation surgery in nearly 60-70 percent patients either upfront or after chemotherapy. Similarly, complete removal of armpit nodes, a procedure done routinely in all patients until a couple of decades ago, has given way to sentinel lymph node biopsy in which only a few nodes need to be tested for presence of tumor. If these sentinel nodes are not involved by cancer, one does not need to remove the remaining nodes thus bringing down the rate of shoulder dysfunction as well as lymphedema (swelling of the arm) significantly. Similar to surgery, personalized systemic therapy (chemo, hormone, immune and targeted therapy) has enabled us to avoid more toxic treatment in patients with a good biology tumor. Two patients with the same size of tumour can have very different outcomes. New age prognostic tests help predict the risk of cancer relapse in early stage breast cancer with high degree of accuracy stratifying patients into low & high-risk, based on their tumour biology. Those patients who fall into low-risk have very limited risk of relapse and may be able to avoid chemotherapy.
Cancer patients are at a higher risk of COVID-19 infection as well as its complications because of their immunosuppressive state as a result of disease itself as well as due to chemotherapy. These prognostic tests that can help them avoid chemotherapy, if used judiciously, can kill two birds with one stone – patients can avoid chemotherapy which is immunosuppressive, and avoid visits to the hospital to undergo chemotherapy.
Radiation therapy has also gone a complete metamorphosis over decades and modern machines enable us to deliver more precise radiation (thus sparing adjacent organs like lungs and heart from high dose of radiation) and in a shorter interval of time (as less as two weeks as compared to the usual five weeks in selected group of patients). While coronavirus is a serious pandemic, it must not make you neglect your overall health, compromise on your regular check-ups and doctor consultations or delay cancer treatment. Of course, all your hospital visits must be undertaken with complete
(The author is MS DNB MRCS(Edin) MNAMS FIAGES Head, Department of Surgical Oncology, Manipal Hospitals Dwarka. Views expressed are personal.)