The Covid-19 pandemic has certainly increased our anxiety levels over the possibility of being infected with this new coronavirus.
Current data shows that all cancer patients and older people, particularly men, are at higher risk of Covid-19-related mortality.
Cancer treatment weakens the immune system, making patients more prone to acquiring infections.
In fact, for those who are currently seeking treatment, walking into a hospital may itself be a risk.
Flying for treatment
This is one of the concerns metastatic breast cancer patient, Sew Boon Lui, who was diagnosed in 2006, has.
“After all the necessary treatments – surgery, i.e. left breast mastectomy, 20 sessions of radiotherapy, eight cycles of chemotherapy, plus five years of hormonal oral medication, my cancer went into remission.
“I continued with regular/annual check-ups and all went well, ” shares the 53-year-old, who lives in Kuching, Sarawak.
However, in 2017, she experienced unexplained chest pain and an occasional dry cough with difficulty breathing deeply.
Upon further investigation and diagnosis, she discovered the cancer had invaded her right lung, liver and some parts of her spine. The news came as a shock.
Drained from the emotional roller coaster, she sought support from family and friends, and her faith, to pull through hard times.
She says, “However, this time, I was blessed to have the endocrine targeted therapy drug that worked for me.”
Sew, who is originally from Johor Baru, is presently being treated at the Sarawak General Hospital in Kuching.
Last month (March 2020), her oncologist discovered that one particular tumour in her liver was growing aggressively and not responding to the microwave ablation procedure carried out last October.
She was recommended to seek stereotactic body radiation therapy (SBRT) in Kuala Lumpur as the treatment is not available in Kuching.
Despite the MCO already being in place, Sew had no choice but to take her supporting medical letter and fly out alone on March 19 (her husband had to work and her two children are in university) to consult the doctor the same afternoon.
Understandably, her main worry was whether she would get infected with Covid-19 during her travels and at the hospital.
When she arrived, the private hospital insisted that she take the Covid-19 test, causing her appointment to be rescheduled to two days later.
Thankfully, the results came out negative.
“With my doctor’s advice, I took all the necessary precautions, including wearing a mask, isolating myself in the hotel room when not in the hospital and practising the highest possible standard of hygiene.
"I didn’t meet any friends or family, including my own sister!
“So, with all this in place and with the hospital practising social distancing in all areas, I think I’ve done all I can to put my worries at rest.
“I completed my sessions the following week and flew back to Kuching on March 29. The monitoring can be continued in Kuching, ” she shares.
To her relief, the return flight was only half full. “Nevertheless, I had to pay an exorbitant airfare for a one-way ticket!” she says.
Sew is still serving the state government’s 14-day Stay Home Notice (which should end today) and reports on a website twice a day.
Deciding case by case
Covid-19 is a new disease, so doctors do not have a lot of specific information on the novel coronavirus or the disease for cancer patients.
The US Centers for Disease Control and Prevention (CDC) is constantly updating its guidelines and it suggests that “elective surgeries” at in-patient facilities be rescheduled if possible.
The American College of Surgeons guidelines (as of March 24,2020) recommend clinicians and patients make individual determinations based on the potential harms of delaying necessary cancer-related surgery.
In many cases, these surgeries cannot be considered “elective” as a delay in treatment could mean an incurable advance in the cancer.
According to consultant clinical oncologist Dr Malwinder Singh Sandhu, new patients need to be evaluated on a case-by-case basis, based on the urgency of the situation, following discussion with the multidisciplinary care team.
“Examples of non-urgent cases that may be delayed for up to two months include prostate cancer patients or certain breast cancer patients, e.g. those with hormone receptor positive tumours.
“Care must be taken to avoid delays in consultation and treatment that may adversely affect potentially curable cancer patients.
“Palliative care patients may experience delays, with the exception of life- or function-threatening situations, e.g. spinal cord compression, ” he says.
Aside from new patients and those needing urgent treatment, there are two other categories of cancer patients visiting hospitals.
These are patients who are on surveillance, i.e. patients with early stage cancer who do not need active treatment, and patients who have completed their treatment and are now on follow-up alone.
“For these groups of patients, most hospitals are converting their clinic visits to phone calls or video calls.
"Another alternative is to delay the appointment until the MCO is over, ” he says.
For patients who are not on immunosuppressive therapy, but are instead on medications like hormonal treatments for breast and prostate cancer, which do not require regular blood-taking or follow-up, Dr Malwinder advises them to stock up an extra month or two’s worth of medications to avoid frequent visits to the hospital.
As for patients who are on systemic immunosuppressive anti-cancer therapy such as chemotherapy, targeted therapy or immunotherapy, which require constant monitoring, he says that decisions on continuing chemotherapy should be based on the goals of care, patient tolerance and the risk of infection.
“The risks and benefits should be weighed, i.e. the potential harm that might arise from delaying treatment versus the risk of contracting Covid-19 while on treatment.”
Dr Malwinder notes that stopping treatment may be an option for patients in remission who are receiving maintenance therapy.
Switching chemotherapy from intravenous (IV) to oral (by mouth) medications is also an option, as that would decrease the frequency of hospital visits for the patient.
Other factors that oncologists need to consider are that:
- Delaying or modifying cancer treatment may pose a higher risk of compromised disease control and long-term survival in certain settings, compared to others.
- Risk of infection with the coronavirus may be considered as an additional factor when weighing the different treatment options for the patient in cases where the absolute benefit of chemotherapy may be quite small, and where non-immunosuppressive options are available (e.g. hormonal therapy in early stage breast cancer).
- Prophylactic growth factors used in high-risk chemotherapy regimens and prophylactic antibiotics may be of potential value in maintaining the overall health of the patient and making them less vulnerable to potential Covid-19 complications.
However, patients who are undergoing radiotherapy, which suppresses the immune system less than systemic anti-cancer therapy, require daily visits to the hospitals.
“Again, a discussion needs to be held between the patient and the oncologist regarding the magnitude of benefit versus risk of contracting Covid-19 during daily travel.
“Some radiotherapy treatment can be delayed if the benefit is small.
“There are also many new recommendations from the United Kingdom to shorten the radiotherapy fractionation without jeopardising the benefit.
“Another choice would be using SBRT, ” he explains.
Besides the general public health recommendations issued by the Health Ministry, cancer patients must also take additional measures to stay healthy.
Dr Malwinder says, “The most important precaution that they should adhere to is to stay home and avoid close contact with people who are sick.
“Washing hands often, along with cleaning and disinfecting frequently touched surfaces, should also be a priority.
“They should also make sure that they have access to several weeks of medications and supplies.
“If going out to public areas becomes unavoidable, then try to avoid crowds and practice safe distancing.”
Some cancer patients describe the pandemic situation as being in a prison within a prison and find it deeply depressing.
To lift up their spirits, he gives the following advice.
“Everyone reacts differently in a stressful situation. How a person responds depends on his background, the person himself and the community he lives in.
“This is a good opportunity to spend time with your loved ones as most people are at home during the MCO.
“Most telecommunications operators are giving free data, so spend some time watching your favourite dramas or movies online, but do be careful of unproven/fake information on the pandemic.
“Hearing about the pandemic repeatedly can be upsetting.
“Worrying thoughts are normal, and they will come and go. Try to keep your worries in perspective.
“Remember that nothing lasts forever and that this too will pass.
“Always remember that you have faced threats in the past, especially the threat of cancer and have overcome it.
“Take care of your body by taking deep breaths, stretching or by meditation.
“Try to eat healthy, well-balanced meals, exercise regularly and get plenty of sleep.
“Connect with others, talk with people you trust such as cancer support groups or Befrienders about your concerns and how you are feeling.”
Sew, who is a co-founder of the Society for Cancer Advocacy & Awareness Kuching, keeps herself motivated by giving talks and sharing her journey with other cancer patients.
“I got motivated with the realisation that I have something valuable to offer people even when I was undergoing treatment.
“So, I stopped working in 2017 and took on a new calling in my life to help other patients when someone refers them to me, ” she shares.
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