Anger and Distress of a Curable Gastric Carcinoma Patient Becoming Incurable: A Dilemma of a Pandemic

INTRODUCTION

A pandemic due to the newly emerged coronavirus that initially affected parts of China has become widespread and affected the whole world.[12]

Because of lack of immunity in the population against the novel virus, it has varied levels of severity among different persons. It is also suggested that people with preexisting comorbidities such as cardiac conditions, diabetes, and cancer have a heightened risk of complications with the infection. People with severe infection commonly present with respiratory failure, sepsis, kidney injury, and even death.[3]

In the present pandemic scenario, major elective surgeries including oncological surgeries have also been postponed. The reason for this consensus is thought to be the need to free up hospital beds and ventilators and infrastructure for COVID patients. Furthermore, it is seen that COVID infection in the perioperative period leads to exaggerated morbidity and mortality.

We, in the present case report, present the agony of a middle-aged female who was diagnosed with early-stage cancer but progressed to an advanced disease due to delay in her surgery because of the pandemic. This case report highlights the indirect harms caused by the pandemic to the health of patients with other comorbidities.

CASE REPORT

A 52-year-old female who recently recovered from a myocardial infarction following a coronary angiography and stenting was not fortunate enough to be in good health thereafter. She developed symptoms such as pain upper abdomen, feeling of fullness even with small meals, and loss of appetite just 1 month after her stenting. Perplexed by her symptoms, she visited the hospital in January 2020. She underwent a battery of investigations including an upper gastrointestinal endoscopy which suggested a growth at the lower end of the stomach compromising the gastric outlet. After having a tissue diagnosis of adenocarcinoma stomach, the patient was devastated and worried about the outcome the disease will have for her. The patient developed a ray of hope when she was planned for surgery considering the localized nature of the disease. She was informed that an early diagnosis and treatment will have favorable outcomes for her. She was scared by the outcomes and extensive nature of the surgery but still hoped to get through it and be better.

However, when her surgery time neared, the country had been hit by the pandemic. Because of the few people being diagnosed of coronavirus, the hospital where her surgery was planned decided to put on hold major elective surgeries to avoid the risk of coronavirus to patients. She was informed that her surgery was canceled to avoid any risk to her health considering her high risk for complications because of the pandemic. She recalled that she felt like the floor slipped off from under her. Her caregiver stated that they understood that the decision of postponing of surgery was in their favor, but they were distressed by the fact that what if it progressed. Their mind kept wondering if there was some way that they could get the surgery done and still did not get the infection. They were advised certain home-based medications for the disease to tide over some time.

After 1½ months of this, the patient presented in the emergency department of our hospital with progressively increasing dysphagia, multiple episodes of vomiting, and significant weight loss. On initial stabilizing, a scan was done which suggested complete gastric outlet obstruction along with metastatic spread to the liver. It was informed that all that could be done for her in the present situation is a feeding jejunostomy to help her intake of food. Because in the present cachexic situation, it will take her some time to build up before she can tolerate a chemotherapy. This left the patient and her relative startled and they could not believe their ears. On explaining about the advanced nature of the disease, they were heart wrenched. The patient was annoyed at the entire situation and said I do not know whom to blame for my current situation. She said that ever since I was diagnosed with this disease, the only good thing I thought was its early stage. But now, because of this pandemic, although I did not get infected, should I be happy or be furious that I am in an even worse situation nearing death. It was a difficult conversation which led us wondering what went wrong that she is in such a situation.

DISCUSSION

Pandemic is a time of great challenge for the health-care setup of any country. It is burdensome to create the capacity to get through the pandemic and, at the same time, provide elective services to the comorbid patients needing health-care services. Considering the time-sensitive treatment of cancer patients, it seems difficult to decide regarding deferring of the anticancer treatment.

It has been suggested in the previous reports that patients who underwent surgery and later contacted COVID-19 were highly prone to severe events due to the infection when compared to those who did not undergo surgery.[4]

A study suggesting the treatment strategy in COVID-19 scenario for gastrointestinal tumor suggests high priority use of multidisciplinary therapy and nonsurgical antitumor therapy.[5] It can be, however, considered to discuss the options in a multidisciplinary setting with all care providers when thinking of deviation from the initial treatment plan. Whenever there is any change in the treatment plan the patient should be well informed, and their fears and queries should be dealt in detail with compassion and honesty.

The psychological distress among people with cancer during the pandemic is very high considering the fear of the infection, heightened risk of complications associated with the infection, fear of infection to their caregivers, and above all, the stress of delay in their cancer treatment. It is sometimes difficult for them to accept whether not visiting the hospital will be beneficial or indirectly harm them by leading to the progression of cancer. Cancer patients' challenges are not only limited to deferred treatment but sometimes even in traveling to obtain access to the hospital services. Our patient had a major setback when she knew that despite the best of her efforts to be cured, she has progressed to an advanced disease and has a limited life expectancy. The whole family had been emotionally and financially drained in the effort to get her treated but without any benefit.

We know that the ending of the pandemic cannot be predicted and the duration of delay in surgery is uncertain. The dilemma of the present situation is that an already stretched system due to the pandemic cannot accommodate for all elective treatments. Also, it has been reported from China that cancer patients have a 3.5 times higher need of mechanical ventilation or dying compared to noncancer[4] suggesting that hospital visits for treatment might be harmful in these patients.

All this has led to great confusion whether to proceed with elective treatments or defer them in the present scenario as there are heightened morbidity and mortality associated with both the situations. Definitively, it becomes difficult to explain to patients when it comes to situation like that described in the present report. But we might need to think it in a broader perspective considering the judicious resource utilization and ensuring the safety of both the patient and caregiver.