COVID-19-Positive Report Posing a Delay in Treatment Course in a Middle-Aged Metastatic Neuroendocrine Tumor Patient
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The COVID-19 outbreak is an unexpected challenge to all areas of health-care delivery, including cancer centers. The novel coronavirus is known to affect individuals in all age groups, especially patients with multiple comorbidities. A nationwide lockdown has restricted the routine patient care, with health-care services focusing mainly on emergency services and COVID patient management. These restrictions in health services may delay the treatments of non-COVID patients. This conundrum is especially true in cancer patients as they require frequent visits to the hospital, and there is a lack of understanding of the treatment prioritization in cancer patients. In this case, we discuss the concerns faced by a 37-year-old male with neuroendocrine tumor of the anal canal who was tested COVID positive. His surgery was canceled following the report and was shifted to the COVID care facility. Best supportive care was given till further management.
The novel coronavirus, also known as COVID-19, which emerged as the cause of a cluster of pneumonia cases in China, now has become a global threat and the major health-care concern of the year 2020. Neuroendocrine tumors (NETs) arise from cells of the endocrine (hormonal) and nervous systems. NETs commonly occur in the lungs, small intestine, rectum, and pancreas. Prognosis depends on their anatomic location.
We describe the case of a 37-year-old male who was diagnosed with metastatic NET of the anal canal. His surgery was canceled following COVID-19-positive report and was shifted to a dedicated COVID quarantine facility at the National Cancer Institute (NCI).
A 37-year-old male residing in a village of Bihar presented to a nearby private hospital in August 2019 with complaints of constipation for 5 days refractory to treatment. He was further evaluated which revealed a mass in the anal canal. He was referred to AIIMS Delhi for further evaluation. He traveled with his father to Delhi, leaving his family of two children (10 and 15 years) and his wife in Bihar.
As the disease progressed, he developed fecal incontinence and had a significant loss of weight. Examination revealed anal incontinence with perianal fistula with an exterior opening at 5'o clock position, 4 cm away from the anal verge. Biopsy revealed high-grade NET of the anal canal. Multiple liver metastasis was revealed in contrast-enhanced computed tomography abdomen done on December 27, 2019. He received chemotherapy and was planned for diversion colostomy following chemotherapy on May 18, 2020. He was tested for COVID during preoperative checkup and was tested positive on May 16, 2020. His surgery was canceled and was asked to continue antibiotics. He was asymptomatic for COVID.
The patient with his father was then shifted to NCI, Jhajjar, on May 15, 2020, a center dedicated to quarantine and management for COVID patients. After screening, he was assessed and was admitted in the COVID ward. The doctors on rounds kept a keen observation daily and monitored his symptom progression. The sudden deviation from the expected course of treatment created the following concerns in the patient.
Physical and symptom concerns (his repellent disease condition)
The patient suffered from constant staining, malodor, and skin excoriation surrounding the fistula, which led to insomnia and malnourishment. He is not able to do self-care and maintain hygiene. ”I know surgery is the only option to stop fecal staining.” Understanding the prognosis, he wanted a way out of his misery and regain his health to an extent where he will be able to meet his activities.
Psychological concerns (missing his family)
He was anxious about whether the disease is going to progress and worsen because of delays in surgery. He was unable to take care of his family, and he was failing to attend to their needs during the corona outbreak. “I don't know how my family will survive without me and my father, lockdown miles away from them.” He was in constant low mood as his surgery was postponed.
Financial and social concerns (unable to play his role in the family)
His family lived in a pukka house in the rural village of Bihar. He is a farmer by occupation and the only breadwinner of the family; there was not enough money. His other family members were also facing similar financial constraints, and he was stressed about the situation.
He also felt a lack of direct access to doctors, which kept him under continual uneasiness and fear. “Doctor kab ayenge?,” “Mera surgery kab hoga?,” he wanted to consult his treating physician. Change of the treatment setting generated anxiousness. He felt lonely and unfrequented.
Spiritual concern (hope amidst despair)
Even if the odds were against him, he had a hope of improvement. He believes in god. He practices the Hindu religion. He does not blame anyone for his illness. He says ”I want to get better and want to rejoin my family.” He prays daily for the same.
Acknowledge the issue
Many patients with cancer are struggling to receive treatment for their cancers due to hospitals cancelling or delaying surgeries and other procedures, which also includes chemotherapy and radiation therapy. This can raise issues in the patient in many aspects such as physical exhaustion, emotional vulnerability, and psychosocial and spiritual concerns
Compulsory isolation without proper communication medium to the patient's family/friends adds to mental stress.
How to proceed
Prioritizing cancer patients based on the magnitude of benefit, outcome results, and quality of life (QOL) will help to approach cancer patients during the COVID-19 pandemic
In our case, NETs in the rectum had the best prognosis, whereas pancreas had the worst. Hence, resuming his actual treatment plan in this patient can provide better treatment outcomes and improve QOL
Symptomatic treatment should be provided while the definitive management is delayed. Meanwhile, psychological and spiritual concerns should be dealt with empathy and compassion, as they are also an essential part of a comprehensive health-care system.
How to accomplish
The rapidly evolving nature of the pandemic taught us that we needed the full and unconditional support of workforce and resources. We were able to accomplish this by regularizing open electronic–communication channels and shared decision-making
Triaging of cancer patients for treatment.
Role of palliative care
Palliative care approach encompassing all domains of care, that is symptomatic treatment, proper counseling, addressing the psychological issues, and empathetic communication between the health-care worker and the patient, will lead to improved understanding in patients about their illness. This will alleviate tension and provide realistic hope to the patient and the caregiver. In the setting of the current pandemic, this approach is very important as access to cancer care may be limited and lifesaving treatments may get delayed. As palliative care physicians, we must explain to the patient the difficult and testing times for the already-overburdened health-care system of our country.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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- CASE REPORT
- Physical and symptom concerns (his repellent disease condition)
- Psychological concerns (missing his family)
- Financial and social concerns (unable to play his role in the family)
- Communication barrier
- Spiritual concern (hope amidst despair)