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Rendezvous of Cancer Patients with Logistic and Socioeconomic Challenges during COVID-19 Pandemic: A Case Series
Address for correspondence: Dr. Seema Mishra, Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R. Ambedkar IRCH, AIIMS, New Delhi, India. E-mail: seemamishra2003@gmail.com
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Abstract
The coronavirus disease 2019 pandemic has shaken the health-care infrastructure worldwide and has led to enormous challenges for cancer patients. They are suffering on various fronts during this pandemic, especially the often overlooked ones such as logistic and socioeconomic. Through the case series, we have highlighted the various components of these challenges the cancer patients are facing and tried to emphasize that the health-care setups and government along with nongovernmental organizations have to come on the forefront to help the patients mitigate these challenges.
Keywords
Cancer patients
case series
coronavirus disease 2019 pandemic
logistic and socioeconomic challenges
INTRODUCTION
The coronavirus disease 2019 also known as “COVID-19” which was first detected in China and later on declared a pandemic by the WHO on March 12, 2020,[1] has created havoc all over the world in a very short span of time. It has impacted every country on various fronts including economic, social, and political.[2] In India also, the count is rising steadily and peak is expected by June to mid-July once the lockdown is lifted in a phased manner all over the country. The older patients and those with underlying serious health conditions, for example, cancer, have an increased risk of admissions into intensive care units.[34] The estimated case fatality rate in cancer patients with COVID-19 is 6%,[5] as compared to 1% among the general population.[6] With the estimated number of cancer cases in India being approximately 2.25 million, the impact of this pandemic on cancer patients will be grave affecting both survival and quality of life.[7] To curb this menace, countries and health-care systems around the world have taken various measures such as that of nationwide lockdown, strict social distancing protocols, and restriction of the health-care facilities to patients and their caregivers by means of triaging. All these steps have definitely helped in preventing the spread of the disease to a large extent, but at the same point of time, it has raised many hurdles and new challenges. There is a paucity of literature regarding the challenges encountered by the cancer patients and their caregivers during this pandemic. Through this case series we want to highlight the logistic and socioeconomic challenges faced by cancer patients during COVID 19 pandemic. Furthermore on the basis of the findings, we suggest few solutions which can be adopted by oncology setups in India to conquer these challenges.
METHODS
Ten consecutive cancer patients who attended the outpatient department of cancer pain and palliative clinic of our tertiary care center on May 12 during the time of lockdown were included in our case series. Basic demographic information in the form of age, gender, and address was noted along with diagnosis, Eastern Cooperative Oncology Group (ECOG) performance status, and treatment received. Various challenges faced by patients in logistic domain and socioeconomic domains were asked, and they had to answer in binary form either Yes/No. After knowing the challenges encountered by the patients they were told about the initiatives taken by the department and the hospital to help them to get through these challenges. They were also provided with psychological support and practical solutions they can adopt to overcome the challenges.
RESULTS
The details of ten patients with their age, gender, diagnosis, duration since diagnosis, ECOG status, treatment status, and comorbidities are mentioned in Table 1. All the ten cases faced some or other challenges on logistic and socioeconomic front. In logistic domain, difficulty in to and fro transportation to hospital due to nonavailability of public transport services was reported by all; along with that, all of them also reported restricted outpatient, inpatient facilities, difficulty in procuring pain medications as well as difficulty in procuring face mask and hand sanitizers for self-prevention and prevention of other family members. Apart from this common logistic issue, 60% of patients reported that there was a postponement of their surgery/chemotherapy and radiotherapy during this pandemic. Fifty percent reported that they could not get their routine investigations done such as complete blood count, liver function tests, kidney function tests, and imaging procedures such as follow-up positron emission tomography scan and computed tomography scans leading to anxiety and stress. On socioeconomic front, all the ten cases reported that they have suffered financial loss during this pandemic. Fifty percent reported that there is a lack of accommodation and there is difficulty in maintaining social distancing because of lack of proper space at home and lack of support system for daily needs such as grocery and medical equipment; two of ten cases also reported that they were facing social outcast during this pandemic. Figure 1 highlights the various logistic challenges faced and Figure 2 socioeconomic hurdles that the patients had to encounter.
| Age (years)/gender | Diagnosis | Duration since diagnosis (years) | ECOG status | Treatment status | Comorbidities |
|---|---|---|---|---|---|
| 52/male | Carcinoma larynx | 2.5 | III | Post-CT/RT | Hypertension, COPD |
| 45/male | Sigmoid colon carcinoma | 1 | II | Postsurgery/Post-CT | Diabetes mellitus, hypertension |
| 19/female | Carcinoma rectum | 3 months | II | No treatment received till now | Nil |
| 59/male | Metastatic CA prostate | 1 | II | Hormonal therapy | Hypertension |
| 67/male | Recurrent CA oropharynx | 7 | II | Post-CT/RT | COPD |
| 37/male | Metastatic osteosarcoma | 1 month | II | No treatment received till now | Nil |
| 55/female | Metastatic CA breast | 6 | III | Postsurgery/CT/RT | Hypothyroid |
| 59/female | Multiple myeloma | 1 | III | Post-CT | Bronchial asthma |
| 40/male | Carcinoma lung | 1 | II | Post-CT/RT | COPD |
| 37/female | Carcinoma ovary | 2 | II | Postsurgery/post-CT | Hypothyroid |
CT/RT: Chemotherapy/radiotherapy, COPD: Chronic obstructive pulmonary disease, ECOG: Eastern Cooperative Oncology Group, CA: Carcinoma
- Logistic challenges
- Socioeconomic challenges
DISCUSSION
Cancer patients have to face a lot of challenges on physical and emotional front. On top of that, the novel COVID-19 pandemic which has now caused enormous damage worldwide has put even more burden on these strata of cases as well as posed a lot of challenges for the health-care system. There is a lot of fear, anxiety, and stress among all the patients – one related to their disease per se and the second because of the coronavirus infection. At one end of the spectrum, there is fear of the progression of disease in absence or delay of treatment, and at the other end, there are stress and depression related to the contraction of coronavirus infection because of the immunocompromised state.[8] Patients are suffering from a lot of symptoms such as pain, nausea, vomiting, and dyspnea, and it is becoming more difficult for them to procure pain medication such as morphine during lockdown. On spiritual front, there is feeling of fatalism and lack of spiritual clarity at the same time. However, apart from these domains, there are two common domains, logistic and socioeconomic, which are often overlooked but are causing a lot of practical problems for all the patients. We have tried to elucidate these domains through the case series. On logistic front, all the cases which we evaluated in the outpatient department said that they were facing enormous difficulty in reaching the hospitals or nearby nursing homes because public transport services have been halted all over the country and within the state. Furthermore, because the hospitals have adopted the policy of triaging and seeing limited number of cases, they are facing difficulty in getting appointments and majority of them feel that due to all these, their treatment in the form of surgery/chemotherapy and radiotherapy is getting postponed indefinitely which may eventually lead to progression of cancer. Furthermore, 50% of them also have not been able to get their routine blood and radiological investigations done on time, which are required for planning the next stage of treatment. Moreover, as if these many challenges were not enough, they also are facing hardships on socioeconomic front. The impact of global lockdown has been dreadful for all the countries, especially economically, and there is a widespread notion that there will be a huge economic downfall and recession in coming years. In developing country like India where many patients coming to hospitals are below poverty line and are daily wage workers, they have lost their jobs and earning sources. In our study also, all the ten patients reported that they have suffered a lot on financial front. They fear that their savings would go away in medicines and other hospital expenses. Patients who got stuck in city before the lockdown have nowhere to go now. Fifty percent of the cases reported that they faced accommodation problems and were unable to maintain suggested social distancing norms because of lack of proper space. The same strata of patients also reported that there was a lack of social support system for daily needs such as bringing grocery from the market. Two patients reported social outcast by the society, with the neighborhood complaining that they maybe carrying coronavirus infection by their repeated hospital visits. Health-care system right now is stuck in a very precarious situation similar to the idiom derived from Greek mythology “Between Scylla and Charybdis” that is to choose lesser of two evils – one being cancer treatment and the other is prevention of the patients from coronavirus infection. For this, the government, corporate sector, and nongovernmental organizations have to come on the forefront and help the patients and their family tide over the challenges. For transportation-related issues, accommodation in the form of “Vishram Sadans” can be provided nearby to the hospital so that the patients do not have to travel much till the time the lockdown opens up. To overcome the problem of limited outpatient and inpatient facility, hospitals all over the country have started with facility of telemedicine[9] where the patients are being guided over the phone and called to the hospital when deemed necessary. Hospitals are also providing necessary personal protective equipment such as face masks at the time of entry to the hospital and at screening areas. To mitigate the socioeconomic issues, a lot of nongovernmental organizations, business houses, and celebrities have come forward to help those in need and are helping poor patients in the form of providing them with food, shelter, medicines, and personal protective equipment. Hospitals and government personnel also from their side are running a lot of awareness campaigns so that there is no social outcast and the stigma associated with disease does not lead to more collateral damage. To conclude, we would like to emphasize that cancer patients are facing enormous challenges on various fronts especially logistic and socioeconomic. Thus, it is the moral responsibility of both the healthcare fraternity and government to come together as one workforce and help these patients to tide over the crisis. Health-care setups have to do a strengths, weaknesses, opportunities, and threats analysis and divide the role of each and every individual and team member[8] so that the task force remains intact as well as the patient care is not compromised.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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