Abstract

Objective Indian data on cancer patients with coronavirus disease 2019 (COVID-19) infection and its outcome are limited. Infectivity and outcome among cancer patients staying in large congregations are not known. We conducted this study to address this lacuna in literature.

Methods This was a retrospective?prospective, observational study of hospitalized cancer patients with proven COVID-19 infection, conducted at tertiary care hospital in New Delhi after ethical approval. We analyzed clinical, laboratorial parameters, and outcomes in these patients.

Results All 32 admitted male patients became COVID-19 positive and 10 (31%) patients were symptomatic. Median age was 37.5 years (range: 16?64). Sixteen health-care workers (HCWs) were working in the cancer ward (paramedical staff: 4, nurses: 6, residents: 4, and consultants: 2). Among HCWs, two nursing staff and three paramedical staff contracted asymptomatic COVID-19. Eighteen (56%) and 14 (44%) patients were on curative and palliative treatment, respectively. Leukopenia (total leukocyte count <4>

Conclusion Seventy percent of cancer patients were asymptomatic. Cancer patients living in congregation areas are susceptible to COVID-19 with 3% mortality rate. Recent chemotherapy and associated cytopenias may not increase the risk in cancer patients with COVID-19 treated with curative intent. Palliative intended patients are at increased risk of death. N-95, personal protective equipment, and adherence to infection control measures should be encouraged.

Introduction

As novel coronavirus disease 2019 (COVID-19) pandemic is worsening, newer challenges are also emerging. People living in congregations such as long-term care facilities and dormitories are at increased risk of infection as norms of social distancing are not executional.[1] [2] [3] Malignancy is a major risk factor for COVID-19-related mortality.[4] [5] Congregation of large number of people on ships (e.g., Diamond Princess ship) face difficulties in mobility and limited access to sanitation, drinking water, and food supply makes them more vulnerable.[6] [7] Cancer care during this pandemic is challenging.

Objective

Indian data on cancer patients with COVID-19 infection and its outcome are limited. Infectivity and outcome among cancer patients staying in large congregations are not known. We conducted this study to address this lacuna in literature and present our experience in managing these patients who lived together and shared common areas of sanitation and food. We analyzed the factors associated with mortality.

All 32 admitted patients were tested positive for COVID-19 by RT-PCR. On the day of the outbreak, 24 patients were positive and the rest became positive after 1 week.

The intent of treatment was curative and palliative in 18 (56%) and 14 (44%) patients, respectively. About 60% of patients received their last chemotherapy within 10 days prior to COVID-19 detection. Clinically, 10 (31%) patients had symptomatic COVID-19. The most common symptom was fever (n = 7.70%). Cough, breathlessness, altered taste, and smell were present in three (30%) patients each. Two (6.25%) patients had features of critical COVID-19. Majority of the patients had hemoglobin levels of more than 10 g/dL (62.5%). Leukopenia (total leukocyte count <4000>

Eight patients received treatment with HCQ and azithromycin. They became asymptomatic in 4 days with no cardiac toxicity. Total five patients died ([Table 2]). Three patients had features of progressive disease with poor PS lacking any definitive evidence suggestive of severe or critical COVID-19 and one patient committed suicide by hanging. Of 2 critical COVID-19 cases, one patient survived and one succumbed COVID-19.

Three fatal outcomes were observed in palliative/best supportive care patients ([Table 2]). When death was analyzed for intent of treatment, palliative intended patients had more probability of death as compared with curative intended patients (4 vs. 0 deaths, p = 0. 027 Fisher?s exact) after excluding patient whose cause of death was suicide.

Median time for RT-PCR to become negative was 18.5 days (range: 9?40). Relationship of time taken for RT-PCR negativity to duration (days) is depicted in [Fig. 1]. At day 30, patients with hematolymphoid malignancies had more RT-PCR positivity as compared with solid tumors (n = 3/7 vs. 0/22, p = 0.02 Fisher?s exact). After excluding deaths, (n = 3/5 versus 0/19), p-value remained 0.01.

Two medical oncologists, four resident doctors, six nurses, and four paramedical staff were working in the cancer ward on rotational duties. They were using N-95 masks and none of them wore Hazmat suits and face shields during the patient care. Among HCWs, those who had close and prolonged contact had contracted infection (5 out of 16). On subsequent screening, all doctors remained negative, two nursing staff were positive, and three out of four paramedical staff became positive. All RT-PCR-positive HCWs were asymptomatic. Only two HCWs used HCQ preexposure prophylaxis.

In the cancer ward, patients shared a common wash room and sanitation area. Dining room was common for all these patients. Twenty-four-hour consistent use of face masks was not practiced by any patient. Twenty-one (81%) and six (19%) patients used cotton cloth masks and surgical masks, respectively.

Discussion

This study clearly brought out the high infectivity rate among patients who are sharing common areas. This finding is of paramount importance for establishments such as armed forces, police departments, prolonged health-care facilities, and other institutions. One hundred percent infection rate among patients in the ward might be due to multiple factors such as viral infectivity, viral load, type and duration of exposure, immunocompromised state, lack of social distancing, and inconsistent use of masks. The 30% infection rate among HCWs further emphasized the national and international priority of protecting HCWs.
Epidemiological investigation of one COVID-19 patient in the general ward revealed protection from transmission with surgical mask, hand hygiene, and basic infection control.
However, surgical masks or triple layer masks may be not adequate for HCWs in cancer wards in pandemic situations. Ministry of Health, Government of India, recommends use of PPE while performing duty in a COVID-19 zone or during an aerosol-generating procedure.

Sixty percent of patients received their last chemotherapy within 10 days prior to COVID-19 infection; even though they had Grades 3 or 4 neutropenia, we did not find increased morbidity for patients receiving chemotherapy.

The role of RT-PCR in asymptomatic COVID-19 patients is not studied.ur patients were negative on the day of admission; repeated testing for a span of 2 to 3 weeks is suggested. Two weeks of quarantine period need to be explored in future studies.

Hematological cancers have the worst outcomes with COVID-19.The time for RT-PCR negativity in our study was significantly more in hematological malignancies as compared with nonhematological malignancies (p = 0.02). Only death directly attributed to COVID-19 in our study suggests augmenting the strategies to save these patients.

COVID-19 infection is associated with profound psychological and social effects. Higher suicidal rates were also observed in patients with advanced malignancies especially lungs as the primary site.We had one patient with metastatic lung cancer who committed suicide. Psychological counseling and measures to reduce stress among these patients are equally important.

Transfer of oncology patients from peripheral hospitals and stagnation at this hospital led to more congregations of patients and remained the same after national lock down. Telemedicine and digital platforms of communication may help curb these issues to some extent.

Cancer patients are more susceptible to COVID-19, so we recommend that oncology departments, wards, and day care centers should remain in a COVID-free zone. As most of the cancer patients with good PS and nonmetastatic disease had a comparable COVID-19-related mortality with the general population and delay in cancer treatment can worsen the disease outcome, their cancer directed therapy should not be delayed. Patients with metastatic disease and poor PS had an increased COVID-19-related mortality and their treatment with increased toxicities should be preferably avoided during the pandemic. Patients on chemotherapy should be closely monitored for cytopenias and prophylactic growth factors may be given to prevent prolonged and profound cytopenia in these patients.

To the best of our knowledge, only limited data are available in the management of cancer patients with COVID-19 and this is the first Indian study conducted exclusively in cancer patients with COVID-19. However, our study has a few limitations. Even though this study included patients with a wide spectrum of malignancies, the number of patients was limited to 32.

Conclusion

Cancer patients living in congregation areas are more susceptible to COVID-19. However, COVID-19-specific mortality was low. Recent chemotherapy and associated cytopenia may not pose increased risk. Palliative intended patients are at increased risk of death. RT-PCR clearance is delayed in patients with hematological malignancies. N-95, PPE, and adherence to infection control measures should be encouraged in cancer wards. Telemedicine and digital platforms of communications must be utilized to avoid congregation.

Conflicts of Interest

There are no conflicts of interest.

Financial Support and Sponsorship

Nil.

References

1. Malard F, Genthon A, Brissot E. et al. COVID-19 outcomes in patients with hematologic disease. Bone Marrow Transplant 2020; 55 (11) 2180-2184
2. Nursing Home Deaths Account for 70-Percent of Ohio?s Overall Total. Available from: https://local12.com/news/ local/nursing-home-deaths-account-for-70-percent-of-ohios-overall-total-ohio-cincinnati. Accessed April 12, 2021
3. What Happens in an Old-Age Home during India?s Coronavirus Lockdown? The Hindu. Available from: https://www.thehindu. com/society/home-for-the-elderly/article31207498.ece. Accessed April 12, 2021
4. Lee LY, Cazier JB, Angelis V. et al. UK Coronavirus Monitoring Project Team. COVID-19 mortality in patients with cancer on chemotherapy or other anticancer treatments: a prospective cohort study. Lancet 2020; 395 (102/41) 1919-1926
5. Dai M, Liu D, Liu M. et al. Patients with cancer appear more vulnerable to SARS-CoV-2: a multicenter study during the COVID-19 outbreak. Cancer Discov 2020; 10 (06) 783-791
6. Sawano T, Ozaki A, Rodriguez-Morales AJ, Tanimoto T, Sah R. Limiting spread of COVID-19 from cruise ships: lessons to be learnt from Japan. QJM 2020; 113 (05) 309-310
7. Moriarty LF, Plucinski MM, Marston BJ. et al. CDC Cruise Ship Response Team; California Department of Public Health COVID-19 Team; Solano County COVID-19 Team. Public health responses to COVID-19 outbreaks on cruise ships - worldwide, February-March 2020. MMWR Morb Mortal Wkly Rep 2020; 69 (12) 347-352
8. Revised National Clinical Management Guideline for COVID-19. Available from: https://www.mohfw.gov.in/ pdf/RevisedNationalClinicalManagementGuidelinefor COVID1931032020.pdf. Accessed April 12, 2021
9. Advisory on the Use of Hydroxychloroquine as Prophylaxis for SARS CoV-2 Infection. Available from: https://www.mohfw.gov. in/pdf/AdvisoryontheuseofHydroxychloroquin as prophylaxis for SARSCoV2 infection.pdf. Accessed April 12, 2021
10. Lapolla P, Mingoli A, Lee R. Deaths from COVID-19 in healthcare workers in Italy?what can we learn?. Infect Control Hosp Epidemiol 2020; 1-2
11. The Lancet. COVID-19: protecting health-care workers. Lancet 2020; 395 (10228) 922
12. Wong CY, Kwong RT, Wu TC. et al. Risk of nosocomial transmission of coronavirus disease 2019: an experience in a general ward setting in Hong Kong. J Hosp Infect 2020; 105 (02) 119-127
13. Guidelines on Rational Use of Personal Protective Equipment. Available from: https://www.mohfw.gov.in/pdf/Guidelines on rational use of Personal Protective Equipment.pdf. Accessed April 12, 2021
14. Woloshin S, Patel N, Kesselheim AS. False negative tests for SARS-CoV-2 infection - challenges and implications. N Engl J Med 2020; 383 (06) e38
15. He W, Chen L, Chen L. et al. COVID-19 in persons with haematological cancers. Leukemia 2020; 34 (06) 1637-1645
16. Mart?n-Moro F, Marquet J, Piris M. et al. Survival study of hospitalised patients with concurrent COVID-19 and haematological malignancies. Br J Haematol 2020; 190 (01) e16-e20
17. Rajkumar RP. Suicides related to the COVID-19 outbreak in India: a pilot study of media reports. Asian J Psychiatr 2020; 53: 102196
18. James J. The impact of the COVID-19 pandemic on suicide rate. QJM Int J Med 2020; hcaa202
19. Rahouma M, Kamel M, Abouarab A. et al. Lung cancer patients have the highest malignancy-associated suicide rate in USA: a population-based analysis. Ecancermedicalscience 2018; 12: 859
20. Keesara S, Jonas A, Schulman K. COVID-19 and health care?s digital revolution. N Engl J Med 2020; 382 (23) e82

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Publication History

Publication Date:
22 May 2021 (online)

? 2021. Indian Society of Medical and Paediatric Oncology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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