Due to the lack of coherent screening program in India, we still diagnose a significant proportion of cases in the later stages of the disease.
Representational image. Pixabay
Breast cancer is the most common cancer affecting women across the world. It contributes to about 15 percent of all cancer-related mortality in India, according to GLOBOCAN data. Due to the lack of coherent screening program in India, we still diagnose a significant proportion of cases in the later stages of the disease.
With growing public awareness and improvement in the overall access to healthcare most patients get treatment.
However, to improve outcomes and decrease mortality it is important that the disease be identified earlier, and treatment initiated as early as possible. It is not only the survival which is increased manifold, but also the cost implications and morbidity of the treatment which also changes manifold.
COVID-19 had significant negative impact in overall delivery of healthcare across the globe and India is no different. We are likely to see increase in cancer-related mortality which will be evident only after few years. By then, it would be too late to act. According to the largest study from different cancer centers across the country the impact of COVID-19 on cancer related services during initial two months of pandemic showed almost 30 to 50 percent drop in chemotherapy, surgery, and radiotherapy appointments.
More alarming is the significant impact on the screening program. The data for the impact during the subsequent peaks (August/September 2020 and April, May 2021) is still unavailable. During these pandemic peaks unavailability of beds for regular cancer related treatment combined with patient and caretaker’s anxiety to visit hospital for care has hampered our efforts to decrease the cancer related mortality.
The impact of COVID-19 on breast cancer patients is manifold. It begins with the screening for the disease. First, regular screening program is affected since the advent of the pandemic and still not reached the pre pandemic level (even though it was not so high in India). Second, patient who has identified the disease with breast self-examination found it difficult to reach hospitals on time for evaluation and treatment. The unintended consequence of the same is the upstaging of the disease.
Third, this led more patients presenting in later stage (stage 3 and stage 4) which requires more treatment (especially stage 3) than early breast cancer. Patients presenting with stage 4 disease are incurable. For example, an early-stage hormone positive breast cancer would require only surgery and hormone therapy (which is only pills), however for the same patient with stage 3 disease would require surgery, radiotherapy, chemotherapy, and hormone therapy. Despite increasing the modalities of treatment in advanced stage the outcomes are still inferior to early-stage breast cancer. Fourth, this likely to increase the long-term treatment related morbidity even though its marginal.
Any estimation of impact of COVID-19 on breast cancer is incomplete without the cost implications of the same. For the same above example, for early-stage hormone positive breast cancer the cost of treatment (which includes only surgery and hormone therapy) would cost Rs 1.5 lakh in a private healthcare setup. The same for a stage 3 cancer would be Rs 4.5 lakh which is almost 3 times the cost for treating an early-stage cancer. It not only likely to increase the financial morbidity to the family but also the chances of cure would also decrease with upstaging of the cancer.
More patients are likely to present with metastatic disease (stage 4 cancer) due to delay in diagnosis and access to healthcare during pandemic times. These patients have incurable disease. The most important factor in treatment of these patients is the general condition of these patients which is estimated by oncologists as performance status using Eastern Cooperative Oncology Group (ECOG) scale with higher the value poorer the patient general condition.
Due to delay in diagnosis and initiation of treatment these patients are likely to land up in emergency in poor performance stages (3,4) where any kind of anticancer therapy is not feasible or considered to have more side effects than benefits. This alone is likely to affect the survival for these patients.
These patients are less likely to receive all of drugs available for stage 4 disease. Based on the recent meta- analyses for outcomes in metastatic breast cancer patients the survival improved form 32 months to 57 months in last 20 years in hormone positive cases and from 14 months to 33 months in hormone negative cases.
All these gains will be difficult to consolidate if the patient presents with increased disease burden and poor performance status. With advent of many therapeutic options for metastatic breast cancer the possibility of exposure to all the available agents sequentially to increase survival has been severely impacted by the pandemic. The cost implications are also huge for these patients.
It’s not only the cancer care which has been impacted by the pandemic but also cancer research. With inability to continue and recruit patients for newer drug therapy trials, patients are losing access to newer therapies. It is already delaying the time to develop newer drugs.
There is huge human cost that is being paid indirectly by the pandemic.
With pandemic still ravaging various parts of the world and uncertainty about its end we need to take measures for these vulnerable patients if only we want to save more lives. All cancer deaths due to these delays in pandemic should also be considered COVID-19 impacted deaths if not COVID-19 deaths.