Effects of Covid 19 on patients of Brain Tumour

Effects of Covid 19 on patients of Brain Tumour either diagnosed or under adjuvant therapy:

The COVID-19 pandemic has disrupted healthcare systems, leading to concerns about its subsequent impact on non-COVID disease conditions. The diagnosis and management of cancer is time sensitive and is likely to be substantially affected by these disruptions.

As of May 12, 2021, according to WHO, the COVID-19 pandemic has affected 222 countries and territories, with more than 159 million cases and more than 3·3 million deaths reported. The COVID-19 pandemic has resulted in widespread mortality and has exposed the frailties of healthcare systems worldwide. National responses have varied by country, with restrictions or lockdowns of varying severity implemented to curb the pandemic, with different outcomes.

On Jan 30, 2020, the first case of COVID-19 was reported in India, and as of May 12, 2021, according to WHO, almost 23 million people had been infected. In response to the pandemic, the Government of India instituted a series of nationwide Impact of COVID-19 on cancer care in India: a cohort study-up lockdown that began on March 24, 2020, with severe restrictions imposed on inter-state and intra-state travel. Data from cancer centres across the world have shown that the provision of oncology services has been considerably reduced during the COVID pandemic.

It has been seen in a study published in Lancet that Between March 1st to May 31, 2020 –

1. There is a 54% decrease in the registration of new cancer patients
2. 49% reduction in the number of major cancer surgeries
3. 52% reduction in the number of minor cancer surgeries
4. 36% decrease in hospital admissions for cancer patients
5. 43% Decrease in radiological diagnostic tests
6. Reductions in the provision of oncology services were higher for centres in tier 1 cities (larger cities) than tier 2 and 3 cities (smaller cities).

Overall, two-thirds of the surveyed countries had included maintenance of health-care services for non-communicable diseases in their COVID-19 preparedness plans; however, substantial disparities were identified between high-income countries and low-income and middle-income countries (72% vs 42%). This lack of preparedness could have a detrimental long-term impact on the outcomes of patients with cancer, especially in resource-poor countries.

In this background, some pertinent questions and topics arise regarding the effects of Covid 19 on Brain tumour which needs to be addressed and these are discussed below :

A. Covid Appropriate Behaviour that should be followed by Brain Tumour patients:

1. Everyone including the patients should wash their hands often with soap water for at least 20 seconds. Do this as many times as possible.
2. They can use an alcohol-based hand rub instead (at least 60-70% alcohol concentration).
3. Should Cough into their elbows or use a tissue when coughing or sneezing.
4. Should not touch mouth, nose, eyes unnecessarily.
5. .They can use a goggle to protect their eyes.
6. Maintain Physical distancing of at least 1-2 meters.
7. Protect face by covering with a mask.
8. To Use personal transport if possible. To Sanitize the doorknob, steering wheel, and other surfaces where one can potentially touch during travel.
9. If they are compelled to use public transport, should try to maintain physical distance as much as possible. To Stay away from people having signs of respiratory or flu-like symptoms like cough, sneezing etc.
10. To follow the guidelines laid down by the hospital. To Ask for the same if one is not aware of it.
11. To Change dress immediately after reaching home. To keep them in a safe place not to be touched by others for five or six hours before washing with soap or detergent. If possible, use one set of cloth for one day.
12. Should Maintain shoe hygiene. Should use separate pair for outside use.
13. Should Sanitize the places at home where people touch very commonly like calling bell, doorknob etc.
14. If someone is an in-patient admitted in cancer ward, to ask his/her health care provider to follow hand hygiene and other protective steps properly.

B. Stage wise guidance for brain tumour treatment during COVID-19 pandemic:

COVID19 has not changed the management protocol of brain tumours yet. If this continues, there might be some guidelines pouring in from large bodies like ASTRO/ESTRO/ASCO for brain tumour patients as well.

Traditionally brain tumours are not staged in a classical manner like other cancers. Brain tumours are classified either as benign or malignant. Malignant tumours are again divided as per their pathological grades into high grade or low grade and so on.

In some centres, radiosurgery instead of surgical removal of tumour is being done to reduce hospital stay. However, radiosurgery is not “magic treatment” for all brain tumours. It can be done only for some very selective conditions like AVM (arteriovenous malformation), pituitary adenoma, craniopharyngioma, a small limited number of metastatic lesions, meningioma, schwannoma etc.

C. Postponing treatment of brain tumour and how long?

Any tumour, which is immediately life-threatening or can cause rapid neurological deterioration or aggressive behaviour (like a glioblastoma) should be treated immediately with surgery, radiation, chemotherapy, or different combinations of them as per indication. It is advisable that patients discuss with an experienced doctor in this field.

D. Risk of postponing treatment and continue treatment in this pandemic:

Risk of continuing treatment:

1. All usual risk and side effects of planned treatment
2. An additional risk of getting coronavirus infection (may not be necessarily from the hospital).

Risk of withholding treatment:

1. Treatment may not provide the desired benefit.
2. Risk of tumour recurrence and/or progression will increase.
3. Survival can be reduced for some tumour and cancers.
4. Potential neurological damage from an uncontrolled progressing tumour.

At the end, it is to be remembered that, the effect between treatment, overall treatment time and expected benefits are all interlinked in a complex manner which varies in between patients and tumours. To suggest an idealistic and holistic approach in this crucial time should be the job of treating physician.

E. Priorities of Primary Brain Tumours:

1. Priorities for OPD Visit :

High Priority:

• Newly diagnosed brain tumour
• New onset or worsening of symptoms indicative of tumour- or treatment-related complications (e.g. neurological symptoms, dyspnoea, chest pain)
• Clinical or radiological evidence for tumour recurrence
• Application of intravenous or intrathecal anticancer treatment
• Wound-healing problems after neurosurgical intervention

Medium Priority:

• Evaluation of clinical status, laboratory or neuroradiological results in known brain tumour patients without new or worsening symptoms and with active therapy (convert to telemedicine visits whenever possible)
• Prescription of oral anticancer treatment (convert to telemedicine visits whenever possible)
• Post-operative patients without need for active therapy and no complications

Low Priority:

• Evaluation of clinical status, laboratory or neuroradiological results in known brain tumour patients without new or worsening symptoms and without active therapy (convert to telemedicine visits whenever possible)
• Visits of patients on a best supportive care regimen
• Visits of psychological support (convert to telemedicine)
• Survivorship visits
• Second opinion visits (convert to telemedicine)

2. Priorities for Neurosurgery:

High Priority:

• Need for acute decompression
• Maximal safe resection in suspected malignant glioma
• Diagnostic biopsy in suspected primary central nervous system lymphoma (PCNSL)

Medium Priority:

• Resection/biopsy of non-contrast enhancing primary brain tumour with stable

neurological symptoms

• Re-resection of recurrent lower WHO grade glioma

Low Priority:

• Partial resection of recurrent malignant glioma

F. Neurological Effects of Covid 19:

• Hypoxic Ischemic Encephalopathy due to Covid ARDS and Type 1 respiratory failure,it is manifested as delirium and coma.
• Ischemic strokes due to microclots in brain due to hyperciagulable state in Covid infection and these may transform into microbleeds later on.
• Seizure disorders secondary to Covid inflammatory process.

G. Vaccination:

All brain tumour patients will have to spend considerable exposure to hospital and because of the disease, chemotherapy, radiotherapy and other medications will be immunocompromised and vulnerable to covid 19 infections and their complications. So, they should be vaccinated at the earliest.

Dr. Manaranjan Jena, Consultant – Neurosurgery, Narayana Multispeciality Hospital, Jessore Road, Kolkata