Written by Dipit Sahu and Chetan Anchan
According to some modelling estimates, approximately 28,404,603 operations were deferred globally over a three month period in the ongoing fight against the COVID-19 pandemic. But these statistics hardly paint the real picture at hand. There are numerous individual stories of missed trauma of the upper limb and the deferred cancer care including that of the bone and soft tissue cancers, that are now presenting as more sinister and complex problems.
A shoulder dislocation is one of the easiest conditions to treat amongst the several traumatic bone disorders. A small reduction manoeuvre in the office or sometimes in the minor operation room is all that is needed to put the shoulder back in its natural joint space. But we recently operated on two young men’s shoulder dislocation after three months of neglect — an awfully long period to leave the shoulder dislocated and untreated. It not only changes the treatment plan from a simple fast office manoeuvre to an extensive open surgical operation with a risk of injury to nerves and vessels but also reduces the extent to which the shoulder motions will recover. In short, a condition which is one of the simplest problems to treat becomes one of the most complicated shoulder operations, to an extent that some surgeons would even ask to patients to live with their disability. Some other conditions also went undetected during the lockdown such as some missed minor fractures of the shoulder and elbow bones that presented to us after a delay of three months. But these problems could be salvaged with more efforts and skilful surgery.
However, dealing with deferred cancer care is a completely different and complex situation, because it directly affects the remaining life years of the patients. If we go by statistics, just the delay in diagnosis of the top four cancers — breast, colorectal, lung, and esophageal — in the UK have already led to an increase in around 3,621 avoidable deaths in the last three months. Our experience with the deferred care of the musculoskeletal tumours has also shown a worrying trend. Consider for example, the situation of some of our patients who could not travel to Mumbai for their radiotherapy and chemotherapy or for their scheduled surgery in that three-month period.
Some cancers, in particular the early and low-grade ones may not have been seriously affected due to a delay of surgery by three months, but for the advanced and high-grade cancers, the delay in surgery has led to an increase in the size of the disease and the stage of the cancer. In one patient, the tumour could not be operated upon during the lockdown, leading to a loss of control over his bladder and bowel function and rendering him unable to use his legs to stand or walk. In patients whose surgery had to be delayed, additional cycles of chemotherapy were used so that the patient continues to remain under treatment and the cancer does not grow.
Radiotherapy was another option for some cancers, to tide over the delay in surgery. But we cannot continue with chemotherapy and radiotherapy indefinitely. At some point, it becomes necessary to operate on the tumour. Further, in some cases, the chemotherapy and radiotherapy work on a law of diminishing returns which means that beyond a certain point, they may not only not work but may also give ample time for the tumour to grow and spread because the tumour starts resisting the chemotherapy.
However, on a positive note, we can say that a six-month delay in surgeries due to any further extension of the lockdown would have led to a greater than 30 per cent reduction in survival of the major cancers as compared to a three-month delay which has caused a greater than 17 per cent reduction already. On the brighter side of things, with the lockdown opening up, most hospitals are returning back on their feet pretty quickly. The damage done can still be contained because the Tata Hospital in Mumbai and Oxford Cancer hospital UK, showed us that even during the severest initial lockdown, several patients could be operated upon with minimal complications.
We obviously do not need to return to another lockdown, even though the infection numbers seem to be rapidly increasing in India, because lessons have been learnt during the lockdown and safety driven protocols have been put in place to tackle the growing menace of COVID 19. One of these lessons learnt through our own institutional experience and through UK hospitals published experience is that the referral centres and the bigger hospitals should have a dedicated non-COVID facility that should be separated from the dedicated COVID facility for suspected or infected patients. A non-COVID place will ensure that hospital acquired infection will be minimised and cross-infections amongst patients will be prevented. Given that cancer patients have an increased tendency to contract COVID infection that may result in increased morbidity, a mandatory preoperative screening by RT-PCR swab and specific postoperative testing for doubtful symptoms of all surgical patients will help us prepare in a better way to deal with surprise complications due to COVID-19. Additionally, healthcare workers may also need to be tested by RT-PCR swab as they may also be a source of cross-infection to the patients. Whereas the lockdown has increased the burden of deferred problems, it has also helped the state machinery to better prepare and fight the growing burden of COVID-19 as we open the lockdown and enter into what seems as a very long drawn fight.
Sahu is a Shoulder Orthopaedic Surgeon in Sir H.N. Reliance foundation hospital Mumbai, Jupiter Hospital Thane and Dr RN Cooper Hospital Juhu. Anchan is a Onco-Orthopaedic Surgeon in Sir H.N. Reliance foundation hospital, Mumbai and Jupiter Hospital Thane