COVID-19: Cancer Care During the Pandemic

Are we ready for summer? (Dr. Noorali Bharwani)
Are we ready for summer? (Dr. Noorali Bharwani)

An article published in JAMA Oncology (online March 25, 2020) the authors report incidence and outcomes of COVID-19 in cancer patients who were treated at a tertiary cancer institution in Wuhan, China.

They found patients with cancer harbored a higher risk of COVID-19 compared with the community.

This increased risk of infection and death among cancer patients creates high psychological pressure of uncertainty. These patients and their families need guidance and support. Moreover, cancer treatments such as surgery, chemotherapy and radiotherapy suppress the immune system. This makes cancer patients more vulnerable to complications like infection.

Physicians and cancer patients have to decide: Does cancer treatment priority outweigh the risk of contracting infection with coronavirus?

An article in Lancet Oncology (Summary of international recommendations in 23 languages for patients with cancer during the COVID-19 pandemic – May 13, 2020), provides professional guidance to promote patients’ safety, treatment, and compliance, and ameliorating patients’ stress.

The authors identified six main areas of recommendations.

The first area concerns general considerations for patients with cancer during the COVID-19 pandemic.

Generally speaking, cancer patients’ immune system is not very strong. Especially the ones who are awaiting or undergoing treatment. The degree of immunosuppression depends on the type of cancer, the patient’s age, fitness, comorbidities, the type of therapy, and the time since last therapy.

Patients should familiarise themselves with COVID-19 symptoms. Early symptoms can be managed at home by way of self-isolation. Immediate medical attention should be sought for more severe symptoms, such as high fever, difficulty breathing, chest pain, confusion, and blue lips or face.

The second area of recommendation regards specific special measures that people with cancer should take to avoid COVID-19 infection. The best way to prevent infection is to avoid exposure to the virus by implementing strict hygienic and behavioural measures.

Hygienic measures include frequent hand washing, disinfecting objects, avoiding handling objects in public places, and washing fruits and vegetables.

Behavioural modifications include staying at home, not gathering in public places, and not touching other people. The use of a face mask is recommended.

The third area – patients with cancer should avoid people with a known exposure, infected asymptomatic people, and infected symptomatic people for at least 14 days and until their symptoms have resolved.

The fourth area of recommendation is related to mental health: guidance on managing anxiety and stress.

Some recommendations include breathing fresh air, engaging in physical exercise and creative activities, and having quality time with their families. Rest, sleep, and healthy eating are important. Talk to your friends and family frequently, engaging in pleasant activities, meditation, yoga and physical exercise. Patients who feel that they cannot cope with their stress should talk to their doctor.

The fifth area of concern is to maintain trust between physicians and patients to enhance patients’ confidence in medical staff decisions and improve their compliance with medical advice.

This may not be very easy. There has been a significant delay in continuity of care. Most patients understand the reasons for delay. But it is not easy.

As things improve with COVID-19 pandemic, cancer centers will be going through painful and difficult process of prioritising patients for treatment. Patients will be evaluated on a case-by-case basis, according to the overall clinical picture, the aggressiveness of the cancer, and the potential health risks from COVID-19.

Finally, the sixth area is the importance of containing spread of COVID-19 to vulnerable people. This can be done by keeping patients and visitors who have symptoms or have been exposed to an infected person not visit their cancer centre, but should first call their doctor’s office for further instruction.

We hope all patients and especially cancer patients get the treatment they need soon.

Take care. Be safe.

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A second wave could come later this year, or not.

Kin Coulee Park, Medicine Hat, Alberta. (Dr. Noorali Bharwani)
Kin Coulee Park, Medicine Hat, Alberta. (Dr. Noorali Bharwani)

“Epidemics are like fires. When fuel is plentiful, they rage uncontrollably, and when it is scarce, they smolder slowly.”
     -Justin Lessler, associate professor of epidemiology at Johns Hopkins University wrote this in the Washington Post in March.

The problem is we do not know how much fuel COVID-19 virus is left with.

This question has been bothering me. So, I went on the Internet and did my research. Here is the summary of what I learnt.

Pandemics are caused by new bugs that the vast majority of humans have no immune protection against. That is what allows them to become global outbreaks.

Let us define what is meant by second wave. Second wave occurs when new cases emerge after a sustained period of time when there is no infection or very few infections.

Is second wave of COVID-19 pandemic imminent? Experts believe it is quite possible but they cannot be sure.

The new virus has spread around the world and is expected to recede. A few months later, it will come back and spread around the world, or large parts of it, again.

While second waves and secondary peaks within the period of a pandemic are technically different, the concern is essentially the same: the disease comes back in force.

It is expected the second wave could emerge later this year and make for an even more dire health crisis. This is because the virus would have been contained, not treated.

The pandemic will resurface with renewed strength, causing a repeat of rising infections, swamped health systems and the necessity of lockdowns. Experts believe a second surge will be harder to contain. A second wave, could be in October, would require more extensive restrictions than were initially imposed.

If the COVID-19 virus mutates, just like the flu virus which mutates constantly, there will be a constant battle each year to find appropriate vaccine.

Experts have suggested that the key to keeping infections low without locking down everyone is to scale up testing and contact tracing.

Health authorities need to find infected people, isolate them, and identify their recent contacts, so they can be tested as well and isolated if necessary. Eventually, it is possible that enough people will become exposed to the coronavirus that herd immunity will develop and it will stop spreading, or that a vaccine against it will be licensed.

Herd immunity is also called community immunity and herd or group protection. Herd immunity happens when so many people in a community become immune to an infectious disease that it stops the disease from spreading.

Dr. Gregory Poland, a Mayo Clinic COVID-19 expert, offers his insight on the effect of a potential second wave of COVID-19 this coming fall in the U.S. (Mayo Clinic website):

  1. When you think about COVID-19 outbreak in the U.S., it started in mid to late February, so we were in fact past our influenza epidemic. It’s unlikely that will happen this fall. Rather, we will have, in an overlapping fashion, influenza epidemics and COVID-19 recurrence occurring.
  2. One problem with that potential scenario, he says, is that the symptoms of the flu and COVID-19 overlap nearly exactly.
  3. The second concern is the tremendous surge in demand on the medical system.
  4. The third concern will be the anxiety around that. Do we really close everything down again and do what we’ve just been through over the last several months?
  5. What’s really going to be key is to encourage everybody six months of age and older, which is the national recommendation, to get a flu vaccine and in this case to get it as early as it’s available – not wait until December and January.

We should be prepared to face the second wave of COVID-19 pandemic this fall and winter. We should get a flu vaccine as soon as it is available and NOT wait until December or January. And take all the precautions which are well known by now. Be safe and take care.

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What do different masks actually do?

An example of a surgical mask while Dr. Bharwani was a surgical resident in Edmonton in 1983.
An example of a surgical mask while Dr. Bharwani was a surgical resident in Edmonton in 1983.

“The wearing of face masks during the 2019 – 20 coronavirus pandemic has received varying recommendations from different public health agencies and governments,” says an article in Wikipedia.

An editorial in the British Medical Journal (COVID -19: should the public wear face masks? – BMJ 09 April 2020) says, “Yes – population benefits are plausible and harms unlikely.”

Is there any direct evidence that wearing a mask would help? The editorial concludes, “…given the gravity of the pandemic, indirect evidence of benefit combined with the low risk of harm should outweigh the absence of direct evidence supporting mask wearing by the general public.”

It has been about five months since COVID-19 hit the headlines and spread infection all over the world. Since then one of the big topics of discussion has been “to wear or not to wear” a face mask. There has been so much disagreement and debate among health agencies and governments, it has left the public confused.

Some groups recommend that all members of the public wear masks, while others recommend that only COVID-19 patients and their caretakers should wear them.

In some countries it is mandatory to wear a face mask. On the other hand, other countries are still struggling to provide appropriate advice to the general public. To top it all there is an acute shortage of masks.

Types of face masks, from least to most protective, include:

  1. Cloth face masks: Although good quality evidence is lacking, some data suggest that cloth masks may be only marginally (15 per cent) less effective than surgical masks in blocking emission of particles, and fivefold more effective than not wearing masks. Therefore, cloth masks are likely to be better than wearing no mask at all (BMJ).

  2. Surgical masks: The standard surgical mask, also known as a fluid-resistant surgical mask (FRSM) is designed to provide a barrier to splashes and droplets for wearer of the mask. It fits fairly loosely to the user’s face. They are used for a variety of procedures in community as well as hospital settings. These are single-use masks. They should not be undone and dangled round the neck between procedures. It should be worn with eye protection.

    Surgical masks do not provide complete protection from germs and other contaminants because of the loose fit between the surface of the face mask and the face. Surgical masks may be labeled as surgical, isolation, dental, or medical procedure masks.

    Surgical masks are recommended for those who may be infected, as wearing a mask can limit the volume and travel distance of droplets dispersed when talking, sneezing, and coughing.

  3. N95 masks: Also known as respiratory mask. It is a disposable mask. Masks ending in a 95, have a 95 per cent efficiency. An N95 mask is a particulate-filtering facepiece respirator. It filters at least 95 per cent of airborne particles. It is the most common respirator used in health care.

  4. Face shields and medical goggles are other types of protective equipment often used together with face masks.

In summary, personal protective equipment, including devices such as N95 respirators, gowns, masks, gloves and face shields, are medical devices in Canada and are subject to requirements under the Medical Devices Regulations. They should be used appropriately. Hope the information provided here helps. Be safe. Stay healthy.

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Irritable Bowel Syndrome and The Invisible Enemy

Valley of the Kings Egypt (Dr. Noorali Bharwani)
Valley of the Kings Egypt (Dr. Noorali Bharwani)

COVID-19 has caused significant stress and anxiety among the general population. Individuals with a history of irritable bowel syndrome (IBS) will have aggravation of symptoms.

IBS is a common medical condition that affects the large intestine. It is a chronic condition that requires long term management. Unfortunately, the pathology and physiology of IBS is not fully understood.

Usually, only a small number of people with IBS have severe symptoms. Some people can manage to control their symptoms by managing diet, make lifestyle changes and controlling stress.

More severe symptoms can be treated with medication and counseling. But management of IBS is not always easy. IBS is a relapsing and remitting disorder in which the predominant bowel habit and symptoms can change over time. It is like COVID-19 except IBS is usually not life threatening.

We don’t know what causes IBS. But we know stress aggravates the symptoms.

Good news is IBS does not cause changes in bowel tissue or increase your risk of colorectal cancer.

The most recent review on this subject was published in the Canadian Medical Association Journal (CMAJ March 16, 2020 – An approach to the care of patients with irritable bowel syndrome).

IBS is a disorder of gut – brain interaction leading to abdominal pain with a change in frequency or form of bowel habit. Forty per cent of patients referred to a gastroenterologist have IBS.

IBS affects four per cent of men and eight per cent of women in Canada, with a peak incidence in ages 18 – 34 years. It can occur in patients with other medically unexplained conditions, such as fibromyalgia and depression or anxiety. Symptoms typically vary in frequency and intensity, and are often aggravated by stress. It is very disruptive to an individual’s work schedule and life style.

When a person has symptoms suggestive of IBS, the burden falls on the physician to make sure other conditions like inflammatory bowel disease (IBD), celiac disease, bile acid diarrhea and carbohydrate malabsorption (e.g. lactose intolerance) are not missed.

Patients who need further investigations are those whose first presentation of symptoms are at age 50 or after, has weight loss, has rectal mass or bleeding, and has family history of colon and rectal cancer.

Diagnosis relies on the identification of chronic typical symptoms characterized by abdominal pain, bloating and change in frequency or form of bowel habit.

The clinical management of IBS can be challenging. The CMAJ article says physician should establish positive therapeutic relationship with patients, underpinned by patient education. That is key to optimizing clinical outcomes. You cannot cure the problem but managing the bothersome symptoms is the mainstay of IBS treatment.

While several management options exist, none of them are effective to cure the problem. They can provide some symptomatic relief. For more information visit: The IBS Network.

In conclusion, IBS is a common disorder characterized by chronic abdominal pain that is associated with a change in frequency or form of bowel habit. The underlying cause is incompletely understood. Therefor treatments are based on symptom management. That include education and reassurance, dietary modifications and pharmaceutical interventions, largely directed toward improving the most bothersome symptoms.

This brings us to the current situation of dealing with the invisible enemy (COVID-19) and the stress it is causing. This is having negative physical and mental effect on our body. Best thing is to do what the experts say and hope for the best.

Manage your stress by doing meditation, yoga, and establish network with friends and family. There are many options available online. Be creative. Be safe and take care.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!