Impact of COVID-19 on cancer care in India: a cohort study.

BACKGROUND: The COVID-19 pandemic has disrupted health-care 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. We aimed to assess the impact of the COVID-19 pandemic on cancer care in India. METHODS: We did an ambidirectional cohort study at 41 cancer centres across India that were members of the National Cancer Grid of India to compare provision of oncology services between March 1 and May 31, 2020, with the same time period in 2019. We collected data on new patient registrations, number of patients visiting outpatient clinics, hospital admissions, day care admissions for chemotherapy, minor and major surgeries, patients accessing radiotherapy, diagnostic tests done (pathology reports, CT scans, MRI scans), and palliative care referrals. We also obtained estimates from participating centres on cancer screening, research, and educational activities (teaching of postgraduate students and trainees). We calculated proportional reductions in the provision of oncology services in 2020, compared with 2019. FINDINGS: Between March 1 and May 31, 2020, the number of new patients registered decreased from 112 270 to 51 760 (54% reduction), patients who had follow-up visits decreased from 634 745 to 340 984 (46% reduction), hospital admissions decreased from 88 801 to 56 885 (36% reduction), outpatient chemotherapy decreased from 173634 to 109 107 (37% reduction), the number of major surgeries decreased from 17 120 to 8677 (49% reduction), minor surgeries from 18 004 to 8630 (52% reduction), patients accessing radiotherapy from 51 142 to 39 365 (23% reduction), pathological diagnostic tests from 398 373 to 246 616 (38% reduction), number of radiological diagnostic tests from 93 449 to 53 560 (43% reduction), and palliative care referrals from 19 474 to 13 890 (29% reduction). These reductions were even more marked between April and May, 2020. Cancer screening was stopped completely or was functioning at less than 25% of usual capacity at more than 70% of centres during these months. 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). INTERPRETATION: The COVID-19 pandemic has had considerable impact on the delivery of oncology services in India. The long-term impact of cessation of cancer screening and delayed hospital visits on cancer stage migration and outcomes are likely to be substantial. FUNDING: None. TRANSLATION: For the Hindi translation of the abstract see Supplementary Materials section.

Superior Vena Cava as Gateway to Heart: Metastatic Breast Carcinoma Causing Ball in a Loop Metastasis to Right Atrium.

Breast carcinoma is the most common invasive cancer in women worldwide. It metastasizes commonly to bone, lungs, regional lymph nodes and brain. Cardiac metastasis of lung and breast cancers is a known but rare complication of advanced disease with tumour metastasising to pericardium via the locoregional lymphatic system. Here we present a case of 59-year-old female presenting with right upper limb oedema, facial puffiness and features of Superior Vena Cava (SVC) syndrome 15 years after mastectomy and adjuvant chemotherapy, radiotherapy for carcinoma of the right breast. Further evaluation revealed extensive thrombus invading the right internal jugular vein, subclavian vein, SVC with intraluminal extension into right atrium causing ball in a loop obstruction at tricuspid valve. Whole body Positron emission tomography scan confirmed the diagnosis of extensive metastatic disease and patient was managed on palliative therapy. Haematogenous spread and intraluminal growth of metastatic deposits from breast carcinoma 15 years ago is rare and clinical presentation as SVC obstruction has not been reported in our review of literature.

Leriche Syndrome: Acute Onset Painful Paraplegia of Vascular Origin with Catastrophic Consequences.

Acute Aorto-Iliac Occlusive Disease (AIOD) is a rare clinical entity which when presents with buttock claudication, erectile dysfunction and absent femoral pulses is termed as Leriche syndrome. A 59-year-old male patient with past history of smoking and dyslipidaemia presented with acute onset lower back pain, paraplegia, intense lower limb pain and was initially evaluated for compressive myelopathy. On further clinical examination there were absent femoral pulses and Computed Tomography (CT) aortogram was done which confirmed the diagnosis of diffuse AIOD. Clinically, it is often challenging to differentiate between vascular or neurogenic origin of acute onset painful paraplegia. A high index of suspicion and careful clinical examination is therefore essential to avoid misdiagnosis of a major vascular event which can result in significant morbidity and mortality.

Hepatic vein waveform in liver cirrhosis: correlation with child's class and size of varices.

OBJECTIVE: To determine the correlation of hepatic venous waveform changes with severity of hepatic dysfunction and grading of oesophageal varices. METHODS: A cross-sectional analytical study was conducted at Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-III, Ward-7 from January 2009 to December 2009. Cirrhotic patients with portal hypertension were included in study. Patients presented with acute variceal bleeding, previous treatment with beta blockers or nitrates, sclerotherapy endoscopic band ligation, portal vein thrombosis, severe clotting defects, hepatic encephalopathy grade III or IV and noncirrhotic portal hypertension; were excluded from the study. Upper G I endoscopy was carried out in all patients after informed consent. Oesophageal varices were classified according to Baveno III while hepatic function was assessed and grouped by Child-Pugh classification. Colour Doppler ultrasound was carried out on all patients. Their waveforms were classified as monophasic, biphasic triphasic and the correlation of these hepatic vein waveforms with Child-Pugh class and size of oesophageal varices was evaluated. Statistical significance was defined as P?0.05. RESULTS: Total of 65 patients who met the inclusion criteria and included in the study with mean age of 47.39 +/- 10.91 (range 23-70) years. Among these 51 (78.5%) were males while 14 (21.5%) were females. On the basis of hepatic function 32 (49.2%) patients presented in Child-Pugh Class A, 23 (35.4%) with Class B and 10 (15.4%) patients had Class C. Hepatic venous waveform was triphasic in 5 (7.7%), biphasic in 18 (27.7%), and monophasic in 42 (64.6%) cases. The relationship of these waveforms had significant relation with hepatic dysfunction (p < 0.012) while insignificant with grading of oesophageal varices (p 0.29). Upper GI endoscopy revealed large grade varices in 37 (56.9%) patients, 17 (26.2%) patients had small grade varices while no varices were found in 11 (16.9%) patients. CONCLUSION: Hepatic venous waveform pressure changes have significant relation with severity of hepatic dysfunction but insignificant relation with grading of oesophageal varices. Further studies using a combination of various Doppler parameters are required to create indices with a better predictive value.