key: cord-0682371-8psfkp0n authors: Okeke, Marvellous; Olayinka, Oderinde; Lin, Liu; Kabula, Deo title: Oncology and COVID-19: Perspectives on Cancer Patients and Oncologists in Africa date: 2020-06-17 journal: Ethics Med Public Health DOI: 10.1016/j.jemep.2020.100550 sha: 7e20a55a80913360f31f3824e289ad052a3575e1 doc_id: 682371 cord_uid: 8psfkp0n Abstract The global communities have been grappling with health pandemics for months since the outbreak of COVID-19, which has been flagged a global health emergency by World Health Organization, WHO. While the entire health sector has been overburdened, cancer patients are also at a high risk of getting infected during this COVID-19 pandemic, hence there is a great concern for these patients because there are little to no data to support their management with the current health care structure in Africa. This article outlines the challenges frontline health workers face in the management of cancer patients, as all the entire health sector calls for effective policy formulation and implementation by the government in their role in ensuring the sound health of their citizenry. les patients atteints de cancer courent également un risque élevé d'être infectés pendant cette pandémie de COVID-19, d'où une grande inquiétude pour ces patients car il n'existe que peu ou pas de données pour soutenir leur prise en charge avec la structure actuelle des soins de santé en Afrique. Cet article décrit les défis auxquels sont confrontés les travailleurs de la santé de première ligne dans la prise en charge des patients cancéreux, car l'ensemble du secteur de la santé exige une formulation et une mise en oeuvre efficaces des politiques par le gouvernement dans son rôle de garant de la bonne santé de ses citoyens. The world has been on a standstill for several months since the outbreak of coronavirus (SARS-COV2) which has been declared as a public health emergency (PHEIC) by the World Health Organisation (WHO). This was consequent upon its spread to almost all parts of the world in a short space of time; Africa inclusive. The spread of these new strains of pneumonia cases was linked to a large seafood and live animal market, in Wuhan and is accompanied by clinical manifestations such as fever, cough and other respiratory symptoms [1] [2] [3] [4] . The average incubation period ranges from 2-14 days, with fever and respiratory symptoms appearing within 3-7 days after exposure to the virus [5] . Coronaviruses SARS-COV2, MERS-COV and SARS-COV all belong to the family coronaviridae because of the unique crown-like shape of their viral envelopes that consist of club-shaped glycoprotein spikes (Figure 1 ). Their reservoir hosts include bats, cats, camels and cattle; suggesting potential animal to human spread and then human to human spread which is a current major concern globally [6]. Africa's link with COVID-19 impact. As at the moment and possibly for years to come, COVID-19 has and has potential to progressively impact every aspect of life and humanity. This has been exacerbated by lockdown, French nationals and a British citizen while Nigeria's index case was an Italian business man, followed by 2 cases in Egypt, 1 case in Tunisia, Morocco and South Africa, respectively [11] . It is important to consider the oncological aspect of the health sector in relation to COVID-19 in Nigeria and Africa as the second largest continent of the world. COVID-19 has brought a huge impact on the general preparedness of the nation and population, be it economic, social, political or educational. Another important aspect plays out with regards to the restriction of mass gatherings as it involves social and religious activities and most profoundly, the psychological demeanor towards each other. COVID-19 as a public health emergency of international concern (PHEIC) provides an opportunity for the further expansion of knowledge based on the implementation of non-pharmaceutical interventions in order to quantify their utilities in pandemic mitigation, mass gatherings including the clearly-defined and spontaneously-occurring being the major determinants of the epidemiological expansion of disease outbreak [12] . The route for the transmission of SARS-COV2 can be through contact-and respiratory transmission, hence in order for oncologists to function maximally, appropriate personal protective equipment (PPE) donning is of apparent need [13] . Currently the number of COVID-19 cases in Nigeria is spiraling with a count of 5,162 confirmed cases, 3,815 active cases, 1,180 discharged cases and 167 deaths on the 16 th May, 2020, with the hotspots of infection being Lagos, Kano and Federal Capital Territory (FCT), while about 23,835 sample tests have been so far conducted in a population of ~200 million [14] . However, the facts that the speed of identifying active cases is slow and testing capacity is low expose the frontline medical personnel to a higher risk as the work pressure has been huge and rising, hence the need for quick intervention of government ( figure 3 ). This can be achieved by speedily creating a quarantine zone for the infected patients, which will be distinguished and properly managed from a COVID-19 free zone for the non-infected medical consumables and life support equipment, absence of life insurance, just to mention a few [16] [17] [18] . It is a glaring reality that during a time like this, the medical workers are the ones that receive the heaviest blow hence the main reason much attention should be directed towards them because the spread of COVID-19 cannot be curtailed without the bravery and sacrifice of the frontline medical workers. The consideration of all the above-mentioned as well as the need for government to efficiently play their role by paying more attention to communication and quick response coupled with fast action, will go a long way handling reasons for the constant alarms raised by the medical community in Nigeria and Africa in general. However, the major concern lies in the implementation of no-mass gatherings and social distancing especially with the effective [20] . Due to the unique vulnerability of cancer patients as a result of their weak immune system, it is reasonable to suspend any form of therapy until they attain asymptomatic state, due to the non-availability of evidence to support withholding or supporting the chemo-/immunotherapy, hence the use of steroid sparing strategies as well as streamlining testing to manage immune-related adverse events will go a long way reducing the COVID-19 impact [21] . Radiotherapy management of cancer patients with COVID-19 is sensitive as well, which may vary in terms of cancer type and stage. For example, in breast cancer management, despite the fact that a radiotherapy boost may decrease loco-regional reoccurrence in breast cancer, its negligible effect on survival and the possibility of omission should be considered. Patients with non-invasive disease with no survival benefit from radiotherapy should opt for omission, while low risk, older patients with minimal survival benefit from radiotherapy and a much higher risk of mortality from COVID-19 should as well be considered for omission. Also, for prostate cancer management during a pandemic, this includes hypo fractionation and treatment delays where necessary as the overall strategies. At this time for low risk patients, being subjected to active surveillance and returning in 6 months for prostate-specific antigen (PSA) testing is recommended. The same is done for patients with favorable intermediate risk but their return should be in 3-6 months for PSA testing repetition, while for high risk patients, a shorter delay of 2-4 months with androgen deprivation therapy (ADT) is a recommended safe and pragmatic approach with data supports to delay radiotherapy in a post-prostatectomy salvage situation [28] . Surgery is an important foundation of cancer treatment that can neither be ignored nor underestimated, as it is the only cure chance for most patients, hence, during this COVID-19 pandemic, it is important for surgical oncologists to find a way to overcome the challenges that are on ground in terms of surgery and follow up of cancer patients, especially having insights on rules adjustment for a secure stable system of management. Res et al. [17] reported that 80% of 371,000 diagnosed new cases of cancer were surgery candidates, however the number of surgeries decreased after 30 days as a result of efficient management of only emergency cases during COVID-19 pandemic. With prompt health facilities' reorganization and swift knowledge evolution during this period, there needs to be formulation of recommendation for adaption as well as hospital reorganization and screening measures for futuristic developing situations. During this COVID-19 outbreak, the major risk for cancer patients is the inability to access necessary medical services from dual points which is getting to the hospital and the provision of essential medical management on their arrival [29] . In regards to the psychological effects of COVID-19 on patients, that cannot be dispelled especially due to the daily media coverage about the COVID-19. There is palpable spreading of fear among healthy individuals about being infected with the virus, which of course, will trigger depressive psychological effect amongst cancer patients' community, based on the vulnerability of their health conditions, if affected by the virus. In this current time, the thoughts of potential cancer patients are more oriented towards the symptoms of COVID-19, indicating that they focus less on other associated signs of cancer including lumps, rectal or bladder bleeding, etc., that would give prompts to consulting physicians. Hence, the anecdotal evidence suggests that cancer patients are starting to fear COVID-19 than the cancer itself [30] . Currently, the best way to manage cancer patients during this pandemic crisis is through telemedicine. Telecommunication has always been a key tool to salvage this present situation, especially with the prohibition of mass gatherings and the implementation of social distancing as close contact between doctors and patients is very crucial in medical practice. So, since this cannot be manifested in present reality for some patients except those in critical conditions, through telemedicine, patients can feel a sense of comfort during this COVID-19 pandemic period. Oncologists can strategize by splitting into two teams namely; the team that will attend to severe and less severe cancer cases, and the team to attend to severe and less severe infected cancer cases. This will assist in reducing the work load and curtail the spread of infection and ensuring the safety has in an unprecedented way, created new opportunities for telemedicine innovations to remotely assist in the monitoring of patients in health management [21] . Sim et al. [28] suggested that financial burden in the name of taxes and levies, to telephone communication should be removed from systems wherever possible to assist in efficient service delivery. Video consultations are also helpful addition to telemedicine but the lack of this technology, especially in poor countries should not inhibit efforts to remote monitoring by telephone. The academic aspect of oncology can as well not be exempted, as COVID-19 pandemic has resulted in the cancellation of many international medical forums and meetings. These include Barcelona, Spain, amongst several others [31, 32] . Furthermore, clinical trials and research which require physical laboratory work sometimes, have been indefinitely suspended and these will negatively have impact on the medical community. As known, continuous research is a major frontier of oncologist to get updated and advanced in their knowledge of patient management, which is also beneficial and apparently a need for cancer patients. However, since the onset of the coronavirus pandemic, there has been few to rare publications from Africa on a clinical study being carried out on how cancer patients are affected in relation to number of infected cancer patients, cancer type and staging, other co-morbidities, sexual predilection and mortality rate with highlights. These are in addition to the challenges the medical personnel in Africa will encounter in order to give oncologists a sense of direction to enhanced patients' management of during this global pandemic. The increase in cases which is still inevitable, should be a wakeup call for Africa, especially the governmental bodies, as the current cancer management in Africa has poor outcomes which have resulted to the loss of a staggering amount of lives and with the addition of present COVID-19 pandemic, it is just a very overwhelming situation. It was reported that ~57.14% out of 14 million diagnosed cancer patients died in 2012, with over a half of the diagnosed cases from Africa resulting into two-thirds of deaths, including other low and middle income regions of the world, with a projection of rise in cases by 2030. [33] Cancer is the leading cause of death in the developed world and also a major cause of morbidity and mortality in low and middle income countries, [30, 34] however, the data associated with cancer incidences and mortalities is almost non-existing from Africa (except Mauritius, France Reunion, Egypt, Morocco, Tunisia, Republic of South Africa, Cape Verde and Sao Tome and Principe) and other low and middle income regions of the world [35] . In order to win the fight against COVID-19 and future occurrences, enhanced team work is required and with the underlying reality of the health care system in Africa, negligence should be avoided. Africa, with the huge human resources is capable of managing this pandemic and bring it to a halt, but with the government paying greater attention to the needs on ground and by prioritizing health sector in addition to increase the more amount spent on medical researches. 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