Covid-19 wrecks cancer care

The outbreak of coronavirus, which has quickly snowballed into a pandemic, shut down vast parts of the world—livelihoods, businesses, services, economy, transport, healthcare.

When Gloria Okwu was diagnosed for breast cancer in 2017, she went into a panic. She considered funds and fear.

“People kept telling me cancer treatment kills. Of course, the treatment is not intelligent. If you take those treatments, you suffer side effects,” she recalls.

“Because of that fear, many people wish they would not undergo those treatments.”

They were the conventional treatments that come in stages—chemotherapy, radiation, surgery—and all have side effects.

Okwu considered herbal treatment, but faced a recurrence in 2018.

“I had no option than to go for the treatment, as I was told,” she says.

She did chemotherapy, went through radiotherapy, and was scheduled for check-ups.

She finished her treatment course in February. The next month, the coronavirus pandemic hit Nigeria and forced the country into a lockdown. Okwu made a drastic decision.

“I was supposed to go for certain check-ups but I declined because I was afraid I would contract Covid-19,” she says.

She is hardly unique.

The outbreak of coronavirus, which has quickly snowballed into a pandemic, shut down vast parts of the world—livelihoods, businesses, services, economy, transport, healthcare.

Healthcare has particularly suffered, says Omolola Salako, in a paper she lead-authored for the journal ecancer.

She is of the department of radiation biology, radiotherapy and radiodiagnosis at the College of Medicine, University of Lagos.

“The novel COVID-19 pandemic has grounded several global activities including the provision of health care services to people with chronic conditions such as cancer.

“Evidence from China suggests that cancer patients with COVID-19 infection are a vulnerable group, with a higher risk of severe illness resulting in intensive care unit admissions or death, particularly if they received chemotherapy or surgery.”

It is a major headache—102,000 new cases and 72,000 deaths in Nigeria each year are captured in Nigeria’s four-year cancer control plan.

Levels of disruption

One fear is getting the coronavirus, and that in itself is a valid concern.

“Beyond the risks that direct acquisition of the virus may carry for patients with cancer, delayed diagnosis and the provision of suboptimal care may have a larger impact for the wider population of patients with cancer,” researchers reported in the journal Nature in March, as countries battened down shutters and spiralled into lockdown.

Apart from Okwu, who deliberately avoided hospitals for fear of contracting coronavirus, other reasons emerged that would impact care for cancer patients.

One group stopped going to hospitals to continue treatment because doctors wouldn’t treat them, as concerns over personal protective equipment for healthcare became a major issue.

Hospitals scaled down services, pared off routine services and focused on emergencies.

Another group was classified as “very important”, especially in line for radiotherapy, and efforts were made to ensure they got treatment despite Covid-19. That designation left many more patients out in the cold, says Okwu, a member of the Network of Persons Affected by Cancer.

“Those who were deemed not critical didn’t receive treatment because doctors were only taking emergency cases.

“Some couldn’t even get surgery. It happened a lot. People who were booked for surgery didn’t get it.”

It was easy to foresee the upheaval coronavirus pandemic would unleash on cancer care. Well before the virus entered Nigeria, the World Health Organisation published a report on its joint mission with China on Covid-19, stating patients with cancer had more to lose.

Overall fatality rate for coronavirus disease was put at 3.8%, and patients without any pre-existing condition had a fatality rate of 1.4%. But cancer patients had a fatality rate of 7.6%–that’s nearly eight in 100 people with cancer who also got Covid-19 could die.

Oncologists were advised to weigh the benefit of treatment against the potential risks for cancer patients.

Snowballing consequences

The Network Okwu has been awash with stories of difficulties members have faced as Covid-19 disrupted health services.

Among them, a woman who was booked for tests at National Hospital. With the disruptions, the test couldn’t proceed.

She went to a private facility and the test cost nearly six times more than she would have paid at a public hospital. But the money wasn’t the only setback.

The test required some specimen. A mastectomy was done to remove breast tissue but the specimen was not preserved.

“It should have been preserved for histopathology, to ascertain what other treatments she would need,” Okwu explains of the mistake.

“You rarely hear of this kind of thing in general hospitals; they are very meticulous with specimen. But this is a small facility; they took a lot of things for granted.”

Covid-19 rips into psychology

Living with and treating cancer is emotionally draining. The toll of Covid-19 on mental health has been a serious concern since the start of the pandemic.

But, in addition to patients, the medical oncologists treating them—as with any other terminal disease—are also at risk.

Researchers this June published studies showing how Covid-19 has exacerbated mental health risks brought on by isolation and exhaustion.

They showed how oncologists in the Philippines used psychological support materials, initiated psychological intervention programmes and established peer support programmes to help oncologists cope.

Covid-19 ripped both emotional and financial support for patients. Support groups which provided meeting grounds for individuals living and dealing with cancer stopped meeting as coronavirus pandemic induced physical distancing.

“There are people ordinarily you would have raced to their house, sit with them, talk them through their issues with treatment and diagnosis, but because of the lockdown, you can’t see them physically,” says Okwu.

“You are stuck in your house; they are in their houses and you can’t be there for them physically.”

Support groups also connect member patients to funding sources. Medications in cancer therapy are hugely expensive.

Early in the year, as the world marked the annual Cancer Day, Medicaid Cancer Foundation connected 10 patients to funds, a total N2 million to aid their treatment.

Several members of support groups have been linked to nongovernment organisations like Medicaid before the pandemic raged into the country and forced a lockdown.

“None of them got any financial support all through this period. Most of the funders are channelling their resources to Covid-19,” says Okwu.

“I know that is what it will be; the attention is on Covid-29 but then other illnesses are suffering right now.”

Suffering services

One of the greatest disruptions in Nigeria was to the fight against cervical cancer a disease which affects more than 14,000 women each year.

It is one of the most common—predominant in countries of sub-Saharan Africa, south east Asia and south America.

“These are the countries that we have a high level of poverty; they are countries in the lower-income cadre, so cervical cancer is now seen as a disease showing how poor people are,” says Olumuyiwa Ojo, of the World Health Organisation, at a cervical cancer stakeholders forum this June.

The forum is the first of conferences for Nigeria to look at the four-year control plan for cervical cancer. The plan elapses next year, four years after it was conceived.

It has taken consultations at global and national levels to come this far. A meeting at the World Health Assembly in May was to ratify strategies for eliminating cervical cancer but it went virtual and short lived on account of Covid-19. So did the stakeholders forum, which had participants from all over the country hooked on Zoom for more than three hours.

“The world generally is moving toward elimination of cervical cancer, and we are agitating to get Nigeria on that boat,” says Zainab Bagudu, founder of Medicaid Foundation.

Forty million women aged 15 and older are at risk of cervical cancer and more than 40,000 are diagnosed each year. Eight in 10 present at an advanced stage, and late presentation means one in four of them could die.

“In order to reverse this trend, we have made efforts to increase our national capacity for prevention, early detection, diagnosis and treatment of precancerous and cancerous lesions of the cervix in Nigeria,” health minister Osagie Ehanire said at the forum.

The National Primary Health Care Development Agency is looking to ramp up access to prevention of cervical cancer in women and girls by rolling out vaccination against human papilloma virus by the first quarter of 2021.

“We are irreversibly on the final stretch of the road to get vaccine to our people,” says Faisal Shuaib, executive director of the agency.

“What bears interrogation is why a primary prevention route as HPV vaccine that’s been around for over 10 years is not in use.”

Cervical cancer is ranked fourth most common worldwide, but receives little attention from international Oncology societies and scientific research studies, experts say.

People living with it could benefit from secondary prevention programmes starting in the states of Lagos, Rivers and Kaduna. The progamme was billed as a collaboration between the federal health ministry and the Clinton Health Access Initiative. It was meant to start in May but has stalled on account of Covid-19.

Another intervention involving CHAI, the American Cancer Society and at least three pharmaceutical companies—Pfizer, Novartis and Mylan—is rolling the Cancer Access Programme to provide “sustainable, affordable” cancer medicines to patients in 11 sub-Saharan African countries.

Cameroon and Ghana are the two newest countries the programme is expanding to. Before then, it has been in Ethiopia, Kenya, Uganda, Rwanda, Tanzania, Malawi, Zimbabwe, Zambia and Nigeria.

CAP started in 2017 with Nigeria, and an announced expansion in June, will broaden health benefits for Africa’s health care system, its backers say. The benefits range from training for health care personnel and development of systems for safe transportation to storage, administration and disposals of hazardous chemotherapy drugs.

The pharmaceutical firm Pfizer has been contributing nine medicines to CAP and is adding two more with the expansion, increasing the number of CAP medicines to 20.

Several of the medicines are already available in multiple formulations, up to 29 in total.

Among them, 21 are on the World Health Organisations “essential medicines list” which draws a threshold for the minimum medicine needs for health care.

These medicines help make up the key regimens for 27 cancers in Africa, including the three most common – breast, cervical, and prostate, Pfizer said in an emailed response to a Daily Trust query about CAP.

CAP works to bring medicines closer to patients by removing bottlenecks and middlemen that contribute to increased drug prices.

Over Zoom, Rhulani Nhlaniki, Pfizer South Africa country manager and Sub-Saharan Africa, explains how the access programme works.

“We provide the medicines; governments then need to procure using their own system. In the forecasting is where CHAI comes in to help the government get better forecasting,” he says. “The partnership in Nigeria has been very successful.”

In a typical money flow, payments by patients buying drugs go into a central pool but drug distributors and suppliers don’t get the money fast enough to replenish drug stock.

CAP creates a “platform where the payment system is routed directly to suppliers, so the cash flow is much easier, so there is continuous replenishment of stock,” says Nhlaniki.

“And when you do that, you are taking away all the markups so the prices being offered are favourable to the patient.”

“By stabilising the market systems, we have found governments are able to save,” he says, citing an average 50% reduction in cost to in countries where the programme operates.

The possibility of boosting her savings was the last thing Okwu thought about.

Covid-19 was on her mind.