COVID-19-Positive report posing a delay in treatment course in a middle-aged metastatic neuroendocrine tumor patient
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/IJPC.IJPC_168_20
Source of Support: None, Conflict of Interest: None
Keywords: COVID-19, metastatic neuroendocrine tumors, palliative care needs, psychological concerns, symptom concerns
The novel coronavirus, also known as COVID-19, which emerged as the cause of a cluster of pneumonia cases in China, now has become a global threat and the major health-care concern of the year 2020., Neuroendocrine tumors (NETs) arise from cells of the endocrine (hormonal) and nervous systems. NETs commonly occur in the lungs, small intestine, rectum, and pancreas. Prognosis depends on their anatomic location.,
We describe the case of a 37-year-old male who was diagnosed with metastatic NET of the anal canal. His surgery was canceled following COVID-19-positive report and was shifted to a dedicated COVID quarantine facility at the National Cancer Institute (NCI).
A 37-year-old male residing in a village of Bihar presented to a nearby private hospital in August 2019 with complaints of constipation for 5 days refractory to treatment. He was further evaluated which revealed a mass in the anal canal. He was referred to AIIMS Delhi for further evaluation. He traveled with his father to Delhi, leaving his family of two children (10 and 15 years) and his wife in Bihar.
As the disease progressed, he developed fecal incontinence and had a significant loss of weight. Examination revealed anal incontinence with perianal fistula with an exterior opening at 5'o clock position, 4 cm away from the anal verge. Biopsy revealed high-grade NET of the anal canal. Multiple liver metastasis was revealed in contrast-enhanced computed tomography abdomen done on December 27, 2019. He received chemotherapy and was planned for diversion colostomy following chemotherapy on May 18, 2020. He was tested for COVID during preoperative checkup and was tested positive on May 16, 2020. His surgery was canceled and was asked to continue antibiotics. He was asymptomatic for COVID.
The patient with his father was then shifted to NCI, Jhajjar, on May 15, 2020, a center dedicated to quarantine and management for COVID patients. After screening, he was assessed and was admitted in the COVID ward. The doctors on rounds kept a keen observation daily and monitored his symptom progression. The sudden deviation from the expected course of treatment created the following concerns in the patient.
Physical and symptom concerns (his repellent disease condition)
The patient suffered from constant staining, malodor, and skin excoriation surrounding the fistula, which led to insomnia and malnourishment. He is not able to do self-care and maintain hygiene. ”I know surgery is the only option to stop fecal staining.” Understanding the prognosis, he wanted a way out of his misery and regain his health to an extent where he will be able to meet his activities.
Psychological concerns (missing his family)
He was anxious about whether the disease is going to progress and worsen because of delays in surgery. He was unable to take care of his family, and he was failing to attend to their needs during the corona outbreak. “I don't know how my family will survive without me and my father, lockdown miles away from them.” He was in constant low mood as his surgery was postponed.
Financial and social concerns (unable to play his role in the family)
His family lived in a pukka house in the rural village of Bihar. He is a farmer by occupation and the only breadwinner of the family; there was not enough money. His other family members were also facing similar financial constraints, and he was stressed about the situation.
He also felt a lack of direct access to doctors, which kept him under continual uneasiness and fear. “Doctor kab ayenge?,” “Mera surgery kab hoga?,” he wanted to consult his treating physician. Change of the treatment setting generated anxiousness. He felt lonely and unfrequented.
Spiritual concern (hope amidst despair)
Even if the odds were against him, he had a hope of improvement. He believes in god. He practices the Hindu religion. He does not blame anyone for his illness. He says ”I want to get better and want to rejoin my family.” He prays daily for the same.
Acknowledge the issue
How to proceed
How to accomplish
Role of palliative care
Palliative care approach encompassing all domains of care, that is symptomatic treatment, proper counseling, addressing the psychological issues, and empathetic communication between the health-care worker and the patient, will lead to improved understanding in patients about their illness. This will alleviate tension and provide realistic hope to the patient and the caregiver. In the setting of the current pandemic, this approach is very important as access to cancer care may be limited and lifesaving treatments may get delayed. As palliative care physicians, we must explain to the patient the difficult and testing times for the already-overburdened health-care system of our country.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.