COVID-19 and surgical cancer care in Brazil

ABSTRACT

Concerned with the evolution of COVID-19 in Brazil and its impact on our health system and oncology surgical assistance, the authors performed a review and suggested strategies for approach based on current evidence.

RESUMO

Preocupados com a evolução do COVID-19 no Brasil e seu impacto em nosso sistema de saúde e assistência cirúrgica oncológica, os autores realizaram uma revisão e sugeriram estratégias de abordagem baseadas em evidências atuais.

Keywords:

Neoplasms - Public health - Evidence-based medicine

Descritores:

Neoplasias - Saúde pública - Medicina baseada em evidências

In Brazil, the estimate for each year of the 2020-2022 triennium points out that there will be 625 thousand new cases of cancer (450 thousand, excluding cases of non-melanoma skin cancer). Non-melanoma skin cancer will be the most incident (177 thousand), followed by breast and prostate cancer (66 thousand each), colon and rectum (41 thousand), lung (30 thousand) and stomach (21 thousand). The most common types of cancer in men, with the exception of non-melanoma skin cancer, will be of prostate (29.2%), colon and rectum (9.1%), lung (7.9%), stomach (5.9%) and oral cavity (5.0%). In women, except for non-melanoma skin cancer, breast (29.7%), colon and rectum (9.2%), cervix (7.4%), lung (5.6%) and thyroid (5.4%) will be among the main ones. Non-melanoma skin cancer will represent 27.1% of all cancer cases in men and 29.5% in women.^[ [1] ^]

A few and limited studies deal with the risk of COVID-19 associated with cancer patients undergoing treatment or even their survivors. We believe that only well-designed studies can provide answers on these very diverse questions. The association of these diseases and their relationship with our population is still poorly understood. The reported characteristics of clinical presentations, contagion and operational overload on health systems in the affected countries are worrying,^[ [2] [3] [4] ^] especially in areas of scarce resources. We lack minimal data to understand the dynamics of the disease and its spread in a country with peculiar characteristics like Brazil, with an estimated population of 211 million, continental dimensions and a predominantly tropical climate.

From the learning and information available so far, we know that cancer patients may be at higher risk of manifestations of COVID-19 disease when compared to individuals without cancer. In addition, it was noted that cancer patients had worse results for the clinical evolution of COVID-19, suggesting that greater attention should be paid to cancer patients, especially in the event of rapid deterioration of the condition.^[ [5] ^]

Three strategies for cancer patients were proposed by teams that experienced this COVID-19 crisis:^[ [5] ^]

Intentional postponement of elective surgeries for cancer can be considered in endemic areas,^[ [5] ^] according to the assessment of the assistant team and in compliance with local conditions of care and guidance from their health authorities;

Stronger personal protection provisions should be made for patients with cancer or cancer survivors;^[ [5] ^]

More intensive surveillance or treatment should be considered when cancer patients are infected, especially in older patients (group with higher mortality), smokers or with other serious comorbidities.^[ [5] ^] Furthermore, cigarette smoking (commonly practiced by cancer patients) is the leading cause of chronic obstructive pulmonary disease, which has been identified as an independent risk factor in severe COVID-19 cases.^[ [6] ^]

The discussion about procrastination or postponing cancer treatment is controversial, since the definition of severity is changeable according to the type of cancer and often subjective, in addition to also causing other emotional and psychological damage to the patients. In Brazil, there are still legal implications with risk of penalties for health managers according to Law No. 12,732/12 (in force since 05/23/2013), which established that the first cancer treatment in SUS (Brazilian Public Health System) must start maximum term of 60 days from the signature of the pathological report.

Current scientific evidence is incipient, show a small sample size with a large amount of heterogeneity, presenting as several types of cancer with different biological behaviors, highly variable disease courses and different treatment strategies, and thus not ideally representative of the whole cancer population. So any generalized conclusions for these patients should be interpreted with caution, but the prolonged effects induced by surgery, including immunosuppression, should not be overlooked.^[ [6] ^]

That said, concerned also with the potential overload of our health system and with the still unknown dynamics of COVID-19 in our country, we agree with the aforementioned strategies suggested in medical literature, associated with determinations and guidance from health authorities, increased attention to personal hygiene and social etiquette, in addition to the protocol recommendations for individual protection for heroic health professionals involved in the care of these serious situations, COVID-19 and cancer.

Conflicts of interest

The authors declare no conflict of interest relevant to this manuscript.

• REFERENCES

• Ministério da Saúde (BR), nstituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Estimate/2020 - Cancer incidence in Brazil [Internet]. Rio de Janeiro (RJ): INCA;; 2020. [cited 2020 Mar 09]; 1-122 Available from: https://www.inca.gov.br/sites/ufu.sti.inca.local/files//media/document//estimativa-2020-incidencia-de-cancer-no-brasil.pdf
• Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China. Summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. . JAMA. 2020. Feb; 24; Epub ahead of print. https://doi.org/10.1001/jama.2020.2648
• Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R.. Features, evaluation and treatment coronavirus (COVID-19). Updated 2020 Mar 20 StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020. Jan; Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/
• Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H. et al Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a singlecentered, retrospective, observational study. Lancet Respir Med. 2020. Feb; S2213-2600(20)30079-5. 2020 Feb 24. Epub ahead of print. https://doi.org/10.1016/S2213-2600(20)30079-5
• Liang W, Guan W, Chen R, Wang W, Li J, Xu K. et al Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol 2020; Mar; 21 (03) 335-337 https://doi.org/10.1016/S1470-2045(20)30096-6
• Xia Y, Jin R, Zhao J, Li W, Shen H. Risk of COVID-19 for cancer patients. . Lancet Oncol. 2020. Mar; S1470-2045(20)30150-9. 2020 Mar; 3; Epub ahead of print https://doi.org/10.1016/S1470-2045(20)30150-9

Publication History

Received: 16 March 2020

Accepted: 20 March 2020

Article published online:
13 April 2020