World Brain Tumor Day 2021: Taking care of Brain Tumor Patients during COVID-19

Introduction

A brain tumor is defined as the rapid growth of abnormal cells in the brain. Brain tumors can be benign (non-cancerous) and malignant (cancerous). Primary brain tumors originate from the brain, whereas secondary brain tumors begin from other parts of the body and spread to the brain. Brain tumors are found more in children and older adults. Exposure to radiation, the male gender, exposure to viruses and infection, high use of mobile phones in children, N-nitroso compounds in the diet, and family history of certain diseases like neurofibromatosis, Turcot syndrome, and many others are some of the risk factors for brain tumors. The symptoms associated with brain tumors may include:

• Nausea and Vomiting
• Frequent and severe headache
• Confusion in making decisions
• Change in behavior and personality
• Loss of peripheral vision
• Blurred Vision
• Gradual loss of sensation and movement in the legs and the arms
• Difficulty in maintaining balance
• Difficulty in hearing and talking

Why Brain tumor patients need care during COVID-19?

It has been found that COVID-19 patients develop many neurological manifestations like Encephalitis, Ancosrria, Viral meningitis, Stroke, Dysgeusia, Anosmia, Guillain-Barre Syndrome, Acute disseminated post-infectious encephalomyelitis/Acute disseminated post-infectious encephalitis and acute cerebrovascular disease. Since COVID-19 affects the lungs, thus the lungs cannot produce enough oxygen to the body. According to Dr. Pravin George, COVID-19 can cause hypoxic-ischemic injury to the brain due to lack of oxygen supply. COVID-19 also leads to tiny clots and bleeding inside the brain, which are critical neurological complications. The risk of requiring mechanical ventilation or ICU admission or mortality due to COVID-19 is 3.5-fold greater in cancer patients than patients without cancer. The increased vulnerability of cancer patients to COVID-19 severe complications can be due to the immunosuppressed status caused by malignancy and anticancer drugs, such as chemotherapy or surgery. Patients suffering from any neurological disorders are very much at risk from COVID-19. Thus, patients suffering from a brain tumor and undergoing treatment need care during the COVID-19 pandemic. Even patients who have a brain tumor and have recovered from COVID-19 need critical care and monitoring. Depression, anxiety, and delirium are not good for mental health. So, patients should be monitored appropriately, and care should be provided to ensure that patients with brain tumors lead a normal life during this pandemic.

Taking care of patients suffering from a Brain Tumor during COVID-19

According to an article published by Kunal Kishor et al. here are the advice given by Michael Wang, the Chief Strategy Officer of the National Foundation for Cancer Research to cancer patients, survivors, and caregivers during the COVID-19 pandemic:

• Before starting the treatment for cancer patients, the following evaluation should be carried out comprehensively:
  1. Clinical symptoms of the patient
  2. Scanned images of the tumor
  3. Results from molecular testing
  4. Proper planning of surgery
• Suppose the patient suffers from a low-grade neuroglia, which has been recently diagnosed and has stable symptoms. In that case, the surgery can be postponed by keeping the patient under constant observation.
• If the person is young and has high-grade Glioblastoma, then maximum resection of the tumor should be performed without delay, so long as best practices to prevent coronavirus infection are in place.
• Biopsy procedures and surgery should not be carried out in geriatric patients who have cancer during this pandemic. They should be first appropriately diagnosed through MRI procedures every three to six months to evaluate the spread of tumor progression. According to Michael Wang’s advice, until a clear picture of the tumor’s feature is not obtained, no aggressive therapy should be given to elderly patients.
• If a patient with recurrent glioblastoma has the presence of wild type IDH as the biomarker, then the surgery should be performed quickly.
• Tumor treating procedure should be carried out at home for patients who are on tumor treating fields (TTF). This is done to prevent the patient form being unnecessarily exposed to COVID-19 in hospital settings.

Similarly, the European Society of Medical Oncology (ESMO) is implementing a tiered method for the management of cancer patients during the COVID-19 pandemic. This strategy takes into account the state of the patient, the urgency of the proposed treatment for cancer, and its expected benefit, including the possible risk of COVID-19 associated with the logistics of providing medication, as well as the services available for the effective provision of treatment.

Based on the above strategy, the patients are grouped in the following tiers:

1. Tier 1 High priority: This group includes patients whose condition is life-threatening or clinically unstable and treatment is of higher priority.
2. Tier 2 Medium priority: This group includes patients whose condition is serious but not immediately life-threatening and where a short delay not longer than 6–8 weeks in treatment can be considered.
3. Tier 3 Low priorities: This group includes patients whose condition is stable enough that any treatment can be safely delayed for the duration of the COVID-19 pandemic.
4. Apart from the above management advice, patients should strictly follow COVID-19 guidelines. Patients should wear a mask, wash their hands with soap or hand sanitizer, and maintain social distancing. They should not step out of the house unless it is not required.

Here are some questions which will clear doubts from your mind?

1. Can Brain Tumor patients take the COVID-19 vaccine?

   Answer: Consult your medical Oncologist before taking any such step. Do not take vaccine without advice from your oncologist.

2. Should immunosuppressive therapy be stopped, or delayed, or interrupted in patients who are infected with COVID-19?

   Answer: This decision lies in the hand of an oncologist. He/she has to take this critical decision as continuing anticancer therapy may lead to suppression of the immune system and more severe complications. According to the UK National Institute for Health and Care Excellence, if a patient has one negative SARS-COV-2 test, then he/she can resume their treatment.

3. Should surgery be canceled or delayed?

   Answer: Yes, surgery should be elective. It depends on the situation. Suppose surgery requires postoperative intensive care, and the hospital has the required number of intensive care units allotted for such cases during the pandemic. In that case, surgery may not be canceled or delayed. Please read the management guidelines mentioned above to get more clarity on the situations where surgery is feasible.

4. If a patient with brain tumor experiences symptoms of COVID-19, should he/she contact a medical oncologist or primary care physician?

   Answer: If the patient is on active cancer treatment during symptoms of COVID-19, he/she should reach to his/her oncologist first. If the patient is not on active cancer therapy, then he/she should go to a primary care physician allotted for treating COVID patients.