KUALA LUMPUR, April 10 — A prolonged lockdown may increase fatalities among cancer and diabetic patients during the Covid-19 epidemic after delaying treatment for a month, experts warned the government.
Patients had to reschedule elective surgeries that were postponed during the Movement Control Order (MCO) that is expected to end on April 14 since it was imposed on March 18. But with uncertainties surrounding the end of the nationwide partial lockdown, many patients are facing trouble rescheduling their surgeries.
An elective surgery does not necessarily mean that it is optional, but that it can be scheduled in advance because it doesn’t involve an urgent life-threatening condition. But still, cancer patients are struggling to come to terms with the delay in their treatments.
Dr Yip Cheng Har, a breast surgeon at Ramsay Sime Darby Health Care, said joint replacement, for example, is an elective surgery, but pointed out that patients’ impression on what is elective and what is not may differ.
“For example, if their joint is painful, they might want surgery early. With MCO, some patients have time on their hands so they want to do the surgery they have been putting off for years,” Dr Yip told CodeBlue.
“Cancer surgery should not wait more than a month. If wait too long, survival will drop. We may find that after Covid-19, cancer mortality may increase.”Dr Yip Cheng Har, breast surgeon at Ramsay Sime Darby Health Care
Dr Azlina Firzah, a consultant breast surgeon at Pantai Hospital Kuala Lumpur, said surgical procedures that can be deferred are those that do not affect “life or limb”. Emergency amputation, for example, cannot be postponed and will still be performed in hospitals that are not designated Covid-19 facilities.
She cited a Ministry of Health (MOH) guideline dated March 24 on surgery during the coronavirus outbreak that said “all elective surgeries should be postponed as to divert our available resources for those suspected or confirmed to have Covid-19”. All staff involved in surgical procedures must also use personal protective equipment (PPE), while all tertiary hospitals should have a dedicated operating theatre for suspected coronavirus patients, according to the MOH guideline.
“Cancer surgeries that are currently being scheduled are mainly for those with breast cancer and colorectal cancers. Other cancer surgeries are scheduled if postponing would cause major problems,” Dr Azlina told CodeBlue.
For patients who require other treatments such as chemotherapy, they will be reviewed on a case-by-case basis.
“If patients require chemotherapy, the patients are reviewed individually to see if postponing the treatment would not cause deterioration of the patient’s condition,” said Dr Azlina.
“We have to think holistically — procedures would involve using equipment like gloves, gowns, protective equipment that would be needed in handling Covid-19 cases. So, we need to save on PPE.”
Public Hospital Patients Face Financial Constraints
Patients who have been going to government hospitals for cancer treatments are the hardest hit, as some do not know how long they have to wait for their medical procedures that were cancelled during the coronavirus outbreak.
Health director-general Dr Noor Hisham Abdullah said yesterday, however, that the elective surgeries cancelled in Covid-19 government hospitals have been transferred to district hospitals and public university hospitals, as well as private facilities at lower rates.
Generally, public patients cannot opt to undergo surgeries in private hospitals due to financial constraints. As per government guidelines, patients across the public and private sectors must be tested for Covid-19 before undergoing operations.
“All patients need to undergo Covid-19 test prior to surgeries to protect HCW (health care workers) and for proper, meticulous planning of how to manage the patients preoperatively, intraoperatively and postoperatively,” said Dr Azlina.
These coronavirus tests are currently not covered by insurance; therefore patients have to fork out their own money.
“Cancer surgery cost depends on what cancer. Can range from RM10,000 for breast cancer to RM50,000 for stomach cancer; maybe more for liver cancer,” Dr Yip said.
“But because of Covid-19, all private hospitals must do compulsory [coronavirus] tests on all pre-surgery patients. And insurance do not pay. These tests cost between RM388 to RM630. Private surgery is expensive for those without insurance.”
Dr Azlina also shared the same sentiment: “Patients who seek medical opinion in public hospitals generally steer clear of private hospitals as they perceive costs are too high.”
New Surgical Patients May Not Be Accepted Post-MCO
Regardless of today’s outcome of the government’s discussion on the status of the MCO, hospitals will need to clear the deferred surgeries and make way for new ones as soon as they can.
“We would have to overcome the backlog caused by the MCO. We would need to prioritise who needs to have procedures ahead of others,” said Dr Azlina.
“We would contact patients who had postponed their appointments, review them as necessary and review the need for surgeries. Those that can connect with their doctors via certain web platforms are encouraged to do so.”
She said all reviews will be on a case-by-case basis, depending on the importance of the surgery and the condition of the patient.
Doctors will most likely reject new surgical patients after the MCO so that they can clear all of their backlogged cases.
“Surgeons are starting back to clear their cases in stages, but since clinics do not accept any new patients, there will be no patients after the backlog,” Dr Yip said.
To avoid this and to ensure patients always have access to treatments and procedures regardless of the status of the MCO, a private hospitals’ group recently requested the government to allow elective surgeries to be resumed soon, saying medical conditions could worsen over time.
Association of Private Hospitals of Malaysia (APHM) president Dr Kuljit Singh told CodeBlue the government has urged private health care providers to avoid elective surgeries involving blood transfusions. Most private hospitals on their own, he said, decided to avoid elective operations during the MCO, as blood supplies were running low either because of coronavirus or due to the lockdown.
“We will follow all precautions stipulated by MOH and advisory from Academy Medicine Malaysia, College of Surgeons and Anesthesiologist Society,” he said.
Former Malaysian Medical Association (MMA) president Dr Milton Lum said private hospitals have seen a drop in elective surgery and clinic appointments at patients’ request during the coronavirus epidemic.
“The question a lot of patients are asking is whether private hospitals test their staff for Covid-19 or not,” Dr Lum told CodeBlue. “I say if you require a patient to check, you also have a responsibility to check your staff. It cuts both ways.”
Diabetes, Kidney Patients Also Struggling With Treatments
Apart from those with cancer, another group of patients that is suffering in the midst of the MCO is those with diabetes and kidney ailments.
Dr Anuar Zaini Md Zain, a consultant endocrinologist at Beacon Hospital, told CodeBlue that many such patients have already missed their appointments and are not getting their regular drug supplies.
“Hence, the rate of hospital admissions due to complications may increase,” he said.
“Diabetic patients are more prone to get higher mortality with Covid-19. So prolonged MCO may be more deleterious for diabetic patients.”Dr Anuar Zaini Md Zain, consultant endocrinologist at Beacon Hospital
“The negative economic burden will also affect the diabetes community — drugs and blood testing facilities are expensive, patient will default on the blood tests as well,” Dr Anuar said.
“All in all, diabetes care will suffer and we can expect poor diabetes control all over and one can predict the consequences post-MCO.”
Out of 67 people who died from coronavirus in Malaysia, a third, or 22 patients, had diabetes. Five victims had kidney disease.
According to the 2015 National Health and Morbidity Survey, 3.5 million adults aged 18 and above in Malaysia had diabetes, which was 17.5 per cent of the adult population. More than half of them, about 1.8 million people, were unaware they had the disease. The 17.5 per cent prevalence in 2015 rose from 11.6 per cent in 2006.
Almost half of the adult population in Malaysia aged 18 and above were overweight and obese, according to the 2015 survey. About one of three adults were overweight (30 per cent), while 3.3 million adults were obese (17.7 per cent).
Healthy Lifestyle A Must
With the MCO in place, people are not allowed to go out of their houses except for emergency reasons and grocery shopping. This may cause them to resort to unhealthy lifestyles, which includes overeating and under-exercising.
“MCO can have a significant effect on lifestyle — physical activities, dietary intake, weight gain and mental health particularly — if it is going to be extended more than six weeks. These will definitely have impact on diabetes control and its complication,” Dr Anuar explained.
“Short MCO may not have significant impact on the general population, but to those who are susceptible, for example, those with obesity, strong family history of diabetes and already having impaired glucose tolerance, and insulin resistance (prediabetes), the conversion rate to full blown diabetes will be expected to be high with change in lifestyle as I mentioned earlier.
“Diabetic patients with kidney disease (complication) following the above scenario of poor diabetes control and altered lifestyle can be badly affected and more of them will move towards dialysis,” Dr Anuar added.
He encouraged those in the high-risk group to practice a healthy lifestyle despite the MCO, as well as to continue exercising and refrain from overeating.
Dr Azlina echoed a similar refrain, saying: “As the global Covid-19 situation is still fluid, we must maintain our state of health but keep up with our nutrition and exercise regularly.”
Dr Rafidah Abdullah, a consultant physician and nephrologist at Putrajaya Hospital, said the rate of diabetes and kidney disease post-MCO depends on the lifestyle of patients.
“It depends on what they actually do during the MCO,” she told CodeBlue.
Boo Su-Lyn contributed to this report.