The Eleventh Hour.

Madam — The SARS-CoV-2 novel coronavirus has precipitated the world into a state of emergency [1,2]. Although the index case was acquired by zoonotic exposure [3], the combined dynamics of rapid human-to-human transmission [4], incubation period dissemination [5], and potential faeco-oral spread [6,7] render cancer patients vulnerable, owing to immunosuppression due to the primary disease or secondary to treatment [8].

India expects an exponential increase in the number of cases in the coming weeks. This was estimated at 300 million in the absence of external interventions [9] and is worsened by low testing rates [10]. To put numbers into perspective, India has an annual incidence of 1.2 million cancer patients, two-thirds of whom require radiotherapy [11]. A shortfall of radiotherapy units, a low clinician to patient ratio, and inadequate financial coverage; a prototype unique to lower–middle-income countries (LMICs) and low-income countries (LICs) already contributes to long waiting lists and patients foregoing treatment with subsequent disease progression [12]. These factors combined with a high population density can result in increased SARS-CoV-2 transmission and mortality in LMICs/LICs, and cautious policymaking is warranted.

Fractionated radiotherapy treatments typically last over a few weeks and stopping or delaying treatment during its course correlates with poor local control and adverse survival. The general measures should include but not be limited to prioritising patients, consideration of induction chemotherapy instead of radiotherapy when there is an evidence-driven choice (e.g. hypopharyngeal and laryngeal cancers), judicious use of advanced radiotherapy techniques that require more time for planning and verification, the use of hypofractionation, and proper administrative handling of staff [13]. Ideally, one needs to achieve an ‘oncological triage’, whereby cancer progression due to logistic delay is balanced by mitigating SARS-CoV-2 transmission by social distancing. Finally, the appearance of pseudoscientific quackery in times of a global pandemic is deeply disturbing [14,15] and should be dealt with sternly. We are already at the eleventh hour and must act now in unison to achieve the best possible outcomes for our patients.

Conflicts of Interest

The author declares no conflict of interest.