Emerging Trend to Have Locally Advanced Malignancies at Initial Presentation: Ignorance, Self-Neglect, or Pandemic Anxiety?

Dear Editor in Chief,

Malignancies are the second commonest cause for in-hospital mortality and one of the leading causes for hospitalization in Sri Lanka [1]. About 29,000 new cancer patients have been reported in 2015 according to the National Cancer Control Program data [2]. Breast and thyroid malignancies have been the commonest cancers among females, while oral cavity and lung cancers have been the commonest among males [2]. It has been studied that a higher percentage of female breast cancers in Sri Lanka to be diagnosed at an advanced tumor, nodal and metastasis stage according to a single tertiary care center pre-pandemic registry data [3]. This fact may be common to almost all other solid organ malignancies in Sri Lanka. Further, presentation delay with advanced cancers at initial clinical review has been a concern in neighboring India over past couple of decades [4-6]. In general, such delayed and advanced cancer at presentation negatively affects the prognosis. Unavailability of screening programs for common malignancies in Sri Lanka appears to be the foremost reason for such delayed cancer presentation, in addition to lack of disease awareness among people, self-neglect, and fear of stigmatization over cancers. Studies from the sub-continent have shared similar reasons [4, 5]. Covid-19 anxiety appears to be the newest addition to this list. These concerns seem to be common not only to India and Sri Lanka but also to entire South Asia.

Since the declaration of the current pandemic by the World Health Organization in early 2020, Sri Lanka has experienced four waves of Covid-19 surge. As a result, elective medical and surgical care services at both hospital and community level have been very much negatively affected. Further, the stigma and discrimination experienced by many Covid-19 patients in the society, work place and at healthcare facilities have worsened pandemic anxiety, and patients have been reluctant to seek medical attention [7]. Within such altered status quo, probably contributed by many other socioeconomic factors including pandemic fear, I have recently encountered many cases of locally advanced malignancies presenting late to healthcare facilities. Fungating breast cancers, ulcerating head and neck cancers/melanomas, and manhood destructing penile cancers which were “diseases of the past” have been re-emerging at a rural District General Hospital in Nuwaraeliya over last 8–10 months. These collateral damages of the pandemic may be a common problem still remaining unnoticed not only in other parts of Sri Lanka but also in other developing countries. The restrictions and altered practices carried out during the pandemic have been obvious and universal. There have been regional, geographical, and individual variations on health policy and threat perception at the height of the pandemic, and we may be experiencing the negative aftermath of such altered behaviors at the moment.

Despite the global trend to detect pre-symptomatic malignancies to achieve optimal outcome, these patients have failed to reach a healthcare provider until they have developed organ destructing, grossly disfiguring, ulcerative malignancies during the pandemic. Reasons for delayed presentation may be multifactorial. As it has been further complicated by the pandemic anxiety and fatigue, it is important for clinicians, preventive medicine experts, and policy makers to be vigilant over these developments to control the collateral “malignant” damages of the pandemic at the verge of another global Covid-19 wave with the Omicron variant.