Balancing the risk of coronavirus disease 2019 (COVID-19) for patients with cancer and health-care workers with the need to continue to provide effective treatment and care is changing how oncology teams work worldwide. “The pandemic has meant a transformation of every aspect of cancer care, irrespective of treatment, inpatient or outpatient, and radical or palliative intent,” said James Spicer (Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK).
High rates of sickness among health workers due to COVID-19 are dramatically reducing the numbers of available staff. A survey done by the Royal College of Physicians in April, 2020, found that about 20% (21·5% in London and 18·3% in the rest of England) of the 2513 members responding were taking time off work. The main reason was suspected COVID-19 followed by self-isolating because another household member had symptoms. “These absences would have had an impact on care delivery were it not for the knock-on effect on workload of deferral and modification of treatment driven by safety considerations and redeployment of staff,” explained Spicer. Academic staff are now working in the NHS full-time, and research fellows have returned to work in clinics and wards because research laboratories have closed. On-call rotas have been increased.
“Keeping surgery and brachytherapy going has been one of the hardest things,” warned Spicer. “Here, the risk-benefit has changed perhaps the most dramatically.” For example, COVID-19-related pneumonia in the postoperative phase is very likely to be fatal. “And the resources, including anaesthetists and beds, are in short supply,” he said.
Oncology teams are adopting new ways of working to minimise risk to patients and staff at the same time as optimising cancer treatment and care. Treatment regimens are being changed to reduce hospital visits. “Regimens with less intensive treatment visits are now strongly favoured, such as 400 mg pembrolizumab six-weekly instead of 200 mg three-weekly,” reported Spicer.
In radiotherapy, using fewer fractions with higher dose per fraction is being considered when possible. “For the commonest disease sites, such as breast, prostate, lung, and head and neck, we discussed the options to use more hypofractionation. This approach can lead to increased toxicity, so we only accepted schemes with which hypofractionation could be done safely,” said Ben Slotman (Amsterdam UMC, Amsterdam, Netherlands). He reported that the number of patients being seen in the radiotherapy department at the hospital has remained relatively stable despite reductions in patients undergoing investigations for new cancer diagnoses and a reduction in cancer surgery.
Drawing on experience from the severe acute respiratory syndrome epidemic in 2003, the National Cancer Institute in Singapore is following the national disease response plan by splitting health-care teams into two with minimal contact between them, according to Ross Soo, from the Institute.
Efforts are also underway to relocate cancer teams and services away from general hospitals caring for patients with COVID-19 as much as possible. In the UK, there has been a move to centralised hubs for cancer care, so that patients do not need to attend hospitals with a high risk of encountering the virus. This approach is also being developed in Australia. “I am working to set up a community centre for oncology treatments, similar to a community dialysis centre. It would be a safer and less medicalised environment,” reported Eva Segelov (Monash Health, Melbourne, VIC, Australia).
Switching outpatient consultations and discussions with other health professionals to online or phone rather than face-to-face is being universally adopted by oncology services. This change is strongly recommended by oncology organisations, including the European Society for Medical Oncology, but it represents a huge change in how staff interact with patients.
Ensuring good communication is essential, advised Segelov. “People with cancer understand competing risks of death. Having the conversations now, and documenting them, is important. Above all we need to reassure them that their cancer is being treated appropriately, but we also need to keep them safe.”
“Doctors have traditionally been very fixed in one clinical environment but are generally finding the move to telehealth positive,” reported Segelov. She cautioned that using telehealth, with which staff and patients can see each other, is preferable to phone consultations because of the importance of being able to see how patients are doing.
Support organisations are filling some of the gaps left by reduced availability of oncology staff. “30% of calls, at least, to our support line are related to COVID,” said Rosie Loftus, joint chief medical officer at Macmillan Cancer Support (London, UK). “We worked really hard at the outset of the crisis to ensure our telephone support line could continue,” she said, explaining that support line staff are now working from home, and appropriately trained people have been moved into this role. The charity has maintained its online forum and developed bespoke patient information on it coronavirus hub.
Cancer specialists predict that new ways of working in cancer care during the COVID-19 pandemic will permanently change oncology services, after evaluating their impact. Slotman said, “This pandemic has led to new ways of working together and we should try to keep the best changes after the pandemic is over.”
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