Global Cancer Care Alterations: Aftermath of The Covid-19 Pandemic

Invited Articles

Global Cancer Care Alterations: Aftermath of The Covid-19 Pandemic

By

Dr. Rahul Saini

Post May 4, 2022

By

Dr. Rahul Saini

Post May 4, 2022

Introduction
Coronavirus disease 2019 (COVID-19), caused by novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which was identified in December 2019, rapidly resulted in the pandemic. According to World Health Organisation (WHO), as of Feb 25, 2022, ~430 million cases and ~6 million deaths are confirmed worldwide(1). This impact of the disease has had a unique impact on daily lives and led to exposing the frailties of the healthcare systems worldwide. The crippled health system affected the timely diagnosis and treatment of other non-COVID diseases/conditions. In particular, the time-sensitive diagnosis and management of cancer were substantially challenged. Delayed diagnosis or treatment due to the existence of COVID-19 has increased the chance of deteriorating conditions in cancer and poor survival outcomes (2). This has prompted the public health systems to develop new approaches such as restructuring clinics/outpatient departments, implementing telemedicine, delaying surgeries or follow-ups, limiting visitors, and creating more sanitary conditions for providers and patients alike to mitigate the impact of the pandemic(3).
This article illustrates the impact of COVID-19 on cancer and discusses the modifications adopted for effective cancer management during the normalized prevention and control of COVID-19.

The deadly interplay of Covid-19 and Cancer
Countries like the USA, England, and Ireland diverted the essential medical services and a huge number of their healthcare staff to address the needs of the pandemic. This led to either suspension or postponing of cancer screening programs by categorizing them as low-priority services(3). In India, March 2020 being the early stage of the pandemic, saw a major drop in screening programs or emergency-department visits, as people feared exposure to the virus. As a result, ~1 in 5 cancers was diagnosed with emergency presentations and led to delayed diagnoses. Cancer screening in India was completely halted during the strict lockdown period and saw a 54% reduction in the registration of new patients (4). Ethnic minority, rural populations were also critically affected by these disruptions(5)

The British Society of Gastroenterology (BSG) classified aerosol-generating upper endoscopy procedures as a risk for SARS-CoV-2 transmission. Based on the data from UK National Endoscopy Database (NED) there was a significant decline in endoscopy procedures in April 2020. The prolonged fecal shedding of the virus during the colonoscopy procedures was also considered risk-prone and thus led to the suspension/postponing of elective endoscopies(6).

Covid-19 demanded additional critical care which caused a reduction in the capacity of surgery as the operation theatre and ventilators were requisitioned for the infected patients and saw a 49% reduction of onco-surgeries in India(4,7). This along with the pandemic scare and patient reluctance resulted in the use of neoadjuvant chemotherapy, hormonal therapy, radiotherapy as initial therapeutic modalities(8,9). The curative or palliative nature of radiotherapy changed in the times of Covid to replace or delay other treatment modalities.

The peak of the pandemic saw the cancellation of many clinical trials. This has had long-lost financial and health consequences. Trial enrolments plummeted as prospective participants shied away from trips to the hospital, and research staff was either furloughed or assigned to aid hospitals’ for COVID-19 treatment(10).

Bruce Johnson, an oncologist at the Dana-Farber Cancer Institute in Boston, Massachusetts said that the cutbacks in elective surgeries and other hospital services have also had a lasting effect on the tumor banks that store cancer samples for use in additional research. Many trials were impacted as they attempt to match treatments with the DNA mutations present in participants’ tumors (22,23).

Healthcare team members also experienced extreme stress and burnout during the pandemic. Certain reports report the prevalence of self-reported psychological symptoms like anxiety and depression among healthcare professionals along with a constant fear of virus transmission(13).

Flexible Solutions
According to WHO, the impact of the pandemic on cancer was nothing short of catastrophic. Global healthcare realized the actual human cost of neglecting a non-communicable disease such as cancer. This proved as a wake-up call, from grassroots to governments, to tackle cancer together, and accordingly, new strategies were developed for the treatment modalities(14).

The screening regimen saw a demand for non-invasive imaging like computed tomography as it ensures lower-infection risk and limits the need for prolonged sanitizing of equipment(6).

As cancer-related surgeries are extremely time-sensitive and involve the risk of disease progression, the American College of Surgeons (ACS) has recommended semi-elective surgery for most gynecological and obstructing colon cancers. Accordingly, only urgent surgeries for obstructed or actively bleeding are conducted during the peak of the pandemic or according to the infection rate (3,15).

Infection control to limit transmission to clinicians also is now considered and airway management and other aspects of anesthetic care are of prime focus (9). Several guidelines recommend performing rapid sequence induction and intubation (RSII) to secure the airway and minimize clinician exposure to airway secretions. The Anaesthesia Patient Safety Foundation (APSF) and Centres for Disease Control and Prevention (CDC) have developed protocols for operating theatre management like the use of disposable airway equipment, double gloves, Personal Protective Equipment (PPE) gown, hand hygiene, eye, face and equipment protection, decontamination techniques, etc(16,17).

The National Institute for Health and Care Excellence (NICE), UK, and the American Society of Radiation Oncology (ASTRO), USA has issued guidance that prioritizes radiation therapy for rapidly proliferating tumors in head and neck cancers. It recommends that a short course of radiation can be used to delay surgery in patients with rectal cancers. Radical radiotherapy for prostate cancer with neo-adjuvant hormone therapy and adjuvant radiotherapy in resected disease is now categorized under lower priority indications. Hypofractionation regimens are implemented to minimize exposure of infections amongst patients. Countries like India, China, Italy have observed only a minor reduction in several patients for radiotherapy and indicate that stringent screening and testing measures can allow undisrupted radiotherapy sessions(3,4,18,19).

The American Society of Clinical Oncology (ASCO) published several guidelines for the systemic treatment of cancer in the following circumstances
I. In the case of many acute haematological malignancies or extensive small-cell lung cancers the chemotherapy must be continued as it is associated with dramatic improvements.
II. When the benefit of the chemotherapy is marginal like acting as a palliative or adjuvant therapy in elderly or comorbid patients then alternative therapy should be considered and chemo can be postponed indefinitely.
III. Oral chemotherapy, low-risk drugs which require intramuscular administration like a gonadotropin-releasing hormone can be prescribed for administering at home.
IV. Neo-adjuvant chemotherapy should not be recommended unless tumors are inoperable and Estrogen-receptor negative(20).

Services are being re-organized and a backlog of semi-elective operations for verified cancers of preliminary stages, partial laryngectomy for head and neck cancers, or endoscopic resections for Sinonasal carcinoma are addressed in the pandemic descending phase. Setting up special Cancer hubs for surgeries is recommended and is being implemented by health systems like National Health Service (NHS) to minimize exposure to SARS-CoV-2(8,21).

Replanning suspended trials is a major financial hurdle and thus jeopardizes the development of new treatments. The US food & drug administration and the European Medicines Agency (EMA) recommends resorting to telemedicine instead of physical visits and transferring study participants to separate site of cancer care in case the primary site is disrupted. ASCO has set goals like pragmatic and efficient trials, reducing regulatory burden, and improved accessibility for getting the trials back on track(22)

Moving forward
The European Society for Medical Oncology (ESMO) has classified the management and treatment as either low or medium priority based on risk or relapse. Such classifications may have implications on disease detection, progression, and other cancer-related complications. Patients or their families should be thus educated and trained for these alterations e.g., Flushing of chemo port at home to decrease hospital visits. The benefits of telemedicine should be reaped to maintain participation during pandemics and ensure uninterrupted care. Such alterations have highlighted the need for psychological support which should be provided wherever possible. Public health systems should try to fill in lacunae of digital exclusion where internet access or digital literacy is lacking and the population majorly consists of elderly or comorbid patients(3,4,15).

Mortality in cancer patients is high and the risk varies for different cancers. Treatment options of monoclonal antibodies like Bamlanivimab and Etesevimab should be considered against prevalent variants like Omicron. The US Food and Drug Administration (FDA) has authorized monoclonal antibodies for symptomatic patients with mild to moderate infections(23).

The immunosuppressive nature in cancer patients makes them more susceptible to SARS-CoV-2-infection and leads to a poor prognosis.  Thus, the public health system should aim to prioritize the vaccination in case of a limited vaccine supply.  The safety, efficacy, and timing of the booster doses along with their ongoing therapy should be carefully monitored and planned(20,23,24).

A multidisciplinary expert team at ESMO has issued a statement related to cancer management during the SARS-CoV-2 which includes strategies for patient management and follow-up, prevention of SARS-CoV-2 in cancer patients, Covid testing when and how, use of thromboprophylaxis, use of immunotherapy, etc. which can be replicated by various healthcare setups for guidance(24–26)

These practices are reconsidered as the pandemic has passed its peak and many screening programs have been resumed with standard protocols in place like mandatory Covid-19 tests, vaccinations, recovery certificates, etc. Moving forward cancer diagnostic services can remain uninterrupted by setting up separate hubs with extensive screening and testing(3).

The risk associated with monoclonal antibodies or immunotherapy is not completely known and hence should be administered after careful studies. The immune checkpoint inhibitor (ICI) related pneumonitis may mimic Covid-19 and can cause unnecessary complications. These associated risks and benefits are complex conversations and require in-person evaluation and administration which are hindered during pandemics but can now be addressed with the advent of telemedicine (3,11,13–15).

Models of cancer care clinics geographically away from hospitals or separate facilities for cancer patients must be replicated to reduce the risk amongst patients and health care staff. Staff and patient testing, reviewing of waiting lists and remote engagement with patients should be executed(3,28,29).

Covid-19 has incurred adverse effects on cancer care delivery services and countries like India will have to adopt strategies with the help of international guidelines and available data from other countries to strengthen the healthcare system. The treatment interruptions should also be taken into consideration considering the lack of household earnings that occurred due to abrupt business closure during the lockdown (29). The government will thus have to adapt to a multimodal approach wherein all the aspects of cancer care treatment will be addressed like lodging or shelters for the increased patient influx in cities, improve the telehealth engagement, or providing social service care serving as a bridge between the doctors and patients when required as many a times language can also hinder the dialogue. Providing free or subsidized cancer treatments, improving the insurance coverages, equipping patients, nurses, or district hospitals with the right education and services to be able to receive treatment at home, utilizing public health for spreading the awareness for the impact of the pandemic on cancer, etc. should be of prime focus(26,29).

The government has already rolled out Ayushman Bharat Yojana Scheme in association with National Cancer Grid to create a network of cancer centers, research institutes, and charitable institutions to develop uniform standards for patient care(9,24). However, the scheme should soon extend its scope to private institutions as it will ensure better support for easing the mental healthcare burden in oncology.  Patients should be counselled for a healthy diet and exercise for better living conditions during this period. Various cancer institutes like Tata, HCG have already published reviews on the need of incorporating multidisciplinary management in improving the quality of life, and thus the public health care system should form a group of psychologists, nutritionists, alternative therapies specialists (e.g., Ayurveda, Homeopathy, Yoga, etc.), and social workers to aid patients in the process(30,31).

Conclusion
The only silver lining amidst this pandemic is that it has helped cancer care evolve. A recent survey of oncologists conducted by IQVIA also emphasized the benefits of patient engagement through telemedicine, minimizing hospital interaction the impact of delayed diagnosis, and limiting personnel visits(14). The public health systems and oncology associations must adhere to these alterations to lessen the impact on cancer prognosis. The effects of a pandemic cannot be understated but with the setup of segregated cancer hubs, telemedicine, and strict infection and prevention policies in place, the negative outcomes can be minimized for better cancer care delivery.

References

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