The impact of COVID on delivery of oncology services

Medical oncologist, Dr Ria David, updates us on how the COVID-19 pandemic has impacted the delivery of oncology services.

The World Health Organisation declared the COVID-19 pandemic in March 2020. Since then, mankind has witnessed sickness and death of a magnitude not seen since the Spanish Flu of 1918. 

South Africa has experienced two waves of infection so far with over 1,5 million infections and nearly 50 000 deaths. This has impacted all aspects of daily life, including delivery of medical services, with most non-COVID patients having to wait for long periods to access medical care.  

Some of the challenges surrounding delivery of oncology services during the pandemic relate to balancing the competing risks of death from cancer with the risks of death and complications of COVID infection in the immunocompromised cancer patient. 

Other challenges include restrictions of clinic visits, delays in screening and diagnosis with many patients eventually presenting with advanced disease, delays in cancer surgeries and other treatments, maintaining physical distancing within the clinic, and the transition to telemedicine. 

Providing safe care for outpatients

The American Society of Clinical Oncology (ASCO) recommends that:

• Oncology patients should be educated about the symptoms of COVID, correct handwashing techniques, hygiene and minimising exposure to the virus. 
• Patients and all visitors to the oncology clinic are urged to wear a cloth mask, properly covering the mouth and nose, regardless of their symptoms. Healthcare providers are also required to wear face masks, which may include surgical masks and N95 respirators. 
• Any clinic visits that can safely be postponed without posing a risk to the patient should be.
• Pre-screening for symptoms of COVID by telephonic interview prior to the clinic visit may be done by the oncology practice. 

Cancer screening, diagnosis and staging

Specific recommendations may be modified periodically depending on the rate of infection in a community at a given time and availability of resources. Few guidelines exist to instruct screening programmes during the pandemic. 

In August 2020, ASCO recommended delaying all screening and diagnostic procedures to conserve health resources, except in cases where a cancer is suspected. 

Due to rising concerns over the delays in cancer diagnosis, advanced cancer presentations and delays in access to oncology treatments which may have an impact on long-term cancer mortality, screening and diagnostic procedures may resume when infection rates are controlled, and with strict adherence to COVID protocols. 

Similarly, staging investigations may also be curtailed in some patients to tests that are absolutely essential to make treatment decisions. Patients should be informed on the possible impact this may have on their cancer management. 

Post-treatment surveillance

Surveillance may be postponed in cases where patients have been asymptomatic during the follow-up interval and where there is a low risk of recurrence. Telemedicine may be employed to assist in the follow-up of suitable patients. It’s crucial to inform patients of the limitations of remote monitoring, one of which is that clinical examination can’t be performed. 

Treatment decisions

The European Society of Medical Oncology (ESMO) advises that:

• In patients with early-stage disease, to consider a wait-and-see approach to local therapies (surgery and radiation) where appropriate. 
• Consider switching intravenous treatments to oral treatments where feasible. 
• Explore options of palliative care and treatment holidays in patients with advanced disease. 
• Consider shorter courses of radiotherapy where appropriate. 
• Reduce clinic visits by using telemedicine to monitor treatment toxicity. 

Telemedicine

Telemedicine was available but seldom used prior to the COVID pandemic. This includes the use of telephonic- and video consultations to address patients who don’t require clinical examination. 

Benefits include reducing clinic visits and exposure to COVID, reduced cost and increased convenience to the patient. However, some aspects of care may be lost in diminishing exposure to the healthcare team which may lead to an increase in misunderstandings and miscommunications among patients. 

Much research is required to determine best standards and practices to ensure consistent delivery of cancer care through telemedicine.

References:

1. Coronavirus disease 2019 (COVID-19): Cancer screening, diagnosis, treatment, and posttreatment surveillance in uninfected patients during the pandemic (uptodate.com).
2. ESMO guidelines: Cancer patient management during the COVID-19 pandemic.