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14th December 2020
Well, I think that’s clear, at least in Spain and in our hospital, but I guess also in very many other countries, that existing and new patients have experienced delayed assessments, basically because the majority of the facilities were committed to dealing with the pandemic and patients with COVID-19. This is why the prognosis of these patients will be impacted.
Also we have observed that, these six months after the start of the pandemic, that some patients have been diagnosed with stage two and stage three disease, instead of stage one and stage three, so their prognosis is worse.
We did not implement many new guidelines and protocols. Sometimes common sense is the best thing to employ.
For example, what is very clear is that, if a patient or a person is suspected as having COVID-19, they have a different treatment procedure and pathway. They are not diagnosed or treated in the same locations as the general population, with facilities specifically dedicated to this.
In addition, for any patient who starts a new chemotherapy strategy, or needs surgery, we first have to be sure that the virus is not present. Also, we have modified some of the chemotherapy protocols. For example, we have tried to decrease the use of three-weekly docetaxel or even three-weekly anthracyclines, and we use more and more weekly paclitaxel. Moreover, we perform breath analysis every week to be sure that the patient does not have lymphopaenia.
Finally, when we have to use anthracyclines, we prefer to use them in combination with growth factors.
So, I think that here we have different situations: that is, is regarding physicians, continuing medical locations, and meetings. Clearly digital platforms and telemedicine are being employed to much greater levels, and
I do not remember the last time we had face-to-face meetings.
However, at least in breast cancer, we must not forget that physical examination is vital.
This is why in general we would prefer to see patients in person if possible, although we understand that some patients prefer not to come to the Centre. For these patients, we try to use telemedicine as best possible, but the most important aspect, which is the physical examination, is lacking.
I think, in general, that we have learnt a lot over these last six months. I would say that the pandemic has taught us that face-to-face meetings are not always required, and virtual platforms, telemedicine and mobile imaging facilities could be implemented more widely in the future. I also think that large scientific meetings and Congresses will continue to be delivered successfully via virtual platforms and face-to-face meetings might be organised less in future.
However, I feel that it is very important that telemedicine does not replace classical medicine. In my opinion, the face-to-face meetings with the patients, and being able to engage with them as human beings is more successful for both those in our care and us as clinicians.
Of course, the technology will always improve, and I think it will be used more and more, but again, not to the detriment of face-to-face meetings, at least in the breast cancer arena.
This is a very difficult question; I would love to know the answer! I think that this will depend on the pandemic situation globally. It will depend on treatments, it will depend on signs, so I think that’s going to be lower than expected, and I think that the situation will remain the same for at least the next 6–10 months. I hope that after next summer, the summer of 2021, we will be able to start to regain normality. I pray that that will happen.
Javier Cortes MD PhD
Head, Breast Cancer Program, IOB Institute of Oncology, Madrid
& Barcelona, Spain
During the COVID-19 pandemic, surgical therapy was severely impacted. Due to the reduced OR, ICU and normal ward capacities, elective surgery for non-malignant diseases were postponed. In our department, it was possible to treat all patients with malignant tumours regularly. However, the patient assignment to our outpatient clinic was significantly reduced. For elderly surgical patients, follow-up treatments were delayed or cancelled whereas further oncological treatment was not impaired.
In our department, several new standard operating procedures (SOPs) and guidelines were established and optimised during the pandemic. First, all general recommendations have been implemented (for example, distance rules, avoidance of unnecessary contacts, face masks). Second, all patients for hospitalisation were screened for SARS-CoV-2 and isolated until the test results were negative. Furthermore, SOPs were established for surgical procedures with a high risk of exposure to SARS-CoV-2 (for example, thoracic surgeries or surgical procedures for COVID-19 patients).
In our department, we newly implemented the possibility of digital consultation hours for our outpatient clinic. For interdisciplinary meetings, consultations or conferences, the use of virtual platforms (for example, Cisco Meetings, Zoom or Microsoft Teams) has been significantly expanded to reduce the risk of unnecessary person-to-person contact.
From our point of view, the pandemic largely impacted surgical treatment in our clinic and the long-term implications are still uncertain.
As recognised for other diseases, hospital admissions of patients with malignant tumors was reduced during the pandemic. It is unlikely that the incidence of malignant tumours decreased during the pandemic but a delayed diagnosis and treatment of patients with tumours seems very possible. Therefore, a key learning appears to be that it is crucial to maintain the patient care (diagnostics, treatment and aftercare) of non-pandemic diseases during a pandemic.
After the pandemic, we will successively (over several weeks) return to ‘normal’ patient care. However, we think that we will face the impact of the pandemic on non-COVID-19 diseases (especially malignant diseases) over many years and this will may indeed overwhelm our health care system.
Karl Hillebrandt MD
Beate Rau MD
Moritz Schmelzle MD
Charité Campus Virchow Klinikum, Berlin, Germany
Professor Curigliano started by noting that in Italy there has been a completely different situation to other countries. At the height of the pandemic there were over 20,000 cases of the virus with over 1000 people dying every day and by February 2020, all hospitals were effectively overwhelmed by COVID-19 patients, requiring intensive care beds and other forms of assistance. However, he said that since May 2020, the situation had been completely different with the number of cases ranging from 300 to 1000 per day, which has meant that the management of oncology patients has returned to normal and today he is seeing the same number of patients as in December 2019, before the pandemic struck.
Professor Curigliano felt that one of the main reasons why oncology services were able to return to normal so quickly after the initial onslaught of the pandemic was that very early on, the health authorities took the decision to reorganise services. For example, it was decided that Professor Curigliano’s hospital, which is a specialised cancer centre, should be deemed a dedicated cancer hub, to be used solely for the management of cancer patients. In contrast, because of the sheer volume of infected patients, many hospitals were turned into treatment centres and demarcated into COVID-secure and COVID-free areas. In practice, this meant that many cancer patients were unable to receive treatment at their usual hospital but could access therapy at Professor Curigliano’s centre.
Although the centre was deemed a cancer treatment hub, it was still necessary to ensure that the centre remained COVID-free. As a result it was necessary to introduce precautionary measures and every patient who came to the hospital for chemotherapy or surgery was tested upon arrival using a PCR swab. Those who tested positive were not allowed to stay at the hospital and were sent home and asked to quarantine for two weeks. The centre also instigated an active surveillance programme among the healthcare staff and which involved PCR swab testing every two weeks to ensure that the doctors and nurses did not bring the virus into the centre.
Although in the UK a second wave of COVID-19 is approaching, Professor Curigliano says that due to the action of the health authorities, Italy currently has the lowest number of cases in Europe.
With the World Health Organization (WHO) producing guidelines for healthcare staff at the start of the pandemic, Professor Curigliano felt that there was no need to develop any further or specific guidance or policies for his centre and the WHO guidance was simply translated into Italian and implemented at the centre.
As in all countries, as the pandemic unravelled, there was a complete suspension of all face-to-face consultations. Though some patients were too unwell to attend the centre, many were actually fearful of catching the virus and preferred to stay at home. Consequently and in order to provide some level of continuity of care, Professor Curigliano described how he and colleagues quickly moved to undertaking video consultations using mytime and this became widely adopted from March 2020. The online consultation was used not only for new referrals, but for patient follow-ups. It proved
to be an invaluable means for discussions with patients, especially when it was necessary to discuss any potential toxicities or side-effects that might arise from ongoing therapy. Professor Curigliano said that a large number
of virtual consultations were undertaken. In the main, patients appeared to be happy with this mode of consulting, particularly as it provided them with access to their physician, who was able to answer any questions that they might have regarding either their condition or treatment, while having the added bonus that they did not have to leave their home.
The use of a virtual platform was also extended to meetings among clinical staff for case discussions. In addition, the technology also enabled clinicians to view any necessary patient imaging or scans and blood test results. Professor Curigliano feels that this way of working has been very useful and is still being used for case discussions.
The pandemic posed many problems for clinicians and two particular problems for oncology patients. Prior to the pandemic, many patients visited the centre on a regular basis to receive infusion chemotherapy. Additionally, as subsequent chemotherapy treatment cycles are dependent upon satisfactory blood test results, which would normally be undertaken at the centre, it was necessary to find an alternative solution to avoid a large number of patients visiting the centre. As Professor Curigliano explained, this was quickly resolved by arranging for blood tests to be carried out at a number of local hospitals. For example, for patients who lived several kilometres from the oncology centre, it was agreed that rather than having to visit the centre, blood samples could be taken at a hospital closer to their home, where COVID- and non-COVID pathways were quickly established and these samples then posted to the oncologist to review.
Although a very small number of patients continued with infusion chemotherapy at the centre, Professor Curigliano described how in an effort to limit the number of individuals visiting the centre and receiving infusion therapy, his centre decided to make a wholesale change to the treatment programme for many of their patients. In a number of cases, this involved a switch from infusion to oral alternatives and some patients were changed to subcutaneous treatments that could be self-administered. Each of these new treatments were then dispensed at the hospital pharmacy and posted out to patients.
As a result of the shift changes to services, Professor Curigliano feels that while initially there had been some delays in patient screening, there were no delays in the provision of treatment and in fact, he said that no patients died during the COVID-19 pandemic period because of treatment toxicities and believes that this was entirely due to the early decision to make his hospital a dedicated cancer centre, allowing the staff to focus on providing chemotherapy rather than treating COVID-19 patients.
Professor Curigliano felt that there were several important lessons from the pandemic. Firstly and perhaps most important, was the need to re-organise services as soon as possible once authorities realised that they were dealing with a pandemic. This enabled appropriate allocation of resources dedicated to the care of those with COVID-19 but also to other specialities such as cardiovascular disease and cancer. Secondly, as some staff had succumbed to the virus, it was necessary to ensure that those treating patients were issued with personal protective equipment to reduce their own risk of infection and finally, it was important to introduce an effective test and trace system so that infected patients can be identified and quickly isolated.
As Professor Curigliano mentioned, the early swift action of the Italian authorities meant that any hiatus to services was quickly resolved and that since May 2020, things were back to normal. Though virtual consultations were introduced out of necessity, he does feel that this form of consultation will remain as part of his service, post-pandemic and he himself is happy to use remote consulting. In addition, the ability to view tumours and scans on-screen also reduces the need for patient attendance at the centre, especially as they are placed together in large groups in the waiting areas. However, moving forward, virtual consultations will probably only be used for patient follow-ups, as new referrals can now be seen at the centre. He said that since May 2020 they are routinely seeing between 200 and 1000 cases per day and while it remains unclear whether the country will be hit by a second wave of COVID-19, Professor Curigliano thinks that his centre is ready and prepared to deal with it if the need arose.
Giuseppe Curigliano MD PhD
Associate Professor of Medical Oncology, University of Milan; European Institute of Oncology, Milan, Italy
Dr Kazmi said that there was a significant impact on services when the lockdown occurred. However, he felt that in many respects the hospital was fortunate because back in 2016, a standalone cancer centre was opened on part of the main hospital campus and staff were able to quickly secure the entrance and exits of the building and continue to provide services such as chemotherapy, radiotherapy and outpatient work. Nevertheless, there was
a particular issue with cancer surgery which had been traditionally done in the main part of the hospital rather than the new unit and Guy’s was one of the most affected hospitals in the country, so it was difficult to create COVID-19 secure pathways. The top four floors of the new cancer centre were privately operated by HCA Healthcare and these were made COVID-19 secure and allowed staff to continue with cancer surgery. Guy’s became a surgical hub for South East London hospitals and Dr Kazmi and colleagues worked with teams from other hospitals to prioritise cases and were able to perform surgery for the majority of high risk, urgent patients. Although the lockdown reduced the total volume of operations performed, Dr Kazmi felt that they were still able to manage a reasonable amount of cases and although non-urgent cases were initially given a lower priority, currently more of these are now being performed.
Very early on, Dr Kazmi and his teams recognised that patients needing chemotherapy or surgery needed to self-isolate and insisted that all patients had two weeks of self-isolation before they came to hospital. Patients were asked to attend hospital 48 hours before their treatment and tested for COVID-19 and, if negative, they could proceed with treatment. In addition, staff were deployed to ‘door duty’, taking patients’ temperatures and asking COVID-19 screening questions and relatives or visitors were prevented from attending.
As Dr Kazmi explained, this was quite a difficult decision to take because cancer patients rely heavily on relatives and carers for support during treatment but it was necessary to reduce the number of people in attendance at the centre. Some exceptions to the rule were made for extenuating circumstances, for example, patients in end of life care where there was likely to be difficult conversations or in cases where there was a vulnerable individual who was unable to comprehend what was happening.
Since implementing this policy, although some patients have died due to complex surgery, there has been no excess mortality due to COVID-19.
For staff, daily temperature checks were undertaken initially although this was stopped after a few months as there was never an instance of a raised temperature and staff who felt unwell didn’t attend work. As per national guidelines, all working staff had access to full personal protective equipment as well as hand gels and this was vigorously enforced to protect patients.
The Trust created its own set of guidelines for staff during the pandemic though these were largely based on the advice provided by the National Institute for Health and Care Excellence (NICE) and Public Health England. For instance, the Trust used NICE guidance on prioritising patients for radiotherapy, chemotherapy and surgery and in fact consultants at Guy’s and St Thomas’s were instrumental in writing many of these guidelines, so the guidance was not a surprise though it was necessary to explore how these national guidelines could be best implemented locally. Dr Kazmi said that the guidelines remained in draft form throughout the pandemic as live documents that could be modified and updated when new information became available.
One major change due to the pandemic was a huge increase in virtual consultations. Dr Kazmi remarked on how literally overnight, the department shifted from none to over 80% of consultations being conducted online. Initially, consultations were held over the phone but this shifted to become virtual, making use of software such as Attend Anywhere.
Currently, and depending on the type of clinic, somewhere between 40% and 60% of consultations are face-to-face with the remainder continuing to be virtual although as Dr Kazmi acknowledges, it can be difficult with cancer patients because they often need to be seen. In addition, since treatment decisions are directed to some extent by blood tests and imaging, there was little point arranging a virtual consultation if the patient was already visiting the centre for various tests.
Virtual consultations continue to be used for some newly referred patients which allow clinicians to assess the patient and to direct the initial set of investigations more appropriately and this has been beneficial for the patient pathway, compared to in the past when every patient was seen in a clinic.
As cancer treatment decisions are often based on blood test results, a decision was made to create mobile blood testing services thus avoiding the need for patients to visit the department. Dr Kazmi described how the team worked with St John’s Ambulance Service to establish mobile blood testing facilities at sites such as supermarket car parks and from where the results could be sent to the centre and interpreted by clinical staff. He thought that patients were very satisfied with this new service because it was both more convenient and safer because they no longer had to travel on public transport to the cancer centre.
Although Dr Kazmi’s department traditionally followed NICE guidance for chemotherapy treatment options, during the pandemic, rapid guideline summaries created by NICE, provided clinicians with more flexibility. For example, the rapid guidance had recommended that cancer teams consider switching appropriate patients from infusional to oral chemotherapy.
Prior to the pandemic, one piece of work that had been planned by Dr Kazmi’s team was to increase the use of self-administered subcutaneous medications. This was driven by the need to reduce attendance for patients who were coming to the centre to receive what amounted to a 5-minute injection, which was clearly a waste of time for both parties. The pandemic accelerated this work and patients who possessed the necessary dexterity skills, were taught how to inject themselves. As Dr Kazmi described, the shift to greater use of self-administration of subcutaneous medication while clearly of benefit to patients during the pandemic will enable increased capacity within cancer centres which has always been a major issue.
Switching patients to oral therapies enabled a further development, which was the home delivery of medication. For example, after a virtual consultation if a clinician decided to continue with the next cycle of chemotherapy, the medication was couriered to a patient and this avoided them having to attend the hospital pharmacy.
As services return to some level of normality, the cancer centre is working to re-build their chemotherapy infusion service and reverting to any pre-pandemic NICE guidance with respect to first- and second-line treatment options.
Dr Kazmi felt concerned that as capacity begins to increase again, there is a worrying number of patients with late presentations of cancer and while this might not have an immediate effect, the full impact will not become apparent until a few years’ time. Dr Kazmi noted that during April 2020, the department’s referrals under the governments two-week wait time reduced from around 2000 a month to about 400. He explained that this would be a problem for time sensitive cancers which can quickly change stage and move from being operable to non-operable. He illustrated this with colorectal cancer. For example, a patient with stage 1 disease has an 80% chance of being alive at five years if operated on at that stage, although if operated on at a later stage, there is a 10–20% of being alive after five years. He thinks that in five years there is likely to be a spike in cancer mortality due to the delay caused by COVID-19.
The second learning for him was that although the NHS did a fantastic job during the pandemic, if there is a second-wave, it is vital to try and maintain as much other activity as possible. During the pandemic he described how the NHS more or less shutdown and having learnt much about the virus and how it behaves, it should be possible to quickly adapt and ensure that as normal a service as possible is maintained.
Dr Kazmi says that as a result of the pandemic, virtual consultations are here to stay. In addition, the pandemic has enabled more flexible working and not all staff need to be in the centre each day. He noted how patients too are now more likely to question why they are being asked to visit the cancer centre. While during the pandemic, there was a reluctance to visit the centre in case they caught the virus and it has taken sometime to gain back patient’s their confidence, he is finding that many will question the need to visit the centre and do so only if it is really necessary.
Although it did not happen to any great extent during the lockdown, Dr Kazmi thinks that the pandemic has provided the stimulus to increase the use of technologies such as wearables, that allow measurement of heart rate, temperature and even ECGs. Overall, these developments will facilitate more remote monitoring, with the data transferred to the clinicians. He and colleagues are working with artificial intelligence companies to develop clinical support tools to direct treatment decisions based on the latest evidence and reduce variation in clinical practice.
Dr Kazmi stated that pre-pandemic, cancer services were struggling to meet the demands placed upon it. Now, as the pandemic resolves to some extent and services resume, there will be an uphill struggle to meet not only existing patient targets but to be able to deal with a huge backlog created by the pandemic. Although meeting the two-week wait will be challenging, a more important metric is the faster diagnosis standard which requires that at least 75% of referred patients with suspected cancer, find out within 28 days whether or not they have cancer. The other target is that by day 62, the patient should have been diagnosed and had their first course of treatment and this was a target that many hospitals struggled to meet. Work done by MacMillan suggests that even with a 20% increase in capacity over baseline
it will take many months to clear the backlog.
Ultimately Dr Kazmi thinks that the pandemic has focused people’s minds on how best to develop a more efficient and patient-centred service. Whereas previously there was a reluctance to start virtual consultations, having had to work virtually has made many realise how useful and easy it has become. Furthermore, it was also felt that mobile blood services would continue, as would home delivery of medicines. The pandemic has taught everyone precisely how doable these innovations are and that it can improve the effectiveness of the service.
Finally, whereas in the past hospitals have worked independently and competitively, Dr Kazmi thinks that the pandemic has resulted in a more collaborative way of working, with, for example, consultants from other hospitals coming to Guy’s to operate on patients. He feels that this collaboration is here to stay although the current funding model needs to be revised as hospitals are separately funded. However, with the evidence that sharing of expertise, avoiding duplication of services and centralising procedures is beneficial, he is hopeful that in the future, funding will be delivered to complete systems rather than individual hospitals and that cancer services will become more efficient and hopefully meet the demands placed upon them.
BMed Biol MD ChB (comm) FRCP FRCPath
Guy’s and St Thomas’ NHS Foundation Trust, UK