Preparedness for COVID-19 in the oncology community in Africa.

The world is experiencing an unprecedented health crisis with the coronavirus disease 2019 (COVID-19) pandemic threatening human existence and livelihood. Patients with cancer are thought to be more susceptible and have higher morbidity and mortality rates from COVID-19 than the general population. Africa, with a heterogeneity of economies, cultures, and disease patterns, is thankfully the last continent to be hit by the pandemic. We acknowledge the points made by our colleagues from Morocco. With many lessons learnt from other countries and the experiences within Africa from the Ebola and cholera epidemics, Africa should be prepared for COVID-19. However, with a record of poor economic discipline, weak health systems, and poor health-seeking behaviours across the continent, outcomes could be dismal. Unfortunately, poverty, low health literacy rates, and cultural practices that negatively affect cancer outcomes will result in poor assimilation of COVID-19 containment strategies in Africa.

The continent, despite many competing health challenges, is now finally implementing cancer prevention strategies, improving treatment access, and expanding the cancer workforce. It therefore seems inappropriate to withhold timely, life-saving cancer treatments under any circumstance. Oncologists in Africa are not empowered to ensure that the governments are attentive to the special circumstances for cancer care in this crisis. We—as oncologists in Africa—follow COVID-19 cancer care guidelines from other high-income countries.3, 4 We realise the urgency to delay the start of adjuvant therapies and regular surveillance, reconsider switching to oral systemic therapies (many of which are inaccessible to our patients), and rethink the effectiveness of further lines of palliative chemotherapy. We must weigh the consequences of exposing our susceptible patients and small cancer workforce to COVID-19 while ignoring oncology principles that we previously did not dare to disregard. We need to make critical decisions because many patients with cancer present with locally advanced disease in Africa, and delaying treatment will result in progression and deterioration of their cancer as well as higher out-of-pocket expenditure for treatments, leading to further psychological distress.

What do we do when a patient with cancer on chemotherapy develops a fever? Would we ignore the possibility of neutropenic fever, malaria, or typhoid? Should we call the overstretched and under-resourced COVID-19 team? The paucity of protective gear and onsite testing kits for patients and health-care staff on the continent is a major flaw in delivering life-saving oncology care during this crisis. The availability of logistics (which are greatly inadequate), institutional guidelines, and the country-specific COVID-19 case burden will dictate our actions, most likely negatively.

In west Africa, COVID-19 protocols are defined by individual institutions. Elective procedures and physical meetings are cancelled and a small number of patients are to be seen per day. Patients are educated about possible additional risk while receiving chemotherapy (ie, of contracting COVID-19 and having poorer treatment outcomes) and appointments are rescheduled. Patients with a fever are referred to the emergency room. A minimum number of essential staff (in protective gear when available) will be rotated, prescriptions refilled remotely, and second-line and third-line palliative chemotherapy halted. Primary radiotherapy treatments will continue, and patients on concurrent chemoradiotherapy will only receive radiotherapy. New referrals, including emergencies, will be triaged on the basis of the effect of treatment delays on outcomes. These strategies will be reviewed as the situation evolves.

South Africa is currently at the beginning of a local epidemic. Of particular concern is the large population infected by HIV, which includes approximately 8 million people. While public hospitals prepare for the first wave of COVID-19 patients, oncology services at this point are still aiming to deliver full service when possible, although follow-up outpatient services have been severely curtailed. Subsequently, adjuvant therapy will be reduced when the risk of COVID-19 outweighs the benefit of treatment to decrease avoidable cancer deaths. Primary therapy will continue in ultra-fractioned short courses to curtail treatment delays. Staff will be divided into teams consisting of core personnel.

In Sudan, despite the low COVID-19 burden, cancer centres have established a contingency plan by deferring new referrals except for emergency cases. Elective surgery, non-urgent intravenous chemotherapy, and follow-up visits are currently suspended for 2 weeks until the situation is better understood. Scheduled appointments for patients on radiotherapy are maintained; however, many remote patients are unable to travel for treatment. Inpatients can only have one visitor per day. Multidisciplinary meetings are strictly done via telecommunication. Medical teams and core support staff work as divided teams after having attended mandatory COVID-19 training sessions.

Oncologists in Africa, in the absence of centralised and resource-appropriate COVID-19 guidelines, are pragmatically safeguarding patients and the workforce while providing essential cancer care. This task is difficult considering the scarcity of cancer workforce and logistics to fight the pandemic as well as compounding health challenges.