Safeguarding cancer care in a post-COVID-19 world.

As the world comes to grips with the coronavirus disease 2019 (COVID-19) pandemic, reports are emerging on how cancer care is being deprioritised, delayed, and discontinued. These decisions made under the duress of the pandemic will have grave consequences for cancer mortality for years to come.

Those recently diagnosed with cancer, or in the midst of cancer treatment, are facing disruption for all but the most urgent procedures because of concerns about their susceptibility to the serious risks of COVID-19, and the redeployment of personnel, beds, and equipment to COVID-19 wards. Hospital capacity has also been depleted due to COVID-19 cases in health-care workers themselves, and oncologists have not been spared. Official advice is that urgent cancer care can continue, but other treatments should be rationed and adapted. These decisions, however, are inconsistent, and not evidence-based—multidisciplinary teams are being put in the unenviable position of making best guesses for each patient. However, treatment delays and adaptations can risk, for example, operable or curable cancers developing into inoperable disease with a far worse prognosis. In many cases, and especially in resource-constrained settings, balancing the risks of undertreatment with those of COVID-19 infection will lead to situations where there is no obvious best course of action. As societies and governments scramble to provide guidelines for patients with cancer, frontline medical staff are being forced to make on-the-fly treatment decisions, and, unfortunately, many patients will receive suboptimal care.

Importantly, cancer screening and diagnosis is also being affected by reprioritisation of health-care services during the pandemic. For example, in the UK, urgent suspected cancer referrals normally eligible for the 2-week wait target are now subject to prioritisation rules that will cause delays. Additionally, because UK screening programmes have been suspended, diagnoses will depend on presentation of patients with cancer symptoms. Worries about spreading and contracting COVID-19, and fear that COVID-19 is rampant in hospitals and other health-care facilities, might dissuade patients with symptoms from contacting their family doctors. Delayed cancer diagnoses during the next weeks and months risks many thousands of cases going undetected and untreated. Knock-on effects, related to a surge in demand for cancer-related services once the pandemic has passed its peak, coupled with an increase in advanced-stage cancers due to diagnostic delays and under treatment, could overwhelm health services and contribute to an excess in cancer-related mortality in the coming years.

The pandemic is also affecting patients with cancer who are in follow up—for example, those in remission or receiving palliative care for late-stage disease. Cancer surveillance and management of cancer-related symptoms and treatment sequelae are managed by primary care physicians in many countries, or as home-based or outpatient services. However, the pandemic has restricted access to just the types of resources these patients need—in-home health-care workers, primary care appointments, and supportive care medications. Because appropriate and timely supportive care can extend overall survival, availability of these services is crucial to prevent not only morbidity, but also premature death.

Overall, disruption to the full spectrum of medical cancer care services will undoubtedly have a large effect on cancer-related mortality. A 5–10% decrease in survival in high-income countries has been predicted, which will account for hundreds of thousands of excess deaths, dwarfing those caused by COVID-19—but we are missing precise data on mortality that can be used to anticipate future cancer care needs. Therefore, we call for research into the long-term impact on cancer-related mortality resulting from cancer care decisions being made globally during the COVID-19 pandemic. Moreover, we advocate that pandemic preparedness plans must account for the resources needed to maintain high-quality, evidence-based continuity of care of people with cancer, including workforce and service capacity needs, and a robust referral and diagnostics service. Oncologists must be included in the group of care workers who require essential equipment and resources during a pandemic. Whether governments and health services could have been better prepared for COVID-19 is debatable, but the need for a quickly deployable, and evidence-based, response is urgent and unmet. The next pandemic is not hypothetical—it will happen again—and guidance must be generated now to prevent patients with cancer becoming collateral damage.

For more on cancer treatment guidelines during COVID-19 see Comment page 619, and https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0119-_Maintaining-cancer-services-_-letter-to-trusts.pdf

For more on changes to cancer care services see https://www.medscape.com/viewarticle/928878, and https://www.theguardian.com/world/2020/apr/07/life-hanging-by-a-thread-for-italian-cancer-patients-in-coronavirus-crisis