The impacts of the novel SARS-CoV-2 outbreak on surgical oncology - A letter to the editor on "The socio-economic implications of the coronavirus and COVID-19 pandemic: A review".

Dear editor,

We read attentively the thought-provoking article by Nicola et al. regarding the socio-economic implications of the COVID-19 pandemic, detailing the response from authorities, impact of the virus on societal sectors and the consequences of isolation measures [1].

In this letter we offer an insight into how the novel COVID-19 pandemic has impacted surgical treatment of oncology patients, focusing on precautions and guidelines in place as well as the impacts of delayed surgical intervention.

The COVID-19 pandemic has caused the National Health Service (NHS) to reallocate precious resources in the fight against the virus, as well as re-train and re-deploy specialists from different areas, including oncology. Social isolation and lockdown measures, while essential in tackling the crisis, have had hugely negative impacts on patients with pre-existing conditions, who would otherwise not delay seeking investigation. Impacts of the COVID-19 pandemic on oncology patients requiring surgical intervention are not yet completely understood, but are likely to include elevated anxiety levels, additional complications and mortality. Despite reassurance from NHS England that oncological treatment should proceed as planned, urgent referrals from General Practices (GPs) for cancer testing have dropped by 76%, with chemotherapy appointments falling 60% also. This is reflected in figures predicting an additional 6270 deaths due to new cancer diagnoses with the figure increasing to 17,915 when including those currently living with the disease. Moreover, patients who present at a delayed stage due to fear of COVID-19 infection will be faced with poorer outcomes and more complex treatment regimens. This considerable backlog of patients, who will require immediate medical attention, poses a significant challenge to oncological services moving forward [2,3].

Despite common assumption, only certain cancer patients are more vulnerable to COVID-19, such as those with blood or bone-marrow cancers and those undergoing treatment. Oncology patients are suffering disproportionally as operating theatres have been transformed into intensive care units to accommodate for coronavirus patients.

The European Society for Medical Oncology (ESMO) have offered guidelines for management of oncology patients during the pandemic, a consequence of the 20% of COVID-19 deaths attributed amongst patients with cancer. Curative therapy with a 20–50% possibility of success has been deemed high priority, whilst non-curative treatment with 15–50% chance of palliation and a life expectancy below 1 year are listed as low priority.

In the current climate, the ESMO and NHS England have shifted cancer care towards bolstering telemedicine services and therapies at home to further avoid unnecessary contact. Currently, a priority list has been established for anti-cancer treatments based on various aspects including; patient-specific risk factors, availability of resources, degree of immunosuppression, and weighing out the risk between no treatment and treatment but falling ill with COVID-19. COVID free cancer hubs are currently operating in 21 areas in England, providing urgent and planned surgery, reassuring cancer patients that treatment will be in a safe and accessible locations. The new centres aim to put in place a framework to manage the backlog of patients and restart surgery safely [3,4].

The rapid and widespread nature of transmission led to the equally rapid response by China's healthcare system. The shift of funding and provisions towards management of the COVID-19 virus increased pressure on Oncologists to ensure the provision of care to their patients. Multiple cross-sectional retrospective studies have shown that cancer patients in China had a higher infection rate and a poorer prognosis compared to non-cancer patients. This is due to the immunodeficiency, increased age and comorbidities associated with cancer. Also, many integrative cancer therapies require close contact between the care provider and patient, increasing the risk of transmission. Consequently, several strategies were implemented across hospitals in China to reduce the transmission and impact of COVID-19 on cancer patients, including; reduced outpatient visits, inpatient admission and online consultations to limit person-to-person contact. In chemo- and immunotherapeutic treatment, patients with advanced cancer had their treatment suspended; whereas adjuvant chemotherapy was reduced in frequency and intensity aiming to preserve some level of immunocompetence. The Cancer Hospital, Chinese Academy of Medical Sciences employed these policies with positive results, as no patients or staff have been diagnosed with COVID-19 as of March 3, 2020 [5].

The measures taken in China successfully demonstrated reduced incidence of COVID-19-associated deaths amongst cancer patients and similar results are anticipated in the UK. Nevertheless, delays in key appointments and surgeries will inevitably increase delayed diagnoses and thus elevate avoidable deaths amongst cancer patients. Healthcare authorities must continue the expansion of COVID free cancer centres across the UK, to prevent further harm to patients and their families.

Ethical approval

Ethical approval was not required for this letter.

Sources of funding

No funding received.

Research registration unique identifying number (UIN)

N/A.

Author contribution

NS was lead author on this letter.

MA, JS and YA contributed equally to the preparation of the manuscript.

Guarantor

Nour Shubber.

Provenance and peer review

Not Commissioned, internally reviewed.

Declaration of competing interest

No conflicts of interest.