New approaches to cancer care in a COVID-19 world.

The effects of COVID-19 on cancer are substantial, highlighting both novel and existing challenges for health-care systems. We were therefore encouraged to see The Lancet Oncology's call for cancer care to be safeguarded in a post-COVID-19 world. We endorse this position for cancer surgery specifically, and propose several recommendations aiming to reduce the so-called collateral damage of COVID-19. The International Cancer Benchmarking Partnership (ICBP) is a global collaboration seeking to compare and improve cancer survival across high-income countries. Within the ICBP, we came together to provide a voice for the international cancer surgery community.

Cancer is a major cause of morbidity and mortality, made acutely worse by the COVID-19 pandemic, and requires sustained investment and coordinated planning in a COVID-19 world. Health leaders now need to safeguard capacity and regain lost progress in cancer control. Available resources should be directed to those most likely to benefit. National media campaigns should be used to boost screening uptake and help-seeking behaviour for potential cancer symptoms, addressing the current delays and barriers in access to health care. Investment in cancer diagnostic workforces will be key, particularly in building up provisions for tests and biopsy procedures and shortening diagnosis-to-treatment intervals. The pandemic has also created opportunities to improve efficiencies in care, such as virtual consultations and visits. Facilitating multidisciplinary team meetings digitally is one of many potential changes requiring long-term investment in technology and infrastructure.

Cancer surgery services need to be well prepared as we navigate through the COVID-19 era. Substantial reconfigurations will be required to deal with heightened caseloads. Together with other time-sensitive and life-threatening procedures, cancer surgery should be prioritised over less urgent operations. Increased theatre space availability, surgeon capacity, and postoperative surveillance resources will be required. More frequent and widespread testing is needed to ensure relatively COVID-19-free hospitals or designated Cancer Hubs that are safe for patients and staff. More acute-care nurses should be recruited to manage more patients preoperatively and postoperatively. The widespread implementation of enhanced recovery after surgery services is recommended to match increased surgical volumes. Expansions in the capacity of intensive care units must remain in place while services manage an unprecedented number of patients with cancer coming back into the system.

Capturing real-time data will be crucial to benchmark hospital performance and inform rapid quality improvement as centres grapple with the new reality of a post-COVID-19 world. We must also prepare for consecutive waves of outbreaks, with the need to restrict services for uncertain periods of time. Finally, efforts to benchmark cancer outcomes internationally and regionally are now essential to better understand the global impacts of COVID-19 on cancer care and enable countries to share knowledge on best practice during pandemics in future.

To support cancer surgery services, we propose several recommendations (panel ). These recommendations should inform policies to deal with a new cancer burden in a post-COVID-19 environment and to mitigate a potential crisis in excess deaths due to cancer. Countries and regions will be affected in different ways and should prioritise these recommendations on the basis of their own resources and planning.

Run media campaigns to boost screening uptake and encourage patients to seek help for potential cancer symptoms

Resume evidence-based screening programmes and other early diagnosis initiatives as soon as possible

Implement risk stratification tools and effective triage assessments to account for restricted diagnostic capacity and to prioritise patients with concerning symptoms or requiring staging over those in follow-up

Mitigate the risks of nosocomial SARS-CoV-2 infection, including testing all patients admitted for major cancer surgery and by using relatively COVID-19-free institutions (designated stand-alone diagnostic and treatment facilities) or isolating within sites

Investing in technology and infrastructure to facilitate virtual consultations, multidisciplinary team meetings, and other innovations

Prioritise cancer surgery over elective and less urgent operations, and among these cancer cases, prioritise patients according to urgency of surgical care and patient benefit

Anticipate increased volumes of cancer surgery with appropriate workforce and resource planning in a slower throughput environment, including theatre space, surgeon capacity, and postoperative surveillance resources, potentially to levels higher than before COVID-19

Maintain increased levels of intensive care unit capacity and standards to ensure prioritisation of patients with cancer and other time critical and life-threatening conditions

Adopt evidence-based perioperative pathways such as enhanced recovery after surgery to improve recovery of patients with cancer after surgery, allowing for increased throughput of patients and capacity of the health-care system

Capture data and track of the number of cases, patient stage, and treatment in real-time to benchmark performance and respond to system stresses

Support cancer health-care teams and administrative staff to minimise and respond to burnout

Prepare and plan for subsequent waves of COVID-19 and other pandemics to reduce future effects on cancer care

Benchmark international and regional cancer outcomes in the new context of COVID-19

SARS-CoV-2=severe acute respiratory syndrome coronavirus 2.