Results of the Survey Conducted Among Caribbean Physicians on a Zoom Meeting Discussing the Article "A Practical Approach to the Management of Cancer Patients During the Novel Coronavirus Disease 2019 (COVID-19) Pandemic: An International Collaborative Group".

The World Health Organization has declared coronavirus disease 2019 (COVID‐19) a pandemic and has identified it as a public health emergency [1]. This has caused widescale disruption of health care services globally and affected the at‐risk population. Patients with cancer are regarded as being at high risk to develop COVID‐19, and oncologists worldwide have had to adopt strategies to provide care without compromising safety. Very few articles have been published discussing cancer care in the present situation, and the oncologists practicing in a resource‐challenged environment are very often left without guidance.

Oncologists practicing in the Caribbean region decided to seek guidance and discuss the importance of continuation of care for their patients. In this regard, Dr. Humaid Al‐Shamsi, the lead author of a landmark article published in The Oncologist, and Dr. Bruce Chabner, the Editor‐in‐Chief of The Oncologist, were invited to discuss COVID‐19 and cancer over a Zoom meeting on April 29, 2020. The discussion was on Dr. Al‐Shamsi's article, “A Practical Approach to the Management of Cancer Patients During the Novel Coronavirus Disease 2019 (COVID‐19) Pandemic: An International Collaborative Group,” and two surveys were recorded before and after the discussion, detailing the responses of the oncologists and other physicians from the various Caribbean islands. Oncologists from the following Caribbean islands took part in the survey and the discussion: Antigua and Barbuda, Bahamas, British Virgin Islands, Cayman Islands, Curaçao, Dominica, Grenada, Guyana, Martinique, St. Lucia, St. Kitts and Nevis, Trinidad and Tobago, and U.S. Virgin Islands.

In total, 42 physicians (16 oncologists and 36 non‐oncologists) took part in the online meeting and the premeeting survey (Table 1). The postmeeting survey was answered by 69% (29/42) of physicians (Table 2). The premeeting and the postmeeting survey forms were different for the oncologists and the non‐oncologists.

Table 1

Premeeting survey results for oncologists and non‐oncologists

Questions	Oncologists (n = 16), n (%)	Non‐oncologists (n = 36), n (%)
The emergence of coronavirus disease 2019 (COVID‐19) has caused a global public health emergency?—Yes	16 (100)	36 (100)
Do you consider cancer patients as high‐risk population?—Yes	16 (100)	36 (100)
How challenging is it to allocate resources in your setting? Scale 1–5: 1, very easy, to 5, very challenging
5	2 (12.5)	11 (30.5)
4	4 (25)	10 (27.7)
3	6 (37.5)	15 (41.6)
2	1 (6.25)	1 (2.7)
Has the pandemic caused delay in diagnosis of cancer patients?
Yes	12 (75)	21 (58.3)
No	1 (6.25)	3 (8.3)
Not sure	3 (18.75)	12 (33.3)
Has the pandemic caused any changes in outpatient care?
Yes	15 (93.75)	32 (88.8)
No	1 (6.25)	4 (11.2)
Has the pandemic caused any changes in care for hospitalized patients?
Yes	12 (75)	27 (75)
No	4 (25)	9 (25)
Have you had any cancer patient diagnosed with COVID‐19?—No	16 (100)	36 (100)
Do you have any psychosocial support for the patients?
Yes	16 (100)	21 (58.3)
No		15 (41.7)
Do you have any strategies in place to avoid burnout in health care workers in the oncology department?
Yes	9 (56.3)	12 (33.3)
No	7 (43.7)	24 (66.6)

Table 2

Postmeeting survey results for oncologists and non‐oncologists

Questions	Oncologists (n = 9), n (%)	Non‐oncologists (n = 20), n (%)
The emergence of coronavirus disease 2019 (COVID‐19) has caused a global public health emergency?—Yes	9 (100)	20 (100)
Do you consider cancer patients as high‐risk population?—Yes	9 (100)	20 (100)
Did the discussion provide ideas to manage and allocate resources better in your setting?
Yes	9 (100)	19 (95)
Maybe		1 (5)
Did the discussion provide any ideas to better manage the pandemic caused delay in diagnosis of cancer patients?
Yes	9 (100)	17 (85)
Maybe		3 (15)
Did the discussion provide any ideas for changes in outpatient care?
Yes	8 (88.9)	20 (100)
No	1 (11.1)
Did the discussion provide any ideas for management and care for hospitalized patients?
Yes	8 (88.9)	17 (85)
Maybe	1 (11.1)	3 (15)
Have you had any cancer patient diagnosed with COVID‐19?
Yes	1 (11.1)	4 (20)
No	8 (88.9)	16 (80)
Do you consider cancers affecting the lung (primary and metastases) as being high risk for COVID‐19?—Yes	9 (100)	20 (100)
Will you consider providing psychosocial support for your patients?—Yes	9 (100)	20 (100)
Will you consider any strategies in place to avoid burnout in health care workers in your department?—Yes	9 (100)	20 (100)
How often would you want to have similar meetings?
Monthly	5 (55.6)	NA
Quarterly	4 (44.4)
Was the Zoom meeting discussing the landmark paper useful?
Strongly agree	5 (55.6)	NA
Agree	3 (33.3)
Strongly disagree	1 (11.1)

Abbreviation: NA, not available.

The meeting began with introductions; Dr. Bruce Chabner then briefly updated the participants on the current situation regarding COVID‐19 in the U.S. He made everyone aware of the importance of preparedness and highlighted the newer trials underway for a vaccine, as well as trials of various therapeutic agents, including monoclonal antibodies. He also commented on the lack of effectiveness of hydroxychloroquine and its apparent association with excess deaths and remarked on the early indications of benefit of remdesivir. Dr. Humaid Al‐Shamsi then discussed his article in detail.

A list of action steps was generated from the discussion, which we believe are easily implementable in cancer centers around the globe, especially for developing nations.

Preparation and triage: The first step is driven by robust infection and environmental control. The triage of patients with respiratory symptoms is critical to reduce exposure to other patients and staff. In this regard, early identification and masking of individuals with respiratory symptoms and fever is initiated for all patients, visitors, and staff and takes place before entering the outpatient clinic and chemotherapy suite. If symptomatic, patients are diverted to a separate secondary screening area for consideration after notifying the appropriate team in charge.

Education and awareness: We understood from the discussion that education and awareness are key components in delivering high‐quality care for patients with cancer. Educational sessions on facts and myths of COVID‐19 were held for patients.

Staff training and report structure: Each of the staff members’ training was reinforced with staff safety measures, including proper donning and doffing of personal protective equipment. In accord with the principle of continuous access to treatment for oncology patients, a comprehensive work policy was established that included a strict “stay at home when ill” policy, restriction of travel, and alternate work schedule. These steps are taken to maintain a stable workforce in the department and to avoid unnecessary exposure of staff to infection.

Patient care continuum: It is important to maintain continuity of care for patients with cancer, and we learned to risk‐stratify them and provide care accordingly. As an example, patients with lung involvement (primary or metastasis) were at a higher risk of infection; hence, special measures were implemented for any of these patients with symptoms that would necessitate immediate quarantine and testing.

Curative and palliative intent: The patients were divided into curative and palliative groups, and those who were on curative treatment continued to get their treatment with minimal modifications. For example, the patients with breast cancer who were on weekly paclitaxel were converted to get the drug every 3 weeks. Palliative treatments were administered depending on the need for symptom relief.

Resource allocation: We learned from the discussion that proper allocation of resources helps maintain good quality care. For example, we implemented patient follow‐ups via telephone or video chats where possible. This ensured that patients were still able to talk to their care teams.

Avoiding burnout: We learned that caring for the carer is essential and as such have implemented policies such as weekly telemeetings (Zoom), alternate outpatient clinics, and psychosocial support for the team via a counsellor to avoid burnout in the health care team.

International collaboration: Finally, the most important lesson from this meeting is that it is possible for physicians staying in different parts of the globe to come together using technology to discuss current topics and, more importantly, develop together immediate actionable steps. As a result of this meeting, we decided to continue to organize our Tumor Boards online and were able to successfully discuss the cases.

Survey Results

COVID‐19 Pandemic as a Global Health Emergency

All the physicians irrespective of their specialty agreed that COVID‐19 is a global public health emergency. The opinion remained the same in the postmeeting survey.

Patients with Cancer as a High‐Risk Population

All the physicians considered patients with cancer to be at a higher risk for COVID‐19 infection. Patients with cancer are immunosuppressed because of their malignancy and the treatment they receive, which makes them more susceptible to infections. Caring for patients with advanced stage cancer is more challenging under the circumstances because of the higher risk [2].

Resource Allocation and Management

Resource allocation and management has been a challenge in developing nations, and in this pandemic, several strategies for patient care have emerged, such as increased application of telemedicine. These strategies, however, have come with their own set of challenges [3]. Before the meeting, the physicians were asked on a scale of 1 to 5 (1 being easy and 5 very challenging) how challenging it was to allocate resources in their setting. They were asked after the meeting if the discussion had provided ideas on how to manage and allocate resources better in their setting. Sixteen oncologists responded to the premeeting question: 12.5% (2/16) marked 5, 25% (4/16) marked 4, 37.5% (6/16) marked 3, and 6.25% (1/16) marked 2. Among non‐oncologists, 36 took the survey: 30.5% (11/36) marked 5, 27.7% (10/36) marked 4, 41.6% (15/36) marked 3, and 2.7% (1/36) marked 2. After the meeting, 87.1% (8/9) of oncologists and 94.4% of other physicians opined that the discussion had provided them with ideas to better manage the resources.

Patient Care

Some countries, such as Italy, that have been severely affected by the pandemic have been able to provide lessons learned to other countries in terms of providing better care for patients [4]. The pandemic has had direct effects on patient care, including delays in diagnosis, outpatient care, and inpatient care.

Before the meeting, 75% (12/16) of the oncologists and 58.3% (21/36) of other physicians agreed that the pandemic had caused delay in diagnosis. Nearly 90% (9 oncologists and 17 non‐oncologists) of physicians who took the postmeeting survey agreed that the discussion had provided ideas for avoiding delay in diagnosis during the pandemic. A minority (6.25%; 1/16) of oncologists and 8.3% (3/36) of non‐oncologists did not believe there was any delay in diagnosing the patients, whereas 18.75% (3/16) of oncologists and 33.3% (12/36) of non‐oncologists were not sure if the diagnostic delays were due to the pandemic.

Nearly all (93.75%; 15/16) of oncologists and 88.8% (32/36) of non‐oncologists agreed that the pandemic was affecting outpatient care, and 88.9% (8/9) of oncologists and 100% (20/20) of non‐oncologists agreed that the meeting had provided ideas to better outpatient care in the current situation.

Inpatient care has become more challenging in these times than before, more so in end‐of‐life situations in which the patients cannot “hold their loved ones’ hands before they close their eyes forever” [5]. Close to 75% of the physicians (12/16 of oncologists and 27/36 of non‐oncologists) agreed that the pandemic was affecting the care of hospitalized patients. The majority (88.9%; 8/9) of oncologists and 85% (17/20) of non‐oncologists agreed that the discussion had provided ideas for better inpatient care.

Comorbidities and COVID‐19

Although very few physicians had under their care a patient with both cancer and COVID‐19, all physicians agreed that comorbidities and involvement of lung (primary and metastatic) adversely affected the recovery of patients with cancer.

Psychosocial Care

Patients with cancer are psychologically strained and need good psychosocial care [6]. Pain in patients with cancer is not just physical but also includes psychosocial and spiritual pain. During the pandemic, patients need utmost support and care for their conditions, and in most developing nations, because of lack of resources, the existing health care staff, including nurses and physicians, take up multiple roles, providing not only medical care but also psychosocial and spiritual support [7]. All (16/16) oncologists and 58.3% (21/36) of non‐oncologists had such care available for their patients.

Health Care Worker Burnout

The best care for patients is possible only when the health care givers are agile and collaborate toward a common goal [8]. More than half (56.3%; 9/16) of oncologists and 33.3% (12/36) of non‐oncologists had strategies in place to avoid burnout in their departments. All physicians agreed to consider putting in place, by discussing with their respective departments, effective measures to avoid burnout in health care workers during the pandemic.

Future Directions

There was a unanimous agreement that Dr. Al‐Shamsi's presentation of “A Practical Approach to the Management of Cancer Patients During the Novel Coronavirus Disease 2019 (COVID‐19) Pandemic: An International Collaborative Group” was beneficial to all and that the discussion with Dr. Bruce Chabner was both helpful and inspirational. Half of the physicians preferred that such meetings be organized every month, whereas the other half wanted such meetings every quarter. The Caribbean experience with cancer care in the COVID‐19 situation will improve as more departments publish their data and physicians collaborate toward a common goal of providing care for their patients [9]. With the pandemic growing, we agree with the view of Dr. Chabner that newer interventions including vaccines and antivirals will have to be developed to prevent further devastation and that this might come at the expense of diverting resources away from activities like research in other medical areas [10].

Disclosures

The authors indicated no financial relationships.