Conceptual Framework for Cancer Care During a Pandemic Incorporating Evidence From the COVID-19 Pandemic.

PURPOSE: With successive infection waves and the spread of more infectious variants, the COVID-19 pandemic continues to have major impacts on health care. To achieve best outcomes for patients with cancer during a pandemic, efforts to minimize the increased risk of severe pandemic infection must be carefully balanced against unintended adverse impacts of the pandemic on cancer care, with consideration to available health system capacity. Cancer Australia's conceptual framework for cancer care during a pandemic provides a planning resource for health services and policy-makers that can be broadly applied globally and to similar pandemics.
METHODS: Evidence on the impact of the COVID-19 pandemic on cancer care and health system capacity to June 2021 was reviewed, and the conceptual framework was developed and updated.
RESULTS: Components of health system capacity vary during a pandemic, and capacity relative to pandemic numbers and severity affects resources available for cancer care delivery. The challenges of successive pandemic waves and high numbers of pandemic cases necessitate consideration of changing health system capacity in decision making about cancer care. Cancer Australia's conceptual framework provides guidance on continuation of care across the cancer pathway, in the face of challenges to health systems, while minimizing infection risk for patients with cancer and unintended consequences of delays in screening, diagnosis, and cancer treatment and backlogs because of service interruption.
CONCLUSION: Evidence from the COVID-19 pandemic supports continuation of cancer care wherever possible during similar pandemics. Cancer Australia's conceptual framework, underpinned by principles for optimal cancer care, informs decision making across the cancer care continuum. It incorporates consideration of changes in health system capacity and capacity for cancer care, in relation to pandemic progression, enabling broad applicability to different global settings.

INTRODUCTION

The COVID-19 pandemic is currently continuing worldwide, with successive infection waves and the spread of new variants of coronavirus SARS-CoV-2, such as the more infective Delta and Omicron variants.[1,2] At early April 2022, more than 490 million confirmed COVID-19 cases and more than 6.1 million deaths have been reported globally.[3] The pandemic continues to have major impacts on health care including potentially overwhelming health systems, with significant impacts on cancer care,[4-6] defined as care across the cancer pathway from prevention and early detection to survivorship and end-of-life care. Changes in cancer care delivery have included changes in use of telehealth, innovative care models, and impacts on cancer research and clinical trials.[4] Adverse impacts of the pandemic on cancer care may be more prolonged and greater in low- and middle-income countries (LMICs).[6]

CONTEXT

Key Objective

Cancer Australia has developed a conceptual framework as an evidence-based planning resource to support optimal cancer care across the continuum during the COVID-19 pandemic and future similar pandemics.

Knowledge Generated

Patients with cancer are at increased risk of severe COVID-19 disease and worse outcomes, so minimizing the risk of exposure to and harm from COVID-19 disease must be considered in cancer care. However, evidence from the COVID-19 pandemic supports the continuation of cancer care wherever possible during this, and similar pandemics, to achieve the best outcomes for patients with cancer and minimize adverse impacts of the pandemic on cancer care, including delays in screening, diagnosis, and treatment.

Relevance

Cancer Australia's conceptual framework reflects changing health system capacity, enabling its broad applicability to different global contexts, and is underpinned by principles for optimal cancer care. The framework provides guidance for cancer care during a pandemic for multiple stakeholders including health services and policy-makers.

Patients with cancer may be at increased risk from a pandemic infection because of factors such as older age; comorbidities such as cardiovascular disease, diabetes, and chronic lung disease; and immunosuppressed state because of the underlying cancer or anticancer treatments.[7-9] Patients with cancer have high levels of interaction with health care providers and may need frequent hospital admissions and visits, presenting another potential risk for pandemic infection. Patients with cancer are heterogenous, so individual factors that enable assessment of risk, including the type and stage of cancer and treatment type, also need to be considered.[10]

Throughout the COVID-19 pandemic, Cancer Australia has actively monitored emerging international evidence and clinical guidance on COVID-19 infection and cancer. In May 2020, Cancer Australia published a conceptual framework for the management of cancer during a pandemic as a thought piece for optimal cancer care during a pandemic.[11] It provided a framework for system-wide approaches to cancer management and decision making about modifications to cancer care, in accordance with the principles of the Optimal Care Pathways (OCPs) for people with cancer.[12]

The scenarios or phases of the pandemic underpinning Cancer Australia's initial framework were based on acute and recovery phases described by the American College of Surgeons[13] across modeled scenarios of COVID-19 cases[14] in relation to whether health system capacity limits were being approached or exceeded. The steps of the cancer care pathway (from prevention and early detection, through to survivorship and end-of-life care) were those defined in the Australian OCPs.[12]

Since the publication of Cancer Australia's initial conceptual framework, the COVID-19 pandemic has undergone successive waves and COVID-19 vaccination has become available. The aim of this review is to investigate the evidence of the impact of the COVID-19 pandemic on health system capacity and on cancer care and to further develop and update Cancer Australia's conceptual framework for cancer care during a pandemic.[11]

The conceptual framework does not include management of the pandemic-related illness, such as COVID-19 disease. The intended audience includes health services, health professionals, cancer organizations, and policy-makers. The framework differs to many other published frameworks and guidance, in that it covers the care of all cancers across the cancer care continuum; is not specific to any tumor site, clinical specialty, or health service; incorporates evidence and learnings from the COVID-19 pandemic; and is generalizable for similar pandemics in a global setting.

METHODS

A review was undertaken for evidence on the impact of the COVID-19 pandemic on patients with cancer, cancer care and health system capacity, and managing the impact of the COVID-19 pandemic, based on searches up to June 2021. A systematic approach was used to provide an evidence base that was fit for purpose. Although PICO criteria were not directly applicable, the following criteria were broadly applied:

Population: patients with cancer during the COVID-19 pandemic.

Interventions: cancer care across the continuum of care, including treatment of cancer. The management of COVID-19 disease/SARS-CoV-2 infection in patients with cancer was excluded.

Comparator: patients with cancer, not during a pandemic.

Outcomes: outcomes of cancer and pandemic infection.

Searches for cancer care (not tumor-specific) during the COVID-19 pandemic were undertaken in the PubMed database using search terms including health system capacity, COVID-19, pandemic, cancer, and oncology. The inclusion criteria were systematic reviews and meta-analyses; peer-reviewed original articles (published since relevant systematic reviews or meta-analyses) on prospective or retrospective controlled studies with large sample sizes; additional high-level evidence or reviews (eg, reviews on the basis of systematic approaches with particular relevance); or existing clinical guidance, recommendations, and position statements from peak cancer organizations. Websites of peak cancer organizations, Australian medical colleges, and databases were searched, and additional relevant articles were identified by Google searches and snowballing techniques.

Abstraction of evidence for the initial conceptual framework was repeated for the updated framework, with input from secondary evidence reviewers. There was an extensive internal Cancer Australia review with a consensus approach used. The conceptual framework was updated on the basis of the evidence identified, current international and national guidance, recommendations, and position statements, broadly similar in principle to a meta-guideline approach.[15] This pragmatic approach enabled the timely incorporation of international and national guidance.

RESULTS

The conceptual framework:

Incorporates consideration of changes in health system capacity and capacity for cancer care during a pandemic.

Is informed by evidence on the effects of COVID-19 disease in patients with cancer.

Is informed by evidence on the impacts of the pandemic on cancer care.

Is underpinned by principles for optimal cancer care.

Health System Capacity During a Pandemic

Health system capacity.

Components of health system capacity relevant to a pandemic similar to the COVID-19 pandemic (listed in Table 1) include availability of resources such as hospital beds and supplies (personal protective equipment [PPE], oxygen, medications, blood, etc); availability of skilled health care staff, intensive care unit (ICU) and ventilator capacity; and access to pathology and imaging services.[16,21] Health system capacity components are dynamic and may increase or decrease during a pandemic, as described in Table 1.[2,16-20] These components may vary in an asynchronous manner during a pandemic, and some may increase, whereas others decrease.

TABLE 1

Health System Capacity Components and Potential Changes During a Pandemic[2,16-20]

Capacity may vary during successive waves of infection because of factors such as preparations undertaken between waves and the relative numbers of infected cases and may vary on a local basis. Measures to maintain or increase health system capacity during a pandemic and mitigate potential shortages include the following: adapting existing hospital beds and ICU capacity,[2,17,18] mitigating health care staff shortages,[2,22] implementing protocols to reduce the risk of pandemic infection for health care workers including nosocomial transmission,[23] maximizing supply of ventilators,[24] and planning logistics for surge capacity.[25]

Health system capacity and impacts of the COVID-19 pandemic vary globally with greater impacts in LMICs.[26] LMICs have lower ratio of hospital beds, ICU, and ventilator capacity relative to the population, compared with higher-income countries[26] and have reported worse impacts of the pandemic on cancer care capacity, including significantly greater shortages of PPE and medications, and less availability of virtual clinics (telehealth) and remote care.[27,28]

Progression of a pandemic and pandemic phases.

Epidemiologic curves, on the basis of the evidential progression of the pandemic under different scenarios of pandemic numbers and severity, can be used to predict the effects of mitigation strategies such as quarantine, social distancing, contact tracing, and lockdowns in subsequent episodes.[14,17,26]

In Figure 1, the progression of a pandemic is shown as the demand on the health system related to the pandemic infection, and health system capacity as a band, with dashed lines representing its range during a pandemic because of multiple components that could increase or decrease at any time (detailed in Table 1). Figure 1A shows phases where the pandemic demands are within, or exceed, health system capacity in an uncontrolled (rapidly increasing) or mitigated (flattened) pandemic scenario. In repeat pandemic waves (Fig 1B), health system capacity may be exceeded at different times. The pandemic curves will also be influenced by rates of vaccination, which may vary locally and globally between low-resource and high-resource countries, and by efficacy of the vaccine.

FIG 1

The progression of a pandemic is plotted as the demand on the health system because of the pandemic infection against time. Health system capacity is shown as a band, with dashed lines representing its range during a pandemic because of multiple components that could increase or decrease at any time. (A) Pandemic phases in relation to health system capacity. The blue line indicates an uncontrolled outbreak with rapidly increasing numbers where health system capacity may be exceeded, and the teal line indicates a mitigated scenario with a slower rate of transmission. Acute and recovery phases, incorporating both the pandemic progression and health system capacity, are indicated. (B) Pandemic with repeat waves. Demand on health system capacity because of the pandemic is plotted for repeat pandemic waves over a period of time. Health system capacity may be exceeded at different times during repeat pandemic waves.

As health system capacity and the demands of pandemic infection vary during the different stages and scenarios of a pandemic, so do the resources available for cancer care delivery. At each step on the cancer care continuum, decisions on cancer care should include consideration of health system capacity and capacity for cancer care, in relation to the progression of the pandemic. Incorporating this consideration into the conceptual framework for cancer care enables its broad application to different pandemic settings and to different health services and global contexts.

Acute and recovery pandemic phases, which incorporate both changing health system capacity and the progression of the pandemic,[13] are used in this conceptual framework:

Acute phase I: Semiurgent setting. Few pandemic infection patients and numbers not rapidly escalating, demand is within health system capacity; hospital supplies and health care staff resources are not exhausted; hospitals still have ICU capacity.

Acute phase II: Urgent setting. Rapidly escalating numbers of pandemic infection patients, approaching limits of health system capacity; hospital supplies and health care staff resources are limited because of factors such as redeployment to pandemic-related activities; ICU capacity increasingly limited.

Acute phase III: Emergency setting. High numbers of pandemic infection patients, health system capacity exceeded; hospital supplies and health care staff resources are overwhelmed or exhausted by pandemic-related activities with no spare capacity; no spare ICU capacity.

Recovery phases. Past the peak of pandemic infection with fewer new daily cases, health system capacity not exceeded; hospital supplies and health care staff resources are more available, including hospital and ICU beds, healthy staff, PPE, and critical testing.

Within these phases, there may be transitions, such as from a preparatory phase with low numbers to a phase with more rapidly increasing numbers during acute phase I. These phases may be repeated during successive waves of infection and with new pandemic variants.

Evidence of Effects of COVID-19 Disease in Patients With Cancer

Risk of COVID-19 disease in patients with cancer.

Early reports and a US retrospective case-control study of electronic health records have indicated that patients with cancer might have increased risk of COVID-19 disease.[29-31] Although the large case-control study had limitations such as those inherent to electronic health records and testing differences between groups, patients with cancer especially those diagnosed within the past year were at significantly increased risk compared with those who never had cancer, and the associations were strongest for those patients with recently diagnosed leukemia, non-Hodgkin lymphoma, and lung cancer.[31]

Severity and complications of COVID-19 disease in patients with cancer.

An increased risk of severe complications of COVID-19 disease or ICU admission for COVID-19 disease patients with cancer compared with COVID-19 disease patients without cancer has been reported in several meta-analyses with increased risks ranging from 1.56 to 2.32.[32-35]

Increased severity of COVID-19 disease has been reported for patients with hematologic malignancies (leukemia, lymphoma, and myeloma) compared with patients with solid organ tumors[36] and for patients with lung cancer compared with other cancers.[37-39]

Mortality because of COVID-19 disease in patients with cancer.

There is an increased risk of death in patients with COVID-19 disease who have cancer compared with those without cancer, with increased risks ranging from 1.66 to 2.97 reported in meta-analyses.[32,35,40] Mortality rates have been reported to be higher for patients with cancer who have COVID-19 disease with hematologic malignancies[36,41-44] and with lung cancer,[42,45,46] compared with other cancers.

Severity of COVID-19 disease and risk of mortality in cancer patients with COVID-19 disease receiving systemic anticancer treatment or radiation therapy.

Recent anticancer treatment before COVID-19 disease has been associated with increased severity of COVID-19 disease or mortality in some studies[47-49] but not in others.[37,50-53] The review by the National Institute for Health and Care Excellence (February 2021) indicated there was, on balance, no difference in all-cause mortality for patients with cancer and COVID-19 disease with any of the systemic anticancer treatments (chemotherapy, targeted therapy, immunotherapy, or hormone therapy) received.[53]

In recent meta-analyses,[29,42] chemotherapy, surgery, or other anticancer treatments were not associated with increased risk of COVID-19 disease severity or deaths in cancer patients with COVID-19 disease.

For specific systemic treatments, a cohort study (4,966 patients with cancer and COVID-19 disease) showed that the anticancer therapies: rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone; platinum combined with etoposide; and DNA methyltransferase inhibitors, were associated with high 30-day all-cause mortality.[54] In another large cohort study (63,413 patients with cancer and COVID-19 disease), recent (within 30 days) cytotoxic therapy was associated with increased risk of all-cause mortality, hazard ratio (HR) = 1.5 (95% CI, 1.1 to 2.1), whereas mortality risk was not increased for patients who had received recent immunotherapies or targeted therapies.[43]

Some studies have reported worse outcomes for cancer patients with COVID-19 disease treated with immune checkpoint inhibitors (ICIs),[52,55,56] whereas other studies have reported no difference in outcomes.[45,54,57] In a meta-analysis (11 studies with 2,826 cancer patients with COVID-19 disease), prior ICI treatment was not associated with higher mortality risk or with disease severity; however concomitant use of ICI and chemotherapy may be linked to higher COVID-19 severity (odds ratio = 8.19; 95% CI, 2.67 to 25.08, with a small sample size).[58]

Evidence on the Impacts of the Pandemic on Cancer Care

Delays in screening, diagnosis, and treatment of patients with cancer during the COVID-19 pandemic.

During the COVID-19 pandemic, delays and disruptions to cancer care have included the following: decreases in screening rates; delays in diagnosis; reduction in number of cancer surgeries; delay in radiotherapy or use of other regimens and alternate systemic regimens; and delay, rescheduling, or cancellation of outpatient visits.[20,28,59-61]

Cancer screening programs, such as for breast, cervical, and colorectal cancers, have been disrupted to varying degrees during the COVID-19 pandemic. Some screening programs such as breast screening were suspended during peaks of pandemic infection in some countries.[60,62,63] The disruptions to cancer screening during the COVID-19 pandemic and strategies for maintaining or resuming cancer screening are affected by health system capacity and whether it is exceeded during the varying phases of a pandemic.[64,65]

In 2020 during the COVID-19 pandemic in Australia, cancer-related diagnostic procedures for 14 cancer types were approximately 8% lower than expected (more than 160,000 fewer services) and therapeutic procedures were approximately 9% lower (more than 14,000 fewer services).[5] In the United States, reductions of 46% in the total weekly number of newly diagnosed breast, colorectal, lung, pancreatic, gastric, and esophageal cancers (in the period from March 1 to April 18, 2020) were reported.[66]

Interruption in cancer treatment was reported by up to 77.5% of patients responding to surveys in a systematic review of 62 studies from Europe, the United States, Asia, and the Middle East.[20] In a global cross-sectional, questionnaire-based study (356 oncology centers from 54 countries), 88% of centers reported reduction in their usual level of cancer care (including surgery, systemic therapy, radiotherapy, and palliative care).[27]

Impacts on cancer outcomes of delays in cancer screening, testing, and treatment during the COVID-19 pandemic.

The impacts of disruptions to cancer screening because of the COVID-19 pandemic have been estimated by modeling studies for different countries with different screening programs.[67-69] Disruption of breast cancer screening programs has been estimated to have varying short- and long-term outcomes, including increased tumor size, stage shifts to higher-stage cancer, increased mortality, and increased public health burden.[67] In the Netherlands, suspension of the breast cancer screening program and a later restart at reduced capacity resulted in a reduction of screen-detected breast cancers by 67% during February to August 2020, equating to an estimated 2000 delayed screen-detected cancers.[62] It has been estimated that cervical cancer screening disruption in high-income countries will increase cervical cancer cases (2020-2030) by up to 5%-6%, with the greatest impact among women age < 50 years in 2020.[68] Disruptions in colorectal cancer screening were estimated to result in additional colorectal cancer deaths in the long term (eg, for 6-month disruption without catch-up screening, 1,961 additional deaths in 2020-2050 in Australia, 678-881 in the Netherlands, and 1,319 in Canada).[69] However, the impact would be minimized by catch-up screening,[69] and in Australia, there was no suspension of the National Bowel Cancer Screening Program.[63]

Delays in diagnosis because of pandemic lockdown measures have been estimated to result in substantial additional cancer deaths in England.[70] Across breast, colorectal, lung, and esophageal cancers, 3,291-3,621 additional deaths within 5 years were estimated after diagnostic delays from March 2020 over 12 months, with increased deaths ranging from 4.8% for lung cancer to 16.6% for colorectal cancer.[70] A consistent effect of delay in cancer treatment on increased mortality has been estimated in a meta-analysis of 34 studies (all retrospective comparative observational studies) published from 2000 to 2020 on seven major cancer types (bladder, breast, colon, head and neck, nasopharyngeal, cervical, and non–small-cell lung cancer) and surgery, systemic treatment, and radiotherapy treatments.[71] Mortality risk for each 4-week delay for surgery was HR = 1.06-1.08, and for systemic treatment, it was HR = 1.01-1.28. For radiotherapy, there was evidence of a mortality impact because of delay in adjuvant radiation therapy for head and neck cancers and for cervical cancer.[71] Interruptions to cancer treatment during the COVID-19 pandemic were further affected by the kinetics of rapid shutting down followed by slower ramping up later, for example, in Canada, where an immediate 60% decrease in mean surgical volume was followed by a slow 6% weekly increase,[61] and may result in large backlogs of cases. Treatment delays and modifications may be prolonged and negatively affect patient care and outcomes, as it will take considerable time for cancer care to resume capacity and adjust models in response to the pandemic.[28]

In a global study of the impact of the COVID-19 pandemic on cancer care (356 centers from 54 countries), the magnitude of the impact on reduction or disruption of cancer care and reported estimates of harm to patients were more pronounced in lower-resource countries,[27] for example, impacts of the pandemic on cancer surgery reduction have been greater in lower-income countries.[72]

Impacts of the COVID-19 pandemic on follow-up and supportive care.

The impacts on follow-up care for patients with cancer during the COVID-19 pandemic include the following: delays or cancellations of follow-up appointments, modifications of follow-up plans (eg, suspension or postponement of imaging and physical examinations and of exercise programs), and increased use of telehealth.[73,74] Although telehealth has replaced many face-to-face appointments,[4] barriers to its implementation include variable access to technology and concerns about anxiety and distress in some patients with cancer related to telehealth.[73,74] Changes in follow-up care may include models such as shared care, nurse-led or GP-led care.[4,73,75]

Patients with breast cancer in Australia have reported concerns around missing social supports from family and friends, lack of access to social support services, and hospital restrictions on visitors during treatment.[76] It has been suggested that closer consideration is given during the COVID-19 pandemic to maintaining inclusion of caregivers, who are an integral component of a patient's care team, in appointments and hospital visits.[77]

Impacts of the COVID-19 pandemic on oncology health professionals.

Negative impacts of the COVID-19 pandemic on oncology professionals reported in an international survey in April/May 2020 (1,520 participants from 101 countries) included being at risk of distress (25%), feeling burnout (38%), and not being able to perform their job compared with the pre–COVID-19 period (66%).[78] In other international surveys, negative impacts of the pandemic on mental health and well-being were reported by approximately 50% of oncologists (surveys from the Middle East, North Africa, Brazil, and the Philippines[79] and from Europe, Australasia, and Asia[80]). Psychological distress, fatigue, and disrupted practice have also been experienced by cancer care clinicians in Australia.[81]

Burnout and fatigue experienced by oncology health professionals because of the COVID-19 pandemic can lead to decreased health care staff capacity (refer Table 1).

Principles Underpinning Optimal Cancer Care During a Pandemic

Seven key principles underpin the OCPs for people with cancer in Australia: patient-centered care, safe and quality care, multidisciplinary care, supportive care, care coordination, communication, and research and clinical trials.[12]

The guidance and evidence identified in the current review support the importance and relevance of these principles during a pandemic (described in Table 2), including provision of safe and quality care by minimizing the risk of pandemic infection for patients with cancer and health care staff[82,83]; patient-centered and multidisciplinary care for individualized treatment and treatment decisions[7,82]; and care coordination and communication, which are essential especially for changes in cancer treatment and treatment planning.[82,90] Supportive care can assist with the psychosocial impacts of a pandemic.[88,90] New opportunities for research and clinical trials, such as those based on large registries, have become available during the COVID-19 pandemic.[93]

TABLE 2

Application of the Principles of Optimal Cancer Care (from the OCPs[12]) in a Pandemic

Evidence on health system capacity and capacity for delivery of cancer care during a pandemic and the impact of the COVID-19 pandemic on cancer care have informed the updating of the content of the conceptual framework. Key areas where the framework was updated included the following: further consideration of health system capacity components and changes during a pandemic, consideration of continuing anticancer treatments and individualizing treatment decisions, supportive care, health professionals' burnout, and vaccination against pandemic infection.

The evidence and rationale underpinning the conceptual framework are summarized in Box 1 (Fig 2).

FIG 2

Summary of evidence and rationale underpinning the conceptual framework.

The evidence supports the continuation of cancer care wherever possible during a pandemic to achieve the best outcomes for patients with cancer and the community and to minimize the adverse impacts of the pandemic on cancer care. At each step of the cancer care continuum, decisions on cancer care should be based on consideration of health system capacity and capacity for cancer care delivery, in relation to the progression of the pandemic and pandemic infection control.

Cancer Australia's conceptual framework, underpinned by principles for optimal cancer care, provides guidance on how to continue cancer care during a pandemic. Detailed guidance is provided in Table 3 and is summarized in Figure 3. The framework is a matrix structure with guidance across the cancer care continuum, from prevention and early detection through to end-of-life care, for the different acute (I, II, and III) and recovery phases of a pandemic that incorporate changing health system capacity and capacity for cancer care delivery.

TABLE 3

Detailed Conceptual Framework: Cancer Care During the Acute and Recovery Phases of a Pandemic

FIG 3

Summary of the conceptual framework for cancer care during a pandemic. aFor telehealth services, videoconferencing is the preferred substitute for a face-to-face consultation.[110,111] GP, general practitioner; IV, intravenous.

The guidance in the conceptual framework is supported by evidence from the COVID-19 pandemic and on guidance, recommendations, and position statements from peak cancer care organizations on cancer care during the COVID-19 pandemic.[82,84,90,91,95,101,102] Many of the guidance and recommendations from peak organizations were expert-based and/or consensus-based. A rapid evidence review[53] informed the National Institute for Health and Care Excellence guidelines on systemic anticancer treatment and radiotherapy for patients with cancer during the COVID-19 pandemic.[82,102]

Vaccination for COVID-19 disease has become available, and cancer organizations have provided guidance that supports offering vaccination against COVID-19 disease to patients with cancer, with consideration of any contraindications and factors such as the type of cancer, type of treatment and timing, and counseling about effectiveness and ongoing prevention measures.[97-99]

Emerging evidence will continue to inform the conceptual framework to guide cancer care during the current pandemic, whereas longer-term evidence and data will inform decisions when faced with another pandemic.

DISCUSSION

The COVID-19 pandemic has affected cancer care because of reduced health system resources available for cancer care and the need to minimize the risk of COVID-19 disease in patients with cancer. The ongoing progression of the pandemic has provided an opportunity to examine the evidence base and reflect on learnings from the COVID-19 pandemic and further develop a conceptual framework for cancer care.

The importance of preventing COVID-19 disease in patients with cancer is predicated by the evidence showing the increased impact of the pandemic infection among patients with compared with patients without cancer. However, the implications of reducing or delaying cancer care across the care continuum, including the impact of rapid shutdown and slow ramping up of services on patient backlogs, are substantial and significant.

Evidence from the COVID-19 pandemic supports the continuation of cancer care wherever possible during a similar pandemic to achieve the best outcomes for patients with cancer and the community and minimize the adverse impacts of the pandemic on cancer care. Underpinned by principles for optimal cancer care and informed by the evidence on cancer care during the COVID-19 pandemic, Cancer Australia's conceptual framework provides detailed guidance on critical considerations and an evidence-based toolkit for cancer care during the current COVID-19 pandemic and future similar pandemics. It reflects changing health system capacity and capacity for cancer care, enabling its broad applicability to different global contexts, and is consolidated by consideration of best practice principles for cancer care. The framework provides a planning resource for multiple stakeholders including health services and policy makers. Emerging evidence and data will continue to inform the evolution of the framework to guide ongoing cancer care during this and future pandemics.