As the world faces the 2019 coronavirus disease pandemic (COVID-19), reports are emerging of how cancer care is being prioritized, delayed, and discontinued. These decisions made under the pressure of the pandemic will have serious consequences for cancer mortality in the coming years.
Those newly diagnosed with cancer, or in the midst of cancer treatment, face discontinuation of all but the most urgent procedures due to concerns about their susceptibility to serious risks of COVID-19, and redistribution. of personnel, beds and equipment for COVID-19 rooms. Hospital capacity has also been reduced due to cases of COVID-19 in the health workers themselves, and oncologists have not been spared. The official advice is that urgent cancer care can continue, but other treatments must be rationed and adapted. However, these decisions are inconsistent and not based on evidence: multidisciplinary teams are putting themselves in an enviable position to make the best guesses for each patient. However, delays and treatment adaptations can risk, for example, operable or curable cancers that become an inoperable disease with a much worse prognosis. In many cases, and especially in resource-constrained settings, balancing the risks of under-treatment with those of COVID-19 infection will lead to situations where there is no obvious best course of action. As societies and governments strive to provide guidelines for cancer patients, front-line medical staff are forced to make treatment decisions on the fly, and, unfortunately, many patients will receive suboptimal care.
Importantly, cancer detection and diagnosis are also affected by the new prioritization of health services during the pandemic. For example, in the UK, cancer-suspicious urgent referrals that are normally eligible for the 2-week wait target are now subject to prioritization rules that will cause delays. Furthermore, because screening programs were suspended in the UK, diagnoses will depend on the presentation of patients with symptoms of cancer. Concerns about the spread and contracting of COVID-19, and fear that COVID-19 is rampant in hospitals and other health care facilities, could discourage symptomatic patients from contacting their GPs. Cancer diagnoses delayed for the next few weeks and months run the risk of thousands of cases going unnoticed and untreated. The side effects, related to an increase in demand for cancer-related services once the pandemic has peaked, along with an increase in advanced-stage cancers due to delays in diagnosis and treatment, could overwhelm health services and contribute to excess cancer-related mortality in the coming years.
The pandemic is also affecting cancer patients who are under follow-up, for example, those in remission or receiving palliative care for late-stage disease. Cancer surveillance and management of cancer-related symptoms and sequelae of treatment are managed by primary care physicians in many countries, or as home or outpatient services. However, the pandemic has restricted access to only the types of resources these patients need: home health care workers, primary care appointments, and supportive care medications. Because adequate and timely supportive care can extend overall survival, the availability of these services is crucial to prevent not only morbidity, but also premature death.
Overall, disruption of the full spectrum of medical cancer care services will undoubtedly have a major effect on cancer-related mortality. Survival in high-income countries is predicted to decrease 5-10%, representing hundreds of thousands of excess deaths, dwarfing those caused by COVID-19, but we are missing accurate mortality data that can be used to anticipate future cancer care needs. Therefore, we request that the long-term impact on cancer-related mortality resulting from cancer care decisions made globally during the COVID-19 pandemic be investigated. In addition, we advocate that pandemic preparedness plans must take into account the resources necessary to maintain continuity of evidence-based, high-quality care of people with cancer, including the needs for labor and service capacity , and a solid referral and diagnostic service. Oncologists should be included in the group of care workers who require essential equipment and resources during a pandemic. It is debatable whether governments and health services could have been better prepared for COVID-19 is debatable, but the need for a rapidly deployable and evidence-based response is urgent and unmet. The next pandemic is not hypothetical, it will happen again, and guidance must now be generated to prevent cancer patients from becoming collateral damage.
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DOI: https://doi.org/10.1016/S1470-2045(20)30243-6
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