Supervised by: Yuhui Zhou, BA (Hons). Yuhui is a 5th year medical student at the University of Cambridge. She gained a First class degree in her intercalated year studying Pathology. She has an interest in Cancer & Immunology and has been awarded a Wellcome Trust Biomedical Vacation Scholarship to study host responses to infection.
Introduction
COVID-19 is caused by the coronavirus SARS-CoV-2 (1). The emergence of SARS-CoV-2 was first observed when cases of unexplained pneumonia were noted in the city of Wuhan, China in late 2019. During the first weeks of the epidemic in Wuhan, an association was noted between the early cases and the Wuhan Huanan Seafood Wholesale Market, as cases were mainly reported amongst operating dealers and vendors (2). By 1 March 2020, the number of confirmed cases reached 87,137 globally (3). Due to the alarming spread and severity of the disease, the World Health Organization (WHO) declared the COVID-19 outbreak a global pandemic on 11 March 2020 (4).
The COVID-19 outbreak impacted all aspects of society, and the healthcare sector was no exception. Specifically, the COVID-19 pandemic has disrupted the spectrum of cancer care, including by delaying diagnoses and treatment, and halting clinical trials (5).
At the time of writing, it has been more than a year since the initial outbreak of COVID-19. During this period, the oncology community has seen innovation at scale and pace, with examples such as telemedicine, accelerated access to innovative types of radiotherapy and more. Recovery, however, is only in progress. It will be a while before services are restored to pre-pandemic levels (6).
Research question
For cancer patients who had their follow-up treatments affected during the COVID-19 pandemic, what are some possible solutions that may help to restore procedures back to pre-pandemic levels?
How did we come up with this question?
Cancer is a broad topic to look into. However, as COVID-19 poses adverse effects on all aspects of cancer care, considering this additional element makes the topic broader, rather than more focused.
To narrow down our scope, we looked into the nature of cancers. Cancers are often deemed to be ticking time bombs. The timing has always been closely related to the effectiveness of cancer treatments, as cancers progress at a high, and thus unpredictable, speed. In this review, we only focus on the care of cancer patients who require follow-up treatments, mainly because once patients are diagnosed, clinicians have the absolute responsibility to work out the best follow-up plans for them before their situations get any worse.
Moreover, we put our emphasis on the possible solutions that would help restore services back to pre-pandemic levels as, instead of focusing on the negatively effects of the past, it would be more purposeful to focus on things that can be done better in the future.
Impacts of COVID-19 on the follow-up treatments of cancer patients
a) Deferral or cancellation of face-to-face outpatient appointments
Accumulating evidence suggests that cancer patients are at higher risk of COVID‐19 infection and more likely to have higher morbidity and mortality than the general population (7), and it was suggested that patients with cancer are more susceptible to infection and are more likely to have severe events due to the immunosuppressive state caused by cancer itself (8).
Since cancer patients are deemed to be a high-risk population during the COVID-19 pandemic, many cancer patients have been hesitant about going to hospitals and clinics for appointments from the very start of the outbreak. As the social distancing policies of different countries tightened, many health systems postponed outpatient visits. As a result, the number of face-to-face appointments for cancer outpatients has decreased substantially.
For example, in the US, impacted by the COVID-19 stay-at-home orders during the first half of 2020, significant utilization reductions were observed in patient evaluation and management (E&M) visits, with the greatest reduction in April hospital outpatient E&M visits (−74%) (9). Similar reductions were observed in the UK. Primary care consultations per person fell from an average of 4.1 before mid-March in 2020 to 3 consultations per person per year (around a 30% reduction) the week after the introduction of lockdown at the end of March, 2020 (10).
b) Deferral of systemic treatments and non-emergency surgeries
The global spread of the COVID-19 disease continues in several jurisdictions, causing significant strain to healthcare systems and its resources (11). For example, respirators that are used to reduce the wearer’s risk of inhaling airborne particles, Intensive Care Unit (ICU) beds for critically ill patients and human resources. Resources have been requisitioned to provide additional critical care capacity for COVID-19 patients (12), which caused non-emergency surgeries to face delays due to shortage in manpower, medical supplies and high-dependency care capacities (13). It was even suggested that two million non-emergency surgeries are being cancelled globally every week due to the COVID-19 pandemic (14).
Systematic treatments also faced deferral. They are mostly suspended as many options expose patients to a higher risk of becoming infected with COVID-19 (15). For example, it was suggested that after chemotherapy, the majority of patients will present with myelosuppression of varying degrees and durations, which will increase the risk of infection (16). Systemic treatments that cancer patients need are therefore deferred in many cases.
c) Deterioration in the mental health of cancer patients
Since cancer patients have already been experiencing mental and physiological stress from cancer treatment, the impacts have been worsened by the addition of COVID-related stressors (17). During the pandemic, cancer patients suffered from anxiety, depression, fatigue, sleep disturbance, cognitive dysfunction and pain (18), and due to all of these, their already-weak immune systems became weaker. It has even been suggested that poor mental health can be a barrier to cancer patients’ survivorship rate, affecting the adherence of chemotherapy (19). Patients’ mental state could become even worse as they feel more physically unwell, which would lead them into a vicious cycle.
Overall, factors like chances of survival, fear of contamination, the difficulty of accessing treatments, distance from family etc. caused anxiety, depression, panic attacks, post traumatic stress disorders, paranoid, psychotic disorders, or even suicidal behaviour among cancer patients. Accumulating evidence has found that the rates of fear and anxiety in cancer patients during the pandemic are high (20).
Telemedicine in response to the delay or cancellation of outpatient appointments
The WHO and American Telemedicine Association defined telemedicine as the use of electronic communications and information technologies in the delivery of clinical services over a distance (21).
In the context of the COVID-19 pandemic, when using telemedicine, healthcare workers could follow-up on patients, discuss their results, evaluate their response to therapy etc. even if face-to-face consultations were not available (22). Telemedicine facilitates patients’ access to essential health benefits (23), while minimizing the need for individuals to visit healthcare facilities, leading to a reduced consumption of PPE by the patients and the doctors, thus saving it for other healthcare professionals and for indicated situations (24), which shows that telemedicine under such circumstances is both beneficial to patients themselves and the healthcare sector as a whole.
As the number of face-to-face appointments deferred or cancelled decreased, the number of telehealth appointments also decreased. Findings from a study by New York University showed a 135% increase in telehealth visits in just over a month, from 2 March 2020 to 14 April 2020 (25). However, even though telemedicine was welcomed by some patients, the implementation of telemedicine faced many challenges.
The first challenge is about technical effectiveness. Although establishing contact is not difficult, ensuring access to a stable connection in remote areas is often problematic (26). Connection problems are a frequent barrier to effective care, especially in developing countries. It was suggested that most developing countries are not able to fully adopt telemedical solutions, specifically in rural areas, due to the low expansion of 3G/4G internet networks (27). Such problems can make it difficult to determine whether information has been received and understood correctly, lowering the efficiency and effectiveness of virtual consultations (28).
In addition, conducting an appropriate and effective clinical examination from a distance is a further challenge. During telemedicine interactive sessions, the patient can miss certain instructions such as discussing reports, side effects of medications, importance of compliance with treatment regimen and adjustment of doses. Lack of physical examination may risk missing vital observations including location of tender areas and swellings, blood pressure measurements, respiratory auscultation, cardiovascular exam and bowel sounds; virtual consultations are therefore less effective than face-to-face appointments (29).
Data storage, moreover, can also prove challenging. When healthcare practices are conducted virtually, and all information is transferred electronically, the situation becomes more complex. Preserving patients’ and families’ privacy, as well as ensuring the security of data, become much more difficult throughout the virtual care process (30). Concerns for privacy issues have been raised even further as there have been recent security problems regarding the vulnerability of some virtual applications such as Zoom, in which users of the platform have been hijacking video conferences (31).
Although the effectiveness of telemedicine can possibly be improved by web support, education, or implementation of laws, telemedicine will always remain less effective compared to face-to-face consultations because of certain unavoidable challenges.
As for the future, even though telemedicine can possibly be implemented to replace certain parts of face-to-face consultations, face-to-face consultations ought to be resumed as soon as is feasibly possible.
Radiotherapy in response to the deferral of systemic treatments and non-emergency surgeries
Radiotherapy can possibly replace certain systemic treatments and non-emergency surgeries.
This is because, firstly, radiotherapy does not generally compete for in-demand resources, such as respirators or Intensive Care Unit (ICU) beds and can continue to remain accessible. In certain scenarios, radiotherapy could even safely be used as an alternative to surgery. Additionally, it is possible to convert many standard fractionation schedules into shorter, hypofractionated ones, which involve fewer visits to the radiotherapy centre, thus reducing the risks of exposing patients to COVID-19. The patient’s fear of contracting COVID-19 during the time spent in the treatment sessions can be minimised as the contact between the doctors and patients diminishes.
Thirdly, in contrast to the majority of chemotherapies, most radiotherapy regimens are only moderately immunosuppressive, meaning that if the patient contracts COVID-19 during their radiotherapy treatment, their immune system will be more effective compared to that of a patient undergoing chemotherapy, which weakens and suppresses the immune system more severely.
Overall, radiotherapy is an effective possible solution for cancer treatment, as it is capable of replacing surgery in certain settings, including cancers of the head and neck, oesophagus, pancreas, prostate or bladder, and non-small-cell lung cancer (NSCLC).
Furthermore, this method has a higher overall survival rate (OS) than conventional surgical methods, which could help to reduce the fear patients have due to the pandemic itself and may reduce therapy postponement rates if this data is made clear to the public (32). A preliminary combined analysis of data from two earlier prospective randomized trials in this setting indicates a 3-year OS rate of 95% in patients receiving stereotactic body radiotherapy (SBRT) compared with 79% in those who underwent surgery. These findings, while preliminary, could justify the adoption of SBRT for patients with early stage NSCLC, particularly in view of the limited access to operating theatres and/or ICUs that thoracic surgeons might encounter during the acute phase of the COVID-19 pandemic.
The current pandemic is affecting every aspect of health care, including the management of patients with cancer. In these times, balancing the risks of infection and mortality with the increased risks of cancer mortality created from delaying treatment is of vital importance. Clinicians from each subspecialty should engage in the exercise of assessing evidence for the deleterious effects of delaying standard treatments and plan patient management accordingly, taking radiotherapy into highest consideration.
Multiple solutions in response to the deterioration of mental health amongst cancer patients
E-health services should include the formation and promotion of community groups that allow patients to connect with the outside world. Patients should be encouraged to maintain contact with family and friends through online platforms if not in person, and their daily schedules when possible, should include outdoor activities, for example a walk or catch up with a friend in the open air. These activities could reduce some of the negative effects of loneliness (33).
Chronic stress can affect your thoughts as well as your feelings. It can trigger inflammation in the body, causing fatigue, insomnia, headaches and depression. It also can cause irritability, lack of motivation and feelings of being overwhelmed (34), Most patients, however, can continue treatment via telemedicine from the comfort and protection of home. It is essential that telephone or internet service channels are urgently implemented in order to increase the efficiency of treatment, as few patients are currently being monitored.
A study by Frontiers in Psychology mentioned that a panel of psychiatrists from 15 countries has developed a protocol for providing mental healthcare during the pandemic. The protocol provides for an initial semistructured assessment and a series of interventions according to the degree of symptom intensity. All interventions follow evidence-based adequacy and efficacy criteria and may vary from psychoeducation to emergency care. This protocol can serve as a starting point for the development of strategies according to the region and the public service. The important 4 aspects from the study were dissemination of information, counseling, emergency support, and more long-term interventions (35).
There were important guidelines introduced in the UK for enhancing the care for cancer patients, including mandatory training and support for the Multi-Disciplinary Team (MDT), early mental health assessments following cancer diagnosis, increased awareness of the psycho-social interventions offered by the third sector, avoidance of a ‘one size fits all’ approach to psycho-oncology services, and addressing regional variations in mental health support (36).
The most important thing for cancer patients is to stay connected with their social support network; guidelines that family members can also follow have been issued. Cancer patients are also encouraged to stay connected through virtual and in-person social and community groups, including those established by and for fellow cancer patients. Some studies also suggest that meditation or mental wellness courses provided by hospitals can have a positive impact on their wellbeing (37).
The efficiency of these treatments depends on how closely they are followed by both cancer patients and the medical team. Telemedicine is not a novelty in oncology, and it has shown satisfactory results, especially for patients living in remote areas (38). However, not all patients are able to access remote services, requiring care alternatives for this population to be considered, for example those detailed in Table (39). This study offers alternative solutions for example, grounding breathing techniques and idtentifying what is within and without personal control for patients struggling with anxiety; sleep hygiene routines, postponing thoughts and eliminating distractions for those struggling to sleep. Considering the higher prevalence of mental health problems in cancer patients, only 1.6% were seeking help through psychological counseling. Around half of the total patients (48.1%) did not pay attention to online mental health services and only 11.2% considered online mental health services as helpful.
Alongside other recommendations from the American Society of Clinical Oncology (40), they call for all patients to be provided with a mental health assessment following a cancer diagnosis. Considering the lack of time and resources for personalized screenings, researchers have recommended programs such as Mental Health and Dynamic Referral for Oncology (MHADRO) to assist with screening for mental health problems in cancer patients. Results indicate that good family relationships had a positive influence on patients’ mental health.
In the results, we found that a higher frequency of receiving COVID-19 information and news was associated with a lower risk of anxiety (41).
Given the scenario, it is relevant for the medical team to recognize the challenges of caring for cancer patients during the pandemic. Thus, it is essential that psychiatric evaluation and psychological support measures are implemented, which may also involve telemedicine, which can be useful for tracking patients at risk, identifying the degree of severity of symptoms, and implementing support strategies considering the social context (42).
Table 1
Conclusion
During the COVID-19 pandemic, the physical and mental health of cancer patients who require follow-up treatments has been put under duress. In this review, we have detailed some possible responses to the challenges posed by COVID-19 in oncological treatment. While it is true none of these could restore procedures to pre-pandemic processes, they have proven effective, thus far, in mitigating the negative impacts in many cases.
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