COMMENTARY

Coronavirus and Cancer Care. Has China Taught Us Anything?

Prof Karol Sikora

Disclosures

March 13, 2020

This transcript has been edited for clarity.

Hello, this is Professor Karol Sikora here, talking about the impact of the coronavirus pandemic on cancer care globally.

So as you know, cancer is a pretty complex disease ­- we use surgery, radiotherapy, chemotherapy, hormones, immunotherapy, to treat it, and it should be done in a timely manner. Interestingly the evidence that you need to treat it at a defined time point is just not there, because no one would be stupid enough to do randomised trials: delaying treatment purposefully would be completely unethical. So we sort of accept that 6 weeks to get started on treatment is what we should be aiming for, maybe even less, and different countries, depending on their capacity to deliver cancer care have different attitudes. So Britain is a bit slower than mainland Europe, which in turn is a bit slower than North America where, you know, it's almost like an emergency - you start treating certain types of cancer within a week. We can't just achieve that in our system because of lack of capacity. So along comes coronavirus and screws everything up, basically – it re-prioritises the whole way hospitals work, the whole way secondary care works, but it shouldn't really impact on the cancer clinic. Cancer clinics are separate, they are nearly all daycare.

Chinese Data

Cancer patients are not exempt from getting coronavirus. But interestingly, data that's already been published coming from China suggests that cancer patients are not that selectively targeted by the virus, and don't necessarily get a worse illness than other people that haven't got cancer. So in an interesting paper coming from China, they collected data on over 2000 patients that had coronavirus, all around China and various hospitals, and they identified 18 that had cancer. And it suggested that of those 18, they had an increased chance of having a serious adverse event due to the coronavirus - intensive care admission, use of a ventilator, and their mortality was slightly higher.

The problem with the paper is that it's the best you can do with the data. And it's a massive effort, I'm not decrying it, but only 18 patients and the age of the cancer patients was higher, smoking history was higher, and there was quite a lot of lung cancer in there again. So these patients would have had surgery, radiotherapy, perhaps immunosuppressive chemotherapy. So it's not that easy with only 18 patients out of the data set of over 2000 to make any significant meaningful comparison in such a short period of time. As we know, with cancer, it's a long haul. Treatment takes a long time and follow up takes a long time.

Prioritise

So how are we coping? What should we do with cancer services? Well, in the UK, we are pretty stretched. And the idea is that we try and treat people within 62 days of the intention to treat, try to get it down to 28 but we struggle because of lack of capacity in the system, in the NHS. So I think what we have to do is look at imaginative ways, we can certainly prioritise things. So I would say younger people on adjuvant therapy that are likely to be cured, early breast cancer that's high risk for example, I would take those patients and make sure they don't delay treatment. I think the treatment of metastatic disease, that's perhaps less high priority, because essentially it's palliation. And there's not much evidence that aggressive treatment of any metastatic cancer of the common solid tumours makes a long-term difference to survival. It may improve quality of life if the patient responds to treatment. And that's great, and we should encourage that to be done in a timely fashion.

Fear

One of the big problems of this pandemic is not so much that it's going to affect the actual treatment plans of cancer patients, but it's going to create fear. And we can't be reassuring. We don't know how difficult it's going to be to keep a normal service for potentially life-threatening diseases but not urgent diseases. So cancer is just one of them; cardiac care, if you have a myocardial infarction, someone has to put a stent in or operate and if you have deep valvular disease, aortic stenosis, again, there's no point cancelling the operation because you may have trouble, developing cardiac failure, making it difficult. But cancer is one of these sort of in between [situations]. It's not urgent, it's not an emergency, but it does need treating. So, getting over the fear is really difficult. And I think people are worried they'll be forgotten about, they'll be pushed to the end of the queue, and it's our job, I think, as an oncologist to make sure they don't feel that, that we're going to prioritise them and get them through.

Staff

The other potential problem, which has got nothing to do with the delivery of the chemotherapy or radiotherapy, is staffing. You know, our workforce inevitably is predominantly female - nurses, radiographers - and if schools get shut as a part of the social distancing policy, that means a lot of them won't be able to come to work. They don't have the infrastructure to suddenly get a nanny or use grandparents to baby-sit for children. If nurseries are shut, schools up to secondary schools, it's going to be difficult and we may run out of staff. Also, they may get ill, they may have to isolate themselves. So these are the problems in management. Hasn't happened yet, but we can see how it might happen.

What's been really encouraging from China, which was obviously the first place to develop this, is the impact on cancer care has not been that great. I was actually in China in October last year, and visited some cancer centres with the Department of Industry here in the UK. And I was really impressed by the organisation of cancer services, they were good, they were as well organised as we have them here. And they seem to have the capacity to cope, and in the burgeoning literature about corona[virus] that's freely available on the internet now, I see very little evidence that cancer patients in China have suffered major delays or major impact. Sure, some of them are getting corona[virus]. They need treatment they may need ventilation even, but it's a very small proportion. Most patients with cancer just carry on their daily business of treatment.

Access

The other problem is access. As social changes happen, when we prevent public gatherings, close down roads, close down public transport and so on, that prevents people accessing therapy including cancer patients. Fortunately, most cancer treatment is delivered on a network basis, so people on the whole can get chemotherapy at local hospitals, which may be supervised by a distant cancer centre in a big town, and that's fine. So that won't be affected. But I think the way forward is to avoid panic. Panic is the enemy of logical moving forward, getting the normal treatment process into patients.

Logistics

Diagnostics shouldn't be a problem, we just have to work longer hours for the diagnostics. And again that may have staff implications. But CTs, MRIs, PET CTs for assessing response are very important, and obviously [also] for staging upfront to determine a choice of therapy. So it all becomes an exercise in logistics. And, you know, we've got to get our management in the health service, whether it's public or private, to be imaginative about how we deal with a situation. So for example, if we do have [coronavirus-infected] positive patients, we put them in together, then clean out the diagnostic service that is being used, and then get fresh patients that haven't been infected. It's those sort of things that have to be thought through using our infection control colleagues to advise us the best way to go. Exactly the same with radiotherapy. And with chemotherapy, again, obviously you can break down and prioritise into where chemotherapy is really effective and where it's not so effective and therefore maybe you could delay treatment, as suggested in the Chinese paper. I mean, what's remarkable they do suggest delaying treatment in certain patients. And I'd be against that, I think we should just carry on and try and follow the guidelines we've already got to minimise the delay in starting treatment and delivering it according to the treatment protocol. We know that for things like head and neck cancer, radiotherapy delivered with delays and with interruptions is less effective than straightforward radiotherapy, and the same must apply to chemotherapy for leukaemia, lymphoma, germ cell tumours and so on: we don't want to lose the chance of cure for these patients and so we have to operate as oncologists within the umbrella of corona around us, it's not going to go away this summer, until the end, and do the best we can for the sake of our patients.

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