COMMENTARY

COVID-19: Is the NHS Making the Right Decisions on Cancer Treatment?

Prof Karol Sikora

Disclosures

March 27, 2020

This transcript has been edited for clarity.

Hello, Professor Karol Sikora here. And I'm going to talk about the implications of COVID-19 on cancer treatment in the UK.

As you know, COVID-19 is causing widespread problems in all health services around the world, and Britain is no exception.

Good planning is in place here and already all routine surgery has stopped.

Patients that don't need to be in hospital have been discharged. And a lot of effort has come around the critical care end of medicine to make sure we have as much capacity as possible, both in the public hospitals and in the private hospitals, to treat patients for the respiratory complications of COVID-19.

How does that leave cancer patients?

Variable Picture

It's a variable picture across the country and no one is really in charge.

NHS England has issued two guidance notes, the first on the 17th March, the second on the 23rd March, and they are really quite sensible. I'm surprised to say that actually, I couldn't do better myself, and I think most of my colleagues feel the same.

What they've done there is prioritise surgery, chemotherapy, and radiotherapy into different priority bands.

Surgery is a bit more complex because often you don't know you have cancer until surgery has been performed and a biopsy has been sent to the histology laboratory. So that's a slightly different issue.

Clearly, if someone comes with an intestinal obstruction, they need to be operated on.

If they come with a diagnostic problem that needs a biopsy, then maybe that can be put off for a month till we get through the peak of the crisis towards Easter.

If it can't be, or if there's some urgent requirement, they should proceed to surgery, that's clear from the protocol.

Chemotherapy

So looking at chemotherapy, there are six priority bands, bands 1-6 and the top two are clearly what we have to get through, we just have to push the patient through.

These will be often young patients, curable cancers, Hodgkin's, germ cell tumours, leukaemias, lymphomas, and various other tumours, that really need treating.

If we look at the list in more detail, curative treatment with a high, greater than 50% chance of cure - so these are the patients that have to go through [to treatment].

Now, not all patients are in that category. Category 2 is with an intermediate chance of success, that's 15% to 50% chance of 5 year survival.

There's a whole swathe of cancers in there where patients may receive chemotherapy, that again should continue.

And we know, that if you take something like breast cancer, one can separate the patients that need urgent adjuvant therapy, those that have a very high chance of recurring, and those that have a much lesser chance of recurring, and the ones that can either delay receiving adjuvant therapy, or even under the circumstances, skip the adjuvant therapy.

And then we go down the list to category 5 and 6, non-curative therapy, less than a year predicted survival.

The problem with all this is there's no blanket approach you can do. You have to go through each patient and categorise them, and then explain to the patient what you're doing.

The other problem with chemotherapy especially, is that it's immunosuppressive. And we don't know as yet if that has an adverse effect on the complication rate from COVID-19. One would presume it would, although you could argue that maybe some of the adverse effect is due to immune stimulation, cytokine storm, and so on, so difficult to know what best to do.

Radiotherapy

I think when it comes to radiotherapy, again, the criteria I can't fault them.

There are now five criteria for radiotherapy, and priority level 1, rapidly proliferating tumours, I assume things like head and neck cancer, again certain lymphomas, and maybe some pelvic tumours. And at the bottom end category 5, radical radiotherapy for prostate cancer, especially on men that are already controlled with hormonal manipulation. So these patients can wait a couple of months safely on hormones. We do this all the time. And that seems a reasonable approach to moving forward.

In terms of other issues with cancer, there's a lot of borderline here and that's going to be the problem - explaining to people why we're delaying or cancelling treatment is not easy.

Dropping them an email is really not good enough. They're going to have to be spoken to. If we can't speak to them in person, it’s going to have to be a down the line conversation with Skype. And for some of the people that are older that's difficult, they don't use Skype normally. And it's not an easy way to deal with a situation.

Now, that's the NHS England guidelines. The ones that came out just this week, 23rd of March, are not significantly different from the ones on the 17th of March. They just add a bit of finesse to it all.

Other Guidelines

The National Institute for Health and Care Excellence (NICE) has issued some guidelines. They've taken the NHS guidelines for prioritising cancer, but they've also added a few other things, and they've honed in on the problem. How do you select patients in whom to delay or even not give chemotherapy because of immunosuppression?

They also talk about how to avoid people that are COVID-positive mixing with people that are COVID-negative. What we need for both reports is clearly better ways for testing patients and they're said to be coming. So hopefully by the middle of next week, we'll have kits to allow us to rapidly, within 15 minutes, determine if someone has antibodies to the coronavirus. In which case if they have IgG and no IgM they can be treated as a cured patient from COVID, and then go on to normal radiotherapy or chemotherapy, knowing they're not going to be infectious to other patients.

So what we don't want to see is what's come out from East London, Barking, Havering and Redbridge University Hospitals Trust, which just cancelled, automatically for 2 weeks, all chemotherapy. That's not a good approach. It's got to be an oncology approach from cancer specialists, nurses, or oncologists, that decide how to sort the patients out, how to triage the patient's out for delay, cancellation, or continuing much as normal.

Certainly if I had testicular cancer, I wouldn't want to wait a month to start chemotherapy, because we know that's the most curative thing there.

China's Experience

Interestingly, there are a couple of papers that are referenced here, one from the epicentre of coronavirus, Wuhan, China. And interestingly, a British delegation of oncologists were there in October of last year.

We don't have patient zero amongst us, this was before any problems in Wuhan. We visited the Cancer Centre there, amongst other towns in China, and we saw really very advanced care. The paper from Wuhan suggests that they were able to continue radical radiotherapy, IMRT, throughout the whole crisis.

Imagine the towns in lockdown, proper lockdown, not as we have here, which is a sort of voluntary lockdown, and it's tremendous how they've got through it.

It's really well worth a read.

The second paper is from Novara, which is the delightful little town in Piedmont, not far from Turin, in Northern Italy, again, a hive of chaos caused by coronavirus. And yet again, they managed to continue with complex cancer treatments throughout, and are still doing so today.

Precautions taken, testing going on, and so on. So, I just hope that by mobilising all aspects of the NHS, including the private sector, including looking at more deliveries at home, including taking IV chemotherapy and converting it to oral chemotherapy, 5-FU to capecitabine, and so on, we'll get schemes in place.

Emotion is running high. Patients with cancer have enough uncertainty, and uncertainty really is a killer as all oncologists know. And now you add another level of uncertainty. You add the coronavirus.

Will they be able to get to a hospital, will the hospital deliver the drugs, and so on.

And it creates a huge problem psychologically for our patients.

So, as professionals, we've got to do everything possible to push them all to the front of the queue to get the treatment they need, so that they have the best chance of long-term success from cancer treatments.

This is Karol Sikora, an oncologist from London. If you have any views, please let me know. Thank you.

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