COMMENTARY

COVID-19: My Social Media Journey Over Cancer Delays

Prof Karol Sikora

Disclosures

April 09, 2020

This transcript has been edited for clarity.

Hello, it's Professor Karol Sikora here, talking not about cancer as usual on Medscape, but about my Twitter account. It is related.

About 3 weeks ago, it was clear that policies about COVID-19 as the infection rate surged in Britain, meant that cancer patients and cardiac patients were being put off, they were being pushed aside.

And of course with cancer, timing of treatment is pretty critical for a lot of patients. Not so much for palliative chemotherapy and metastatic disease, but certainly for adjuvant therapy, for upfront chemotherapy, neoadjuvant therapy, these are important timing points in relationship to surgery, and sometimes radiotherapy.

What I did was get a Twitter account and just put out my views and gradually I become a COVID 'expert' in Britain.

The problem we've got is how to accommodate cancer patients.

Cancer Guidelines

About 3 weeks ago, NHS England put out some very sensible guidelines. And we've talked about them on Medscape before:  six priorities for chemotherapy, five priorities for radiotherapy, couldn't do better myself. You can argue here and there about the definition. They were issued to all hospitals, to all clinical directors of oncology services, including the emphasis that someone should be in charge. It doesn't need to be the same person every week, but someone should make the decisions.

Of course, the decisions have to be personalised, and I think that's been the problem. It's sometimes difficult to fit patients into any of those categories. Some, you could say are in category one, but they could well be in category four.

My thesis is that we don't need to do this. What we've seen over the last few days is the incidence of COVID-19 is beginning to fall, we're in a plateau, the numbers are bouncing around, but they are going to go down over this weekend.

I agree that the surge of healthcare demand on the whole system is coming. We're not there yet.

And it's probably this weekend, and maybe even Tuesday and Wednesday of next week, we're going to see an increased activity in ITUs and so on.

But we can still manage cancer patients, they're still going to come and be placed in chemo units and radiotherapy centres. And we can treat those and they are usually far away from the hub of activity around coronavirus.

Delays

One of the biggest problems though, is going to be the delay that occurs for people that don't know they've got cancer, at least today. But over the next few weeks, some people will develop symptoms, they may have to delay getting a CT or MRI, they may delay getting a biopsy, and when they do, they're at the back of the queue. The backlog is just going to be horrendous.

We've seen it with cardiac patients as well. There the position is a little more stringent, in that if you've had a heart attack and you need percutaneous intervention, stenting, you need to have it there and then.

Thrombolysis is only of secondary value compared to urgent stenting. And then of course people with aortic stenosis. So rather like cancer, these people can't wait. It's not like a hip replacement, where you can say have it in the autumn and we'll sort it out.

The real problem for everybody: politicians, healthcare providers, patients, families, is we don't know how long this is going to last. And the sooner we can get back to a semblance of normality, the better for everybody. I mean, the way we're going here, makes me feel some time at the end of April we'll be able to open things up.

If it's only a month delay, no cancer patient will really suffer too much, provided obviously germ cell tumours, and lymphomas, leukaemias, continue on chemotherapy.

There are home delivery services for chemotherapy but they’re swamped. They can't take new patients now it's just not feasible to expect them to.

So we have to use our chemotherapy most effectively. The analogy, of course, is the midwifery service. They're no longer doing home delivery. Midwives and their patients are coming into the hospital to be as a group. It’s a much more efficient way for the system. Exactly the same with chemotherapy, it's more efficient, less staff time required, to do it in the hospital setting.

So as we move forward, radiotherapy can be done. We need to check people for temperature as they come in, we need to keep our radiotherapy departments COVID-19 free, and we need to just get on with it.

The other problem of course, both in chemotherapy and radiotherapy, predominantly skilled female staff. And women obviously have families, and they're often the key family person. If one of their children has a temperature, they have to isolate. And so we've got this horrible problem of about 20% staff reduction. So a lot of people are working long hours, sacrificing a lot to keep the whole service going, and we really owe it to them for that.

Testing 'Chaos'

The other problem is antibody testing. This is really to me complete chaos. I mean, I did a PhD in cancer immunology a long time ago, and I have a vague understanding of how to do these tests. They're not complicated, but we need to do them in a lot of people. We need to find if the IgG or the IgM is raised in people that have had either symptoms or even no symptoms. So we can say you've got high IgG against coronavirus, specifically against COVID-19, if you have, that's great, you're immune from it, you can go back to work.

And not only that, you can mix with other people. You can get to the point where you have your COVID-19 positive people with IgG and they can all go to a bar together with an IgG positive bartender.

It's not infeasible that that could happen over the next few weeks. A much better way is that the test reveals that a large percentage of the population is indeed immune to SARS-CoV-2 already. In other words, they've had the infection.

On the cruise ships, the Diamond Princess, for example, in Yokohama harbour, 50% of those tested positive for the virus actually had no symptoms whatsoever. And yet they've had the infection and passed through it. And yet no symptoms, nothing. No sore throat, no runny nose. Now, and these people are elderly and the demographics of cruise ships is predominantly people over 70.

So if that's the case, that's a case for joy, because it means that maybe we're reaching herd immunity without knowing it. So whilst the epidemiologists argue, and almost to fisticuffs these guys, they've done it for cancer, now they're doing it for infection. Oxford group, Imperial group, UCH group, all saying different things, looking at the same numbers.

That's, what epidemiologists are good at, looking at the same numbers and coming up with different conclusions.

Strange Twitter Effect

But going back to my Twitter account, it does seem to have worked. I put out a tweet and it has a response. It's a very strange effect. I haven't appreciated social media before. I do nothing else and I don't think I want to do anything more.

You get a bit of stick from people, best not to look at that too much, and you get some bizarre, hateful messages, and I think that puts people off.

But you know, oncologists on the whole around the world have pretty thick skin. You have to in this business. So I think we can cope with that.

But it is a useful way of trying to push a point and to make people realise that cancer patients need treating whatever is going on around them. And this has got to come to an end.

The argument is about when. Is it 1st May? Is it 1st June? Is it, and I really hope not, 1st January next year?

Let's hope we can move COVID-19 down the pathway, get out of this mess, and into a bright new future. It's spring here in England, you can see my garden behind me, the buds are coming out on the trees. Let's hope by the time the leaves are fully out, we're back on the streets with no dependency on lockdown or any form of social reduction. So thank you for listening to me. Your views, as always, are welcome.

You can follow Karol Sikora on Twitter

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