COMMENTARY

COVID-19: Why Restarting Cancer Services Can't Come Soon Enough

Prof Karol Sikora

Disclosures

April 30, 2020

This transcript has been edited for clarity.

Hello, I'm Professor Karol Sikora, oncologist, and I'm going to talk about cancer in the COVID-19 era here in the UK.

So right at the beginning of this pandemic, in mid-March, various guidances were issued by NHS England, about cancer patients and how to deal with the situation.

There are really three problems in the treatment of cancer.

The first, a patient's already having chemotherapy and radiotherapy at a time when a lot of the resources in hospitals were being transferred to manage respiratory illness caused by COVID-19.

So that's one group of patients.

The second group of patients are those about to start chemotherapy or radiotherapy. Should they be delayed for their own sake because of the immunosuppression of both modalities, especially chemotherapy of course?

Would it be better to delay for a month or 6 weeks to make sure the wave of the pandemic has passed through?

And then the third group of people are those that don't even know they have cancer yet. Those that are not diagnosed, that can't get in to a diagnostic pathway. There's no access to the consultants, there are no appointments, the scanners are not available, the endoscopy units are closed, and so on.

Tracking Progress

So, these are the three groups of people. How well have we done with it?

Well, it has to be individualised. And in mid-March, NHS England issued six priority groups for chemotherapy, five priority groups for radiotherapy, which is great. And that was a really good start, that made sense. There were a few arguments here and there amongst my colleagues about some nuances in there, but on the whole, they made good sense, and you could easily prioritise individual patients into the various bands.

So people with high priority: Hodgkin's disease, germ cell tumours, leukaemias, and so on, would continue with chemotherapy, they'd start chemotherapy even though it was immunosuppressive, because on balance, the risks were much greater that they would have a poorer cancer outcome than they would get troubled by COVID and its consequences.

The next group of patients is more difficult, and that's those that are not yet known to have cancer. How do they get into the system? On 30th of March an edict came out from NHS England and last night a press release came out about encouraging people to go to their doctors.

What's triggered the press release? Well, over the last month, the month of April, which is nearly over, the number of cancer patients that have come forward under the 2-week wait, and other referral pathways have dropped absolutely dramatically.

Monitoring

Probably the best way to monitor it is actually go down the pathology department, and there, there's no doubt the number of biopsies coming through are something like a 10th of what we'd normally expect for the month. That's a lot of people that have not been diagnosed. So what's going to happen next? We've just got to get things open. The 30th of March missal from NHS England suggested there'll be 19 COVID-free cancer hubs, including private sector, where surgery could be carried out in a clean environment. Patients will be tested on arrival, and provided they were fine, go through their journey for all the different specialties.

What was less clear about these 19 hubs is where they were and how the doctors were going to come out of wherever they were working and work there.

Again, the details were a little bit scanty. And I haven't seen that much evidence that it's really taken place as yet. But now we're coming out of COVID. We know there’s capacity in all our hospitals, the Nightingale hospitals were never used. We've got to get going again. And it's difficult to see how we're going to achieve that.

The other problem is fear. We've been brainwashed on the radio, on the television, on the railway stations: 'Stay home. Protect the NHS. Save lives.'

Not Wanting to Trouble the NHS

So the implication for many people is they have to stay at home. They don't want to trouble the NHS, they feel they're taking it away from someone else, especially older people.

We've got to get them back. Older people again don't really like telephone conversations. They don't like consultations by Skype. They may not be so familiar with these media. But they are a remarkably good way of quickly sorting out what to do next.

It's remarkably more efficient for the whole structure. You don't have to park your car, you don't have to pitch up at a hospital, and it's much cheaper to do for the system in terms of staff time.

So getting used to the idea that a lot of triage can be done at a distance by these media makes such good sense. And it's a matter of persuading people to use it.

Even when patients present there's still uncertainty about the diagnostic pathways being open.

We've got to get the endoscopy suites open. What's going to happen when this gets better, which it will, is that we're going to have a lot of cancer patients. So most of April's cancer patients will catch up with May's cancer patients, which in turn will catch up with June's cancer patients. So by June, we'll have a lot of people that have had surgery that are suddenly wanting adjuvant chemotherapy, wanting adjuvant radiotherapy, and even primary things like brain tumours treated with radiotherapy, including proton therapy.

There'll be a queue of people suddenly wanting to go out and have it.

Surge Management

We've got to develop a mechanism to take care of that surge of people that need cancer treatment over the next 3 months.

Now, various calculations have been looking at how many people would actually die because of these delays. Well, I reckon, back of the envelope, if 30,000 people are presenting a month normally, and we've only seen 5000 then that puts 25,000 people at risk for delay. If that delay is only a month, and we can get started again in May, then it's not too bad.

The actual relative risk, a total death rate because of a month delay, is probably around a handful of patients, 500 patients at the most of the whole 350,000 that get cancer in a year.

But if the delay went on to September, or even worse to December, or even worse to next year because we’re wanting to get a vaccine out, that's going to mean a lot of deaths and much further than we've had with coronavirus, much greater, and across a much wider age spectrum. Not so much the elderly, but right across the board.

So, we’ve got to balance the two. And the only way is to get going. It may be difficult. Testing's here, the kits are here to look out for the RNA of the virus. The only problem is you have to repeat it. Because just because you're negative one day doesn't mean tomorrow, you're [not] going to be positive.

And we've got to keep the 19 COVID-free hubs clean, otherwise the whole business falls apart.

Imaginative Solutions

Should we use the Nightingale Hospital somehow? Why not? Let's get patients out of our hospital service with COVID and let them recover and get to rehabilitation in the Nightingale system, just for 3 months and then we'll be back on track.

You know, we've got to use imagination here. The private sector is willing to help with the surge when the dam opens and the flood of patients needing post-operative care with radiotherapy and chemotherapy comes. There are three private networks - HCA in London, Genesis Care, and the Rutherford, the one that I'm the Chief Medical Officer of - all are willing to help, all have agreed with NHS England that we'd be there.

The documentation is already in place because all three treat, under contract, NHS patients already.

It's just a matter of implementing it locally. And it has to be done locally, it’s the only way it can be done, with NHS England's blessing. I hope that's what's going to happen. So, the diagnostic pathway will start moving forward, the surgical patients will go into COVID-free environments, including the private sector hospitals, and then finally, everybody will join together in moving the whole thing forward for chemotherapy and radiotherapy, a mix of private provision, public provision, moving forward using the local MDTs, using expert staff around the country.

There's a high level of motivation to do it. We've just got to get going. And for the sake of cancer patients, we've got to get going fast.

Any points you have, please let me know. Thank you.

You can follow Prof Karol Sikora on Twitter

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