COMMENTARY

COVID-19 Cancer Delays: We've Got to Get Going

Prof Karol Sikora

Disclosures

June 12, 2020

This transcript has been edited for clarity.

Hello, my name is Professor Karol Sikora, and I'm talking to you today about data of how we've coped with cancer in the NHS in the era of COVID-19.

There's a report out from NHS England looking at various parameters, the metrics of cancer referral.

And if you look at the whole hospital activity, routine admissions, and compare April of last year, with April this year - remember the peak of COVID was over the Easter period just coming up to the 8th, 9th April - in 2019 there were 280,209 admissions, in April 2020 only 41,121, a fall of 85%.

If we look at urgent cancer referrals, the number last year was 199,217, and this year 79,573, a fall of 60%.

And if we take urgent breast referrals from GPs to secondary care, to breast clinics and from screening and so on, the fall was precipitous: 16,753 last year 3759 this year, a fall of 78%.

Worrying Data

What does this mean? It means that the patients were not seen in that period of time. It's not that they aren't there. They're out there. Did they come in May the month later? Some of them probably so, but even then, surgery was very restricted. And even now, in the second week of June, we're seeing problems.

We've got to get going here. And clearly, this data is really worrying. We're still not fully functional.

So, what does this mean? Well a month's delay is probably not that important, it's not going to affect outcomes that drastically, but if it goes on for more than 3 months, we will see stage shift migration to later stages, poorer prognoses, and then of course, the surge effect: the fact that all the patients are going to come at once towards the end of the summer, whenever we get moving again.

'Convenient, Modern Treatment'

The second document that I'd like to consider, which is part of the same thing, is a press release from NHS England: 'Convenient modern cancer treatment for patients during COVID-19 pandemic'. And it really has two parts, two initiatives, which are interesting. The first is SABR, stereotactic ablative radiotherapy, highly focused, highly precise, low fraction number radiotherapy. Normally we give 20 to 30 fractions depending on site and volume and so on. Here, it's a single volume, a single fraction in many cases, certainly no more than 5 fractions.

This requires greater precision. The chances of error because of image degradation, because of motion management, because of errors in setting up, are disastrous, because obviously, if we're only giving 1 or 2 fractions, for example, each fraction becomes critical to give to the right place to avoid organs at risk and to target the cancer.

The problem we've got is that there are 52 centres in the UK that do radiotherapy, that's in the NHS. There are 26 in the private sector network around the country, the idea it's just London that has private networks is wrong; it's all around the country. Of those 52 centres in the NHS, 25 actually already have SABR. NHS England was planning to make them all active by 2022. This has now been brought forward, according to this press release, so that by the end of this financial year, what does that mean, the code for March next year, I guess, March 2021.

Will this help with COVID? It probably will be too late for the surge that's coming in terms of cancer. And the idea would be to treat some of the cancers that SABR is good for: lung, pancreas, certain types of nodal cancers, even bone metastases in certain areas, and soft tissue tumours, soft tissue deposits that require sculpting with the dose. These could all be susceptible to good SABR treatment, as well of course as oligometastatic disease, which is one of its classic uses at the moment. So that's really encouraging to see that.

Chemotherapy Buses

The second thing is chemotherapy, and the idea of chemotherapy buses. You could actually get chemotherapy delivered to convenient locations where patients can go and have day care, obviously for relatively safe regimens. To use these, the staff are the key. And that's one of the big problems here. If you do anything out of a hospital site, you lose your efficiency in terms of staffing, because you need more specialist staff to go out. You have to have a chemotherapy nurse specially trained to go with the bus, whereas in the hospital, you're going to have one or two nurses that have no chemotherapy experience that just follow the direction of a specialist chemotherapy nurse. So we'll see how that works.

Oral Drug Conversion

The other thing, it was clearly the conversion of IV regimens to oral regimens, and the one drug that's obviously crying out for conversion is 5-fluorouracil (5-FU) in colorectal regimens and breast regimens, including adjuvent in both cases. So a lot of patients on both these schedules having 5-FU, can we convert them to capecitabine and just deliver a box of pills to their door, perhaps with a volunteer driver to do it, instead of them needing to come to the hospital?

And they may have another drug such as oxaliplatin or epirubicin, depending on which disease they have, but at least you reduce the footfall in the chemotherapy unit in part.

So, that was encouraging.

Action Radiotherapy

Action Radiotherapy is a charity set up to promote good practice in radiotherapy. It was set up by Professor Pat Price, who was one of my first ever housemen when I was a very young and inexperienced consultant. She was great then, and she's great now. I do encourage you to look at the website.

The charity sent an open letter to Matt Hancock, England's Health Secretary, last week, urging exactly what the Department of Health has done to get SABR going.

Precision radiotherapy can be a lifesaver. And there are three types.

First of all SABR. Secondly, the MR-lLinac, and the third one is proton beam therapy.

And by using those three technologies together, one can actually obviate the need for a lot of surgery. And we're going to have to find mechanisms to get away from surgery, probably for the next year or so during this whole post-COVID plateau of activity. We've got to look at more innovative ways of treating primary cancers. All three precision techniques can be used in circumstances to obviate the need for surgery.

My Five Point Plan

Then the final thing I'd like to talk about is what are we actually going to do? We are going to be in a crisis when all the patients come together.

My five point plan would be not to walk complacently along. We've got to have a grand plan for cancer.

First of all, keep the cancer centres COVID-19 free. Take a history, check everybody's temperature as they come through the door, test the staff at least once a week continuously for virus by PCR, and antibody testing, we've done it, but it's not that effective because less than 10% are actually positive. What does it really mean? So effective PCR is necessary.

The Premier League for football is opening next week. They've done testing twice a week for the last month, and they've tested 3000 players and staff, and 10 positives in that period of time, taken out told to go and do something else from home.

We've got to have the same rigour in cancer.

The second is to monitor cancer biopsy numbers. It's not easy to get hold of them, but that's the best test of when the surge is going to come. The biopsies come and then the patients present for radiotherapy and chemotherapy a month after that, on the whole. So monitoring that is really useful.

Using all the available capacity: I've mentioned that there are 26 independent sector radiotherapy units. There are 65 places you can get chemotherapy. We're all in this together. Let's get them to work together.

The fourth is to coordinate prioritisation and the abbreviation of treatment regimens with both radiotherapy and chemotherapy. We can do that. It has to be done locally. It has to be either a committee or a single person that's responsible for prioritising patients moving forward.

And then finally, something that won't be popular with staff, but let's look at the weekend and evening working. We can do it. We did it for COVID-19; the hospitals did it fantastically well, for COVID-19, we can do it for cancer. It'll only be for a period of 3 months if we get all hands on deck, we'll go forward. I'm happy to go and do it. I'm happy to work at my local chemotherapy- radiotherapy unit. And let's look at imaginative ways of getting staff back, so we've got Saturday and Sunday radiotherapy going on, and change the schedules, so it fits the new pattern of working.

Let's see what happens. I think we are going to be in for a rough ride, probably by September, and then it'll gradually smooth out until October/November.

The predictions for COVID-19, there's the optimists like me that say, 'that's it, we're coming out of it now'. There's the pessimists that say, 'no, there's going to be a second wave in September'; that's going to throw everything up in the air, it's going to stop education, it's going to stop the NHS from functioning, and it's going to blow the economy even more than it has done so far.

Let's hope I'm right, and not the rather doom-mongering epidemiologists that predict apocalypse. Thank you for listening.

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