COMMENTARY

ESMO: How Cancer Services Were Hit by COVID-19 First Wave

Prof Karol Sikora

Disclosures

September 25, 2020

This transcript has been edited for clarity.

Hello, it's Professor Karol Sikora here, talking about COVID in cancer, and this time reporting on a fascinating survey carried out and presented at the European Society for Medical Oncology (ESMO), which was a virtual meeting last weekend.

A lot of papers about the impact of COVID on cancer services, mainly across Europe, but from some other countries as well.

So a lot of effort went into organising this as a virtual meeting, the first time that ESMO has actually had a virtual conference, and it was well done.

The programme was well put together, easy to follow, and you know, maybe the days of international travel to jamborees are over. This is maybe our future now. Forget the virus, it's so much cheaper to organise it.

How the pharmaceutical industry will react to this. And, you know, all the other service industries that contribute advertising revenue, and the exhibitions at these meetings, how that's all going to figure in the future is not for me to decide. And I suspect it's going to create a few headaches and a change in the business model.

Oncologists' Survey

But the paper I'd really like to talk about most is a survey that was carried out by Dr Guy Jerusalem, who is an oncologist at the Centre Hospitalier Universitaire Sart Tilman, a major cancer centre in Belgium. And the paper basically surveys and quantifies COVID-19's impact on oncology.

And what he did, he went to 20 oncologists from 10 of the countries most affected by COVID-19 and collected responses from as many of their friends as possible. So we ended up with 109 oncologists in 18 countries.

And then the study was done in mid-June to mid-July. So if you remember back then, we were in the first wave, it was coming to an end, the end was in sight in many countries in Europe. Some countries were doing really well at that time: Austria, Czech Republic, Germany, they were coming out of it. Others were not doing so well, such as the UK.

The survey consisted of 95 items about the organisation of cancer care. And the respondents had worked predominantly at academic centres - because I think Dr Jerusalem is an academic, he sent it to his friends, and that's how they got the data. That's how they got the numbers up.

The most common specialty of course was the common cancers, breast cancer, which was 60%, gastrointestinal cancer 10%, urogenital 9%, lung cancer 8%.

It just reflects the distribution of service levels in treating a range of cancers.

When we look at the impact on treatment caused by the COVID-19 pandemic, surgery was affected in 34% of the centres. It's certainly been affected round here in Britain.

Then, chemotherapy 22%, radiotherapy slightly less 14%, checkpoint inhibitor therapy 10%, antibody delivery 9% and oral therapy only 3.7%.

And that's important, of course, that oral therapy could carry on throughout. The patient just needs to be given, or sent by courier service, a pack of pills, and they can do their own chemotherapy.

Alternatives

And indeed, in the UK we've seen a lot of conversion of intravenous therapy - especially 5FU for breast cancer, and for GI cancer - conversion to capecitabine oral, it's slightly more complex as capecitabine can be quite toxic, and it does require medical supervision but this could be done on the telephone.

Surprisingly, in the survey, 11% of respondents suggested there was a decrease in the use of double immunotherapy. I'm not quite sure whether that meant that the whole of immunotherapy went down as well or it was just the combination of ipilimumab and nivolumab that actually went down. That's really only given in melanoma so it may just be one or two people reporting it.

I think the other problem we've got is that many patients, basically, were too frightened to come to the chemotherapy clinic. And for their own sake, they chose to omit chemotherapy, and the hospitals allowed people to do that.

More worryingly in all this, 37% expected to see significant reductions in clinical trials this year.

They had major protocol violations, they weren't able to get scans, they weren't able to get the necessary assessments at the right time. And there's no doubt that clinical trials have been badly hit by COVID-19.

We heard in this country, that Cancer Research UK, Britain's biggest cancer charity, is withdrawing from any new clinical trials until next year. This may be extended now in view of the increased activity of COVID-19, the resurgence of it.

Diagnostic Pathways

The problem we've got, I guess now, is keeping the diagnostic pathways open for cancer. And then obviously, keeping the treatment pathways open.

The problem is the diagnostic pathway. That requires the whole function of the whole hospital. It's not just the oncologists. And there's no doubt what we saw in the UK, where the peak was on April 8th, and for April and May, the new number of new cancer patients coming forward was greatly reduced, less than a half of what we'd expect.

In June and July, it started creeping up. Now it's almost back to normal, not quite, there’s still some reduction in what you'd expect for September. But I suspect by October we're heading back to normal.

Of course, now we're beginning to see 6000 COVID-19 new cases a day, a slight uptick in hospital admissions with COVID. Everybody is waiting to see what that really is going to be in terms of health service demands. Will it be the chaos we saw in April, or will it be controllable? And that critically depends on not so much reducing the infection rate and all the measurements that politicians are trying to do to stop that, but the way in which hospitals function, and the way in which the primary to secondary care interface works, bringing patients that have potential cancer symptoms into the clinic for investigation.

If you think of the four common cancers, breast cancer is least affected, or has been throughout in terms of diagnostic pathways, because most patients on their first visit, or even if they don't visit if they do it down the telephone, they can get a diagnosis of a breast lump. And as we know, 9 out of 10 breast lumps prove to be benign, but the one that is malignant could easily be identified by mammogram, ultrasound, biopsy, needle biopsy, and so on. No aerosol generation, so that's an easy one to keep going. The more difficult ones are lung cancer, which require a bronchoscopy. GI cancers, certainly upper GI, is aerosol generating endoscopy, lower GI, less risky, but again, problematic getting patients into colonoscopy suites.

And then finally, prostate cancer. Well, that's not too bad. If you can get a biopsy, you can put people on hormones as a holding operation and consider radiotherapy rather than surgery in more cases.

So for the main cancers, we've got to put a lot of effort now if the cases do rise, and the hospitalisations do rise, in actually keeping going with the diagnostic pathways. That's the key.

We have the protocols in place with the shorter fractions for breast and prostate cancer, so less footfall in radiotherapy departments. And we also have other chemotherapy schemes, including the capecitabine shift for 5FU and perhaps some changes around the timing to just make it once every 21 days to avoid the weekly schedules, just to avoid the trips to the department.

We'll see risk assessments of individual patients, and maybe for some people it's not going to be worth giving chemotherapy unless it's an attempt to cure. But palliative radiotherapy may be better delaying if there's going to be a new surge of COVID activity.

This is Karol Sikora commenting on the ESMO virtual meeting last weekend looking at the impact of COVID-19 on cancer this year.

You can follow Prof Sikora on Twitter.

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