To date, no therapies have shown efficacy against Covid-19. How is this affecting surgical oncological care?

In healthcare, our professional schedules have changed in the interest of public safety. New official policies, largely based on mathematical epidemiological models, aim at predicting the trajectory of the Covid-19 pandemic. 

Leaders use measures of potential disease burden (infection and mortality estimates), to inform the steps for strengthening healthcare capacity and civic imperatives. The short-term public health decisions for the optimal use of resources based on epidemiological models should be grounded in data for local predictions – epidemics do not follow identical paths globally. The validity of the data, confirmed and rigorously evaluated, will ensure that these projections are robust and reliable.

The public safety narrative galvanised us to vacate wards and intensive care units in preparation for the tsunami of patients. Some operating theatres have been allocated for the sole purpose of operating on persons under investigation (PUI) or Covid-19 patients. Elective lists have been indefinitely cancelled. Outpatient clinics have been cancelled (or significantly reduced), and patients moved to telehealth platforms.

To save resources and preserve the surgical workforce, it is envisioned that the personnel working in surgical departments will be available on the frontline of Covid-19 management. We have been subjected to many drills on donning and doffing personal protective equipment (PPEs). A daily avalanche of protocols, revised protocols, new directives and testing policies flood our email InBoxes. Many of these are conflicting or confusing; all increase anxiety. Each day brings new information, forcing us to once again adapt our workflow. The pandemic is overwhelming and stressful: We need to keep calm, be sensible and promote evidence-based information and continue to manage all our patients.

What is the evidence?

Postponing clinic visits and surgery is hardly in the best interest of all patients with cancer. While it is unclear whether elective cancer surgery is safe during this period, alternatives are equally ambiguous. In some cancers, e.g. breast cancer, delaying surgery is associated with poor cancer outcomes. A paper from Geneva (Lancet 2005) compared the outcome of women with breast cancer who refused surgery to those who had surgery: Their mortality was doubled. 

Many societies, (for example European Society Surgical Oncology) acknowledge that running a normal cancer care service in these challenging times is unlikely, and have issued guidelines relating to clinic visits (relegating most referrals/reviews to telehealth), and cancer treatments, including surgery. Most have made the assumption that the delay to surgery may be three months. It is unclear whether these guidelines are applicable in a resource-constrained environment.

Telehealth is an attractive alternative to real-time clinic visits, but may not be an attainable goal in the public sector in South Africa where mobile phone numbers are unreliable and most patients cannot afford smartphones or own tablets/computers.

As the humanitarian catastrophe continues to unfold, with over 3.2 million infections and over 220,000 deaths globally, and no sign of infections abating, we are presented with managing patients with non-Covid-19 conditions, such as cancer. 

It will not be “business as usual”. Acknowledging that cancer patients face double jeopardy during the Covid-19 pandemic, it is important to strike a balance between the immediate needs of Covid-19 patients and the ongoing needs of non-Covid-19 patients who need lifesaving medical care and limited exposure to nosocomial infections. The challenge will be to find a tenuous balance between under-treatment, potentially resulting in more deaths in the medium-to-long term from cancer recurrences, and an increasing risk of death from Covid-19 in this vulnerable patient population.  

In this war, waged on two fronts, patients and clinicians will deliberate on difficult decisions. Equal importance should be given to ensuring effective prevention of cross-infection with Covid-19 and rational provision of cancer treatment. The collision of cancer care and Covid-19 can be compared to a battle and Kutikov et al state that “the combat plan during this battle must involve patience, communication, diligence and resolve. Risks must be balanced carefully, public health strategies thoroughly implemented and resources utilised wisely.”

How can the available evidence guide convincing decisions regarding cancer care?

Tables stratifying patients into a low, intermediate or high-risk category of progression with cancer if delays ensue, versus the attendant risk for significant morbidity from Covid-19 infection are consensus-based, but do provide recommendations on whether or not to proceed with surgical or oncological treatments. Categorising cancer care into four timelines has also been used to triage patients based on whether delays to treatment impact on the quality and quantity of life.

A limitation of these strategies is that local conditions and resources are not taken into consideration. The trajectory of the pandemic is highly variable across different regions and the capacity of the local healthcare systems to meet existing and projected needs relating to Covid-19 need to be considered. 

This requires knowledge of the pandemic phase in the local healthcare system. In the preparatory phase, the healthcare workforce and resources are available, whereas in the acute and crisis phases, there is either limited functional capacity that through strategic planning can deliver routine cancer care, or there is no surplus capacity due to an overwhelming number of Covid-19 cases, respectively.

The provision of palliative care (PC) for terminal patients must be protected. Guidelines for administering PC to patients with Covid-19 have been developed, however, PC services in  South Africa are not able to cope with the existing burden of disease. The full impact of the Covid-19 pandemic on community-based services has yet to be realised and we have already witnessed PC patients with symptoms of shortness of breath seeking hospital care, being incorrectly triaged as being, PUI making access to care even more problematic.

The most compelling guidelines have been issued by the American College of Surgeons, combining the phase of the pandemic with the priority category of cancer patients. They have mitigated the blanket ban on “elective” surgery in a considered manner, so that even during the acute phase of the pandemic, safe cancer care can be offered to ensure optimal patient outcomes.

Within a short period, our approach to patient care has been transformed. A recent NEJM Perspective relating to Covid-19-ventilated patients remarked that maintaining physical distancing in a caring profession is unchartered territory for most of us. It is necessary to find ways of bridging this difficult situation while concurrently maintaining our humanity and patient-centred approach. 

A concern for cancer patients is that their needs will be neglected during the Covid-19 crisis. It is our hope that the inherent empathy of cancer clinicians will maintain this focus and overcome the barricades presented by the Covid-19 pandemic. DM/MC

Dr Ines Buccimazza is head of the Clinical Unit of Breast and Endocrine surgery, Inkosi Albert Luthuli Central Hospital, Durban. (University of KZN). She is currently the President of ASSA (Association of Surgeons South Africa). Dr Jenny Edge is head of the Breast and Endocrine Unit, Division of Surgery, Department Surgical Sciences, Stellenbosch University (affiliated with Tygerberg Hospital).