How cancer services are fighting to counter covid-19’s impact

Patient prioritisation

It wasn’t possible to just stop cancer treatment, something they recognised right from the start, says Johnson. “We needed to adapt and make sure it was safe,” he says. For surgical teams this meant the consolidation of surgery within 21 covid-19-free hubs—a combination of independent and NHS providers overseen by regional Cancer Alliances, partnerships that were given a leadership role in implementing local care under the NHS long term plan.

“It was very clear very quickly that surgical capacity was going to be constrained,” says Johnson, partly because of infection control risk but also because many anaesthetists were redeployed. “Talking to colleagues and clinicians in Italy it was clear that the only way to do this was to plan for covid-19-protected environments where surgery could safely take place.”

The idea of covid-19-free—or, more realistically, “covid-19 light”—sites was initially led by a few specialist centres, including the Royal Marsden Hospital in London, before being rolled out across England at the start of May. Measures such as patients having to self-isolate for 14 days before surgery, as well as having a covid-19 test 48 hours before the operation, have kept sites safer. In Wales and some parts of England, independent private sector hospitals have been co-opted as “clean” sites for surgery.

For the first six weeks, as clinicians across the NHS adapted rapidly to remote working, cancer teams focused on how to prioritise those who could not wait. Nicholas Van As, medical director at the Royal Marsden NHS Foundation Trust, says surgical patients were categorised into three groups: the first requiring an operation in the next 24 to 48 hours; the second within the next month; and the third those whose surgery could wait longer. “We were only doing priority one and two at the start—now we are doing everyone,” he says.

Even with cancer hubs providing a safe place to carry out surgery, operating while wearing personal protective equipment and infection control procedures mean that teams cannot schedule as many patients as they usually would, so matching demand and capacity is important, explains Johnson.

Radiotherapy departments at the Christie Hospital in Manchester also prioritised patients, initially stopping some treatment altogether. “We had priority lists and got together and decided who really needed to continue treatment and who could defer,” says Corinne Faivre-Finn, professor of thoracic radiation oncology at the University of Manchester. That lasted six weeks and the Christie is now operating as normal, as are most departments around the country, she says.

Tim Somervaille, professor of haematological oncology at the Christie NHS Foundation Trust, says initially all but the most urgent chemotherapy treatments were put on hold as the hospital braced itself for a flood of covid-19 patients that never came. “As soon as it became clear that we weren’t going to be overwhelmed we opened up urgent and priority treatments. Bone marrow transplantation has begun again. Chemotherapy is back up and running, which is great news,” he says.

Jo Gardiner was relieved that her chemotherapy for a third recurrence of splenic marginal zone lymphoma was able to continue at the Christie. “I was nervous that they’d stop the treatment,” she tells The BMJ. “I’d have gone along with whatever decision was made but I really hoped they wouldn’t cancel or delay.”

Adapting treatment

For the procedures that had to go ahead, adaptation was necessary. To reduce the number of times they had to come to hospital, evidence based guidance on reduced fractionation was new initiatives included a phlebotomy service that allows patients to wait in their car for their turn and arrangements for medicines to be couriered to patients’ homes.

This meant working out, on a case-by-case basis, where delayed or less immunosuppressive treatment regimens could be an option. Graham Collins, consultant haematologist at Oxford University Hospitals NHS Foundation Trust, says doctors have had to make difficult judgments around the risks of delaying therapy compared with the dangers of bringing shielded patients into hospital for immunosuppressive treatments.

Others who could not have their operation were sometimes referred to secondary treatments. This is what happened to Kathryn Ward, who says she was “disappointed” to be referred for radiotherapy, having seen her planned stem cell transplantation as “light at the end of the tunnel” after three years of almost continuous treatment. “It’s likely that radiotherapy was the second best treatment, but it’s still a bit of an unknown,” she says, now awaiting a scan that will take place eight weeks after her three weeks of radiotherapy.

Ward lays no blame at the feet of her clinicians. “I did understand that it was beyond anyone’s control,” she says. “Within the constraints of the system, I did feel that my needs were considered. They gave me an alternative, they reassured me that should it come back very quickly they would do something, and I had a phone number to ring. I felt disappointed but there wasn’t another option. I didn’t think there was anything they could have done differently.

“I’m really grateful to them because I’ve not just fallen off the radar.”

Patient reassurance

In the scramble to retool the system, it’s patients that should be kept at the forefront of minds. The “stay at home” message caused a great deal of anxiety for patients requiring treatment for cancer. Gardiner, for instance, was nervous about how social distancing would work when she went into hospital.

As a result, a lot of work has gone into offering reassurance. “We’ve done our best to create confidence that it’s safe to come to hospital,” says Somervaille. “We have staff and patient entry and exit sites with health questionnaires and we’ve installed a temperature screening device. All staff wear face masks at all times on the premises.”

Staff are regularly tested, not just patients. “All staff can get a covid-19 test up to once a week and now an antigen test,” says Collins, “That gives us quite a lot of confidence.”

For Gardiner a phone call before her appointments put her mind at ease. “It reassured me about what they were doing to limit risk, so I had a good idea of what it would be like when I went in,” she says, “It was reassuring and well managed. On the whole I felt very safe.”

Delayed surge

Services are now grappling with the huge backlog that lack of access to screening, diagnostics, and referrals has generated.

Part of the problem is that patients haven’t sought help for suspicious symptoms, thinking that services were closed or because they were afraid to go to hospital in the middle of a pandemic. Joanna Franks, a breast and oncoplastic surgeon at UCLH and a coordinator for the Pan London Breast Hub, says they were only seeing about 40% of their normal referral pattern. “We’re up to about 60% now,” she says, “But that’s still 40% of people at home, not getting treated, and worrying.”

Muireann Kelleher, clinical director for cancer at St George’s Healthcare NHS Foundation Trust, says their modelling shows most units will be operating between 85% and 100% by July. The data suggest that referrals—after a drop in London of 70%—are starting to pick up again. “If missing patients appear at the same time as a second wave or new ripple of covid-19, that’s going to be hard, but we have a plan to keep cancer services protected.”

That plan includes not redeploying cancer staff to intensive care where possible and keeping in place covid-19-free pathways for diagnostics and treatment. At St George’s they are also rolling out rapid diagnostic clinics, which will screen all referred patients virtually before inviting them to see the most appropriate clinician.

“The rapid diagnosis project was already planned from 2019-20 but it will truly become a covid-19 recovery pathway giving GPs a ‘one stop shop’ to refer patients to if they’re worried about cancer,” Kelleher adds.

Azeem Majeed, a GP and professor of primary care at Imperial College London, says work is ongoing to restart oncology services in his area. “At present, all parts of the pathway—referral, outpatient appointment, testing, and treatment—are still delayed compared with earlier in the year before the pandemic,” he says.

Franks is concerned about less urgent treatment continuing to be squeezed. “Time critical things will get done. But there are other things that aren’t necessarily so visible but are important to each patient’s treatment,” she says. “For breast cancer, for example, that would be things like doing further work to improve aesthetics or making sure that we’ve done the symmetrising surgery. In the recovery phase we need to work out how we’re going to do all these things.”

Major UK cancer charities, including Cancer Research UK, Macmillan Cancer Support, Breast Cancer Now, and Bowel Cancer UK, have published a 12 point plan for the restoration, recovery, and transformation of cancer services3 and called for the government to support the NHS in setting out a clear plan.

In response to this call, a Department of Health and Social Care spokesperson said, “The NHS has adapted how it runs its cancer services to ensure the safety of both patients and staff. This includes establishing dedicated cancer hubs for urgent treatment and diagnosis which are separate from hospitals dealing with covid-19.”

For Richard Johnson, consultant breast surgeon and Royal College of Surgeons director in Wales, the key will be finding a way to cope with the expected extra demand, given operating lists will have to be shorter. “The main message is even if you turned on all the capacity you had before you would not be able to treat the same number of patients. You need extra capacity to make up for that,” he says.

And planning is not straightforward because it’s hard to plan too far ahead. “Throughout the past three months, what I imagined would be the case two or three weeks later didn’t turn out that way,” says Somervaille. “We need to be as flexible as possible.”