Provision of cancer care during the COVID-19 pandemic

Impact of the COVID-19 pandemic on breast cancer patient pathways and outcomes in the United Kingdom and the Republic of Ireland - a scoping review

The COVID-19 pandemic brought unplanned service disruption for breast cancer diagnostic, treatment and support services. This scoping review describes these changes and their impact in the UK and the Republic of Ireland based on studies published between January 2020 and August 2023. Thirty-four of 569 papers were included. Data were extracted and results thematically organized. Findings include fewer new cases; stage shift (fewer early- and more late-stage disease); and changes to healthcare organization, breast screening and treatment. Examples are accepting fewer referrals, applying stricter referral criteria and relying more on virtual consultations and multi-disciplinary meetings. Screening service programs paused during the pandemic before enacting risk-based phased restarts with longer appointment times to accommodate reduced staffing numbers and enhanced infection-control regimes. Treatments shifted from predominantly conventional to hypofractionated radiotherapy, fewer surgical procedures and increased use of bridging endocrine therapy. The long-term impact of such changes are unknown so definitive guidelines for future emergencies are not yet available. Cancer registries, with their large sample sizes and population coverage, are well placed to monitor changes to stage and survival despite difficulties obtaining definitive staging during diagnosis because surgery and pathological assessments are delayed. Multisite longitudinal studies can also provide guidance for future disaster preparedness.

Rapid in situ mutation detection in extracellular vesicle-DNA

A PCR- and sequencing-free mutation detection assay facilitates cancer diagnosis and reduces over-reliance on specialized equipment. This benefit was highlighted during the pandemic when high demand for viral nucleic acid testing often sidelined mutation analysis. This shift led to substantial challenges for patients on targeted therapy in tracking mutations. Here, we report a 30-minute DNA mutation detection technique using Cas12a-loaded liposomes in a microplate reader, a fundamental laboratory tool. CRISPR-Cas12a complex and fluorescence-quenching (FQ) probes are introduced into tumor-derived extracellular vesicles (EV) through membrane fusion. When CRISPR-RNA hybridizes with the DNA target, activated Cas12a can trans-cleave FQ probes, resulting in fluorescence signals for the quantification of DNA mutation. Future advancements in multiplex and high-throughput mutation detection using this assay will streamline self-diagnosis and treatment monitoring at home.

COVID-19, deaths at home and end-of-life cancer care

During the COVID-19 pandemic there was a period of high excess deaths from cancer at home as opposed to in hospitals or in care homes. In this paper we aim to explore whether healthcare utilisation trajectories of cancer patients in the final months of life during the COVID-19 pandemic reveal any potential unmet healthcare need. We use English hospital records linked to data on all deaths in and out of hospital which identifies the cause and location of death. Our analysis shows that during the periods of peak COVID-19 caseload, patients dying of cancer experienced up to 42% less hospital treatment in their final month of life compared to historical controls. We find reductions in end-of-life hospital care for cancer patients dying in hospitals, care homes/hospices and at home, however the effect is amplified by the shift to more patients dying at home. Through the first year of the pandemic in England, we estimate the number of inpatient bed-days for end-of-life cancer patients in their final month reduced by approximately 282,282, or 25%. For outpatient appointments in the final month of life we find a reduction in face-to-face appointments and an increase in remote appointments which persists through the pandemic year and is not confined only to the periods of peak COVID-19 caseload. Our results suggest reductions in care provision during the COVID-19 pandemic may have led to unmet need, and future emergency reorganisations of health care systems must ensure consistent care provision for vulnerable groups such as cancer patients.

Bio-ethical issues in oncology during the first wave of the COVID-19 epidemic: A qualitative study in a French hospital

BACKGROUND

Using a specific bioethical theory (=global bioethics) and method (=a posteriori), we try here to identify and evaluate the bio-ethical issues raised by the COVID-19 pandemic, and possible solutions, to improve the management of cancer patients at the hospital in future pandemics, before the emergence of vaccines or scientifically validated treatments.

MATERIALS & METHODS

Our work is based primarily on the clinical experience of three oncologists from the oncology department of Foch Hospital in France, who were on the frontline during the first wave of the epidemic. We compared their perceptions with published findings, to complete or nuance their views.

RESULTS

Three bio-ethical issues were identified, and possible solutions to these problems were evaluated: (1) scientific evidence versus lack of time → the creation of emergency multidisciplinary team meetings (MTM); (2) healthcare equality versus lack of resources → the development of telemedicine; (3) individual liberties versus risk of contamination → role of cancer patients' associations, psychologists and bioethicists.

CONCLUSION

We consider the creation of an emergency MTM, in particular, in addition to a true ethics committee with real competence in bioethics, to be a first solution that would be easy to implement in hospitals in many countries.

A population-scale temporal case-control evaluation of COVID-19 disease phenotype and related outcome rates in patients with cancer in England (UKCCP)

Patients with cancer are at increased risk of hospitalisation and mortality following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, the SARS-CoV-2 phenotype evolution in patients with cancer since 2020 has not previously been described. We therefore evaluated SARS-CoV-2 on a UK populationscale from 01/11/2020-31/08/2022, assessing case-outcome rates of hospital assessment(s), intensive care admission and mortality. We observed that the SARS-CoV-2 disease phenotype has become less severe in patients with cancer and the non-cancer population. Case-hospitalisation rates for patients with cancer dropped from 30.58% in early 2021 to 7.45% in 2022 while case-mortality rates decreased from 20.53% to 3.25%. However, the risk of hospitalisation and mortality remains 2.10x and 2.54x higher in patients with cancer, respectively. Overall, the SARS-CoV-2 disease phenotype is less severe in 2022 compared to 2020 but patients with cancer remain at higher risk than the non-cancer population. Patients with cancer must therefore be empowered to live more normal lives, to see loved ones and families, while also being safeguarded with expanded measures to reduce the risk of transmission.

The Enduring Effects of COVID for Cancer Care: Learning from Real-Life Clinical Practice

For three years, COVID-19 has circulated among our communities and around the world, fundamentally changing social interactions, health care systems, and service delivery. For people living with (and receiving treatment for) cancer, pandemic conditions presented significant additional hurdles in an already unstable and shifting environment, including disrupted personal contact with care providers, interrupted access to clinical trials, distanced therapeutic encounters, multiple immune vulnerabilities, and new forms of financial precarity. In a 2020 perspective in this journal, we examined how COVID-19 was reshaping cancer care in the early stages of the pandemic and how these changes might endure into the future. Three years later, and in light of a series of interviews with patients and their caregivers from the United States and Australia conducted during the pandemic, we return to consider the potential legacy effects of the pandemic on cancer care. While some challenges to care provision and survivorship were unforeseen, others accentuated and amplified existing problems experienced by patients, caregivers, and health care providers. Both are likely to have enduring effects in the "post-pandemic" world, raising the importance of focusing on lessons that can be learned for the future.

A Hybrid Algorithm of ML and XAI to Prevent Breast Cancer: A Strategy to Support Decision Making

Worldwide, the coronavirus has intensified the management problems of health services, significantly harming patients. Some of the most affected processes have been cancer patients' prevention, diagnosis, and treatment. Breast cancer is the most affected, with more than 20 million cases and at least 10 million deaths by 2020. Various studies have been carried out to support the management of this disease globally. This paper presents a decision support strategy for health teams based on machine learning (ML) tools and explainability algorithms (XAI). The main methodological contributions are: first, the evaluation of different ML algorithms that allow classifying patients with and without cancer from the available dataset; and second, an ML methodology mixed with an XAI algorithm, which makes it possible to predict the disease and interpret the variables and how they affect the health of patients. The results show that first, the XGBoost Algorithm has a better predictive capacity, with an accuracy of 0.813 for the train data and 0.81 for the test data; and second, with the SHAP algorithm, it is possible to know the relevant variables and their level of significance in the prediction, and to quantify the impact on the clinical condition of the patients, which will allow health teams to offer early and personalized alerts for each patient.

Revitalising cancer trials post-pandemic: time for reform

The COVID-19 pandemic posed significant risk to the health of cancer patients, compromised standard cancer care and interrupted clinical cancer trials, prompting dramatic streamlining of services. From this health crisis has emerged the opportunity to carry forward an unexpected legacy of positive reforms to clinical cancer research, where conventionally convoluted approvals processes, inefficient trial design, procedures and data gathering could benefit from the lessons in rationalisation learned during the pandemic.

Cancer stage and time from cancer diagnosis to first treatment during the COVID-19 pandemic

Introduction

The COVID-19 pandemic has impacted cancer care and the diagnosis of new cases of cancer. We analyzed the impact of the COVID-19 pandemic on patients with cancer by comparing the number of newly diagnosed cases, cancer stage, and time to treatment in 2020 with those in 2018, 2019, and 2021.

Methods

A retrospective cohort of all cancer cases treated at A.C. Camargo Cancer Center in 2018–2021, identified from the Hospital Cancer Registry, was studied. We analyzed single and multiple primary cancer case and patient characteristics — by year and by clinical stage (early vs. advanced). Times from diagnosis to treatment were compared according to the most frequent tumor sites between 2020 and the other study years.

Results

Between 2018 and 2021, a total of 29,796 new cases were treated at the center including 24,891 with a single tumor and 4,905 with multiple tumors, including non-melanoma skin cancer. The number of new cases decreased by 25% between 2018 and 2020 and 22% between 2019 and 2020, followed by an increase of about 22% in 2021. Clinical stages differed across years, with the number of new advanced cases decreasing from 17.8% in 2018 to 15.2% in 2020. Diagnoses of advanced-stage for lung and kidney cancer decreased between 2018 and 2020, while the number of thyroid and prostate cancer cases diagnosed in advanced-stages increased from 2019 to 2020. The time from diagnosis to treatment decreased between 2018 and 2020 for breast (55.5 vs. 48 days), prostate (87 vs. 64 days), cervical/uterine (78 vs. 55 days) and oropharyngeal (50 vs. 28 days) cancers.

Conclusion

The COVID-19 pandemic affected the numbers of single and multiple cancers diagnosed in 2020. An increase in the number of advanced-stage cases diagnosed was observed only for thyroid and prostate cancer. This pattern may change in coming years due to the possibility that a significant number of cases went undiagnosed in 2020.

Impact of the COVID-19 Outbreak-Delayed Referral of Colorectal and Lung Cancer in Primary Care: A National Retrospective Cohort Study

The Coronavirus disease 2019 (COVID-19) outbreak impacted health care. We investigated its impact on the time to referral and diagnosis for symptomatic cancer patients in The Netherlands. We performed a national retrospective cohort study utilizing primary care records linked to The Netherlands Cancer Registry. For patients with symptomatic colorectal, lung, breast, or melanoma cancer, we manually explored free and coded texts to determine the durations of the primary care (IPC) and secondary care (ISC) diagnostic intervals during the first COVID-19 wave and pre-COVID-19. We found that the median IPC duration increased for colorectal cancer from 5 days (Interquartile Range (IQR) 1-29 days) pre-COVID-19 to 44 days (IQR 6-230, p < 0.01) during the first COVID-19 wave, and for lung cancer, the duration increased from 15 days (IQR) 3-47) to 41 days (IQR 7-102, p < 0.01). For breast cancer and melanoma, the change in IPC duration was negligible. The median ISC duration only increased for breast cancer, from 3 (IQR 2-7) to 6 days (IQR 3-9, p < 0.01). For colorectal cancer, lung cancer, and melanoma, the median ISC durations were 17.5 (IQR (9-52), 18 (IQR 7-40), and 9 (IQR 3-44) days, respectively, similar to pre-COVID-19 results. In conclusion, for colorectal and lung cancer, the time to primary care referral was substantially prolonged during the first COVID-19 wave. In such crises, targeted primary care support is needed to maintain effective cancer diagnosis.

Impact of the COVID-19 Pandemic on Diagnosis and Management of Gynecological Cancer: A Single-Center Analysis

Background and Objectives: The COVID-19 pandemic impacted health systems worldwide, particularly cancer care. Because the actual implications of these changes on gynecological oncology healthcare are still unclear, we aim to evaluate the impact of this pandemic on the diagnosis and management of gynecological cancer. Materials and Methods: This is a single-center retrospective observational study, including patients diagnosed with gynecological malignancies between January 2019 and December 2021. Patients were included into three groups based on the timing of cancer diagnosis: pre-pandemic (2019), pandemic with high restrictions (2020) and pandemic recovery (2021). Results: Overall, 234 patients were diagnosed with gynecological cancer during the period of study. A decrease in the number of newly diagnosed cervical cancers and other rare tumors (leiomyosarcoma, invasive hydatidiform mole) was apparent in 2020. Some aggressive histological types of endometrial and ovarian cancer were more commonly diagnosed in the pandemic recovery group (p < 0.05), although no differences were demonstrated concerning tumor staging in all gynecological cancers. The median time between the first multidisciplinary team meeting and the treatment initiation was higher after the COVID-19 pandemic in endometrial cancer (23.0 vs. 34.0 vs. 36.0 days, p < 0.05). Patients with ovarian cancer were more frequently proposed for neoadjuvant therapy in 2020 compared to the other periods (33.3% vs. 55.0% vs. 10.0% p < 0.05). A significant reduction in the laparoscopic approach was observed during 2020 in endometrial cancer (32.1% vs. 14.3% vs. 36.4%, p < 0.05). No significant differences were registered regarding median hospitalization days or intra- and post-operative complications between these periods. Conclusions: The COVID-19 pandemic had a significant impact on the diagnosis and management of most gynecological malignancies, namely, on time to first treatment, chosen oncological therapies and surgical approaches. These results suggest important clinical and healthcare implications that should be addressed in future prospective studies.

Challenges faced in the cancer diagnosis and management-COVID-19 pandemic and beyond-Lessons for future

The COVID-19 pandemic with multiple waves of infection has caused panic and distress globally. Cancer patients being immuno-compromised are more susceptible to infection leading to increased morbidity and unpredictability of their survival. There has been a halt in the diagnosis and treatment of patients suffering from cancer because of the COVID-19 pandemic. Oncologists have the tedious task of assessing the urgency of managing cancer patients against the risk of Coronavirus infection. Timely diagnostic services along with the treatment strategy are needed for the proper management of cancer patients. Since the laboratories are already overwhelmed with the investigations related to the COVID-19 management, there has been a compromise and delay in the diagnosis, thus leading to an overall lag in the management of cancer patients.

An analysis of changes in wellbeing during the COVID-19 pandemic in the UK

Purpose

We investigated the trajectory of wellbeing over the course of the first wave and sought to determine whether the change in wellbeing is distributed equally across the population. Specifically we investigated pre-existing medical conditions, social isolation, financial stress and deprivation as a predictor for wellbeing and whether there were community level characteristics which protect against poorer wellbeing.

Methods

Using online survey responses from the COVID-19 modules of Understanding society, we linked 8379 English cases across five waves of data collection to location based deprivation statistics. We used ordinary least squares regression to estimate the association between deprivation, pre-existing conditions and socio-demographic factors and the change in well-being scores over time, as measured by the GHQ-12 questionnaire.

Results

A decline in wellbeing was observed at the beginning of the first lock down period at the beginning of March 2020. This was matched with a corresponding recovery between April and July as restrictions were gradually lifted. There was no association between the decline and deprivation, nor between deprivation and recovery. The strongest predictor of wellbeing during the lock down, was the baseline score, with the counterintuitive finding that for those will pre-existing poor wellbeing, the impact of pandemic restrictions on mental health were minimal, but for those who had previously felt well, the restrictions and the impact of the pandemic on well-being were much greater.

Conclusions

These data show no evidence of a social gradient in well-being related to the pandemic. In fact, well-being was shown to be highly elastic in this period indicating a national level of resilience which cut across the usually observed health inequalities.

Breast Cancer and COVID-19: Challenges in Surgical Management

The harsh healthcare reality imposed by the COVID-19 pandemic resulted in wide clinical practice alterations, postponements, and shortages, affecting both patients and caregivers. Breast-cancer management, from diagnosis to treatment and follow up, was a field that did not escape such changes, facing a challenging set of obstacles in order to maintain adequate cancer care services while diminishing viral spread among patients and personnel. In this review article, we discuss the impact of the COVID-19 pandemic on several aspects of breast-cancer management, and the subsequent modifications adopted by clinicians, scientific groups, and governments as a response to the novel conditions. Screening and diagnosis, as well as breast-cancer treatment paths-especially surgical interventions-were the most affected domains, while patients' psychological burden also emerged as a notable consequence. The aftermath of diagnostic and surgical delays is yet to be assessed, while the treatment alterations and the introduction of new therapeutic schemes might signify the opening of a novel era in breast-cancer management.

The Impact of the COVID Pandemic on the Incidence of Presentations with Cancer-Related Symptoms in Primary Care

Simple Summary

The coronavirus pandemic profoundly affected how patients access health care services, as many individuals attempted to minimise risks of infectious contact and reduce burdens on health systems. This study aims to explore the effects of the coronavirus pandemic on patient presentations for cancer-related symptoms in primary care. It utilises routine clinical data for 1.23 million people in the Netherlands, comparing the first year of the pandemic to the two years prior. These data identify a 34% reduction in the incidence of cancer-related symptoms during the first wave (March to June 2020), with overall incidence returning to pre-corona levels after this period. In the first wave, the incidence of many symptoms was substantially reduced: breast lump (−17%), haematuria (−15%), abdominal mass (−21%), tiredness (−45%), lymphadenopathy (−25%), and naevus (−37%). In the second wave (October 2020 to February 2021), the incidence of breast lump and rectal bleeding was increased (both +14%), and tiredness was decreased (−20%), with the majority of other symptoms being similar to pre-COVID levels. These data describe large-scale primary care avoidance that did not increase until the end of the first COVID year for many cancer-related symptoms, suggestive that substantial numbers of patients delayed presenting to primary care.

Abstract

Introduction: In the Netherlands, the onset of the coronavirus pandemic saw shifts in primary health service provision away from physical consultations, cancer-screening programs were temporarily halted, and government messaging focused on remaining at home. In March and April 2020, weekly cancer diagnoses decreased to 73% of their pre-COVID levels, and 39% for skin cancer. This study aims to explore the effect of the COVID pandemic on patient presentations for cancer-related symptoms in primary care in The Netherlands. Methods: Retrospective cohort study using routine clinical primary care data. Monthly incidences of patient presentations for cancer-related symptoms in five clinical databases in The Netherlands were analysed from March 2018 to February 2021. Results: Data demonstrated reductions in the incidence of cancer-related symptom presentations to primary care during the first COVID wave (March-June 2020) of −34% (95% CI: −43 to −23%) for all symptoms combined. In the second wave (October 2020–February 2021) there was no change in incidence observed (−8%, 95% CI −20% to 6%). Alarm-symptoms demonstrated decreases in incidence in the first wave with subsequent incidences that continued to rise in the second wave, such as: first wave: breast lump −17% (95% CI: −27 to −6%) and haematuria −15% (95% CI −24% to −6%); and second wave: rectal bleeding +14% (95% CI: 0 to 30%) and breast lump +14% (95% CI: 2 to 27%). Presentations of common non-alarm symptom such as tiredness and naevus demonstrated decreased in-cidences in the first wave of 45% (95% CI: −55% to −33%) and 37% (95% CI −47% to −25%). In the second wave, tiredness incidence was reduced by 20% (95% CI: −33% to −3%). Subgroup analy-sis did not demonstrate difference in incidence according to sex, age groups, comorbidity status, or previous history of cancer. Conclusions: These data describe large-scale primary care avoidance that did not increase until the end of the first COVID year for many cancer-related symptoms, suggestive that substantial numbers of patients delayed presenting to primary care. For those patients who had underlying cancer, this may have had impacted the cancer stage at diagnosis, treatment, and mortality.

Covid-19-related ruminations: A qualitative study based on the perspectives of the cancer survivors

Cancer survivors can develop repetitive ruminations due to the unexpected and challenging effects of Covid-19. This qualitative descriptive design study aimed to comprehend the Covid-19-related ruminations from the subjective perspective of cancer survivors (n = 33), accessed via online Facebook self-help groups of a cancer association. A semi-structured interview guide was used for data collection followed by systematic analysis. Based on the descriptive analysis of the data, three main themes emerged-"Welcome to my life," "Cancer versus Covid-19," and "Fight versus lose"-based on cancer survivors' experience and having two subthemes each. The findings suggested that cancer survivors have many ruminations about cancer and the pandemic. Their ruminations were mainly concerned with the possibility of suffering from cancer again and catching Covid-19. Nonetheless, participants also had positive cognitions that they could overcome the pandemic as they have previously beat cancer. The findings may also offer a promising resource for nurses to understand the ruminations of cancer survivors and develop novel approaches and interventions to help cancer survivors replace their intrusive ruminations with deliberate ones.

Impact of COVID-19 on the Organization of Cancer Care in Belgium: Lessons Learned for the (Post-)Pandemic Future

The COVID-19 pandemic has posed tremendous challenges to healthcare systems. Care for oncology patients, a vulnerable population during the pandemic, was disrupted and drastically changed. A multicenter qualitative study was conducted in 11 Belgian hospitals with the aim to provide an overview of the most important changes that were made in the care of oncology patients in Belgium. In each hospital, a nurse or physician was interviewed by telephone. Two rounds of structured interviews-during the first and second waves of the pandemic-were conducted. The data were analyzed using content analysis. The impact of COVID-19 on care practices for patients with cancer was enormous during the first wave. Major changes, including good but also less patient-centered practices, were implemented with unprecedented speed. After the initial wave, regular care was resumed and only limited new care practices were maintained. In only a few hospitals, healthcare teams reflected on lessons learned and on the maintenance of good practices that came from the COVID-19 experience. As a result, opportunities for healthcare innovation and quality improvement seemed to be missed. Our recommendations aim to support policymakers, hospital managers, and healthcare professionals to learn from the COVID-19 pandemic and to drive patient-centered initiatives in future cancer care.

Oncology During the COVID-19 Pandemic: a Lockdown Perspective

Purpose for Review

This perspective piece aims to understand the impacts of the COVID-19 pandemic on the field of oncology, exploring the factors provoking a fall in cancer diagnostic rates, interruption of cancer screening programmes, disruption of oncological treatment and adjuvant care, and the necessary adaption oncological practice has undergone (and will be required to undergo) post-pandemic, including the shift to digital consultations.

Recent Findings

During the COVID-19 pandemic, the field of oncological research has faced significant challenges. Yet, innovation has prevailed with new developments being made across the globe. Looking to the future of oncology, this piece will also suggest potential solutions to overcome the late-stage ramifications of the COVID-19 pandemic.

Summary

The COVID-19 pandemic has triggered a global health crisis, the ramifications of which have reached every corner of the world and overwhelmed already overburdened healthcare systems. However, we are still yet to see the full domino effect of the pandemic as it continues to reveal and exacerbate pre-existing weaknesses in healthcare systems across the world.

Cancer as a risk factor for distress and its interactions with sociodemographic variables in the context of the first wave of the COVID-19 pandemic in Germany

The COVID-19 pandemic poses a psychological challenge, especially for individuals with chronic illnesses. The aim of this study was to investigate associations of cancer with distress, including its interplay with further risk and protective factors. We conducted a representative survey of the German population (N = 2503, including N = 144 with a cancer diagnosis) during the first wave of the pandemic. In multiple linear and logistic regression analyses, we tested associations of cancer with depression and anxiety symptoms and suicidal ideation. We also investigated moderating effects of age, gender, income, living situation, marital status, and loneliness. Individuals with cancer were more likely to report anxiety symptoms (φ = .061), suicidal ideation (φ = .050), and loneliness (φ = .044) than other participants. In regression analyses that controlled for sociodemographic differences, cancer was still associated with anxiety symptoms. We also observed interaction effects, indicating that this relation was especially strong in men with cancer and that cancer survivors with a low income were particularly likely to report anxiety symptoms. The findings demonstrate that cancer survivors are a vulnerable group and that factors of different life domains interact in shaping well-being in the population, necessitating comprehensive risk assessment and support offers during the pandemic and beyond.

The COVID-19 pandemic: a new epoch and fresh challenges for cancer patients and caregivers-a descriptive cross-sectional study

PURPOSE

Cancer patients and their caregivers are overwhelmed with features of uncertainty, fear, shock, worry, anxiety, sadness, and grief. To add on to their misery, the COVID-19 pandemic has severely afflicted the cancer care delivery. The study was conducted to observe the challenges faced by cancer patients and their caregivers and to formulate strategies for oncological setups to overcome those challenges.

METHODS

After obtaining institutional ethical clearance, a descriptive cross-sectional study was conducted to observe the challenges faced by patients and their caregivers at the level of various domains (physical, logistic, psychological, socioeconomic, and spiritual) who visited the outpatient and inpatient department of cancer pain and palliative care unit. The results were expressed in absolute numbers.

RESULTS

Major challenges encountered were suffering from physical symptoms like pain, nausea, vomiting, dyspnea (90%), postponement of cancer treatment (80%), fear of contracting COVID infection due to hospital visit (93.5%), lack of accommodation (70%), and lack of spiritual clarity and hope (50%).

CONCLUSIONS

Major challenges faced by patients were in physical and psychological domains, and those by caregivers were in socioeconomic domains and handling physical symptoms of their patients. It is imperative to recognize and be cognizant of the challenges faced by cancer patients and their caregivers. Health care setups should formulate strategies to alleviate these challenges and provide holistic care to cancer patients. These strategies will hold in good stead for future pandemics also.

Cancer Patients’ Challenges During COVID-19 Pandemic: An Approach to Decision-Making in Management and Policy-Making

Context: Cancer patients are more susceptible to novel coronavirus infection due to their immune system deficiency and anticancer treatments. During the COVID-19 outbreak, cancer patients have faced many challenges. The present study aimed to review the literature on cancer patients’ challenges during the COVID-19 pandemic to offer an approach to decision-making in management and policy-making. Evidence Acquisition: In this review study, national and international databases were searched. Inclusion Criteria were the risk of COVID-19 in cancer patients, medical services, surgery, and cancer screening during the COVID-19 pandemic, cancer patients’ challenges during the COVID-19 pandemic, and management and policy-making in this pandemic. Results: Cancer patients’ challenges during the COVID 19 pandemic were classified as follows: (1) risk of COVID-19 for cancer patients; (2) access to medical services and screening during the COVID-19 pandemic; and (3) psychological disorders during the COVID-19 pandemic. Studies have revealed that individuals with cancer experience a higher risk of the COVID-19 infection and mortality compared to healthy individuals. Most oncology clinics postpone unnecessary appointments; however, patients with invasive cancer are treated with no delay. Proper management, disease control, and attention to mental health care can prevent psychological disorders. Conclusions: Managing cancer patients’ challenges during the SARS-CoV-2 is of paramount importance. Cancer clinics need to develop new care and follow-up protocols. Moreover, policy-makers should provide appropriate policies to address the challenges of this disease in the future.

Recommendations for the management of COVID-19 in patients with haematological malignancies or haematopoietic cell transplantation, from the 2021 European Conference on Infections in Leukaemia (ECIL 9)

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a novel virus that spread worldwide from 2019 causing the Coronavirus disease 19 (COVID-19) pandemic. SARS-CoV-2 infection is characterised by an initial viral phase followed in some patients by a severe inflammatory phase. Importantly, immunocompromised patients may have a prolonged viral phase, shedding infectious viral particles for months, and absent or dysfunctional inflammatory phase. Among haematological patients, COVID-19 has been associated with high mortality rate in acute leukaemia, high risk-myelodysplastic syndromes, and after haematopoietic cell transplant and chimeric-antigen-receptor-T therapies. The clinical symptoms and signs were similar to that reported for the overall population, but the severity and outcome were worse. The deferral of immunodepleting cellular therapy treatments is recommended for SARS-CoV-2 positive patient, while in the other at-risk cases, the haematological treatment decisions must be weighed between individual risks and benefits. The gold standard for the diagnosis is the detection of viral RNA by nucleic acid testing on nasopharyngeal-swabbed sample, which provides high sensitivity and specificity; while rapid antigen tests have a lower sensitivity, especially in asymptomatic patients. The prevention of SARS-CoV-2 infection is based on strict infection control measures recommended for aerosol-droplet-and-contact transmission. Vaccinations against SARS-CoV-2 has shown high efficacy in reducing community transmission, hospitalisation and deaths due to severe COVID-19 disease in the general population, but immunosuppressed/haematology patients may have lower sero-responsiveness to vaccinations. Moreover, the recent emergence of new variants may require vaccine modifications and strategies to improve efficacy in these vulnerable patients. Beyond supportive care, the specific treatment is directed at viral replication control (antivirals, anti-spike monoclonal antibodies) and, in patients who need it, to the control of inflammation (dexamethasone, anti-Il-6 agents, and others). However, the benefit of all these various prophylactic and therapeutic treatments in haematology patients deserves further studies.

Modification to Systemic Anticancer Therapy at the Start of the COVID-19 Pandemic and its Overall Impact on Survival Outcomes in Patients with Colorectal Cancer

BACKGROUND

Since the beginning of the COVID-19 pandemic, multiple changes to the provision of cancer care has been introduced to maximize patient safety and protect staff. We aimed to identify factors influencing clinicians' decision on treatment modification during the initial phase of the pandemic, and to assess its impact on outcomes in patients with colorectal cancer.

PATIENTS AND METHODS

Electronic records of patients seen in a large United Kingdom tertiary cancer center was reviewed. The frequency and type of changes to systemic anticancer therapy , as well as the factors predicting clinicians' decision were assessed.

RESULTS

A total of 418 patients; mean age 63 ± 12 years and 57% male were included. More than half of the patients had modification to their treatment; with treatment delay (21%) or cancellation (10%), being the most common. Majority of patients on neoadjuvant treatment (97%) proceeded with treatment, with some form of treatment modification in 20%. Half of patients on adjuvant treatment had their treatment plan modified. Overall, a change in treatment was more likely in older patients (OR 1.028 [95% CI 1.010-1.047]; P = .002), and in patients who had already received higher number of cycles of systemic anticancer therapy (OR 1.040 [95% CI 1.016-1.065]; P = .001). A change in treatment was less likely further out of the first national lockdown (OR 0.837 [95% CI 0.758-0.925]; P < .001). Patients on third-line treatment were most likely to have alterations to their treatment plan (69%, n=33/48).

CONCLUSION

During the first wave of COVID-19 in the United Kingdom, clinicians adapted clinical practice in accordance to local and national guidance, especially amongst older patients and those on third-line treatment. Further real-world data are needed to document the important impact of changes to treatment on outcomes in patients with cancer.

Supportive Care Interventions for People With Cancer Assisted by Digital Technology: Systematic Review

BACKGROUND

Although relatively new, digital health interventions are demonstrating rapid growth because of their ability to facilitate access and overcome issues of location, time, health status, and most recently, the impact of a major pandemic. With the increased uptake of digital technologies, digital health has the potential to improve the provision of supportive cancer care.

OBJECTIVE

This systematic review aims to evaluate digital health interventions for supportive cancer care.

METHODS

Published literature between 2000 and 2020 was systematically searched in MEDLINE, PubMed, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, and Scopus. Eligible publications were randomized controlled trials of clinician-led digital health interventions to support adult cancer patients. The interventions included were determined by applying a digital health conceptual model. Studies were appraised for quality using the revised Cochrane risk of bias tool.

RESULTS

Twenty randomized controlled trials met the inclusion criteria for the analysis. Interventions varied by duration, frequency, degree of technology use, and applied outcome measures. Interventions targeting a single tumor stream, predominantly breast cancer, and studies involving the implementation of remote symptom monitoring have dominated the results. In most studies, digital intervention resulted in significant positive outcomes in patient-reported symptoms, levels of fatigue and pain, health-related quality of life, functional capacity, and depression levels compared with the control.

CONCLUSIONS

Digital health interventions are helpful and effective for supportive care of patients with cancer. There is a need for high-quality research. Future endeavors could focus on the use of valid, standardized outcome measures, maintenance of methodological rigor, and strategies to improve patient and health professional engagement in the design and delivery of supportive digital health interventions.

TRIAL REGISTRATION

PROSPERO CRD42020149730; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=149730.

COVID-19 and the impact on gynecologic cancer care

The COVID‐19 pandemic resulted in significant reconfiguration of gynecologic cancer services and care pathways across the globe, with a transformation of working practices. Services had to adapt to protect their vulnerable patients from infection, whilst providing care despite reduced resources/capacity and staffing. The international gynecologic cancer community introduced modified clinical care guidelines. Remote working, reduced hospital visiting, routine COVID‐testing, and use of COVID‐free surgical areas/hubs enabled the ongoing and safe delivery of complex cancer care, with priority levels for cancer treatments established to guide decision‐making by multidisciplinary tumor boards. Some 2.3 million cancer surgeries were delayed or cancelled during the first peak, with many patients reporting significant anxiety/concern for cancer progression and COVID infection. Although COVID trials were prioritized, recruitment to other cancer trials/research activity was significantly reduced. The impact of resultant protocol deviations on outcomes remains to be established. During the recovery healthcare services must maintain capacity and flexibility to manage future surges of infection, address the large backlog of patients with altered or delayed treatments, along with salvaging screening and prevention services. Training needs/mental well‐being of trainees need addressing and staff burnout prevented. Future research needs to fully evaluate the impact of COVID‐19 on long‐term patient outcomes.

This article reviews the global changes introduced to gynecologic cancer care due to COVID‐19, and their impact on services and patients. Key lessons are considered for the recovery and future.

The impact of the Covid-19 pandemic on breast cancer early detection and screening

The COVID-19 pandemic affects mortality and morbidity, with disruptions expected to continue for some time, with access to timely cancer-related services a concern. For breast cancer, early detection and treatment is key to improved survival and longer-term quality of life. Health services generally have been strained and in many settings with population breast mammography screening, efforts to diagnose and treat breast cancers earlier have been paused or have had reduced capacity. The resulting delays to diagnosis and treatment may lead to more intensive treatment requirements and, potentially, increased mortality. Modelled evaluations can support responses to the pandemic by estimating short- and long-term outcomes for various scenarios. Multiple calibrated and validated models exist for breast cancer screening, and some have been applied in 2020 to estimate the impact of breast screening disruptions and compare options for recovery, in a range of international settings. On behalf of the Covid and Cancer Modelling Consortium (CCGMC) Working Group 2 (Breast Cancer), we summarize and provide examples of such in a range of settings internationally, and propose priorities for future modelling exercises. International expert collaborations from the CCGMC Working Group 2 (Breast Cancer) will conduct analyses and modelling studies needed to inform key stakeholders recovery efforts in order to mitigate the impact of the pandemic on early diagnosis and treatment of breast cancer.

COVID-19 in Immunocompromised Cancer Patients: A Case Series and Review of the Literature

The global pandemic of the novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has presented newfound challenges to the oncology community regarding management of disease progression in immunocompromised and cancer patients. Further, the large influx of COVID-19 patients has overwhelmed healthcare facilities, limited access to intensive care unit beds and ventilators, and canceled elective surgeries causing disruptions to the cancer care continuum and re-organization of oncological care. While it is known that the potential threat of infection is greatest in elderly patients (>60 years of age) and patients with underlying comorbidities, there is still insufficient data to determine the risk of COVID-19 in cancer patients. Given the immunosuppressive status in cancer patients arising from chemotherapy and other comorbidities, management of COVID-19 in this patient population carries a unique set of challenges. We report three cases of COVID-19 in immunocompromised cancer patients and discuss the challenges in preventing, diagnosing, and treating this vulnerable group.

"Saying goodbye all alone with no close support was difficult"- Dying during the COVID-19 pandemic: an online survey among bereaved relatives about end-of-life care for patients with or without SARS-CoV2 infection

BACKGROUND

During the SARS-CoV2 pandemic, protection measures, as well as visiting restrictions, had a severe impact on seriously ill and dying patients and their relatives. The study aims to describe the experiences of bereaved relatives of patients who died during the SARS-CoV2 pandemic, regardless of whether patients were infected with SARS-CoV2 or not. As part of this, experiences related to patients' end-of-life care, saying goodbye, visiting restrictions and communication with the healthcare team were assessed.

METHODS

An open observational post-bereavement online survey with free text options was conducted with 81 bereaved relatives from people who died during the pandemic in Germany, with and without SARS-CoV2 diagnosis.

RESULTS

67/81 of the bereaved relatives were female, with a mean age of 57.2 years. 50/81 decedents were women, with a mean age of 82.4 years. The main underlying diseases causing death were cardiovascular diseases or cancer. Only 7/81 of the patients were infected with SARS-CoV2. 58/81 of the relatives felt burdened by the visiting restrictions and 60/81 suffered from pandemic-related stress. 10 of the patients died alone due to visiting restrictions. The burden for relatives in the hospital setting was higher compared to relatives of patients who died at home. 45/81 and 44/81 relatives respectively reported that physicians and nurses had time to discuss the patient's condition. Nevertheless, relatives reported a lack of proactive communication from the healthcare professionals.

CONCLUSIONS

Visits of relatives play a major role in the care of the dying and have an impact on the bereavement of relatives. Visits must be facilitated, allowing physical contact. Additionally, virtual contact with the patients and open, empathetic communication on the part of healthcare professionals is needed.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00023552).

Functional Impairments in the Mental Health, Depression and Anxiety Related to the Viral Epidemic, and Disruption in Healthcare Service Utilization Among Cancer Patients in the COVID-19 Pandemic Era

Purpose

Literature is scarce regarding cancer care utilization during the massive outbreak of coronavirus disease 2019 (COVID-19) in the Republic of Korea. We investigated functional impairments in mental health and their relationships with depression, anxiety regarding the viral epidemic, and disruptions in healthcare service utilization among cancer patients in the COVID-19 pandemic era.

Materials and Methods

We used an online survey with questions related to the disturbances faced by patients with cancer in utilizing healthcare services in the pandemic era. Current mental health status was assessed using the Work and Social Adjustment Scale (WSAS), Stress and Anxiety to Viral Epidemics-6 (SAVE-6) scale, Patient Health Questionnaire-9 (PHQ-9), Insomnia Severity Index (ISI), Brief Resilience Scale (BRS), Cancer-Related Dysfunctional Beliefs about Sleep Scale (C-DBS), and Fear of COVID-19 over Cancer (FCC).

Results

Among the 221 responders, 95 (43.0%) reported disruptions in healthcare service utilization during the COVID-19 pandemic. Logistic regression analysis revealed that functional impairment in the mental health of these patients was expected due to disruptions in healthcare service utilization, high levels of depression, anxiety regarding the viral epidemic, fear of COVID over cancer, and low resilience. Mediation analysis showed that patient resilience and cancer-related dysfunctional beliefs about sleep partially mediated the effects of viral anxiety on functional impairment.

Conclusion

In this pandemic era, patients with cancer experience depression, anxiety regarding the viral epidemic, and disruptions in healthcare service utilization, which may influence their functional impairments in mental health.

Remote Contouring and Virtual Review during the COVID-19 Pandemic (RECOVR-COVID19): Results of a Quality Improvement Initiative for Virtual Resident Training in Radiation Oncology

The need to minimize in-person interactions during the COVID-19 pandemic has led to fewer clinical learning opportunities for trainees. With ongoing utilization of virtual platforms for resident education, efforts to maximize their value are essential. Herein we describe a resident-led quality improvement initiative to optimize remote contouring and virtual contour review. From April to June 2020, radiation oncology (RO) residents at our institution were assigned modified duties. We implemented a program to source and assign cases to residents for remote contouring and to promote and optimize virtual contour review. Resident-perceived educational value was prospectively collected and analyzed. All nine RO residents at our institution (PGY1–5) participated, and 97 cases were contoured during the evaluation period. Introduction of the Remote Contouring and Virtual Review (RECOVR) program coincided with a significant increase in mean cases contoured per week, from 5.5 to 17.3 (p = 0.015), and an increased proportion of cases receiving virtual review, from 14.8% to 58.6% (p < 0.001). Residents reported that the value of immediate feedback during virtual review was similar to that of in-person review (4.6 ± 0.1 vs. 4.5 ± 0.2, p = 0.803) and significantly higher than feedback received post hoc (e.g., email; 3.6 ± 0.2, p < 0.001). The implementation of a remote process for contour review led to significant increases in contouring, and virtual contour review was rated as highly as in-person interactions. Our findings provide a data-driven rationale and framework for integrating remote contouring and virtual review into competency-based medical education.

Impact of COVID-19 on healthcare organisation and cancer outcomes

BACKGROUND

Changes in the management of patients with cancer and delays in treatment delivery during the COVID-19 pandemic may impact the use of hospital resources and cancer mortality.

PATIENTS AND METHODS

Patient flows, patient pathways and use of hospital resources during the pandemic were simulated using a discrete event simulation model and patient-level data from a large French comprehensive cancer centre's discharge database, considering two scenarios of delays: massive return of patients from November 2020 (early-return) or March 2021 (late-return). Expected additional cancer deaths at 5 years and mortality rate were estimated using individual hazard ratios based on literature.

RESULTS

The number of patients requiring hospital care during the simulation period was 13,000. In both scenarios, 6-8% of patients were estimated to present a delay of >2 months. The overall additional cancer deaths at 5 years were estimated at 88 in early-return and 145 in late-return scenario, with increased additional deaths estimated for sarcomas, gynaecological, liver, head and neck, breast cancer and acute leukaemia. This represents a relative additional cancer mortality rate at 5 years of 4.4 and 6.8% for patients expected in year 2020, 0.5 and 1.3% in 2021 and 0.5 and 0.5% in 2022 for each scenario, respectively.

CONCLUSIONS

Pandemic-related diagnostic and treatment delays in patients with cancer are expected to impact patient survival. In the perspective of recurrent pandemics or alternative events requiring an intensive use of limited hospital resources, patients should be informed not to postpone care, and medical resources for patients with cancer should be sanctuarised.

The Post-Normal Challenges of COVID-19: Constructing Effective and Legitimate Responses

The ongoing COVID-19 emergency clearly presents novel challenges, both in terms of difficulties for maintaining public health and in assuring that governmental responses are ethically sound. Centrally, responses must respect, as best as possible, fundamental human rights and human values. Conflicts among values arise in response to the crisis, and public officials have no choice but to prioritize some while sacrificing others. Utilizing the concepts of effectiveness and legitimacy within the framework of post-normal science (PNS), we investigate and recommend processes and measures to address COVID-19 that support increased public health, while upholding established rights and values. The effectiveness and legitimacy of science-led policymaking requires investigation of how that policy ought to be made (e.g. concepts of policymaking and PNS), as well as how it ought to interact with diversely-constituted publics (e.g. public inclusion in policymaking and policy communication).

Cancer and COVID-19: Why are cancer patients more susceptible to COVID-19?

The COVID-19 pandemic has engulfed the entire world and has claimed more than 3 million lives worldwide. This viral disease is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and mainly characterized by fever, dry cough, fatigue, anosmia, anorexia, and dyspnea. The severity of the disease increases with age and presence of comorbidities, including cancer. Multiple clinical studies have shown that the cancer patients are highly susceptible to the severe form of the viral disease. In this review article, we have summarized the available scientific literature regarding the molecular links between COVID-19 and cancer, which make the cancer patients highly susceptible to COVID-19. Few studies have shown that the angiotensin-converting enzyme 2 (ACE2) receptor, transmembrane protease serine 2 (TMPRSS2), and the immune response and inflammation establish the interconnection between the two diseases. Additionally, we have also discussed whether SARS-CoV-2 can contribute to cancer development in COVID-19 patients. A recent study has suggested that SARS-CoV-2 may create a microenvironment that may support cancer cell proliferation and induce the activation of dormant cancer cells (DCCs). In another study, the blood sera of COVID-19 patients were found to activate epithelial-to-mesenchymal transition (EMT) in cancer cells. Overall, this review article will surely help the scientific community to understand why the cancer patients are so much prone to COVID-19 and will also motivate the researchers to find new therapeutic strategies that may save the lives of many COVID-19-infected cancer patients.

From Fear to Hopelessness: The Buffering Effect of Patient-Centered Communication in a Sample of Oncological Patients during COVID-19

Background: COVID-19 represents a threat both for the physical and psychological health of oncological patients experiencing heightened distress levels to which the fear of the virus is also added. Moreover, fear of COVID-19 could lead oncological patients to experience feelings of hopelessness related to their medical care. Patient-centered communication may act as a buffer against the aforementioned variables. This study aimed to test the role of doctor–patient communication in the relationship between fear of COVID-19 and hopelessness. Methods: During the COVID-19 pandemic, a sample of 90 oncological outpatients was recruited (40 males (44.4%) and 50 females (55.6%), mean age = 66.08 (SD = 12.12)). A structured interview was developed and used during the pandemic to measure the patients’ perceived (A) fear of COVID-19, and (B) feelings of hopelessness, and (C) physicians’ use of empathetic and (D) clear language during the consultation. A multiple mediation model was tested, and the effects between males and females were also compared. Results: Empathetic and clear doctor–patient communication buffered the adverse effect of the fear of COVID-19 on hopelessness through a full-mediation model. The effects did not differ between males and females in the overall model but its indirect effects. Discussions: Patient-centered communication using empathy and clear language can buffer the adverse effect of the fear of COVID-19 and protect oncological patients from hopelessness during the pandemic. These findings might help to improve clinical oncological practice.

COVID-19 in Patients with Cancer

With more than 5 million cases and 333,212 deaths, COVID-19 (or SARS-CoV-2) continues to spread. General symptoms of this disease are similar to that of many other viral respiratory diseases, including fever, cough, dyspnea, and fatigue, with a chance of progression to more severe complications. However, the virus does not affect all people equally, and cases with comorbidities such as malignancies, cardiovascular diseases, respiratory diseases, and kidney diseases are at higher risk of developing severe events, including requiring intensive ventilation, intensive care unit (ICU) admission, and death. Patients with cancer are more likely to be infected with COVID-19, which is possibly due to their immunological dysfunction or frequent clinic visits. Also, there is a higher chance that these patients experience severe events because of the medication they receive. In this chapter, we will review the main clinical manifestations of COVID-19 in patients with cancer. Recommendations and challenges for managing resources, organizing cancer centers, treatment of COVID-19-infected cancer patients, and performing cancer research during this pandemic will also be discussed.

Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales

BACKGROUND

Compared to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing COVID-19 pandemic and its major impact on cancer referrals. The ThinkCancer! workshop is an educational behaviour change intervention aimed at the whole general practice team, designed to improve primary care approaches to ensure timely diagnosis of cancer. The workshop will consist of teaching and awareness sessions, the appointment of a Safety Netting Champion and the development of a bespoke Safety Netting Plan and has been adapted so it can be delivered remotely. This study aims to assess the feasibility of the ThinkCancer! intervention for a future definitive randomised controlled trial.

METHODS

The ThinkCancer! study is a randomised, multisite feasibility trial, with an embedded process evaluation and feasibility economic analysis. Twenty-three to 30 general practices will be recruited across Wales, randomised in a ratio of 2:1 of intervention versus control who will follow usual care. The workshop will be delivered by a GP educator and will be adapted iteratively throughout the trial period. Baseline practice characteristics will be collected via questionnaire. We will also collect primary care intervals (PCI), 2-week wait (2WW) referral rates, conversion rates and detection rates at baseline and 6 months post-randomisation. Participant feedback, researcher reflections and economic costings will be collected following each workshop. A process evaluation will assess implementation using an adapted Normalisation Measure Development (NoMAD) questionnaire and qualitative interviews. An economic feasibility analysis will inform a future economic evaluation.

DISCUSSION

This study will allow us to test and further develop a novel evidenced-based complex intervention aimed at general practice teams to expedite the diagnosis of cancer in primary care. The results from this study will inform the future design of a full-scale definitive phase III trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04823559 .

Psychological distress among cancer survivors during implementation of a nationwide Movement Control Order over the COVID-19 pandemic

Objectives

This study aimed to investigate the psychological distress and its associated factors among cancer survivors in Malaysia during the COVID-19 pandemic.

Methods

An anonymous Internet-based study was conducted between 23 April and 26 June 2020. During the study period, the country underwent phase 3 and phase 4 of the Movement Control Order (MCO), Conditional Movement Control Order (CMCO), and Recovery Movement Control Order (RMCO). Psychological distress was measured using the Hospital Anxiety and Depression Scale (HADS), which is a 14-item self-assessment scale for measuring distress (total HADS score; HADS-T) with two subscales, namely, anxiety (HADS-A) and depression (HADS-D). Perceived threat of infection was measured based on the health belief model.

Results

From a total of 631 responses received, the proportion of participants with anxiety and depression symptoms (above threshold score of 8 on HADS-A and HADS-D) was 29.0 and 20.9%, respectively. Psychological distress (HADS-T > 16) was reported in 22.3% of the respondents. A total of 16.5% had combined anxiety and depression symptoms. The highest HADS-A (6.10; 95% CI 5.64–6.56), HADS-D (5.61; 95% CI 5.14–6.08), and HADS-T (11.71; 95% CI 10.84–12.58) scores were reported among respondents during phase 4 of the MCO. Partial least square-based structural equation modelling (PLS-SEM) revealed that self-perceived health status, perceived susceptibility, and severity of COVID-19 have the greatest effect, leading to higher HADS-A, HADS-D, and HADS-T scores.

Conclusion

Heightened psychological distress was evident in cancer survivors particularly during the enforcement of the MCO over COVID-19. Providing support to address cancer survivors’ psychological and emotional needs during the COVID-19 pandemic is essential.

Care Delivery Impact of the COVID-19 Pandemic on Breast Cancer Care

PURPOSE

COVID-19 has altered healthcare delivery. Previous work has focused on patients with cancer and COVID-19, but little has been reported on healthcare system changes among patients without COVID-19.

METHODS

We performed a retrospective study of patients with breast cancer (BC) in New York City between February 1, 2020, and April 30, 2020. New patients were included as were patients scheduled to receive intravenous or injectable therapy. Patients with COVID-19 were excluded. Demographic and treatment information were obtained by chart review. Delays and/or changes in systemic therapy, surgery, radiation, and radiology related to the pandemic were tracked, along with the reasons for delay and/or change. Univariate and multivariable analysis were used to identify factors associated with delay and/or change.

RESULTS

We identified 350 eligible patients, of whom 149 (42.6%) experienced a delay and/or change, and practice reduction (51.0%) was the most common reason. The patients who identified as Black or African American, Asian, or Other races were more likely to experience a delay and/or change compared with White patients (Black, 44.4%; Asian, 47.1%; Other, 55.6%; White, 31.4%; P = .001). In multivariable analysis, Medicaid compared with commercial insurance (odds ratio [OR], 3.04; 95% CI, 1.32 to 7.27) was associated with increased odds of a delay and/or change, whereas stage II or III BC compared with stage I (OR, 0.38; 95% CI, 0.15 to 0.95; and OR, 0.28; 95% CI, 0.08 to 0.092, respectively) was associated with decreased odds of a delay and/or change.

CONCLUSION

Almost half of the patients with BC without COVID-19 had a delay and/or change. We found racial and socioeconomic disparities in the likelihood of a delay and/or change. Further studies are needed to determine the impact these care alterations have on BC outcomes.

COVID-19 and Cancer: Questions to Be Answered

The World Health Organization (WHO) declared the coronavirus disease 2019 (COVID-19) outbreak to be a pandemic on March 12, 2020. In Korea, there have been 24,027 confirmed cases of COVID-19 and 420 deaths as of October 3, 2020. The clinical spectrum of COVID-19 ranges from asymptomatic infection to death. Cancer care in this pandemic has radically changed. The literature was reviewed. The COVID-19 pandemic has made it urgently necessary to profoundly re-organize cancer patients' care without compromising cancer outcomes. Several important questions in regard to COVID-19 infection in cancer patients have emerged. Are patients with cancer at a higher risk of COVID-19 infection? Are they at an increased risk of mortality and severe illness when infected with COVID-19? Does anticancer treatment affect the course of COVID-19? Based on the existing research, cancer patients with immunosuppression are vulnerable to COVID-19 infection, and cancer patients are more likely to experience severe COVID-19. However, chemotherapy and major surgery do not seem to be predictors of hospitalization or severe disease. Korean background data on patients with cancer and COVID-19 are lacking. Prospective multicenter studies on the outcomes of patients with cancer and COVID-19 should be conducted.

The effectiveness of the Guy's Rapid Diagnostic Clinic (RDC) in detecting cancer and serious conditions in vague symptom patients

BACKGROUND

Rapid Diagnostic Clinics (RDC) are being expanded nationally by NHS England. Guy's RDC established a pathway for GPs and internal referrals for patients with symptoms concerning for malignancy not suitable for a site-specific 2WW referral. However, little data assessing the effectiveness of RDC models are available in an English population.

METHODS

We evaluated all patients referred to Guy's RDC between December 2016 and June 2019 (n = 1341) to assess the rate of cancer diagnoses, frequency of benign conditions and effectiveness of the service.

RESULTS

There were 96 new cancer diagnoses (7.2%): lung (16%), haematological (13%) and colorectal (12%)-with stage IV being most frequent (40%). Median time to definitive cancer diagnosis was 28 days (IQR 15-47) and treatment 56 days (IQR 32-84). In all, 75% were suitable for treatment: surgery (26%), systemic (24%) and radiotherapy (14%). Over 180 serious non-neoplastic conditions were diagnosed (35.8%) of patients with no significant findings in two-third of patients (57.0%).

CONCLUSIONS

RDCs provide GPs with a streamlined pathway for patients with complex non-site-specific symptoms that can be challenging for primary care. The 7% rate of cancer diagnosis exceeds many 2WW pathways and a third of patients presented with significant non-cancer diagnoses, which justifies the need for rapid diagnostics. Rapid Diagnostic Centres (RDCs) are being rolled out nationally by NHS England and NHS Improvement as part of the NHS long-term plan. The aim is for a primary care referral pathway that streamlines diagnostics, patient journey, clinical outcomes and patient experience. This pilot study of 1341 patients provides an in-depth analysis of the largest single RDC in England. Cancer was diagnosed in 7% of patients and serious non-cancer conditions in 36%-justifying the RDC approach in vague symptom patients.

Impact of the COVID-19 pandemic on neuroendocrine tumour services in England

PURPOSE

During the COVID-19 pandemic, there have been particular concerns regarding the related impact on specialist tumour services. Neuroendocrine tumour (NET) services are delivered in a highly specialised setting, typically delivered in a small number of centres that fulfil specific criteria as defined by the European Neuroendocrine Tumour Society (ENETS). We aimed to address the COVID-19-related impact on specialist NET tumour services in England and other countries.

METHODS

Electronic survey addressing patient access and delivery of care distributed to all ENETS Centres of Excellence (CoE) in England and matching number of ENETS CoE elsewhere. Semi-quantitative and qualitative analyses of survey responses were performed.

RESULTS

Survey response of ENETS CoE in England was 55% (6/11). Responses from six non-UK ENETS CoE elsewhere were received and analysed in a similar manner. Relevant disruption of various NET services was noted across all responding Centres, which included delayed patient appointments and investigations, reduced availability of treatment modalities including delayed surgical treatment and a major negative impact on research activities. The comparison between English and non-UK ENETS CoE suggested that the former had significantly greater concerns related to future research funding (p = 0.014), whilst having less disruption to multidisciplinary meetings (p = 0.01). A trend was also noted towards virtual patient appointments in ENETS CoE in England vs. elsewhere (p = 0.092).

CONCLUSIONS

Restoration of highly specialised NET services following COVID-19 and planning for future service delivery and research funding must take account of the severe challenges encountered during the pandemic.

Mental Health in Persons With Chronic Myeloid Leukemia During the SARS-CoV-2 Pandemic: The Need for Increased Access to Health Care Services

Mental health problems in the general population have been reported during the SARS-CoV-2 pandemic; however, there were rare data in persons with chronic myeloid leukemia (CML). Therefore, we performed a cross-sectional study on mental health evaluated using the 9-item Patient Health Questionnaire (PHQ-9; depression), the 7-item Generalized Anxiety Disorder (GAD-7; anxiety), and the 22-item Impact of Event Scale-Revised (IES-R; distress), including subscales of avoidance, intrusion, and hyper-arousal in persons with CML, non-cancer persons, and immediate family members of persons with cancer as controls (≥16 years) by an online survey. Data from 3,197 persons with CML and 7,256 controls were collected. In multivariate analyses, CML was significantly associated with moderate to severe depression (OR = 1.6; 95% Confidence Interval [CI], 1.4, 1.9; p < 0.001), anxiety (OR = 1.4 [1.1, 1.7]; p = 0.001), distress (OR = 1.3 [1.1, 1.5]; p < 0.001), and hyper-arousal (OR = 1.5 [1.3, 1.6]; p < 0.001). Moreover, delay in regular monitoring was significantly associated with depression (OR 1.3 [1.0, 1.7]; p = 0.024), anxiety (OR = 1.3 [1.0, 1.8]; p = 0.044), avoidance (OR = 1.2 [1.0, 1.4]; p = 0.017), and intrusion (OR = 1.2 [1.0, 1.4]; p = 0.057); tyrosine kinase-inhibitor dose reduction or discontinuation, depression (OR = 1.9 [1.3, 2.8]; p = 0.001), distress (OR = 2.0 [1.4, 2.8]; p < 0.001), avoidance (OR = 1.6 [1.2, 2.1]; p = 0.004), intrusion (OR = 1.6 [1.1, 2.1]; p = 0.006), and hyper-arousal (OR = 1.3 [1.0, 1.8]; p = 0.088). We concluded that persons with CML during the SARS-CoV-2 pandemic have worse mental health including depression, anxiety, and distress symptoms. Decreasing or stopping monitoring or dose resulted in adverse mental health consequences.

Safety, Precautions, and Modalities in Cancer Rehabilitation: an Updated Review

PURPOSE OF REVIEW

Providing rehabilitation to patients with cancer can be challenging due to the medical complexity associated with the illness and its treatments. This article provides the reader with a summary of frequently encountered medical conditions in the cancer population and associated safety considerations and precautions. An update on treatment modalities commonly used for symptom management is also presented.

RECENT FINDINGS

Cancer and cancer treatments can cause changes in multiple organ systems. Special considerations and precautions are necessary to provide safe and effective rehabilitation. Physical modalities can be used as monotherapy or adjunct to treatment for common cancer-related side effects with recent studies noting benefit with a variety of modalities.

SUMMARY

Detailed assessment of the cancer patient is necessary before implementing a rehabilitation program. Understanding cancer and side effects of treatments, including newer options, are necessary to provide safe care.

Cancer treatment in the coronavirus disease pandemic

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COVID-19 patients with cancer had increased risk of death and severe outcomes compared to those without cancer.

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There is no conclusive evidence indicating that antineoplastic treatment aggravates COVID-19 disease

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There was no significant difference in COVID-19 severity regardless of PD-1 blockade exposure.

Half a year after its emergence, severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) has resulted in a pandemic, with cases continuing to increase in nearly every country. Surges in coronavirus disease of 2019 (COVID-19) cases have clearly had profound effects on current cancer treatment paradigms. Considering the effect of antineoplastic treatment and the immunosuppressive properties of cancer itself, cancer patients are deemed to be more vulnerable to SARS-CoV-2. Hence, the specific risk of SARS-CoV-2 must be carefully weighed against the benefit of antineoplastic treatment for cancer patients in the COVID-19 era. In this review, we discuss the current evidence in this important field, and in particular, the effect of SARS-CoV-2 on antineoplastic treatment.

Radiotherapy management of rectal cancer in the backdrop of the COVID pandemic

Background

COVID‐19 outbreak was declared as a pandemic by the World Health Organization in March 2020. Over the last 3 months, the pandemic has challenged the diagnosis and treatment of all cancer, including rectal cancer. Constraints in resources call for a change in the treatment strategy without compromising efficacy.

Recent Findings

Delivery of shorter treatment schedules for radiotherapy offers advantages like short overall treatment time, improved throughput on the machine, improved compliance and reduced risk of transmission of COVID 19. Other strategies include delaying surgery, reducing the intensity of chemotherapy and adoption of organ preservation approach.

Conclusion

The curative treatment of rectal cancer should not be hindered during the COVID pandemic, and modifications in the multi‐modality treatment will help achieve quality care.

Liability of Health Care Professionals and Institutions During COVID-19 Pandemic in Italy: Symposium Proceedings and Position Statement

BACKGROUND

On May 12, 2020, a symposium titled "Liability of healthcare professionals and institutions during COVID-19 pandemic" was held in Italy with the participation of national experts in malpractice law, hospital management, legal medicine, and clinical risk management. The symposium's rationale was the highly likely inflation of criminal and civil proceedings concerning alleged errors committed by health care professionals and decision makers during the COVID-19 pandemic. Its aim was to identify and discuss the main issues of legal and medicolegal interest and thus to find solid solutions in the spirit of preparedness planning.

METHODS

There were 5 main points of discussion: (A) how to judge errors committed during the pandemic because of the application of protocols and therapies based on no or weak evidence of efficacy, (B) whether hospital managers can be considered liable for infected health care professionals who were not given adequate personal protective equipment, (C) whether health care professionals and institutions can be considered liable for cases of infected inpatients who claim that the infection was transmitted in a hospital setting, (D) whether health care institutions and hospital managers can be considered liable for the hotspots in long-term care facilities/care homes, and (E) whether health care institutions and hospital managers can be considered liable for the worsening of chronic diseases.

RESULTS AND CONCLUSION

Limitation of the liability to the cases of gross negligence (with an explicit definition of this term), a no-fault system with statal indemnities for infected cases, and a rigorous methodology for the expert witnesses were proposed as key interventions for successfully facing future proceedings.

COVID-19 risk for patients undergoing anticancer treatment at the outpatient clinic of the National Cancer Institute of Milan: the COVINT study

Background

In the midst of the COVID-19 pandemic, patients with cancer are regarded as a highly vulnerable population. Overall, those requiring hospital admission for treatment administration are potentially exposed to a higher risk of infection and worse outcome given the multiple in-hospital exposures and the treatment immunosuppressive effects.

Methods

COVINT is an observational study assessing COVID-19 incidence among patients receiving anticancer treatment in the outpatient clinic of the Istituto Nazionale dei Tumori di Milano. All consecutive patients with non-haematological malignancies treated with intravenous or subcutaneous/intramuscular anticancer therapy in the outpatient clinic were enrolled. The primary endpoint is the rate of occurrence of COVID-19. Secondary endpoints included the rate of COVID-19-related deaths and treatment interruptions. The association between clinical and biological characteristics and COVID-19 occurrence is also evaluated. COVID-19 diagnosis is defined as (1) certain if confirmed by reverse transcriptase PCR assay of nasopharyngeal swabs (NPS); (2) suspected in case of new symptoms or CT scan evidence of interstitial pneumonia with negative/not performed NPS; (3) negative in case of neither symptoms nor radiological evidence.

Results

In the first 2 months (16 February–10 April 2020) of observation, 1081 patients were included. Of these, 11 (1%) were confirmed and 73 (6.7%) suspected for COVID-19. No significant differences in terms of cancer and treatment type emerged between the three subgroups. Prophylactic use of myeloid growth factors was adopted in 5.3%, 2.7% and 0% of COVID-19-free, COVID-19-suspected and COVID-19-confirmed patients (p=0.003). Overall, 96 (8.9%) patients delayed treatment as a precaution for the pandemic. Among the 11 confirmed cases, 6 (55%) died of COVID-19 complications, and anticancer treatment was restarted in only one.

Conclusions

During the pandemic peak, accurate protective measures successfully resulted in low rates of COVID-19 diagnosis, although with high lethality. Prospective patients’ surveillance will continue with NPS and serology testing to provide a more comprehensive epidemiological picture, a biological insight on the impact of cytotoxic treatments on the immune response, and to protect patients and healthcare workers.