Cancer care and COVID-19: tailoring recommendations for the African radiation oncology context

Cancer Care During the COVID-19 Pandemic: The African Narrative and Prospects

The COVID-19 pandemic has had a significant impact on healthcare services globally. Whilst it has been particularly disruptive for cancer care in low-resource settings, a few African countries have been able to adapt strategies to enable continued delivery of medical care to persons with cancer. This study seeks to highlight how much effect the coronavirus pandemic has had on oncological care in Africa and to indicate the way forward. For this narrative review, PubMed and Google Scholar were used to search for literature addressing the effect of the coronavirus pandemic on the care of patients with cancer in Africa with ensuing coping strategies. Selection criteria were manuscripts published since the onset of the pandemic in 2019 and written in the English language with Africa being the focus. In total, 52 research papers involving up to 21 African nations were found and reviewed. Across the board, the COVID-19 pandemic resulted in the deferral of oncological screening programs and a halt in immunization activities routinely scheduled for preventable cancers. It caused a colossal shortage in the availability of appropriately trained medical personnel, reduced frequency and duration of outpatient consultations, and a delay in cancer investigations and diagnosis. It also stirred up the substandard modification of chemotherapy regimens and radiotherapy due to the scarcity of anticancer medications and radioisotopes and engendered the cancellation of cancer surgical procedures. Palliative care for patients with locally advanced and metastatic disease was in many cases interrupted and cancer research activities were abruptly deferred. Ultimately, these led to poor patient outcomes and increased cancer-related fatalities. However, a few African countries - Rwanda, Ghana, and Tunisia - have continued to adapt telemedicine, small unmanned aircraft systems (sUAS), and home therapy to facilitate cancer care. To date, there is a paucity of data concerning the successes and cost-effectiveness of these relatively new methods recently adapted to cater to the medical needs of cancer patients in Africa. The pandemic has presented the African community an opportunity to advance her healthcare systems, especially as it pertains to the delivery of medical care to persons with cancer. The need of the hour is to study further the alternative cancer care delivery systems initiated during the pandemic in order to determine their sustainability in Africa at large.

The Prevalence of Compassion Fatigue among Oncology Healthcare Professionals in Three Public Healthcare Facilities in Kwazulu-Natal, South Africa

Compassion fatigue (CF) is a serious global challenge among healthcare professionals dealing with diseases with poor health outcomes in clinical settings. Chronic exposure to the suffering of others is inevitable in the oncology setting and remains one of the main contributors to CF. Therefore, this study determined the prevalence of CF among oncology healthcare professionals (OHPs) in three public healthcare facilities in KwaZulu-Natal, South Africa. This cross-sectional descriptive study was conducted among 73 OHPs using the Professional Quality of Life Scale version 5 questionnaire, and the data were analysed using the Statistical Package for Social Sciences. More than half (56.2%) of the participants reported average scores for CF, with 43.8% of them scoring low. The participants from Inkosi Albert Luthuli Central Hospital had the highest CF mean score (26.8) compared to those from Addington Hospital (21.2) and Greys Hospital (22.9). Female OHPs had a higher mean score (24.3) for CF, compared to their male counterparts (20.6). The CF scores were positively correlated with older age and longer work experience of the OHPs. The prevalence of CF among OHPs was average, compared to those reported by other local and international studies. Nevertheless, these results cannot be taken lightly, given the straining effects of unmanaged CF on the healthcare system generally and on patient care in particular. The results of this study can potentially contribute to policy development and the planning of intervention strategies towards the effective management of CF among OHPs.

Hypofractionation in Breast Cancer Radiotherapy Across World Bank Income Groups: Results of an International Survey

PURPOSE

Hypofractionated breast radiotherapy has been found to be equivalent to conventional fractionation in many clinical trials. Using data from the European Society for Radiotherapy and Oncology Global Impact of Radiotherapy in Oncology survey, we identified preferences for hypofractionation in breast cancer across World Bank income groups and the perceived facilitators and barriers to its use.

MATERIALS AND METHODS

An international, electronic survey was administered to radiation oncologists from 2018 to 2019. Demographics, practice characteristics, preferred hypofractionation regimen for specific breast cancer scenarios, and facilitators and barriers to hypofractionation were reported and stratified by World Bank income groups. Variables associated with hypofractionation were assessed using multivariate logistic regression models.

RESULTS

One thousand four hundred thirty-four physicians responded: 890 (62%) from high-income countries (HICs), 361 (25%) from upper-middle-income countries (UMICs), 183 (13%) from low- and lower-middle-income countries (LLMICs). Hypofractionation was preferred most frequently in node-negative disease after breast-conserving surgery, with the strongest preference reported in HICs (78% from HICs, 54% from UMICs, and 51% from LLMICs, P < .001). Hypofractionation for node-positive disease postmastectomy was more frequently preferred in LLMICs (28% from HICs, 15% from UMICs, and 35% from LLMICs, P < .001). Curative doses of 2.1 to < 2.5 Gy in 15-16 fractions were most frequently reported, with limited preference for ultra-hypofractionation, but significant variability in palliative dosing. In adjusted analyses, UMICs were significantly less likely than LLMICs to prefer hypofractionation across all curative clinical scenarios, whereas respondents with > 1 million population catchments and with intensity-modulated radiotherapy were more likely to prefer hypofractionation. The most frequently cited facilitators and barriers were published evidence and fear of late toxicity, respectively.

CONCLUSION

Preference for hypofractionation varied for curative indications, with greater acceptance in earlier-stage disease in HICs and in later-stage disease in LLMICs. Targeted educational interventions and greater inclusivity in radiation oncology clinical trials may support greater uptake.

Covid-19 and radiotherapy: a systematic review after 2 years of pandemic

Introduction

Following the Covid-19 pandemic spread, changes in clinical practice were necessary to limit the pandemic diffusion. Also, oncological practice has undergone changes with radiotherapy (RT) treatments playing a key role.Although several experiences have been published, the aim of this review is to summarize the current evidence after 2 years of pandemic to provide useful conclusions for clinicians.

Methods

A Pubmed/MEDLINE and Embase systematic review was conducted. The search strategy was "Covid AND Radiotherapy" and only original articles in the English language were considered.

Results

A total of 2.733 papers were obtained using the mentioned search strategy. After the complete selection process, a total of 281 papers were considered eligible for the analysis of the results.

Discussion

RT has played a key role in Covid-19 pandemic as it has proved more resilient than surgery and chemotherapy. The impact of the accelerated use of hypofractionated RT and telemedicine will make these strategies central also in the post-pandemic period.

Organisation of cancer care in troubling times: A scoping review of expert guidelines and their implementation during the COVID-19 pandemic

This scoping review mapped the main themes in existing expert guidelines for cancer care issued during the COVID-19 crisis from the period of March 2020-August 2021. The guidelines published during the research period principally relate to the first two waves in Europe and until the beginning of the vaccination campaign. They elaborated recommendations for cancer care reorganisation, in particular triage and quality of care issues. The article highlights the ethical, epistemological, as well as practical reasons that guidelines were not always followed to provide some lessons learned for future crises to enable better guideline development processes. We also elaborate early evidence on the impact of triage decisions and different perspectives on cancer care reorganisation from ethics and social science literature.

Moderately hypofractionated versus conventionally fractionated radiation therapy with temozolomide for young and fit patients with glioblastoma: an institutional experience and meta-analysis of literature

PURPOSE

Shorter hypofractionated radiation therapy (HF-RT) schedules may have radiobiological, patient convenience and healthcare resource advantages over conventionally fractionated radiation therapy (CF-RT) in glioblastoma (GBM). We report outcomes of young, fit GBM patients treated with HF-RT and CF-RT during the COVID-19 pandemic, and a meta-analysis of HF-RT literature in this patient subgroup.

METHODS

Hospital records of patients with IDH-wildtype GBM treated with HF-RT (50 Gy/20 fractions) and CF-RT (60 Gy/30 fractions) between January 2020 and September 2021 were reviewed. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Univariable analysis was performed using Cox regression analysis. A systematic search and meta-analysis of studies from January 2000 to January 2022 was performed.

RESULTS

41 patients were treated (HF-RT:15, CF-RT:26). For both HF-RT and CF-RT groups, median age was 58 years and 80-90% were ECOG 0-1. There were more methylated tumours in the HF-RT group. All patients received concurrent/adjuvant temozolomide. At 19.2 months median follow-up, median OS was 19.8 months and not-reached for HF-RT and CF-RT (p = 0.5), and median PFS was 7.7 and 5.8 months, respectively (p = 0.8). HF-RT or CF-RT did not influence OS/PFS on univariable analysis. Grade 3 radionecrosis rate was 6.7% and 7.7%, respectively. 15 of 1135 studies screened from a systematic search were eligible for meta-analysis. For studies involving temozolomide, pooled median OS and PFS with HF-RT were 17.5 and 9.9 months (927 and 862 patients). Studies using shortened HF-RT schedules reported 0-2% Grade 3 radionecrosis rates.

CONCLUSION

HF-RT may offer equivalent outcomes and reduce treatment burden compared to CF-RT in young, fit GBM patients.

Radiotherapy based management during Covid-19 pandemic - A systematic review of presented consensus and guidelines

Treatment management of cancer patients in the radiation oncology departments during the current COVID-19 pandemic is challenging. A systematic review of published consensus/guidelines on the role of radiotherapy prioritization, suggested treatment protocols, and set up management was undertaken based on the PRISMA protocol and through PubMed/PMC, Scopus, Google Scholar, Web of Science databases until 01/20/2021. One hundred and sixty-eight publications or regional consensus were included. Summary of recommendations contained: (1) using hypo-fractionated (Hypo-F) regimens for therapeutic/palliative indications, (2) delaying radiotherapy for several weeks or until pandemic over, (3) omitting radiotherapy by replacement of alternative therapies or active surveillance, (4) applying safer patients' setup and preparation protocols, (5) developing telemedicine/telehealth service. To conclude, it is essential to carefully weigh the risk of exposure to COVID-19 infection and the benefit of treating cancer patients during the pandemic. Trying to have a global guideline facing this or any other probable crisis is crucial for health care service.

Impact of the COVID-19 pandemic on cancer diagnosis, treatment and research in African health systems: a review of current evidence and contextual perspectives

The coronavirus disease 2019 (COVID-19) pandemic has immensely disrupted health care services globally. The pandemic has been particularly disruptive for cancer services and more so in low-resource settings. In this narrative review, we highlight the reported impact of the COVID-19 pandemic on cancer prevention, screening, diagnosis, treatment and research across the African continent. We also explore ways in which identified structural and contextual constraints can be navigated for the re-escalation of oncological activities, while discussing how the pandemic has necessitated the reimagination of how oncology services can be delivered now and in the future. We conducted a literature search of MEDLINE (via PubMed) and Scopus for relevant articles and synthesised the findings thematically. In spite of the dearth of data, available evidence suggests a substantial impact of the pandemic on the various aspects of cancer management in African countries. Aggravating factors include pre-existing health system and cancer management gaps in many countries within the region, which are typically faced with inadequate availability of oncology resources, oncologists and other vital resources; in addition to the acute and lingering consequences of social distancing, movement restrictions and other public health measures implemented to contain the spread of the virus. As the pandemic evolves and movement restrictions are eased, there is a need for the timely and safe return to normal oncological care. This will require a risk-adjusted and multidisciplinary approach, with the aim of mitigating the further impact of the disruption on cancer patients, their families and healthcare providers.