ACP Position Statement on COVID-19 and Cancer Care (Updated Feb 2021)
The ACP acknowledges the enormous impact of the COVID-19 pandemic on society, the entire UK health service, and especially on the provision of cancer care. With many lessons already learned from the first peak, we are now in a better position to use this knowledge to help inform and adapt our clinical practice and overcome the challenges of continuing to provide and maintain safe and effective oncology services in the months ahead.
One of the biggest challenges, which has received a lot of media publicity and support, has been the reluctance of patients to come forward with symptoms which may be cancer-related and one report has estimated that around 50,000 fewer cancer diagnoses have been made since the beginning of the pandemic.1 This is currently supported by an extensive TV cancer awareness campaign #HelpUsHelpYou.2 The ACP fully supports this campaign, and we continue to urge and encourage patients that, if they have any worries, they should not hesitate to seek medical advice. It is understandable that patients have concerns about the hospital environment, but we seek to provide reassurance that huge investment and many measures have been taken to make hospitals safer physical spaces, with strict adherence to improved hygiene and safety procedures. Regular and rapid provision of COVID testing of staff will help identify pre-symptomatic cases and take appropriate action.
Concerns about the spread of COVID through aerosol-generating diagnostic procedures have been largely resolved by the use of appropriate PPE and COVID screening. However, although substantial progress has been made, diagnostic services, including radiology, have still not returned to pre-COVID levels. Doctors, scientists and oncologists are all looking at alternative, less invasive, ways to make the cancer diagnosis, eg Ct-DNA.
There needs to be a balanced approach to the perceived increased risks of treating patients with chemotherapy during COVID. Emerging data demonstrate that there are some increased risks, but mainly seen in patients with haematological malignancies.3 In solid tumour chemotherapy, the level of risk is not as high as first thought. Research has shown that the immune response to COVID and recovery in patients with solid tumours was good; in contrast, patients with haematological cancers demonstrated delayed or negligible seroconversion, highlighting the need for careful oversight in these patients.4 In addition, there does not appear to be a much accentuated risk from immunotherapy or small molecule targeted drugs. NICE/NHSE rapid guidelines on systemic anticancer treatments have proved useful to allow modification of treatments, and permit the use of oral regimens and less immunosuppressive treatments and, together with remote consultations, can help reduce the need for patients to attend hospital. It is vitally important that we continue to treat patients with cancer as soon as can and continue to support them as we would pre-COVID.
Cancer clinical research has been hugely impacted by the COVID pandemic, with most trials paused for recruitment during the first peak and many research laboratories closed. Although some centres, particularly large academic institutions with a strong research framework, did see a near full recovery of their trials portfolio, suspension of clinical trials remains a massive issue in most parts of the country and there are concerns that, with the second wave, clinical research may be damaged irreparably for quite a while. However, most hospitals are still encountering issues with significant redeployment of research staff, together with competing and conflicting priorities at a trust level.
Some interventional trials are viewed as needing extra capacity to deliver, with additional hospital visits and longer treatment durations. Although the NIHR’s Restart Framework understandably prioritises COVID research, it does emphasise that non-COVID research must continue. The ACP supports the view that cancer research should be flagged as a higher priority as it does have the potential benefit of increasing survivorship.
During the first wave of the COVID-19 pandemic, there was huge public support for an already over-stretched hospital workforce. During the second wave, staffing levels are likely to be adversely affected with staff sickness and self-isolation. Studies of wellbeing and burnout in oncologists and other oncology professionals, supported by the ACP, acknowledge this to be a real and continuing issue,5 and the ACP continues to support an increase in the cancer workforce.
It is important that all aspects of cancer management continue uninterrupted and the cancer community continue to work towards delivering the service as far as is possible throughout the pandemic. The main risk for patients is progression of their cancer without treatment, rather than death from COVID-19.
In summary, the ACP makes the following recommendations:
- Encourage and educate patients with possible cancer-related symptoms to seek medical advice.
- Use of advanced diagnostics such as CtDNA.
- Patients and staff should be tested regularly for COVID-19 to ensure a safe environment for the delivery of SACT.
- Treatment should not be de-escalated or stopped without clear discussion with patients about the attendant risks and benefits.
- Full utilisation of the NICE guidance for cancer patients during the pandemic.
- Use of digital platforms to facilitate remote consultations.
- Ensure access of carers for end-of-life care discussions and treatment changes related to recurrence or progression of cancers.
- Continue to support clinical cancer research.
- Access and safety of COVID-19 vaccines for cancer patients and their carers; there is no contraindication to the use of current vaccines from Pfizer, Moderna or Oxford/Astra Zeneca in cancer patients. The UK Chemotherapy Board have produced guidance on vaccination in patients on SACT based on advice from the JCVI and the “Green Book”.6