Continuity of Cancer Care: The Surgical Experience of Two Large Cancer Hubs in London and Milan

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.

The experience of surgical cancer patients during the COVID-19 pandemic at a large cancer centre in London

BACKGROUND

The COVID-19 pandemic has had an enormous impact on the experiences of patients across all health disciplines, especially those of cancer patients. The study aimed to understand the experiences of cancer patients who underwent surgery during the first two waves of the pandemic at Guy's Cancer Centre, which is a large tertiary cancer centre in London.

METHODS

A mixed-methods approach was adopted for this study. Firstly, a survey was co-designed by the research team and a patient study group. Patients who underwent surgery during the COVID-19 pandemic were invited to take part in this survey. Results were analysed descriptively. Three discussion groups were then conducted to focus on the main themes from the survey findings: communication, COVID-19 risk management and overall experience. These discussion groups were transcribed verbatim and underwent a thematic analysis using the NVivo software package.

RESULTS

Out of 1657 patients invited, a total of 250 (15%) participants took part in the survey with a mean age of 66 (SD 12.8) and 52% females. The sample was representative of a wide range of tumour sites and was reflective of those invited to take part. Overall, the experience of the cancer patients was positive. They felt that the safety protocols implemented at the hospital were effective. Communication was considered key, and patients were receptive to a change in the mode of communication from in-person to virtual.

CONCLUSIONS

Despite the immense challenges faced by our Cancer Centre, patients undergoing surgery during the first two waves of the COVID-19 pandemic had a generally positive experience with minimal disruptions to their planned surgery and ongoing care. Together with the COVID-19 safety precautions, effective communication between the clinical teams and the patients helped the overall patient experience during their surgical treatment.

Evaluation of treatment delays in hepatopancreatico-biliary surgery during the first COVID-19 wave

INTRODUCTION

The COVID-19 pandemic has caused oncological services worldwide to face unprecedented challenges resulting in treatment disruption for surgical patients. Hepatopancreatico-biliary (HPB) cancers are characterised by rapid disease progression. This study aims to assess delays in receiving surgery for this patient cohort during the first COVID-19 wave.

METHODS

Patients undergoing surgery between April and July 2020 (COVID-19 period) were compared with a control group from the preceding year. Delay in receiving surgery was defined as more than 50 days between referral and surgery date. Statistical analysis was carried out to evaluate predictors of delay and short-term outcomes.

RESULTS

During the COVID-19 and pre-COVID-19 periods, 94 and 115 patients underwent surgery, respectively. No patients contracted COVID-19 postoperatively. Some 118 patients waited more than 50 days for surgery versus 91 who received surgery within 50 days from referral. Independent predictors for surgical delay were undergoing surgery in the COVID-19 era (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.2-4.1; p=0.015), referral pathway (OR 35.1, 95% CI 4.2-296; p=0.001) and presenting pathology (OR 8.3, 95% CI 1.2-56.1; p=0.03). Short-term outcomes were comparable between groups.

CONCLUSIONS

Patient referral pathway and presenting pathology may contribute to delays in undergoing HPB cancer surgery during COVID-19 outbreaks. It is hoped that a better understanding of these factors will aid in designing shifts in healthcare policy during future pandemic outbreaks.

Has the COVID-19 pandemic changed the clinical picture and tumour stage at the time of presentation of patients with colorectal cancer? A retrospective cohort study

Introduction

Treatment of patients with Coronavirus Disease 2019 (COVID-19) has affected the management of patients with colorectal cancer (CRC). The aim of this study was to compare the diagnosis delay, symptoms, and stage of patients with CRC during the pandemic with a control cohort.

Material and methods

Patients referred to the CRC multidisciplinary team between September 2019 and January 2020 (cohort 1, control group) were compared with those who presented between September 2020 and March 2021 (cohort 2, pandemic group).

Results

389 patients were included, 169 in cohort 1 and 220 in cohort 2. No differences were observed in the main characteristics of the patients. CRC screening and anaemia were the most common causes leading to the diagnosis of the tumour in cohort 1 and 2, respectively (p < 0.001). Diagnostic and therapeutic delay was longer in cohort 2 [6.4 (95% CI 5.8-6.9) vs. 4.8 (95% CI 4.3-5.3) months, p < 0.001]. More patients required non-elective treatment in the pandemic cohort (15.5% vs. 9.5%, p = 0.080). The tumour stage was more advanced in patients in cohort 2 [positive nodes in 52.3% vs. 36.7% (p = 0.002), and metastatic disease in 23.6% vs. 16.6% (p = 0.087)].

Conclusion

CRC patients in the pandemic cohort had a longer diagnostic and therapeutic delay and less patients were diagnosed because of CRC screening. In addition, patients with CRC during the pandemic needed non-elective treatment more frequently than patients in the control cohort, and their tumour stage tended to be more advanced.

Has the COVID-19 pandemic changed the clinical picture and tumour stage at the time of presentation of patients with colorectal cancer? A retrospective cohort study

INTRODUCTION

Treatment of patients with Coronavirus Disease 2019 (COVID-19) has affected the management of patients with colorectal cancer (CRC). The aim of this study was to compare the diagnosis delay, symptoms, and stage of patients with CRC during the pandemic with a control cohort.

MATERIAL AND METHODS

Patients referred to the CRC multidisciplinary team between September 2019 and January 2020 (cohort 1, control group) were compared with those who presented between September 2020 and March 2021 (cohort 2, pandemic group).

RESULTS

389 patients were included, 169 in cohort 1 and 220 in cohort 2. No differences were observed in the main characteristics of the patients. CRC screening and anaemia were the most common causes leading to the diagnosis of the tumour in cohort 1 and 2, respectively (p<0.001). Diagnostic and therapeutic delay was longer in cohort 2 [6.4 (95% CI 5.8-6.9) vs. 4.8 (95% CI 4.3-5.3) months, p<0.001]. More patients required non-elective treatment in the pandemic cohort (15.5% vs. 9.5%, p=0.080). The tumour stage was more advanced in patients in cohort 2 [positive nodes in 52.3% vs. 36.7% (p=0.002), and metastatic disease in 23.6% vs. 16.6% (p=0.087)].

CONCLUSION

CRC patients in the pandemic cohort had a longer diagnostic and therapeutic delay and less patients were diagnosed because of CRC screening. In addition, patients with CRC during the pandemic needed non-elective treatment more frequently than patients in the control cohort, and their tumour stage tended to be more advanced.

A 3D Ex Vivo Tumor-Immune Coculture System Mimicking In Vivo Tumor Environmental Stress on CD8+ T Cells Exhaustion

Dissection of exhaustion trajectories of immune cells under tumor selection pressure in the tumor microenvironment (TME) elucidates the underlying machinery in anti-tumor immunity, which still lacks easy-to-use models to decipher. Herein, gelatin methacryloyl (GelMA)-poly (ethylene oxide) (PEO) based 3D hydrogel microspheroids are constructed with non-immunogenicity and controllable macroporous structure to establish a tumor-immune cell coculture (3D-HyGTIC) system. In 3D-HyGTIC system, when immune cells embarked, stepwise up-regulation of main immune checkpoints (ICs) molecules is observed with compromised cytokine production in CD8⁺ T cells, the trajectory of which is in lineage correlation with in vivo grafted tumors. Reinvigoration of CD8⁺ T cells is more obvious with the addition of an anti-PD-1 regimen at the early time point, which is recapitulated during the coculture of patient-derived tumor fragments (PDTF) and autologous T cells. Moreover, the upregulation of LAG-3 on CD8⁺ T cells after anti-PD-1 treatment is uncovered. Sequential addition of anti-LAG-3 successfully rescues the otherwise failed reactivation of CD8⁺ T cells. Therefore, the 3D-HyGTIC system is not only inclined to mimic the early differentiation trajectories of tumor-infiltrating CD8⁺ T cells but also may facilitate an evaluation of the efficacy of IC blockades and guide the designing of combination immunotherapy.

Long-term effects of COVID-19 on cancer patients: the experience from Guy's Cancer Centre

Background: Few studies have investigated the long-term effects of COVID-19 on cancer patients. Materials & methods: The authors conducted a telephone survey on the long-term symptoms of cancer patients from Guy's Cancer Centre. They compared patients whose symptoms occurred/got worse over 4 weeks after COVID-19 diagnosis (classified as long COVID) with patients who did not develop symptoms or whose symptoms occurred/got worse in the first 4 weeks after diagnosis. Results: The authors analyzed responses from 80 patients with a previous COVID-19 diagnosis; 51.3% (n = 41) developed long COVID. The most common symptoms were fatigue, breathlessness and cognitive impairment. Conclusion: Findings suggest that over half of the cancer population will experience long-term effects after their initial COVID-19 diagnosis. Further studies are required to validate the findings of this study.

Safe Surgery During the COVID-19 Pandemic

PURPOSE OF REVIEW

Coronavirus Disease-2019 (COVID-19) has had an enormous impact on all aspects of healthcare, but its effect on patients needing surgery and surgeons has been disproportionate. In this review, we aim to understand the impact of the pandemic on surgical patients and teams. We compiled the emerging data on pre-operative screening methods, vaccinations, safe-surgery pathways and surgical techniques and make recommendations for evidence-based safe-surgical pathways. We also present surgical outcomes for emergency, oncological and benign surgery in the context of the pandemic. Finally, we attempt to address the impact of the pandemic on patients, staff and surgical training and provide perspectives for the future.

RECENT FINDINGS

Surgical teams have developed consensus guidelines and established research priorities and safety precautions for surgery during the COVID-19 pandemic. Evidence supports that surgery in patients with a peri-operative SARS-CoV-2 infection carries substantial risks, but risk mitigation strategies are effective at reducing harm to staff and patients. Surgery has increased risk for patients and staff, but this can be mitigated effectively, especially for elective surgery. Elective surgery can be safely performed during the COVID-19 pandemic employing the strategies discussed in this review.

Radical cancer treatment is safe during COVID-19: the real-world experience of a large London-based Comprehensive Cancer Centre during the first wave

Background

During the COVID pandemic, there was a paucity of data to support clinical decision-making for anticancer treatments. We evaluated the safety of radical treatments which were delivered whilst mitigating the risks of concurrent COVID-19 infection.

Methods

Using descriptive statistics, we report on the characteristics and short-term clinical outcomes of patients undergoing radical cancer treatment during the first COVID-19 wave compared to a similar pre-pandemic period.

Results

Compared to 2019, the number of patients undergoing radical treatment in 2020 reduced by: 28% for surgery; 18% for SACT; and 10% for RT. Within SACT, 36% received combination therapy, 35% systemic chemotherapy, 23% targeted treatments, 5% immunotherapy and 2% biological therapy. A similar proportion of RT was delivered in 2019 and 2020 (53% vs. 52%). Oncological outcomes were also similar to pre-COVID-19. The COVID-19 infection rates were low: 12 patients were positive pre surgery (1%), 7 post surgery (<1%), 17 SACT patients (2%) and 3 RT patients (<1%). No COVID-19-related deaths were reported.

Conclusions

Whilst there were fewer patients receiving radical anticancer treatments, those who did receive treatment were treated in a safe environment. Overall, cancer patients should have the confidence to attend hospitals and be reassured of the safety measures implemented.

Primary care and cancer: an analysis of the impact and inequalities of the COVID-19 pandemic on patient pathways

OBJECTIVES

We explore the routes to cancer diagnosis to further undertanding of the inequality in the reduction in detection of new cancers since the start of the pandemic. We use different data sets to assess stages in the cancer pathway: primary care data for primary care consultations, routine and urgent referrals and published analysis of cancer registry data for appointments and first treatments.

SETTING

Primary and cancer care.

PARTICIPANTS

In this study we combine multiple data sets to perform a population-based cohort study on different areas of the cancer pathway. For primary care analysis, we use a random sample of 5 00 000 patients from the Clinical Practice Research Datalink. Postreferral we perform a secondary data analysis on the Cancer Wait Times data and the National Cancer Registry Analysis Service COVID-19 data equity pack.

OUTCOME MEASURES

Primary care: consultation, urgent cancer referral and routine referral rates, then appointments following an urgent cancer referral, and first treatments for new cancer, for all and by quintile of patient's local area index of multiple deprivation.

RESULTS

Primary care contacts and urgent cancer referrals in England fell by 11.6% (95% CI 11.4% to 11.7%) and 20.2% (95% CI 18.1% to 22.3%) respectively between the start of the first non-pharmaceutical intervention in March 2020 and the end of January 2021, while routine referrals had not recovered to prepandemic levels. Reductions in first treatments for newly diagnosed cancers are down 16.3% (95% CI 15.9% to 16.6%). The reduction in the number of 2-week wait referrals and first treatments for all cancer has been largest for those living in poorer areas, despite having a smaller reduction in primary care contact.

CONCLUSIONS

Our results further evidence the strain on primary care and the presence of the inverse care law, and the dire need to address the inequalities so sharply brought into focus by the pandemic. We need to address the disconnect between the importance we place on the role of primary care and the resources we devote to it.

The impact of hospital attendance on COVID-19 infection in cancer patients: an assessment of data from Guy's Cancer

Objective: The authors monitored positivity rates of asymptomatic SARS-CoV-2 tests during the second wave of COVID-19 at Guy's Cancer Centre. Methods: Logistic regression was used to investigate factors associated with asymptomatic COVID-19 positivity rates between 1 December 2020 and 28 February 2021 (n = 1346). Results: Living 20-40 km and 40-60 km from the alpha variant was associated with a reduced chance of a positive SARS-CoV-2 test compared with 0-20 km (odds ratio [OR]: 0.20; CI: 0.07-0.53 and OR: 0.38; CI: 0.15-0.98, respectively). An increased number of tests was associated with an increased chance of a positive SARS-CoV-2 test (OR: 1.10; CI: 1.04-1.16). Conclusion: The COVID-19 positivity rate of asymptomatic cancer patients is partly due to increased testing, with some contribution from the proximity of the patient population to the epicenter of the alpha variant.

Association between COVID-19 burden and delays to diagnosis and treatment of cancer patients in England

Background

Methods

Results

Conclusion

Policy summary

Impact of the COVID‐19 pandemic on urological cancers: The surgical experience of two cancer hubs in London and Milan

Objective

Materials and Methods

Results

Conclusion

Fewer head and neck cancer diagnoses and faster treatment initiation during COVID-19 in 2020: A nationwide population-based analysis

Background

Inevitably, the emergence of COVID-19 has impacted non-COVID care. Because timely diagnosis and treatment are essential, especially for patients with head and neck cancer (HNC) with fast-growing tumours in a functionally and aesthetically important area, we wished to quantify the impact of the COVID-19 pandemic on HNC care in the Netherlands.

Material and Methods

This population-based study covered all, in total 8468, newly diagnosed primary HNC cases in the Netherlands in 2018, 2019 and 2020. We compared incidence, patient and tumour characteristics, primary treatment characteristics, and time-to-treatment in the first COVID-19 year 2020 with corresponding periods in 2018 and 2019 (i.e. pre-COVID).

Results

The incidence of HNC was nearly 25% less during the first wave (n = 433) than in 2019 (n = 595) and 2018 (n = 598). In April and May 2020, the incidence of oral cavity and laryngeal carcinomas was significantly lower than in pre-COVID years. There were no shifts in tumour stage or alterations in initial treatment modalities.

Regardless of the first treatment modality and specific period, the median number of days between first visit to a HNC centre and start of treatment was significantly shorter during the COVID-19 year (26–28 days) than pre-COVID (31–32 days, p < 0.001).

Conclusion

The incidence of HNC during the Netherlands’ first COVID-19 wave was significantly lower than expected. The expected increase in incidence during the remainder of 2020 was not observed. Despite the overloaded healthcare system, the standard treatment for HNC patients could be delivered within a shorter time interval.

Coping With Oral Tongue Cancer and COVID-19 Infection

To date, April 19, 2021, the coronavirus disease 2019 (COVID-19) caused about 140,886,773 confirmed cases and more than 3,000,000 deaths worldwide since the beginning of the pandemic. Oncology patients are usually frail due to the fear of prognosis, recurrence, and outcomes of treatments. Thus, coping with cancer is a complicated process that is necessary to overcome oncological challenge, even more in case of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) disease. This is a brief case report on a middle-aged man affected by advanced oral tongue cancer and COVID-19, describing his experience of cancer diagnosis, surgical treatment, and rehabilitation during the hospital quarantine for COVID-19. Besides the traumatic experience due to the functional alteration in breathing, eating, and speaking caused by major surgery and the concurrent facial disfigurement, our patient had to face a COVID-19 diagnosis, which implied hospital and social isolation. The aim of this perspective work is to focus on the role of the psychological support in the management of hospital distress related to COVID-19 psychophysical loneliness or alienation. In our experience, such support should anticipate patients' oncological surgery or treatment and should be implemented through telemedicine in case of isolation or after hospital discharge.