One of the questions in response to the blog post https://winstonliauw.com/2021/01/01/what-will-a-covid-19-endemic-world-look-like/ was what would be the impact on oncology?
The impact on COVID-19 on oncology may vary quite a bit from country to country depending on the degree to which the healthcare system coped: in some countries there have been huge impacts on presentations with cancer and in some cases the ability to provide timely treatment. Where I work, in New South Wales, Australia, there has been negligible impact on the new cancer notifications and little reduction in the capacity to provide care.
The first major observation is that the pandemic acts as an accelerant driving change that was already happening in healthcare. The most obvious change is in virtual care including telehealth. When the pandemic starting impacting healthcare services activities in virtual care that had been trundling along with pilots and limited implementations over a decade were suddenly scaled up and implemented in a matter of weeks. In Australia, telehealth was ultimately catalysed and embraced by the medical community when fee-for -service arrangements were recognised after many failed years of lobbying. The systems aren’t perfect but they are now here to stay.
The acceptance and adoption of telehealth-related technologies including both software and (mobile) hardware enable a number of important activities that are useful in oncology. It can provide capacity for home-based care, particularly when monitoring is required. Being able to detect a deteriorating patient at home when they are being treated for specific conditions allows for rapid intervention. There will be increased capacity for shared care with primary care physicians and both in the treatment and survivorship phases of care more care can be delivered in a virtual fashion. Enhancing the ability to provide 24/7 care is particularly important for patients receiving palliative and terminal care.
Capturing patient reported outcome measures (PROMS) as well as patient reported experience measures (PREMS) is a high priority in the field of oncology as this has been shown to improve symptom management and oncologic outcomes, potentially reduce costs of care, and also can enhance the patient experience. In a virtual care environment PROMS and PREMS potentially become even more important as they can be incorporated into the workflow of a telehealth consultation to capture information that in turn guides the clinician as to how to direct the consult.
The response to COVID-19 in oncology/haematology led to rationalisation of care protocols for many situations. In oncology and many other fields a lot of unnecessary care was identified and suspended at least temporarily. The classic example is fractionation regimens in radiation oncology. Shifting to hypo-fractionated regimens is a much debated area of clinical variation in routine care but once there was a need to minimise patient visits to healthcare settings and to ration linear accelerator time it made instant sense to adopt such protocols. Whether or not these changes will stick will depend on time. Fortunately the impact in terms of outcomes can also be monitored via cancer registries.
One of the observations I made in my practice was that at the time there were restrictions on visiting hospitals and lockdowns were in place some of my patients re-considered their goals of care and decided against active treatment in favour of quality of life at home. The pandemic has re-ignited the need to have goals of care discussions and establish advanced care directives.
The biggest logistic challenge cancer services face is a consequence of the successes of new cancer therapies over the last 30 years and in particular the last decade. Essentially all common cancer types and many rare cancers have effective 1st-line and 2nd-lines of therapy and in some cases many more. In cancers like breast cancer screening, early detection and highly effective adjuvant therapy have increased the numbers in survivorship care. Many incurable/metastatic cancers now can be chronic disease with many patients living for years with cancer and the burden of treatment. Many of the treatments aren’t low toxicity treatments that can just be taken at home. Often the therapies are intravenous and repeats fortnightly to monthly for long periods of time. This has lead to a substantive increase in activity both in terms of visits to cancer specialists and visits for treatment. This growth in activity is not sustainable without having impacts on patient care such as increased waiting times which in their own right result in inferior outcomes.
Addressing the increased activity could be addressed by increasing resources but this is not likely to happen. Investment will be in physical infrastructure to boost the economy and the prospects of politicians. We will need to take many of the learnings from the pandemic to manage this problem. This will include development of novel models of care that exploit virtual care and in closely looking at what is necessary care versus optional care, how the care is delivered and by whom. Reducing arguably unnecessary follow-up of probably cured patients to free-up resources for chronic care cancer needs to be considered.
Oncology, as a subset of the whole healthcare system, will change long-term in response to COVID-19 but these changes were already happening and we haven’t been wasting the opportunity of a good crisis.