Managing cancer in the light of the COVID-19 pandemic

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ACHAIKI IATRIKI | 2025; 44(3):131–137

Review

Ourania Kyriakopoulou1, Dimitra Koumoundourou2, Christos Michailides3, Maria Lagadinou3

1Emergency Department, University Hospital of Patras, Greece
2Department of Pathology, University Hospital of Patras, Greece
3Department of Internal Medicine, University Hospital of Patras, Greece

Received: 30 May 2024; Accepted: 05 Nov 2024

Corresponding author: Ourania Kyriakopoulou, Emergency Department, University Hospital of Patras, Rion 26500, Greece, E-mail: rkyriakopoulou@gmail.com

Keywords: Cancer management, COVID-19, pandemic

 

Abstract

Since the emergence of the COVID-19 pandemic, several domains of healthcare delivery have been profoundly transformed and deprioritized in order to confront the unprecedented crisis. As with many other chronic health conditions, cancer patients have experienced to a great extent detrimental impacts on their routine management.

Due to the pandemic, cancer screening programs were significantly interrupted, and treatment schedules were modified, leading to delayed diagnosis and worse outcomes overall. Furthermore, given their immunosuppressive status, cancer patients were disproportionately affected by COVID-19, resulting in increased morbidity and mortality. Scientific research, traditionally focused on oncology care, has been suspended, curtailing available treatment options and long-term development. Throughout this new era, massive efforts to mitigate adverse implications for cancer patients have deployed telemedicine to maintain universal and optimal care. In association with variations in digital literacy competencies and level of access to innovative technologies that complicate the immediate adaptation of telemedicine in oncology, considerable cancer-related health disparities have escalated and need to be addressed. The recent pandemic brought out several dysfunctions regarding the management of healthcare crisis. Thus, stakeholders should invest in preparedness plans and effective policies to confront future challenges without jeopardizing the continuum of cancer care.

Introduction

In December 2019, a novel coronavirus, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2), was isolated in Wuhan, China, and was identified as the causative agent of Coronavirus Disease-2019 (COVID-19) [1]. The unprecedented worldwide spread of the virus urged the World Health Organization (WHO) to declare COVID-19 as a pandemic on March 11, 2020 [2]. Currently, the world has surmounted the global threat, but the pressure posed to healthcare and financial systems due to the COVID-19 pandemic is still apparent.

Globally, cancer –including solid tumors and hematological malignancies- is the second leading cause of mortality. As a result of the enormous “public health crisis” since the beginning of the pandemic in early 2020, many aspects of cancer care were dramatically affected, and health workers in the oncology community struggled to provide their patients with appropriate treatment in this challenging context of universal emergency concern. Over the last decades, substantial progress in oncology has been achieved through the early detection of new cases with screening and implementation of effective treatment modalities [3]. Unfortunately, the progress mentioned above has been endangered by the reallocation of healthcare staff and facilities. Despite all efforts to preserve resources, a detrimental impact on every aspect of cancer care remains a major concern.

Throughout the pandemic, cancer patients, by definition susceptible to infectious agents, experienced a higher risk of viral transmission and a disproportionate number of adverse outcomes including hospitalization, ventilation, and death [4]. The negative impact of the COVID-19 pandemic on oncologic patients was also reflected in the decline of cancer screening, the deceleration of cancer diagnosis rates, the increase in newly diagnosed cases at advanced stages, and the eventual rise in mortality. Hence, maintaining the cancer care continuum during the pandemic proved to be more than just a significant challenge for most oncologists, and medical societies instituted concrete recommendations to ensure best practices [5].

The present article aims to clarify the complex aspects of cancer management during the COVID-19 pandemic. Particular emphasis will be given to several factors that contributed to a “delayed” healthcare system regarding cancer management. Hopefully, patients and cancer caregivers can benefit from strategies designed to confront future challenges stemming from the recent pandemic, with a focus on preparedness from a global standpoint.

Patients with cancer are vulnerable to COVID-19

Even though patients with cancer present a diverse clinical course of COVID-19 disease ranging from mild to extremely severe cases, they are indiscriminately designated as a susceptible population subgroup at increased risk of severe morbidity and mortality [4]. Apart from the immunocompromised status caused by the disease, the more significant weakening of their immune system derives from the cytotoxic treatments they receive either through chemotherapy, radiotherapy, or immunomodulatory agents. Further complexity in dealing with these patients arises due to the usually advanced age, overall impaired health status, and underlying chronic comorbidities such as diabetes, hypertension, and lung disease [6].

Significantly, a considerable confusion results from the difficulty of diagnosing COVID-19 infection in cancer patients, given that clinical signs of both diseases often overlap. To avoid underdiagnosis, reverse transcription polymerase chain reaction (PCR) and computed tomography (CT) scans are highly recommended to clarify the diagnosis among cancer patients [7].

Considering the increased risk of adverse outcomes for cancer patients, since late 2020, they have been prioritized to receive COVID-19 vaccination, including both primary and booster regimens. However, significant uncertainty remains regarding less effective immunological responses, and further clinical research is needed to establish the vaccines’ efficacy among patients with cancer [8].

With the rapid spread of COVID-19, the overburdened hospitals, and frequent shortages of staff, equipment, and pharmaceutical supplies, clinicians faced ethical dilemmas regarding life support for patients infected by COVID-19 who also had a poor overall prognosis due to cancer per se. In fact, many practitioners inevitably discussed proactive palliative and end-of-life plans with patients in such difficult scenarios. Applying medical ethics in practice was paramount in delivering optimal treatment to most patients with the appropriate allocation of resources [9].

COVID-19 and its impact on cancer screening programs

Since 2020, national authorities worldwide have enforced restrictive measures towards interpersonal distancing to hinder the COVID-19 spread. Many cancer screening procedures have been disrupted and subsequently delaying the diagnosis of tumors that traditionally benefit from early detection, such as breast, colon, cervix, and prostate cancers [3].

The necessity to shift medical services to address the burden of COVID-19 and adaptations of policies to mitigate exposure, forced many cancer centers to temporarily decelerate screening programs for adults. Furthermore, out of fear of exposing themselves to the virus, people showed remarkable reluctance to attend healthcare appointments, as revealed by the increased cancellations and postponements of scheduled visits [10].

Significant declines in screening procedures have been noticed regarding invasive procedures such as colonoscopy, the cornerstone of colorectal cancer diagnosis, compared to the non-invasive mammography and Papanikolaou smear tests, tools for early detection of breast and cervical cancer, respectively [10].

It is of great interest in the context of colon cancer that many countries have adopted “neglected” alternative approaches to counteract the damage caused by reduced surveillance colonoscopies. Integrating the fecal immunochemical test (FIT) to detect hidden blood in the stool, which can be efficiently performed even in the domestic setting, was associated with an additional colon cancer diagnosis rates [11]. Furthermore, many cancer institutions have adopted the option of computed tomography colonoscopy (CTC), a faster procedure that aligns with mandates of restricted patient-staff contact [12].

Data derived from a broad spectrum of oncology centers in different parts of the world brought to light the anticipated impacts of the curtailed screening programs, including the slower rate of precancerous lesion detection, upstaging at delayed diagnosis, increased unresectable or metastasized disease, more aggressive and complex treatment interventions, and eventually, increased mortality [13][14]. Managing advanced cancer stages at diagnosis requires more intense treatments, increasing healthcare costs. In extremely advanced cases, palliative care may be the only option instead of curative intention. Medical communities estimate that the financial burden and the workload of caregivers have been aggravated due to the surge of cancer diagnoses in the post-COVID era. Health systems’ capacity has been temporarily overwhelmed and failed to meet patients’ needs for optimal cancer care [15].

Challenges of cancer treatment during the pandemic

Delivering cancer treatment during the COVID-19 era presented unique challenges, and especially at the beginning of the pandemic, it was a subject of vigorous debate among clinical oncologists. At first, reductions in immunosuppressive treatment appeared as a sensible approach in order to protect cancer patients from contracting COVID-19 infection. On the other hand, maintaining intensive therapeutic protocols for patients with impaired immune systems in a time of uncertainty could endanger any possible benefit. In response to pragmatic needs regarding cancer treatment during the pandemic, stakeholders from medical societies published recommendations on patients’ management during this complex and constantly evolving situation while assuring their safety, autonomy, and participation in the decision-making process [5].

Cancer experts, therefore, outlined three priority levels (high, medium, and low) to deliver strong guidance to patients and healthcare professionals regarding the degree of necessity for treatment. The decision-making process encompassed the tumor’s aggressiveness, performance status, potential risks and benefits, and gains in terms of overall survival (OS), quality of life (QoL), and patient preferences [5]. Another critical issue to consider, while prioritizing cancer treatment and care intensity, was the epidemiological features and local Ro index (measure to estimate how many people would be infected by a single case) of the disease and the available resources [16].

Generally, all cancer patients should be provided with health education and be aware of any warning symptoms and signs of an underlying infectious process. Outpatient visits, during the COVID-19 era, were restricted to the most acceptable and safe level, mainly during the peak period of the epidemic.

It was recommended that patients requiring active treatment in the form of chemotherapy or surgery should receive timely, appropriate treatment to ensure curative outcomes. According to scientific bodies’ advice and individual clinical judgment, delays in delivering treatment and elective surgeries should remain within safe time boundaries.

Furthermore, modifications to cancer treatment regimens to mitigate the risk of exposure to the virus emerged as practical, safe, and effective options. Such options included delivering extended dosing intervals of cancer, switching patients with stable disease from intravenous to oral route treatment, and considering intermittent chemotherapy for appropriate cases when scientifically justified [17].

Moreover, another critical issue was patients’ mental health and psychological disorders that affected this population subgroup, leading to impaired chemotherapy adherence and a worse prognosis [18].

Impact of the pandemic on cancer research

Cancer researchers made substantial efforts to maintain their scientific work intact, provide innovative treatments and ensure patients’ benefits during the pandemic. Scientific research projects in oncology also dealt with inevitable challenges during the pandemic due to limited or interrupted clinical trials worldwide [10].

During the COVID-19 pandemic, the imposed restrictions and measures affected the physical access of researchers to the laboratories resulting in a shortage of human staff dedicated to monitoring or enrolling new participants in clinical trials [19].

Moreover, oncology trials are, by default, extremely demanding processes affecting patients and their families. Participation in a study requires considerable time allocation, travelling, and a meticulous record of signs and symptoms, which further inhibit patients΄recruiting, particularly in the context of a pandemic. Interestingly, a clinical trial implemented remote electronic consent (e-Consent) in order to maintain recruitment for research regarding prostate cancer patients [20]. Consistently, clinical trial stakeholders emphasized the importance of maintaining ongoing studies by reinforcing patients’ safety and strengthening remote assessments via digital communication. Additionally, clear guidance was provided to prioritize Phase II and III trials but temporarily ceased the early phase ones [21].

Use of telemedicine in oncology care during COVID-19 times

The COVID-19 pandemic dramatically changed how healthcare was delivered worldwide, prompting healthcare providers to reframe the existing context. In a global effort to compensate for the disrupted medical services, adapting telemedicine as an alternative option rapidly began to expand worldwide. Τelemedicine and teleoncology, in particular, are defined as medicine conducted remotely, a process that harnesses digital strategies to maintain the continuum of cancer care, improve cancer patients’ access to treatment and reduce the travel burden [22].

Before March 2020, the use of telemedicine in oncology was limited, mostly to patients in remote areas. Additionally, telemedicine was treated with skepticism for several decades. Patients and caregivers crave detailed information about their disease, treatment plans, and interaction with their physicians, and a virtual visit might not fulfill this distinct need. However, given the new scene in healthcare delivery induced by COVID-19, many oncology societies and institutions recommended and adopted digital solutions to alleviate the multifaceted, adverse effects of the pandemic and tackle healthcare facilities towards universal coverage [22]. By definition, telemedicine is being conducted through various approaches, including phone calls, video calls, and remote patient monitoring [23].

The rapid escalation of telemedicine options during the recent pandemic highlighted its beneficial role in many aspects of cancer care. Specifically, telemedicine assures convenience, safety regarding the risk of exposure, and decreases health-related costs by reducing emergency visits and the need for travel, especially for residents in rural areas. Since most oncology institutions are usually located in big cities, telemedicine strategies to reach remote patients might also reduce geographical inequities [22].

The application of telemedicine during the recent pandemic received an enormous boost through its impact on cancer prevention, screening, and treatment. Interestingly, prevention campaigns for smoking cessation through mHealth (mobile health) are considerably effective strategies in most countries. Additionally, teleconsultation approaches to maintain cancer screening programs amid the pandemic were of paramount importance. Furthermore, medical organizations such as the European Society for Medical Oncology (ESMO) highly recommend integrating digital technology in patients’ assessment regarding toxicity evaluation, dose regimens adjustment, symptoms management, and even supportive and palliative care approaches in end-stage disease [5][22].

The use of telemedicine during the SARS-CoV-2 pandemic waves promoted capacity building for many healthcare professionals through virtual training sessions focused on managing respiratory failure derived from COVID-19 infection. Remote monitoring of patients participating in clinical trials was also achieved through telemedicine [22].

It is of great interest that a considerable body of literature critically assesses and delineates patients’ satisfaction with the transformed cancer care they receive. Promising results regarding telemedicine arose from a European multicenter study which enrolled 829 patients with various non-metastatic cancers and evaluated effects of remote monitoring of chemotherapy related side-effects through novel technologies. The reduction of symptom burden and enhanced health-related quality of life parameters in the intervention group favored remote monitoring systems [24]. Further evidence from published data demonstrates that virtual visits gain ground over in-person visits. Patients were satisfied and confident with the quality of care and considered telemedicine a safe and effective strategy during the epidemic [25][26]. The policy above might not fit with the diagnosis of a new cancer case that carries unique patterns of anxiety and depression and therefore demands extended in-person visits and particular psychological support [26].

Routine implementation of telemedicine policies addresses several barriers, including digital literacy and access variances. Disparities in digital literacy across diverse demographics, including advanced age, lower socioeconomic status, and individuals of racial or ethnic minorities, build obstacles to the universal implementation of telemedicine and widen health inequalities. It has been postulated that a significant portion of the population owning digital devices like smartphones may still lack the skill to download applications for video visits or they do not even have an e-mail address at all. Furthermore, financial constraints to accessing technological devices further deteriorate the practical application of telehealth strategies. Additionally, impaired internet speed at different geographical locations may discourage patients and providers from adopting virtual visits [22].

Though inherent difficulties in navigating a relatively new model such as telemedicine are recognized, there is an urgent need to increase and maintain digital technologies beyond the recent pandemic. Prioritization of reducing telemedicine access inequities and getting acquainted with the digital world is essential for yielding optimum outcomes for cancer patients in the future.

Proposal for cancer patient management

The COVID-19 crisis instigated unexpected challenges to cancer care delivery. Healthcare systems, initially unprepared, were obliged to adjust their routine activities to compensate for the decline of medical services triggered by the pandemic. Consequently, a profound reorganization of oncology institutions, communities and cancer management overall, took place globally to accommodate current distinctive demands (Table 1).

At the beginning of the recent pandemic, the availability of healthcare for non-COVID-19 patients and specifically for cancer patients was significantly decreased in terms of screening, diagnosis, and treatment, especially in countries with a higher prevalence of COVID-19. The impact of haltered screening procedures and delayed diagnosis has been revealed and affected long-term mortality and survivorship [27].

Implementing vaccination programs and reducing COVID-related restrictions recently enabled oncology communities to recommence their routine activities. Interestingly, innovative strategies regarding cancer care, experimented with throughout the COVID-19 period, could serve as a blueprint for future pandemic strategies.

A fundamental principle during public health emergencies is prioritizing patients by urgency and fragility and better allocating available resources. Importantly, oncology healthcare resilience amid crisis demands preserving continuity of care and ensuring access to medical services.

In the current setting, it is imperative to promote cancer screening through increased public awareness and better health education via technology facilities. Broadcasting informational programs in mass media encourages compliance with screening programs. Moreover, supporting campaigns for preventive health protocols to address patients’ reluctance to present to oncology institutions due to fear of exposure warrants enhanced participation in screening and treatment procedures [11]. In the short term, oncology wards should designate safe cancer hubs to accommodate patients, meeting preventive and control needs.

Establishing alternative low-cost options of self-testing at home, within the patients’ comfort zone, offers flexibility that ensures adherence to screening and counters impaired access to services of the underserved population [12]. Additionally, stakeholders should engineer outreach activity systems to track patients in communities and enhance their access to provided services to retain the stability of screening and diagnosis [15].

There is an urgent need to optimize telemedicine beyond the recent pandemic since appropriate integration of this relatively new technology in cancer care revealed the potential to mitigate significant challenges posed by COVID-19. Full utilization of telemedicine during the pandemic and rapid adaptation from patients and physicians, in many cases, emphasized the need for proper training and primarily for equitable access to continue inroads into universal health care. While facing difficulties needed to overcome, such as variances in digital literacy and access, it seems beyond doubt that telemedicine accounts for an innovative approach to cancer care delivery in terms of cost, convenience, safety, and satisfaction [23].

Unfortunately, a considerable proportion of the population failed to achieve adequate cancer care and precautions during the recent pandemic, including self-protection from exposure, optimal screening and treatment options, advanced technology for remote assessment, and psychological support. Furthermore, the COVID-19 pandemic brought health inequalities into focus, affecting to a greater extent diverse aspects of cancer care for racial and ethnic minorities as much as aged people or those of middle and low socioeconomic status. It is critical for medical communities and national authorities to resume collaboration and accelerate efforts to strengthen public health interventions, promote health coverage and minimize inequities in the post-pandemic era.

During the pandemic, the global health community learned that most issues regarding chronic conditions, such as cancer, derived from the lack of preparedness plan. At this time of recovery and rehabilitation, with the increased likelihood of impending pandemics, healthcare systems should further invest in designing wise approaches and feasible policies to deter future “disasters” without compromising essential functions such as qualitative cancer care.

Conflict of interest disclosure

None to declare

Declaration of funding sources

None to declare

Authors’ contribution

All authors contributed equally to the completion of this narrative review

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