Seeking the balance point and taking the first steps in decision making
James Fleck: Anticancerweb 28 (04), 2020
Despite the difficulties expected in the organization of health resources during a pandemic, the predicted problems can be mitigated with a rational approach. The social distance strategy was promoted as an effective historical alternative toward early intervention during outbreaks of rapidly evolving diseases. Promptly, lead time is used to better equip the health system, providing conditions to support the growing demand. The COVID-19 Dashboard by the Center for Systems Science and Engineering at Johns Hopkins is now showing worldwide more than 3 millions confirmed cases, leading to 212,221 deaths. The health care system in some European countries and some US states has already faced and are still struggling with undesirable overload. Patients with comorbidities are at higher risk for severe acute respiratory syndrome and need for Intensive Care Unit (ICU) support. Data, first reported from China, revealed 39% of COVID-19 confirmed cancer patients requiring ICU support. This finding, although preliminary, has generated uncertainties in the recommendations for diagnosis, treatment and monitoring of cancer patients. This is an unusual time when the guidelines for cancer treatment need to be temporarily revised. Although it is impossible to use a single model, the general recommendations would contribute to a better organized system. In addition, our current knowledge of tumor biology and its clinical behavior has shown that some tumors do not require immediate intervention.
Recently published in Annals of Internal Medicine, the article called "A War on two Fronts" draws attention to the treatment of cancer during the COVID-19 pandemic. A group of well-recognized physicians from the Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA, proposed general recommendations for cancer care as long as the pandemic scenario persists. Suggestions were made based on patient protection. The strategy emphasizes the concept of mitigation. The reduction of severe cases in the health system reduces the risk of overload, preventing an unacceptable increase in the mortality rate. The natural vulnerability of cancer patients, ironically combined with adverse events related to surgery, chemotherapy or radiation therapy, requires a balanced decision-making process. In this atypical period of time, some diagnostic and therapeutic procedures can be postponed with relative safety due to the indolent biological behavior of some tumors. On the other hand, aggressive tumors must be treated immediately. Looking both ways in the current pandemic scenario, cancer screening should be postponed and futility should be avoided, more than ever, in terminally ill patients. In clinical trials, the integrity of ongoing studies should be preserved, with special attention to patient safety during the pandemic. Telemedicine should be implemented, providing good quality services and avoiding unnecessary traveling to a health care facility. As history has shown, the pandemic will pass, but a lesson on adaptive flexibility will be learned.
References:
1. Alexander Kutikov, David S. Weinberg, Martin J. Edelman, Eric M. Horwitz, Robert G. Uzzo, and Richard I. Fisher: A War on Two Fronts: Cancer Care in the Time of COVID-19, Annals of Internal Medicine, March 27th, 2020.
2. Wenhua Liang, Weijie Guan, Ruchong Chen, et al: Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China, Lancet Oncol, Feb 14th, 2020
3. Image: Photo by Jossuha Théophile composed with the CDC photo published in Unsplash
Covid-19’s high mortality rate among cancer patients highlights the need to reorganize protocols and guidelines in a pandemic scenario. Thus, the benefits of scientific and technological advancements becomes clear, mainly by means of molecular discrimination as a tool to predict prognosis which leads to the best recommendations to face crises with the least possible harm.
The most appropriate and beneficial conduct for each ailment at any given time is constantly revised and subject to change, based on the most recent and accurate scientific evidence, as well as on environmental circumstances; such is the case during the current SARS-CoV-2 pandemic and oncology as a field is no exception. As stated in the articles, due to the indolent nature of some neoplasms - such as skin and thyroid cancers -, interventions (ranging from surgery to chemotherapy or radiation therapy) and screenings can be momentarily delayed up to and about 3 months without representing any additional risks, on the contrary, mitigating damage to vulnerable patients and avoiding unnecessary exposure of frail and immunocompromised individuals to additional pathogens. Physicians, thus, must hearken to the evidence and expeditiously adapt the protocols and guidelines already in place.
Although the article says that some surgeries and screening tests can be delayed due to the pandemic, it is important to make it clear that patients who are already undergoing treatments, like chemotherapy or radiation therapy, should not interrupt their current treatment on their own. All decisions must be taken in conjunction with the medical team.
Undoubtedly, the COVID-19 brought challenges that require a temporary restructuring of health care in the world. It is necessary to assess risks and benefits for the best management possible of patients in these times. Therefore, postponing non-urgent diagnostic and therapeutic procedures seems to be the most prudent action at the moment. On the other hand, the pandemic can also be seen as an opportunity for the health care model that we currently use to be reinvented and even improved. Telemedicine, for example, is essential right now and will prove to be a great asset even after the pandemic.
The sad scenario of the pandemic raised doubts about the treatment of cancer. This article is enlightening in the aspect of cancer treatment in the pandemic and this is mainly due to the article “A War on two Fronts” which proposed suggestions such as: some diagnostic and therapeutic procedures should be postponed when the tumor is indolent, but that we must immediately treat aggressive tumors.
More than a year after this article was written, I think that its view still describes the current scenario we’re living in. In Brazil we are, yet, living moments where hospitals need to direct their human resources from all sectors to take care of patients with COVID-19, at the cost of reducing time for treating other diseases, like cancer. For patients that are very ill, with bad prognosis, physicians need to think twice before beginning a treatment with highly toxic potential and side effects, because it can make patients more vulnerable in a critical time where health resources are restrict.
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