By Professor Eva Segelov, Monash University, Melbourne.
Here we sit, in Australia, having furiously prepared for the potential of COVID-19 overwhelming our health system. With the mantra that we were “two to four weeks behind” Europe, Australian health services have been working overtime to redesign patient flow, redeploy personnel, secure PPE and implement telehealth. In the community, there was strong lobbying by both public health authorities and spontaneously-formed independent health care worker action groups for strict social distancing and lockdown. The aim of ‘flattening the curve” was precisely to control the infection to a level where ‘usual care’ was minimally impacted. Yet with the horror beaming in from Italy, France, Spain, New York and the UK, we did not really believe that we could escape this.
Provision of care for new and current patients with cancer and other chronic illness was front of mind to their clinicians and patient advocacy groups. We were acutely aware that the clinical load of COVID-19 in the northern hemisphere was so overwhelming that in many places, cancer services were severely impacted. Our patients became increasingly anxious about not getting appropriate care if they contracted COVID-19, nor for their underlying cancer. Discussion of ‘prioritisation’ of intensive care services from Italy and New York, along with the broad community debate about allowing herd immunity to develop by sacrificing the more vulnerable in our society, precipitated further alarm in already overburdened cancer patients and their families.
So we set about diligently preparing our cancer services, battling for attention within our health system with its huge momentum of COVID-19 preparation; something not even in our vocabulary just four months prior. We gathered informal expert groups using our personal networks, initially frustrated at the reluctance of some of our formal bodies to take leadership in coordinating recommendations in this space. There was an explosion of whatsapp, facebook and telegram groups, connecting individuals through many different threads of commonality. As well as important messages and data sharing, memes kept our sense of humour and morale high. The overarching question: What should we do in this evidence-free wasteland to keep our cancer patients safe? What was enough and what would be too much?
One weekend in early March, a collection of around 15 individuals - not all initially known to each other - met by zoom and over a furious week of videocalls, thrashed out the key issues that we thought would confront Australian cancer patients and services. A document was produced that first articulated broad principles but then moved to detail specific options for consideration in adapting patient care by tumour type. The paper aimed to serve an audience comprising not only highly subspecialised oncologists, but general oncologists, physicians and even general practitioners, who it was anticipated may have to care for cancer patients without the usual backup and guidance.
Soon our national cancer and specialty groups came on board and endorsed these guidelines. Many other craft and health service consortiums produced valuable documents, covering a broad spectrum of anticipated scenarios. Protocols were shared for service delivery adaptation based on reduction in staffing, move to home or community-based services, and rationalisation of treatment (including switch to oral or subcutaneous medication, consideration of treatment de-escalation, shorter regimens or treatment holidays). Fearing the increased reporting of significant nosocomial spread of COVID-19, we lobbied government to relax some of the very tight restrictions for reimbursement of cancer drugs and services, to allow options requiring less hospital visits (sadly still awaiting changes). Suddenly, we were advised that health workers were now cross-registered to allow deployment in any service within the state, even in the private sector. For oncology, we could use this to plug workforce gaps arising from COVID-19 (but not, unfortunately, to address long term disparities!)
In the state of Victoria, a Cancer and COVID-19 Taskforce was established, with an excellent portal providing resources and connection for discussion of issues by theme, including not only tumour types but telehealth, ethics and patient communication. Patient resources and assistance included boosting of help lines and translation of COVID-19 information for our Culturally and Linguistically Diverse communities. There was frantic data gathering to collect the changes to cancer care that different jurisdictions had made and were planning. Many surveys were distributed, to the point where one of my colleagues answered that the greatest stress he faced was answering surveys!
A huge amount of change in a short time, with uncertainty, fear and oftentimes mixed messages. Lots of community and expert debate. Working from home, changes to schooling and the huge economic impact across the community. I look at my wardrobe full of fancy suits each morning, as I don my tracksuit. Now organising a zoom party for the ASCO plenary session - hmmm, what to wear?
The calm before the storm persisted. With 72 deaths to date, and now very few cases diagnosed daily even with extensive testing, it is very much looking like the pandemic is under control in Australia. The message has turned to articulating exit strategies and the best way for a slow release of the societal brake. Suddenly there is thought of COVID-19 eradication, as per our neighbour New Zealand, not conceived possible initially, when containment was the goal. And in the health system and for our cancer patients, we now need to decide “What next?”. Recommencing cancer screening and non-emergency cancer surgery is a high priority. There may in fact be a ‘mini-tsunami’ of new cancer patients, where people present having previously been reluctant to attend health services and have symptoms investigated. Meanwhile our resources remain largely diverted within hospital settings, poised to flex for a COVID-19 spike; cautiously reclaiming them is likely to take many months.
Undoubtedly, our health system has changed forever, even in the absence of the catastrophe faced by almost every other country around the globe. Evolutions in cancer service delivery have occurred that we would be well placed to continue beyond the pandemic: telehealth as the norm; treatments at home or in community-based centres; a deeper conversation about ‘competing risks of death’ when prescribing treatments of potentially marginal benefit significance; levels of inter-hospital and interdisciplinary co-operation not imaginable several months ago. Although there is a lurking shadow of reduced health budgets and research funding for ‘usual care’, as a legacy of the COVID-19 outlay.
These are ‘problems’ that we all hoped (but didn’t really quite believe) that we would be facing. There is a huge sense of pride and team spirit within Australia (not withstanding our New Zealand colleagues who continue to voice their superiority!), although much caution about not wasting this advantage and ‘sticking it out for the long haul”. For our cancer patients, the pandemic has bought great anxiety but also a very rapid pointy end to designing truly patient-centred systems, as keeping cancer patients safe and at home is the ultimate patient-centred care goal. Now it behoves all of us to make this legacy, in the name of those who have died for it, last to the benefit of us all.
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