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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 2  |  Page : 74-78

Effect of COVID-19 pandemic on oncology services and the impact of specific measures in reducing the delays


Department of Medicine, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia

Date of Submission12-Dec-2020
Date of Decision09-Jan-2021
Date of Acceptance13-Jan-2021
Date of Web Publication06-Aug-2021

Correspondence Address:
Dr. Khalid AlSaleh
Department of Medicine, Division of Hematology/Oncology (Oncology Center), College of Medicine and King Khalid University Hospital, King Saud University, Riyadh
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joah.joah_216_20

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  Abstract 


BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic has caused disruption of oncology services, but data on actual delays are lacking. We sought to study the delays faced by the cancer patients during the COVID-19 pandemic and the impact of measures carried out to reduce the delays.
METHODS: We carried out a review of inpatient and outpatient oncology services from March 15 to June 15, 2020, at our institution. We obtained data on delays in referrals, diagnosis, chemotherapy, and treatment delivery for cancer patients. To examine the delays, patients were assessed in the inpatient and outpatient settings and according to cancer types.
RESULTS: A total of 505 patients' events were included in the study, with 136 referral delays, 167 diagnostic delays, 121 chemotherapy delays, and 81 treatment delays. In the outpatient settings, maximum referral delays were faced by breast cancer patients (9.5 ± 3.3 days, range 7–14), followed by hematologic malignancy (hematology) patients (8.4 ± 4.5 days, range 0–14). Maximum diagnosis delay was faced by hematology patients (11.75 ± 5 days, range 0–14), followed by breast cancer patients (11.2 ± 3.4 days, range 7–14). Breast and colorectal cancer patients faced maximum chemotherapy delays (9.5 ± 6.6 days, range 0–14), followed by hematology patients (7.3 ± 6.6 days, range 0–14). In the inpatient setting, maximum diagnosis delays were faced by hematology patients (11 ± 2 days, range 10–14), followed by gastrointestinal cancers (8 ± 2.4 days, range 5–10). Maximum chemotherapy delays were faced by hematology patients (8.5 ± 5.9 days, range 0–14) and breast cancer patients (8 ± 2.4 days, range 5–10). Hematology patients were most affected by treatment-delays (6.75 ± 4.7 days, range 0–10). Comparison of delays during the earlier part of the study with the later part showed that referral delays improved by 3.5 days (P = 0.02), diagnosis delays improved by 6.1 days (P < 0.001), chemotherapy delays improved by 7.7 days (P < 0.001), and treatment delays improved by 8 days (P < 0.001).
CONCLUSIONS: COVID-19 pandemic caused delays in the diagnosis and management of most cancer patients. Measures adopted to overcome delays resulted in a significant reduction in delays.

Keywords: Cancer, coronavirus disease 2019, delay, oncology service, pandemic


How to cite this article:
AlSaleh K. Effect of COVID-19 pandemic on oncology services and the impact of specific measures in reducing the delays. J Appl Hematol 2021;12:74-8

How to cite this URL:
AlSaleh K. Effect of COVID-19 pandemic on oncology services and the impact of specific measures in reducing the delays. J Appl Hematol [serial online] 2021 [cited 2021 Dec 2];12:74-8. Available from: https://www.jahjournal.org/text.asp?2021/12/2/74/323332




  Introduction Top


Pandemics pose unique challenges and weigh heavily on health-care delivery systems around the globe. The coronavirus disease 2019 (COVID-19) pandemic, caused by the SARS–CoV-2, has disturbed all aspects of life[1] and posed unprecedented challenges to health-care systems. Limited movements due to lockdowns, appointment cancellation, and reduced hospital bed capacity have all contributed to limited services for non-COVID-19 patients.[2],[3]

Cancer patients frequently visit the hospital for diagnostic services, treatment, or follow-up, and the COVID-19 pandemic has posed novel challenges to the oncology services.[3] Cancer patients appear to be at increased risk of contracting SARS-CoV-2 as compared to the general population, with initial reports suggesting disproportionate vulnerability of cancer patients to COVID-19 infection.[4] Moreover, cancer patients are more vulnerable to COVID-19 complications with a higher likelihood of experiencing severe symptoms, requiring ventilatory support,[4] and increased mortality.[5],[6],[7] This might be related to the cancer itself causing an immune-compromised state, a treatment with chemotherapy, and/or immunotherapy, or the presence of comorbid conditions, rendering the patients unable to mount an immune response in the face of COVID-19.

These concerns, along with logistic and organizational issues, have all contributed to disruption and delays in the diagnosis and management of cancer patients during the COVID-19 pandemic. This has necessitated the implementation of strict infection control measures to protect the patients and staff and the development and application of guidelines for optimal management of cancer patients during the pandemic.[8],[9],[10]

With extended hours of curfew and travel restrictions in place in Riyadh and other cities in Saudi Arabia for the most part of March to June 2020, access to health-care facilities was restricted. In addition, shortages of staff and hospital beds due to exposure and quarantines, and relocation of staff and units to COVID-19 patients, caused significant disruption of oncology services and made it very challenging to accommodate all cancer patients. This study was conducted to assess the effect of the COVID-19 pandemic on oncology services, in terms of delays, in a tertiary care hospital in Saudi Arabia, and to evaluate the impact of measures taken to reduce the delays.


  Methods Top


This study assessed the impact of the COVID-19 pandemic on oncology services in terms of delays in referrals, diagnosis, treatment, and chemotherapy delivery for cancer patients at King Khalid University Hospital, Riyadh, KSA, from March 15, 2020 to June 15, 2020. Records of all cancer patients attending the oncology department during the study period were reviewed. This study was carried out as part of an audit to quantify delays and to assess the effectiveness of measures to reduce delays and to improve patient-centric services. All cases admitted or planned to be admitted to oncology inpatients or outpatient for diagnostic evaluation, treatment and chemotherapy, were included. One of the standard operating procedure during COVID-19 was to keep the admission and appointment to the chemo suite or inpatient under 10 days.

Data collection

We obtained data on delays in transfer and admission after referral, delays in diagnostic evaluation, (e.g., delay in performance of radiology scans or biopsies), and delays in treatment/chemotherapy, covering both inpatient and outpatient services. Any unplanned delay of the referral, diagnosis, or treatment/chemotherapy cycle(s) of one day or more was counted as an event. We excluded extreme cases/delays, which exceeded 3 standard deviations (SDs) (only 2 cases) as outliers. The study was approved by the institutional review board.

Definitions

To examine the delays, we categorized the setting into inpatient and outpatient (daycare). We also categorized patients based on cancer type and studied the delays in each category separately. Patients with types of cancer studied included breast, colorectal, gastrointestinal (GI), hematological malignancies (hematology), and others (genitourinary, liver, lung, and sarcomas).

We defined referral delay as the elapsed time between referral from another department and seeing the patient in the oncology department. Diagnostic delay was defined as the time lapse between the request of the diagnostic test or procedure (laboratory or radiology) and the actual performance of the test. The most common types of diagnostic or procedure delays included radiology scans and intervention procedures like biopsies and insertion of central lines. Treatment/chemotherapy delay was defined as the time difference between the required treatment/chemotherapy administration date and the actual booking date of the treatment/chemotherapy delivery. Any type of therapy other than chemotherapy was defined as “treatment,” which also included the insertion of central lines.

Measures to reduce delays

As part of the quality improvement plan, we also assessed the impact of specific measures carried out to reduce the delays. In brief, the measures included: (1) strict infection control measures and the use of telemedicine/virtual clinics to minimize the spread of infection and disruption of services, as described by us and others,[11],[12],[13] and (2) specific measures to reduce delays which included the rescheduling of appointments according to priority, the opening of extra slots for chemotherapy on weekends (Saturdays), and the accommodation patients wherever a bed could be available.

Statistical analysis

Descriptive statistics were computed as baseline means, SD, and minimum and maximum values for continuous variables. Delays (in number of days) caused by the COVID-19 disruption to referrals, diagnosis, chemotherapy, and treatment appointments, are presented as means ± SDs, along with ranges. Delays and number of patients affected over the study period (3 months) are provided as bar graphs. Students' t-test was used to compare delays during the earlier part of the study with the later part. We used the software STATA v. 13.0 (Stata Corp., College Station, TX, USA) for the analysis. A statistical significance threshold of P < 0.05 was adopted.


  Results Top


A total of 505 patients' events were included in the study, with 136 referral delays, 167 diagnostic delays, 121 chemotherapy delays, and 81 treatment delays.

Outpatient delays

In the outpatient setting (daycare), the maximum referral delay was faced by breast cancer patients (9.5 ± 3.3 days, range 7–14). Maximum diagnosis delay was faced by hematology patients at (11.75 ± 5 days, range 0–14), followed by breast cancer patients at (11.25 ± 3.4 days, range 7–14). In terms of chemotherapy delays, both breast cancer patients (9.5 ± 6.6 days, range 0–14) and colorectal cancer patients (9.5 ± 6.6 days, range 0–14) faced similar delays, followed by hematology patients (7.3 ± 6.6 days, range 0–14). We found breast cancer patients (12.2 ± 8.8 Days, range 0–12) to be most affected by treatment interruption, followed by colorectal cancer (6 ± 4.2 days, range 0–10) and hematology patients (6 ± 4 days, range 0–10).

Inpatient delays

In the inpatient settings, cancer patients admitted for interventional radiology procedures faced delays related to booking or availability of services, where the maximum impact was observed on hematology patients (11 ± 2 days, range 10–14), followed by GI cancers at (8 ± 2.4 days, range 5–10) and breast cancer patients (7.7 ± 1.5 days, range 7–10). The most common procedures getting delayed included diagnostic biopsy procedures and insertion of central lines. Maximum chemotherapy delay was faced by hematology patients (8.5 ± 5.9 days, range 0–14), followed by breast cancer patients (8 ± 2.4 days, range 5–10). Hematology patients were found to be most affected by treatment delays (6.75 ± 4.7 days, range 0–10), followed by others (5.6 ± 4.3 days, range 0–10).

To highlight the magnitude of staffing problems, there were 60 inpatient health-care workers (HCW) quarantined (mostly nurses) during the months of April and May, and 5 in June, while 20 outpatient HCWs (also, mostly nurses) were quarantined during the months of April and May, and 5 in June. [Table 1] presents delays in the number of days for referrals, diagnoses, chemotherapy delivery, and treatment for patients with different cancer types, (means with SDs and ranges). [Figure 1] and [Figure 2] present the number of patients with different types of cancers facing delays in the inpatient and outpatient settings, respectively. Of note, because of the restrictions and as the inpatient resources were diverted toward COVID wards, minimal new oncology inpatient referrals were observed during the study period.[14]
Table 1: Delays faced by oncology patients with different types of cancers during the study period

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Figure 1: Number of patients with different type of cancers facing coronavirus disease 2019 related delays in the inpatient setting

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Figure 2: Number of patients with different type of cancers facing coronavirus disease 2019 related delays in the outpatient setting

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Impact of specific measures to reduce delays

To assess the impact of measures to reduce delays, a comparison of delays during the earlier part with the latter part of the study showed that referral delay improved by 3.5 days (P = 0.02), diagnosis delay improved by 6.1 days (P < 0.001), chemotherapy delay improved by 7.7 days (P < 0.001), and treatment delay improved by 8 days (P < 0.001). [Figure 3] depicts the delays over the study months for breast and colon cancer patients and highlights the significant improvement achieved at the end of the study (month of June).
Figure 3: Comparison of delays faced by breast and colon cancer patients during the study months, showing a significant reduction in delays during the month of June

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  Discussion Top


The COVID-19 pandemic has caused an immense health-care burden globally and posed unprecedented challenges to non-COVID-19 medical areas, particularly cancer care services. Cancer care requires a multidisciplinary approach; the provision of cancer care is challenging even during normal circumstances because of its complexity and need for expensive resources.[11] Limited accessibility to medical facilities due to lockdowns, closure of many services, and patient reluctance to attend because of the fear of exposure to infection, have all contributed to delays in cancer diagnosis and treatment.[15],[16] Management pathways and guidelines have been modified to minimize the exposure of cancer patients to decrease the risk of infection and to optimize management.[8] However, even short delays in the treatment of many cancers can significantly impact patient survival and may result in increased mortality.[15],[17] Moreover, many screening programs have been on hold, reducing the chances of early diagnosis and likely compromising the outcomes. The National Cancer Institute has predicted tens of thousands of excess cancer deaths in the next decade as a result of delayed diagnosis and treatment due to the COVID-19 pandemic.[18]

Although the delay in the diagnosis and treatment of cancer patients has been commonly observed during the COVID-19 pandemic,[1] there is a paucity of data quantifying actual delays faced by cancer patients.[16] While several studies have reported quality-based steps to plan cancer care during the COVID-19 pandemic, data on the impact of actual disruption of cancer care services are lacking.[9],[10],[11],[12] Moreover, despite the publication of various regional and international guidelines and expert opinions on the management of cancer patients during the pandemic, the effect of the application of these recommended measures has not been well documented in an original research.[19]

Our study shows that oncology patients at our center faced significant delays in the diagnosis and treatment of most types of cancers during the height of the COVID-19 pandemic. Breast cancer patients faced the maximum delays along with patients with hematological malignancies. Patients with colorectal cancer and other types of cancers also suffered delays. This is despite the fact that there was an overall reduction in the referral of new cancer patients to our center since the outbreak, as has been observed in other parts of the world.[14],[20],[21],[22] As the follow-up of our patient cohort is short, the impact of these delays cannot be assessed for the time being, but we hope the impact on patient outcomes will be minimal/is minimal.

To our knowledge, this study is the first to document actual delays faced by cancer patients due to the COVID-19 pandemic, as well as to assess the impact of specific measures in reducing the delays. These data are important as they record the ongoing delays faced by cancer patients and can help to improve services. Our patients faced maximum delays during the month of April, but the delays decreased significantly during the month of June, particularly treatment and chemotherapy delays. This was achieved and made possible by the implementation of guidelines and specific measures, as mentioned earlier.

This study documents the significant disruption of cancer care services that situations like the COVID-19 pandemic can cause and demonstrates that the implementation of guidelines and specific measures are effective in reducing such delays.[23] Particularly, measures to accommodate patients in a flexible way by extending the services out of hours and over the weekends can help mitigate delays and restore near-normal delivery of care to cancer patients. As the COVID-19 pandemic continues with the possibility of further waves of viral spread over the coming months,[24] these measures should remain in place and be diligently followed to minimize the disruption of cancer care in the future, which will, hopefully, improve oncology patient outcomes in the long run.


  Conclusions Top


The COVID-19 pandemic caused delays in the diagnosis and management of most cancer patients. Implementation of guidelines and measures adopted to overcome delays were effective and resulted in a significant reduction in delays and the improvement of cancer care delivery. Physicians caring for cancer patients need to implement measures which carefully balance the risk of potential COVID-19 exposure with minimum disruption and optimal delivery of cancer care, to achieve the best possible outcomes.

Financial support and sponsorship

This study was supported by the College of Medicine Research Centre, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.

Conflicts of interest

There are no conflicts of interest.



 
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