Scientific evidence is lacking in many domains as COVID-19 is a novel disease. Such situation prompted decision making processes in healthcare based on expert opinion. An article published on 16 April 2020 in the Nature Medicine features how seven comprehensive cancer centres within Cancer Core Europe have reorganised in a short time as a response to COVID-19 pandemic. They pinpoint critical research priorities with an aim to mobilise the global research community to generate the data and enable evidence-based remodelling of cancer care during the COVID-19 pandemic.
Cancer Core Europe operates as a legal entity since 2014 to maximise critical mass in cancer research. In particular, the Netherlands Cancer Institute, Karolinska Institute, Institute Gustave Roussy, Cambridge Cancer Center, Istituto Nazionale dei Tumori di Milano, German Cancer Research Center and Vall d’Hebron Institute of Oncology work closely together within this entity.
In their perspective article published yesterday, the Cancer Core Europe team describes the steps taken by their institutions to preserve high standards of cancer care during COVID-19 pandemic, while battling with shortages in personal protective equipment, beds, staff, etc. They provide an overview of their experiences, as well as common principles in general measures. They have also observed differences in specific implementation strategies, which are in part the result of the way healthcare is organised in different countries or the sense of urgency for action.
In terms of clinical activities, in German Cancer Research Center, Institute Gustave Roussy, Istituto Nazionale dei Tumori di Milano and Netherlands Cancer Institute which are institutions with dedicated cancer centres, there was an attempt to stay COVID-19 free facilities and to ensure that enough clinical and intensive care capacity could be reserved for critical cancer surgeries or management of side effects of systemic anticancer treatment. Such scenario allows local general hospitals to transfer cancer patients to these Cancer Core Europe centres for treatment. However, keeping Cambridge Cancer Center, Vall d’Hebron Institute of Oncology and Karolinska Institute as COVID-19 free was not a realistic or pursued goal as they are located within general hospitals.
The authors address in their article various aspects of adaptation of standard-of-care treatment regimens and underline that the COVID-19 pandemic offers a unique window of opportunity for assessing the effects of de-escalating anticancer regimens. They tackle also the problems of providing patient information and psychosocial care, as well as support of qualified personnel, capacity of cancer care facilities, downscaling research activities, organisational strategy to prepare for dynamic up- and downscaling, as well as preparing for the future.
They report that as of 2 April 2020, when the article was written, countries have employed two fundamentally different approaches to control COVID-19, namely suppression and mitigation. The choice of strategy is critical, as it determines how profoundly cancer care will be reorganised during the pandemic. From an oncological perspective, the authors wrote that a suppression strategy would be preferred, as successful nearly complete suppression has the potential to make COVID-19-adapted protocols for cancer care obsolete.
As resolving the current crisis may be a lengthier process, the oncologists urgently need models as well as the data to enable systematic, evidence-based assessments of the risk/benefit ratio of anticancer therapies during the COVID-19 pandemic. Although the treatment’s added benefit for cancer control under normal conditions is known for many anticancer treatments, there are many cases for which the effects of treatment modifications on cancer control are less clear. Therefore, it is critical that cancer centres collect as much as possible real-world information to quickly assess this.
For the immediate future, however, the treatment’s additional risk for COVID-19-related morbidity and mortality represents the most pressing knowledge gap. Estimation of the increased risk associated with anticancer therapy during the COVID-19 pandemic depends on a patient’s risk of COVID-19 over the course of the anticancer therapy and a patient’s additional risk for serious complications or death, in case the patient becomes infected.
The Cancer Core Europe team identified next research priorities to enable evidence-based adjustment of anticancer regimens during the COVID-19 pandemic:
- Collection of real-world data on the effects of adjusted and de-escalated treatment regimens on the outcomes of cancer patients.
- Determination of the symptomatic and asymptomatic incidence of COVID-19 by large-scale serological testing in the general population and in patients with cancer treated with chemotherapy, targeted therapy and immune checkpoint inhibitors.
- Development of an epidemiological model to estimate the cumulative incidence of COVID-19 for cancer patients within a specific timeframe.
- Determination of the COVID-19 morbidity and mortality in cancer patients treated with chemotherapy, targeted therapy, immune checkpoint blockade and/or G-CSF.
The Cancer Core Europe team foresee two future problems for cancer care caused by COVID-19 crisis. In particular, there are patients with less favourable outcomes who demand an explanation for why they are treated in a different way. In addition, reprioritisation of care will result in a queue of patients who need to undergo anticancer treatment in rapidly growing waiting lists.
van de Haar J, Hoes LR, Coles CE, et al. Caring for patients with cancer in the COVID-19 era. Nature Medicine; Published online 16 April 2020. DOI: https://doi.org/10.1038/s41591-020-0874-8