Coronavirus means difficult, life-changing decisions for me and my cancer patients
An article I wrote for the Guardian newspaper, published 19 March 2020
The way we treat cancer over the next few months will change enormously. As oncologists, we will have to find a tenuous balance between under-treating people with cancer, resulting in more deaths from the disease in the medium to long term, and increasing deaths from Covid-19 in a vulnerable patient population. Alongside our patients we will have to make difficult decisions regarding treatments, with only low-quality evidence to guide us.
The evidence suggests that people with cancer have a significantly higher risk of severe illness resulting in intensive care admissions or death when infected with Covid-19, particularly if they have recently had chemotherapy or surgery. Many of the oncology treatments we currently use, especially those given after surgery to reduce risk of cancer recurrence, have relatively small benefits.
In the current climate, the balance of offering these treatments may shift; a small reduction in risk of cancer recurrence over the next five years may be outweighed by the potential for a short-term increase in risk of death from Covid-19. In the long term, more people’s cancer will return if we aren’t able to offer these treatments.
In advanced cancer, can we justify offering treatments to improve quality and quantity of life if we potentially expose patients to severe Covid-19 infection that may kill? People on chemotherapy have been advised by the government to stay at home if possible. Yet people on chemotherapy will, inevitably, need to attend hospitals for treatment, which will increase their chance of infection. People on treatment who are doing their best to self-isolate but become unwell may be scared to come into hospital for assessment for fear of infection.
And what about cancer surgery? We simply don’t know how bad this is going to get for hospitals. Big cancer surgery often requires recovery in intensive care. If hospitals are inundated with sick patients with Covid-19, how many beds will be available for those needing cancer surgery? We just don’t know.
Our workforce will be reduced. We will be treating patients with, at best, simple face masks, gowns and gloves. We will get infected and at some point, we will need to stay at home. Oncology capacity, in terms of workforce and delivery, will be reduced significantly.
We may start by making decisions based on risk and benefit, but at some point we may have no choice but to stratify treatments according to priority. Our working patterns are already changing. We are switching to phone consultations when possible; minimising routine follow-ups; adding prophylactic drugs to chemotherapy regimes to minimise risk of complications requiring hospital admissions; trying to work out how on earth we best prioritise treatments when capacity is full. We are planning for the worst with no real idea how bad the worst might be. We are making judgments on risk without really understanding how high the risk might be.
The emotional consequences of all of this for people with cancer must not be underestimated. Nor can the emotional consequences on healthcare professionals working in oncology: we will be making difficult, life-changing treatment decisions without good evidence. We will be counselling against treatments we would normally recommend. We will, no doubt, see some patients die sooner, not because of coronavirus but because we are not able to treat their cancers as we would normally.
We will be watching patients, for whom perhaps this is their last summer, shut themselves off from the world, unable to do what they want to do with the time they have left. We will be watching patients go through cancer with fewer visitors, less contact with friends and families, and very possibly inferior treatments. And we will, in all likelihood, be keeping away from older people we love, to avoid passing on infection to them.
I feel unbearably sad when I put myself in the place of some of my patients who have already gone through the unimaginable because of their cancer. A 17-year-old who probably won’t be able to have the big 18th birthday party that has kept him and his family going since he started treatment; a young mum with two children who has to weigh up how much she isolates her kids while she continues treatment; patients who have just finished treatment, with expectations of a glorious spring; patients whose cancer has just returned, who now face difficult choices.
There is no doubt the next few months will be challenging on multiple levels, probably in ways we can’t yet imagine. But every day we learn from our patients who show us just how strong humans are in the face of adversity. And cancer services are made up of good people who are used to doing their best in difficult situations. That, I think, will be what gets us through.