Question: My wife’s cancer surgery has been postponed because of the COVID-19 pandemic. We’re worried that the cancer could spread in the meantime. Could the delay in treatment affect her chances of survival?
Answer: Getting a cancer diagnosis is stressful enough at the best of times. But the pandemic has certainly added to the anxiety of many patients and their families.
To prepare for the expected surge in COVID-19 cases, hospitals have been putting on hold all elective or non-emergency operations – including many cancer surgeries.
This extraordinary step is being taken to conserve limited health-care resources and to help slow down the spread of the illness.
It’s also intended to protect patients. Coming to a hospital increases the likelihood that a patient will come into contact with a person who is infected with the novel coronavirus which is causing COVID-19.
And the last thing a cancer patient needs is a serious infection, says Dr. Maureen Trudeau, a medical oncologist at Sunnybrook Health Sciences Centre in Toronto.
“Cancer patients, in general, are probably sicker, probably have weaker immune systems and will probably do worse with a COVID-19 infection than other people,” she says. “You really don’t want them getting it.”
So, cancer-care providers across Canada are going through lists of patients to determine who needs immediate surgery and who can wait a while longer for an operation.
In Ontario, health-cancer teams are following guidelines that have been drafted by Cancer Care Ontario (CCO), which is now part of the provincial super-agency Ontario Health.
The guidelines, created in consultation with numerous experts, essentially create a priority list.
“If your tumour is growing rapidly, you will get your surgery,” says Dr. Trudeau.
A major consideration is whether a delay in a procedure could put the patient’s life at risk. That might include tumours that are bleeding or compromising another vital organ, says Dr. Frances Wright, a breast cancer and melanoma surgeon at Sunnybrook.
“At the local and provincial levels, people have really tried to prioritize who absolutely needs surgery – weighing the pros and cons of not having cancer surgery versus the risk of coming into hospital and potentially getting infected,” she says.
Many cancer patients want to receive treatment as soon as possible and they are understandably concerned that any delay – even for a brief period of time – could affect their chances of successfully overcoming the disease.
“Usually, cancers don’t change in days and weeks in terms of how they are progressing. And, in fact, rapidly progressing cancers represent the absolute minority of cases,” says Dr. Wright.
More typically, she adds, cancers tend to spread over a time frame of months and even years.
Although surgeries have been temporarily deferred for many cancer patients, this does not mean their treatments will come to a stop. Indeed, health-care providers might offer them other therapies or alter their treatment schedule.
“We are looking at changing the order of treatments,” explains Dr. Trudeau. “Rather than having surgery followed by chemotherapy or radiation, maybe we do chemotherapy or radiation first and then surgery.”
She notes that, in some cases, patients already receive chemotherapy (pills or intraveous medications) before surgery. The chemo can help to shrink a tumour and make it easier to remove.
Other patients might be candidates for endocrine or hormone therapy which is taken in pill form. Hormones such as estrogen and progesterone act as fuel for some tumours. So, endocrine therapy, which inhibits the body’s production of these hormones, can help to keep the cancer in check while a patient awaits surgery.
Dr. Wright says treatments will be “individualized” – or tailored to each patient’s needs, based on the type of cancer and the disease process.
Patients will be followed as closely as possible to make sure the cancer doesn’t unexpectedly take a turn for the worse, says Dr. Trudeau. Some appointments may also be done virtually rather than in person.
Despite these efforts to maintain care, the pandemic will still create challenges for delivering non-surgical therapies. Certain types of chemotherapy are given intravenously in medical clinics. How frequently and how long a patient receives chemo might need to be adjusted in order to reduce the time spent in public places, says Dr. Trudeau.
“All of the oncology teams are working together to come up with a safe process for everyone,” says Dr. Wright.