The shortage of resources in healthcare systems around the world during the COVID-19 pandemic raise difficult ethical questions - not just around the treatment of patients infected with the virus, but also around the care provided to people with long-term illnesses such as cancer. Massimo Di Maio, Director of the Medical Oncology Division at Mauriziano Hospital and Professor of Medical Oncology at the University of Turin, Italy, insists that cancer patients should not be treated as a homogeneous category and that the intent of care does not have to be curative to be considered non-deferrable.
How has the COVID-19 outbreak affected your hospital’s resources?
Resource shortages have been a reality in every region affected by the outbreak. Italy’s national healthcare system was not prepared to sustain such a large number of critically ill patients at the same time. For instance, we have had problems obtaining enough masks of good medical-grade quality to use during our daily clinical practice. This has made the medical staff understandably nervous and has added to the most serious problem we are currently facing: a shortage of human resources on top of hospital resources. In the current situation, we would need many more physicians and nurses than under normal operating conditions. Instead, many colleagues in our existing hospital staff are falling ill with COVID-19 and we are running understaffed even by our usual standards. In addition, our hospital has been completely reinvented in the last three to four weeks because many divisions have been converted to COVID divisions, and a number of oncologists have been asked to assist there. As a result, in oncology, we are forced to reorganise all our activities on a daily basis.
A critical aspect of managing cancer patients who test positive to coronavirus is balancing the need to suspend cancer treatment against the risk of tumour progression. What is the common strategy adopted in these cases?
Unfortunately, there is not yet an established rule. Of course, you have to wait for the complete resolution of the infection in order to consider starting or continuing anti-cancer treatment. However, the optimal timing of re-treatment or delay is not well-known at the moment, so we are having discussions with colleagues and sharing clinical cases to discuss the best way to manage them. It very much depends on the situation - the type of cancer, the patient’s characteristics, the type of treatment and its intent: the risk you are exposing the patient to clearly varies according to these factors.
There have been reports that shortages of medical equipment in intensive care units have led to ageism in patient management there. How can these issues be addressed ethically and consistently, and where do cancer patients fit in?
It is extremely disturbing to hear that some patients will not get appropriate treatment and assistance because they are fragile or have a lower chance of surviving than others in a situation where not everyone can be given the best care . That’s why it is absolutely essential that oncologists are actively involved in discussing the prognosis and the management of cancer patients who are critically ill in COVID divisions. It would be wrong to consider all cancer patients as one homogeneous category: a person who received surgery three years ago for cancer and who is now free of the disease has a completely different prognosis from an advanced or terminally ill patient who received four lines of treatment and has disease progression. Aggressive intensive care could be appropriate in one case and may not be in the other. Cancer patients are worth discussing on a case-by-case basis and it is important that oncologists, who are well aware of this, communicate this message to other specialists.
What can oncologists contribute to discussions about palliative and end-of-life care in the current situation?
Properly accompanying patients who are transitioning from active treatment to palliative and end-of-life care is one of the most difficult issues we face at the moment. In oncology, although the activation of simultaneous care could make the transition easier, this is a phase in the disease trajectory that requires a lot of assistance in the hospital, involving a lot of visits and often repeated contact with the clinicians. In a context where the rule is to reduce contacts and access to the hospital, and where interactions with general practitioners and other healthcare services outside of the hospital have been suddenly reorganised, it becomes very difficult to guarantee physical assistance, pain control and home care for every patient who needs it. Unfortunately, suboptimal management is a risk we now commonly face in our daily practice.
However, as oncologists we consider this type of care to be non-deferrable, which is why all our efforts are going towards making sure that none of our cancer patients are left unattended. Moreover, this could be an occasion to implement the use of electronic patient-reported outcomes and telemedicine on a larger scale - also for the management of patients receiving active treatment - to help us better understand what patients need, if they have developed new symptoms, as well as which of their symptoms are not effectively controlled. Sometimes a simple phone call with the patient can allow a discussion of how to improve their quality of life.
In an editorial recently published in ESMO Open, you and other colleagues from Italian cancer institutes have shared the perspective of being young oncologists. What is the key message from this collaborative effort?
The key intent, not only of the editorial, but also of our interactions with colleagues in the last few weeks, has been to share every impression and experience, every consideration about the management of the pandemic, because we are more confident in making decisions if they are rooted in a commonly agreed-upon approach. Our goal is to come to a consensus on how best to manage our clinical activity for cancer patients during this time. The important message we conclude with is summarised by the acronym YOP, which stands both for our “Young Oncologists’ Perspective” and for the three facets of what we consider the biggest imperative to get through this crisis: protection. As fellow oncologists, we call on you to protect Yourselves, at work and in your personal lives; to protect Oncology care itself, by setting priorities while trying to minimise the emergency’s impact on the standard of care; and of course to protect Patients, by making sure they do not feel abandoned and continue receiving the care that is essential for their prognosis and for their disease. Our mission now must be to prevent cancer patients from being even more unfortunate than others in this generally unfortunate situation.