Introduction

Since its launch in May 2019, the All.Can efficiency hub has published examples of innovative solutions to improve the efficiency of cancer care, ranging from child-friendly imaging machines and guidance for cancer survivors to rapid learning health systems and digital follow-up platforms.
The importance of efficiency has become more evident than ever following the outbreak of the COVID-19 pandemic. As healthcare systems adapt and restructure to manage this crisis, we must focus on using resources efficiently and effectively to support the fight against COVID-19, minimise the impact of the pandemic on cancer services and patient outcomes, and protect people with cancer, their families and carers from infection.
The All.Can efficiency hub hopes to contribute to these efforts by sharing innovative examples of how cancer care is adapting in response to COVID-19.

Minimising the risk of COVID-19 infection

The Tata Memorial Centre in Mumbai,  India has implemented measures to safely postpone hospital visits and reduce overcrowding in its clinics.1 It set up screening stations outside the hospital to first screen people for potential COVID-19 infection and then review whether a hospital visit was urgent or could be safely postponed.

While this approach reduced crowds in the hospital by almost 35%, it was resource-intensive and unsuitable for people travelling long distances to be seen at the hospital.1 Therefore, doctors began conducting telephone consultations ahead of booked clinic appointments. They reviewed medical records and cancer symptoms, addressed concerns, recommended further testing where needed (to be conducted locally) and postponed in-person visits where possible. These visits could be safely postponed for up to 80% of patients and people felt reassured following direct telephone contact with their treating doctor.1

Healthcare systems in various countries have introduced ‘COVID-free centres’ to continue essential services for cancer, including surgery, chemotherapy, radiotherapy and provision of medicines. This approach has been easier to implement and maintain in dedicated cancer centres that do not offer healthcare for other conditions.2 However, access to dedicated cancer centres may vary based on location, and cancer services in general hospitals may carry a higher risk of COVID-19 infection. To address this issue, the National Health Service in England  has designated 21 healthcare centres as regional ‘COVID-free hubs’ dedicated solely to cancer care.3

Reducing the burden on emergency care

The Seattle Cancer Care Alliance in the United States (US) launched an Acute Evaluation Clinic specifically for cancer- and treatment-related pain and symptoms.4 People with cancer often present to emergency care for these issues and the Acute Clinical Evaluation clinic offers an alternative route for support.

The clinic is staffed by physician assistants or nurse practitioners (known as ‘advance practice providers’) who are highly trained and educated similarly to doctors. Cancer care teams can refer people for a variety of issues including gastrointestinal discomfort, fever, dehydration, dizziness and light-headedness, difficulty swallowing, urinary tract infections, swelling and skin conditions.4

Shifting to digital and telehealth solutions

Healthcare providers are using remote monitoring systems to provide ongoing support to people with cancer, even with reduced face-to-face contact. These systems typically collect healthcare data from people with cancer and notify healthcare professionals when a person’s health status changes.5

The Gustave Roussy Cancer Institute in France uses a remote monitoring system to collect daily symptom reports from people with cancer and confirmed COVID-19, who are isolating at home.6 Nurses monitor these reports and arrange admission to emergency care or COVID-19 wards if needed, and people can contact their care team directly using the system’s secure messaging feature.

Researchers are developing artificial intelligence to distinguish between symptoms of COVID-19 and side effects from lung cancer treatment, as both can include a cough, breathlessness and inflammation in the lungs.7 The study, conducted at the Royal Marsden NHS Foundation Trust in the United Kingdom (UK), aims to make this distinction by using machine learning to analyse computed tomography (CT) scans. This tool will help clinicians rapidly identify the cause of symptoms and select appropriate treatment for patients.7

Changes in reimbursement policies reflect the shift towards telehealth. Previously, telemedicine was often only reimbursed when provided by certain physicians and for specific conditions.8 The Centre for Medicare and Medicaid Services in the US recently expanded its telehealth reimbursement policy to include more healthcare professionals and services in response to the COVID-19 outbreak.5 This enabled cancer care providers to shift towards telehealth, with one oncology network reporting a safe reduction in physical clinic attendance by up to 80%.

Similarly, the National Institute for Health and Disability Insurance in Belgium temporarily expanded insurance policies for healthcare professionals to include telehealth approaches, which means that multidisciplinary oncology teams can now conduct their meetings virtually.9 10

Sharing information and best practice

Cancer associations and centres have set up online platforms to share information and best practice regarding cancer care and COVID-19. Memorial Sloan Kettering Cancer Center in the US, for example, has set up a COVID-19 Innovation Hub webpage to make safety innovations and relevant knowledge available to the public.11

Both the American Association of Cancer Institutes (AACI) and Association of Community Cancer Centers (ACCC) have introduced members-only forums to discuss challenges and best practices surrounding COVID-19.12 13 The AACI hosts its forum on Slack and the ACCC has an online member community called ACCCExchange. These platforms support rapid communication between cancer centres. For example, cancer centres hit hardest by COVID-19 are sharing best practice with centres beginning to feel the impact of the pandemic via ACCCExchange.13

Adapting cancer research

Clinical trials are being adapted to ensure continuation of valuable cancer research during the COVID-19 pandemic.14 The outbreak has led to a significant drop in trial enrolment, while researchers have been forced to adapt ongoing studies in line with public health considerations.

The National Cancer Institute in the US, for example, is now shipping some drugs directly to people enrolled in its clinical trials, eliminating the need for people to pick up their medication at a clinic or hospital.14 It is also relying on local doctors to manage tasks that were previously performed at large trial centres. Such tasks include administering drug infusions, collecting samples, conducting laboratory tests and completing patient assessments.

Testing innovations from the cancer world for COVID-19

Researchers in the UK are examining whether dogs can be trained to detect COVID-19 in people, even before the onset of symptoms.15 The study, still in its initial phase, is funded by the UK government and led by researchers at the London School of Hygiene and Tropical Medicine and Durham University, in collaboration with the charity Medical Detection Dogs.

Bio-detection dogs have previously been trained to identify the presence of cancer in patient samples, alert people with diabetes about low blood sugar and detect pre-symptomatic malaria.16 If this approach proves accurate and reliable, bio-detection dogs could offer a fast and non-invasive way to test for COVID-19 in the future.

Protecting healthcare professionals from exposure to COVID-19 during oral cavity biopsies

A team at the Tata Memorial Centre in Varanasi, India, has developed a disposable customised aerosol containment chamber to protect surgeons from potential exposure to COVID-19 during oral cavity cancer biopsies.17 Oral cavity cancers account for 10% of cancer incidence in India,18 but biopsies have become an increasingly challenging procedure during the COVID-19 pandemic due to the high risk of exposure to saliva, nasal secretions and coughing.

The chamber looks like a plastic tent with a filter attached for air supply, covering the patient and shielding the surgeon during an oral cavity biopsy. It is made from materials that are cheap, disposable and readily available in most operating theatres. It offers a simple and easily replicable solution that can be implemented across low-resource settings to protect healthcare professionals and avoid potential delays in diagnostic procedures for oral cancer during the COVID-19 pandemic.

Shifting to online support for people with cancer and their caregivers

Many patient organisations have turned to technology to maintain activities during the COVID-19 pandemic. Action Bladder Cancer UK purchased online videoconferencing licenses and made them freely available to bladder cancer support groups wishing to conduct virtual meetings.19 They developed guidance on hosting and attending virtual meetings for group leaders, and their support officers are available to provide additional help – for example, to conduct test runs or facilitate presentations during meetings.

Another patient organisation, the Workgroup of European Cancer Patient Advocacy Networks (WECAN), used an unconditional COVID-19 educational grant to support video conferencing for their members. The grant part-funded licenses, equipment (e.g. cameras and microphones) and the development of a dedicated online resource centre with information on hosting online meetings and webinars.20 WECAN also collected COVID-19 resources created by its member organisations on a single webpage.

Using innovation from the cancer world to support COVID-19 research

The outbreak of COVID-19 created intense demand to speed up standard research procedures, and innovation from cancer research is being used to meet this global challenge. The canSAR database in the UK is capable of processing billions of cancer research findings in a matter of minutes.21 It was expanded to include a COVID-19 arm (Coronavirus canSAR), which generates daily summaries of global information about COVID-19, its impact on the human body and potential treatment options. Through artificial intelligence, Coronavirus canSAR helps researchers to rapidly identify and prioritise the most promising opportunities for new therapies based on emerging evidence.21

In another innovative move, DreamLab, a commercial mobile application used for cancer studies, is now also being used to support research into the treatment of COVID-19, thanks to a new partnership between Vodafone Foundation and Imperial College London.22 DreamLab enables users to lend the data processing power of their smartphones to research studies.23 No personal data is downloaded to or processed from the user’s smartphone. Instead, DreamLab connects to a cloud-based processing network while smartphones are on charge overnight. This is a highly efficient approach – for reference, a desktop computer would take decades to process the same amount of research data as a network of 100,000 smartphones.23

References:

  1. Indian Journal of Cancer. The COVID-19 pandemic and the Tata Memorial Centre response 2020 Available here: http://www.indianjcancer.com/article.asp?issn=0019-509X;year=2020;volume=57;issue=2;spage=123;epage=128;aulast=The [accessed: June 2020]
  2. van de Haar J, Hoes LR, Coles CE, et al. Caring for patients with cancer in the COVID-19 era. Nature Medicine 2020;26(5):665-71
  3. Moss L. 2020. Coronavirus: Thousands of cancer ops at 'Covid-free' hubs [online]. Available here: https://www.bbc.co.uk/news/health-52454831 [accessed: June 2020]
  4. Seattle Cancer Care Alliance. 2020. Seattle Cancer Care Alliance (SCCA) Opens Acute Clinical Evaluation Clinic, Enhancing Medical Oncology Care. Available here: https://www.seattlecca.org/sites/default/files/page_content/2020-05/SCCA_ACE_Clinic.pdf [accessed: June 2020]
  5. DiGiulio S. 2020. Oncology's Telehealth Growth in the COVID-19 Pandemic [online]. Available here: https://journals.lww.com/oncology-times/blog/onlinefirst/pages/post.aspx?PostID=2112 [accessed: May 2020]
  6. Scotté F, Minvielle E, Mir O, et al. 2020. A patient reported outcome platform, a useful tool to improve monitoring and effective management of Covid-19-positive patients with cancer. European journal of cancer (Oxford, England : 1990) 132: 1-4
  7. Brogan C. 2020. AI being developed to help cancer patients during the COVID-19 pandemic. Available here: https://www.imperial.ac.uk/news/197433/ai-being-developed-help-cancer-patients/ [accessed: May 2020]
  8. Liu R, Sundaresan T, Reed ME, et al. 2020. Telehealth in Oncology During the COVID-19 Outbreak: Bringing the House Call Back Virtually. JCO Oncology Practice 16(6): 289-93
  9. Rijksinstituut voor ziekte- en invaliditeitsverzekering. 2020. COVID-19: Vergoedingen voor verstrekkingen op afstand zonder fysiek aanwezigheid. Available here: https://www.riziv.fgov.be/SiteCollectionDocuments/20200429-prestations-distance-tabel-nl.pdf [accessed: June 2020]
  10. Rijksinstituut voor ziekte- en invaliditeitsverzekering. 2020. Medisch advies via de telefoon: een specifiek honorarium gedurende de COVID 19-crisis. Available here: https://www.inami.fgov.be/nl/nieuws/Paginas/specifiek-honorarium-medisch-advies-telefoon-covid19.aspx [accessed: June 2020]
  11. Memorial Sloan Kettering Cancer Center. 2020. MSK COVID-19 Innovation Hub. Available here: https://www.mskcc.org/clinical-trials-updates/msk-covid-19-innovation-hub [accessed: June 2020]
  12. Association of American Cancer Institutes. 2020. AACI COVID-19 Resources. Available here: https://www.aaci-cancer.org/covid-19-resources
  13. Association of Community Cancer Centers. 2020. Cancer care in the time of COVID-19. Available here: https://www.accc-cancer.org/acccbuzz/blog-post-template/accc-buzz/2020/03/26/cancer-care-in-the-time-of-covid-19
  14. Owermohle Sarah. 2020. Adapting cancer research to coronavirus. Available here: https://www.politico.com/newsletters/prescription-pulse/2020/04/10/adapting-cancer-research-to-coronavirus-488861 [accessed: June 2020]
  15. Department of Health and Social Care. 2020. COVID-19 detection dog trial launches. Available here: https://www.wired-gov.net/wg/news.nsf/articles/COVID19+detection+dogs+trial+launches+18052020161000?open [accessed: June 2020]
  16. London School of Hygiene and Tropical Medicine. 2020. Using dogs to detect COVID-19: about. Available here: https://www.lshtm.ac.uk/research/centres-projects-groups/using-dogs-to-detect-covid-19#about [accessed: June 2020]
  17. Sharma SS, Singh DK, Yadav AK, et al. Disposable customized aerosol containment chamber for oral cancer biopsy: A novel technique during COVID-19 pandemic. Journal of Surgical Oncology 2020;122(2):120-21. doi: 10.1002/jso.25962
  18. Dar M, Sharma K. Burden of cancer in India: GLOBOCAN 2018 Estimates incidence, mortality, prevalence and future projections of cancer in India. 2019;6:505-14. doi: 10.1729/Journal.22750
  19. Filicevas A. Personal communication by e-mail, 2020
  20. Oliver K. Personal communication by e-mail, 2020
  21. Kounde D. COVID-19: The cancer experts leading their tech to the search for a treatment 2020 Available here: https://scienceblog.cancerresearchuk.org/2020/05/13/covid-19-the-cancer-experts-lending-their-tech-to-the-search-for-a-treatment/
  22. Dunning H. New COVID-19 project will use the power of smartphones to search for treatments 2020 Available here: https://www.imperial.ac.uk/news/196733/new-covid-19-project-will-power-smartphones/
  23. Vodafone Foundation. DreamLab app helps fight cancer and coronavirus while users sleep Available here: https://www.vodafone.com/about/vodafone-foundation/focus-areas/dreamlab-app