Ontario doctors who perform cancer surgeries say a "significant" dip in referrals during the COVID-19 pandemic has them worried that people with cancer are going undiagnosed and that it could be too late for some once cancer screening ramps up again.
Prior to the province seeing an influx in COVID-19 cases and the closure of some of Ontario's economy, Dr. Shady Ashamalla, a surgical oncologist specializing in colorectal cancer and head of the division of general surgery at Sunnybrook Health Sciences Centre, would receive about five to seven new cancer referrals each week.
This would include individuals who had an abnormal fecal immunochemical (FIT) test, which looks for blood in the stool, and needed a follow-up test like a colonoscopy, or people who had already been diagnosed with colon or rectal cancer and were being referred for surgery. Ashamalla said he's now getting one or two referrals each week, which means discovering the cancer is a "weak spot" right now.
"That doesn’t mean cancer has slowed down, it means that those people are walking around not knowing they have cancer because we’re not doing what we know we need to do for screening," said Ashamalla, noting that screening for colorectal cancer has essentially stopped. As screening is increased and doctors "find" the cancers out there, people will get medical attention, he noted, but the fear is that "many will come to medical attention far too late to be curable...and then we will see a surge, not a COVID-19 surge, but a cancer surge, a surge of all diseases that were meant to (be) found early."
"All of our work as a province to identify patients early in order to operate on them, in order to save their lives, in order to save the significant morbidity is not being applied right now," Ashamalla said. "We know that screening saves thousands of lives each year, so that has stopped and it needs to start."
The purpose of screening for colorectal cancer is to find the disease early enough so that it can be surgically removed and cured, Ashamalla said, adding that if the cancer is left long enough, it will metastasize and grow and "not be curable at some point."
"What COVID-19 has done, it has essentially stopped our ability to screen for colorectal cancer, so yes, we are doing colorectal cancer surgery and the patients we know about who are at high risk of their prognosis changing, we’re operating on, but the patients we don’t know about who are out in society right with colorectal cancer unknown to them are not being identified early and that’s a danger."
Dr. Michael C. Ott, a general and colorectal surgeon at London Health Sciences Centre's Victoria hospital, has seen a similar trend and said "everything has changed" with the COVID-19 pandemic.
Pre-COVID-19, Ott would get around three or four referrals each month for new cancer patients. He noted that there are about 20 general surgeons between two teaching hospitals in London and that when the pandemic hit, they decided to create a central pool so referrals could go to whichever surgeon had the time. But there have only been about six or seven colorectal cancer referrals hitting the pool in a month.
"There’s a significant decrease in referrals," said Ott, who is also the program director for the general surgery training program at Western University's Schulich School of Medicine and Dentistry. "To be honest, we thought that we would have trouble keeping up because of the decrease in the resources that we had to get patients through the system, so we created this central referral process to try and ease that burden and it turns out we didn’t need to do that because the referrals just aren’t coming because people aren’t having their disease diagnosed."
The fact that such cancers are going undiagnosed is "really concerning," Ott said. "There’s probably a population of people who are undiagnosed and maybe aren’t aware they have a disease, and depending on the timeframe...that may result in the difference between their disease being treatable or untreatable and so that is concerning."
Health Minister Christine Elliott announced on March 15 that the province was asking all hospitals to ramp down "elective surgeries and other non-emergent clinical activity" in order to create capacity for the surge in COVID-19 cases that Ontario was seeing. The "guiding principles" the province asked hospitals to follow included using an "ethical framework" to make decisions, preventing transmission and preserving health care capacity.
Cancer Care Ontario (CCO), which now falls under the Ontario Health super-agency, noted on its website in messages for both the public and health-care providers that it was "recommending that all routine cancer screening tests be deferred." The notice added that LifeLabs was temporarily not mailing out FIT tests to people.
A CCO guidance document that was distributed in March identified the need to have a "system to determine a priority for consultation and treatment of patients with cancer."
The document outlined a "cancer patient priority classification." Priority A patients were those deemed "critical," so for example, those whose conditions were considered life-threatening. Priority B identified patients whose situations were not deemed life-threatening and services that could be deferred during a pandemic wave. Priority C were services that could be discontinued for "the entire pandemic event."
The guidelines noted that if a community were affected by the pandemic, the types of Priority C services that could be discontinued included routine screening appointments.
"All routine screening appointments can be deferred for the entire pandemic since screening activities for the healthy population would not be recommended while there is pandemic activity in the province," the document said.
Like Ashamalla, Ott said the decrease in referrals is not because the disease has "gone away," but rather because screening programs have been put on hold.
"That is going to result probably in some people having more advanced disease at the time of diagnosis and there’s going to be a wave of people once this all starts to open up again that are going to need treatment," he said.
While both Ashamalla and Ott said they were still performing surgeries, the numbers have decreased. Previously Ott said he'd be doing between 50 to 60 hours of surgeries a month — this includes elective and cancer surgeries. Now, with about one or two operations a week, he's in the operating room for about 15 hours a month. The surgeries he is doing are mostly cancer or "very urgent" cases.
"There would be people who have very symptomatic cancers so bleeding or obstruction or people who have undergone pretreatment with chemotherapy and radiation and so their surgery is timed for a specific date because of their pre-treatment and that’s mostly what we’ve been doing up until now," Ott said. "If you’re diagnosed with a colorectal cancer and it’s not bleeding and it’s not obstructing, in theory we could make you wait some weeks or months, but that may have negative consequences in people’s outcomes."
Ashamalla said Sunnybrook established a "pandemic planning task force" at the end of February to determine how the hospital could "scale down" procedures and activity with the goal of increasing capacity.
Normally the hospital has 25 operating rooms running at any given time, but as part of its pandemic plan Sunnybrook established different tiers — in the first, the operating rooms would be cut to 10, in the second there would be four and in the third there be just two for urgent procedures only. By March 16, the hospital went down to 10 operating rooms. For cancer care, this meant deciding who was at "highest risk of prognostic change" without an immediate surgery.
The hospital already had a multidisciplinary cancer group that would meet to discuss new cancer cases and so these "tumor boards" took on the task of triaging cancer cases.
By the end of March, the hospital was down to four operating rooms, meaning triaging shifted and the group would meet several times a week — prioritizing surgery for those who were at risk of a prognostic change or death without surgery.
"We never stopped doing cancer surgery," Ashamalla stressed, adding that hospital staff are "now feeling that it is very safe to start to come out of this four (operating rooms) and start ramping up service again."
"Cancer surgery is not part of the recovery of COVID-19," he said. "Yes we had to ramp down, but we had to ramp down until the unknown was known, not because we’re waiting for COVID-19 to go away or not because we’re waiting to recover from COVID-19."
He said the province "didn’t know the gravity of what was coming and now that we have a much better understanding of the gravity of what’s coming and what’s here, we’re not waiting for COVID-19 to go away as we ramp back up again."
It really just comes down to "saving people’s lives, people who are just as important to us as our COVID-19 patients," Ashamalla said.
While the government is providing hospitals with important guidance, it's really up to these institutions to work on implementing their own "game plans," Ashamalla said. There are several things to consider including drug shortages, enabling physical distancing in waiting rooms or patients needing to do CT scans in the hospital before a surgery.
"We are working very hard to slowly open up rooms and increase our cancer output, we’re increasing surgical activity based on patient acuity," he said. "Because of the way colorectal cancer works, we have paused for a safe window allowing our urgent cases to get done...so I feel like we’ve kept everybody safe, but that is strongly dependent on a ramp up that has to occur now."
While officials made good decisions based on the information they had, Ott said there needs to be an "exit strategy" as well.
"There’s going to be a large number of people who have been sitting on the sidelines waiting for either diagnostic tests or intervention that’s going to overwhelm the capacity if we just go back to the way it was," he said.
Hayley Chazan, spokesperson for Elliott, said the province is "taking a measured approach to ramping up scheduled care" and that the province has created an expert committee of clinicians to "develop a plan to resume services while maintaining COVID-19 preparedness."
"This approach will need to weigh the benefit of treatment against the transmission of COVID-19 to both patients and health care workers," she said. "It will also need to take into consideration staffing capacity, access to diagnostic imaging, laboratory services, pre-operative assessment, anesthesia services and levels of personal protective equipment."
She said the province would be releasing a framework to guide Ontario hospitals as they "resume" elective surgeries and procedures "shortly."
Ott said while hospitals are doing the best they can, the pandemic has taken a "personal and emotional toll" on doctors having to triage patients weekly and see people "sitting on the sidelines," not getting the care they need.
"I think the outcomes of the decisions that people made are pretty good because we’re in a decent place in Ontario compared to other jurisdictions, but there needs to be a thought process of what are the consequences of those decisions and how are we going to slowly turn the system on and how are we going to make sure that we have the resources available to deal with the backlog," he said.
Photo courtesy of Sunnybrook Health Sciences Centre