Impact of the Early Phase of the COVID Pandemic on Cancer Treatment Delivery and the Quality of Cancer Care: A Scoping Review and Conceptual Model

Abstract

Background:
The disruption of health services due coronavirus disease (COVID) is expected to dramatically alter cancer care; however, the implications for care quality and outcomes remain poorly understood. We undertook a scoping review to evaluate what is known in the literature about how cancer treatment has been modified as a result of the COVID pandemic in patients receiving treatment for solid tumours, and what domains of quality of care are most impacted.

Methods:
Citations were retrieved from MEDLINE and EMBASE (1 Jan 2019 to 28 Oct 2020), utilizing search terms grouped by key concept (oncology, treatment, treatment modifications and COVID). Articles were excluded if they dealt exclusively with management of COVID-positive patients, modifications to cancer screening, diagnosis or supportive care, or were not in English. Articles reporting on guidelines, consensus statements, recommendations, literature reviews, simulations or predictive models, or opinions in the absence of accompanying information on experience with treatment modifications in practice were excluded. Treatment modifications derived from the literature were stratified by modality (surgery, systemic therapy and radiotherapy) and thematically grouped. To understand what areas of quality were most impacted, modifications were mapped against the Institute of Medicine's quality domains. Where reported, barriers and facilitators were abstracted and thematically grouped to understand drivers of treatment modifications. Findings were synthesized into a logic model to conceptualize the inter-relationships between different modifications, as well as their downstream impacts on outcomes.

Results:
In the 87 retained articles, reductions in outpatients visits (26.4%), and delays/deferrals were commonly reported across all treatment modalities (surgery: 50%; systemic therapy: 55.8%; radiotherapy: 56.7%); as were reductions in surgical capacity (57.1%), alternate systemic regimens with longer treatment intervals or use of oral agents (19.2%), and the use of hypofractionated radiotherapy regimens (40.0%). Delivery of effective, timely and equitable care were the quality domains found to be most impacted. The most commonly reported facilitator of maintaining cancer care delivery levels was the shift to virtual models of care (62.1%), while patient-initiated deferrals and cancellations (34.8%), often due to fear of contracting COVID (60.9%), was a commonly reported barrier.

Conclusions:
As it will take a considerable amount of time for the cancer system to resume capacity and adjust models of care in response to the pandemic, these treatment delays and modifications will likely be prolonged, and will negatively impact quality of care and patient outcomes.

Full text

International Journal for Quality in Health Care, 2021, 33(2), 1–12
doi: https://doi.org/10.1093/intqhc/mzab088
Advance Access Publication Date: 1 June 2021
Systematic Review
Systematic Review
Impact of the early phase of the COVID
pandemic on cancer treatment delivery and the
quality of cancer care: a scoping review and
conceptual model
MELANIE POWIS1,2, CARISSA MILLEY-DAIGLE1, SAIDAH HACK1,
SHABBIR ALIBHAI2,3, SIMRON SINGH2,4, and
MONIKA K. KRZYZANOWSKA1,2,3
1Cancer Quality Lab (CQuaL), Princess Margaret Cancer Centre, University Health Network, 700 University Ave,
Toronto, ON M5G 1X6, Canada, 2Institute of Health Policy, Management and Evaluation, University of Toronto, 155
College St, Toronto, ON M5T 3M6, Canada, 3Department of Medicine, University Health Network, 200 Elizabeth St,
Toronto, ON M5G 2C4, Canada, and 4Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave,
Toronto, ON M4N 3M5, Canada
Address reprint requests to: Monika K. Krzyzanowska, Department of Medical Oncology & Hematology, Princess Mar-
garet Cancer Centre, 700 University Avenue, Suite OPG 7-825, Toronto, Ontario M5G 1X6, Canada. Tel: +1-416-946-6542;
Fax: +1-416-956-6546; E-mail: monika.krzyzanowska@uhn.ca
Received 8 March 2021; Editorial Decision 17 May 2021; Revised 27 April 2021; Accepted 31 May 2021
Abstract
Background: The disruption of health services due to coronavirus disease (COVID) is expected to
dramatically alter cancer care; however, the implications for care quality and outcomes remain
poorly understood.
Objective: We undertook a scoping review to evaluate what is known in the literature about how
cancer treatment has been modied as a result of the COVID pandemic in patients receiving
treatment for solid tumours, and what domains of quality of care are most impacted.
Methods: Citations were retrieved from MEDLINE and EMBASE (from 1 January 2019 to 28 Octo-
ber 2020), utilizing search terms grouped by the key concept (oncology, treatment, treatment
modications and COVID). Articles were excluded if they dealt exclusively with management of
COVID-positive patients, modications to cancer screening, diagnosis or supportive care or were
not in English. Articles reporting on guidelines, consensus statements, recommendations, literature
reviews, simulations or predictive models, or opinions in the absence of accompanying informa-
tion on experience with treatment modications in practice were excluded. Treatment modications
derived from the literature were stratied by modality (surgery, systemic therapy (ST) and radio-
therapy) and thematically grouped. To understand what areas of quality were most impacted, modi-
cations were mapped against the Institute of Medicine’s quality domains. Where reported, barriers
and facilitators were abstracted and thematically grouped to understand drivers of treatment mod-
ications. Findings were synthesized into a logic model to conceptualize the inter-relationships
between different modications, as well as their downstream impacts on outcomes.
Results: In the 87 retained articles, reductions in outpatients visits (26.4%) and delays/deferrals were
commonly reported across all treatment modalities (surgery: 50%; ST: 55.8% and radiotherapy:
56.7%), as were reductions in surgical capacity (57.1%), alternate systemic regimens with longer
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2Powis et al.
treatment intervals or use of oral agents (19.2%) and the use of hypofractionated radiotherapy reg-
imens (40.0%). Delivery of effective, timely and equitable care was the quality domains found to be
the most impacted. The most commonly reported facilitator of maintaining cancer care delivery lev-
els was the shift to virtual models of care (62.1%), while patient-initiated deferrals and cancellations
(34.8%), often due to fear of contracting COVID (60.9%), was a commonly reported barrier.
Conclusions: As it will take a considerable amount of time for the cancer system to resume capacity
and adjust models of care in response to the pandemic, these treatment delays and modications
will likely be prolonged and will negatively impact the quality of care and patient outcomes.
Key words: COVID, coronavirus, quality of care, treatment modications, cancer, conceptual model
Introduction
Beyond the devastating effect of coronavirus disease 2019 (COVID-
19) infection itself [1–3], the broader disruption of health services is
expected to dramatically alter cancer care [4–6]. Numerous guide-
lines for treatment modication have been published, aimed at
reducing in-person visits and mitigating potential issues with staff
and resource shortages [6–8]. Proposed changes include the use
of oral over intravenous therapies, alternate modalities (surgery vs
chemo-radiation) and virtual care, modication of dosing schedules
and prioritization of curative intent treatments [8–11]. However,
it remains unclear which treatment modications have been imple-
mented into practice and to what extent the quality of care has been
impacted globally. As it will take a considerable time to resume full
capacity following the pandemic, it is highly probable that treatment
delays and modications will be prolonged and may negatively affect
patient outcomes [9,12]. Following disruptions to cancer care during
Hurricane Katrina, the 10 year mortality among survivors diagnosed
with breast, lung or colon cancers within 6 months of the hurricane
was higher relative to case-matched controls from other jurisdictions
during the same time period [13]. Emerging models predict 20%
excess mortality in the oncology population as a result of delays in
diagnosis and treatment during this pandemic [14].
To further understand the impact the COVID pandemic has had
thus far on cancer care, we undertook a scoping review guided by the
question ‘how cancer treatment has been modied as a result of the
COVID pandemic in patients receiving treatment for solid tumours,
and what domains of quality of care are most impacted?’. A scoping
review was utilized as the study focuses on the initial wave of the pan-
demic so there is no existing comprehensive review on the topic [15],
and the broad scope of retained studies (methods and study design)
makes formal meta-analysis in feasible [16,17]. Findings were syn-
thesized in a logic model to conceptualize the inter-relationship
between care modications and potential downstream outcomes. We
also evaluated barriers and facilitators driving changes in care.
Methods
Data sources
Citations from 1 January 2019 to 28 October 2020 were retrieved
from MEDLINE and EMBASE [18]. Search terms were grouped
by key concept (oncology, treatment, treatment modications and
COVID); syntax and subject headings were translated as appropriate
for the included databases (Online Supplementary File 1). Resulting
citations were imported into Covidence (Veritas Health Innovation;
Melbourne, Australia) and duplicates were removed. The study was
carried out according to the PRISMA guideline extension for scoping
reviews [19].
Study selection and abstraction
Titles and abstracts were screened for relevance by two reviewers
(M.P. and C.M.D.). Full text articles were reviewed for inclusion by
two reviewers (M.P. and C.M.D. or S.H.); any questions regarding
eligibility for inclusion and conicts were discussed, if study eligi-
bility was unclear, a consensus decision was made with the third
reviewer. The population of interest was patients diagnosed with
solid tumour cancers accessing or receiving treatment with surgery,
radiotherapy or systemic therapy (ST). Articles were excluded if they
dealt exclusively with management of COVID-positive patients, can-
cer screening, diagnosis or supportive care, or were not in English. As
such, articles reporting on guidelines, consensus statements, recom-
mendations, literature reviews, simulations or predictive models, or
opinions in the absence of accompanying information on experience
with treatment modications in practice were excluded. Data were
extracted using a study-specic electronic abstraction form in Cov-
idence by one reviewer (C.M.D. or S.H.). A second reviewer (M.P.)
extracted data from a random sample of 25% articles to evaluate the
reliability of the data abstraction process; there were no discrepancies
between reviewers.
Analysis
Treatment modications were grouped by treatment modality
(surgery, ST or radiotherapy) and thematically categorized; modica-
tions spanning the three treatment modalities were deemed ‘overall.’
The proportion of articles reporting a modication out of the num-
ber of articles reporting on the modality was calculated (overall:
87, surgery: 56, ST: 52 and radiotherapy: 30). Modications were
mapped to the Institute of Medicine’s six domains of quality frame-
work (safe, effective, patient centred, timely, efcient and equitable)
to evaluate which aspects of quality of care were most impacted
utilizing the existing domain denitions and example quality mea-
sures through consensus by two authors (M.P. and M.K.K.) [20].
To understand potential drivers of the observed treatment, modi-
cations barriers and facilitators to maintaining care delivery were
thematically categorized. A logic model [21,22] was utilized to
synthesize ndings and conceptualize the inter-relationship between
reported modications to care and downstream outcomes likely to
be impacted. Inputs included barriers to maintaining care; change
activities were those primary mitigation strategies that had been
implemented by the cancer centres. Downstream modications to
treatment resulting from these inputs and change activities were
categorized as early, intermediate and late outcomes.
Results
Literature description
The search returned 464 articles (211 MEDLINE and 253 EMBASE),
including 107 duplicates; 357 unique titles and abstracts were
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COVID and cancer care quality • Systematic Review 3
Figure 1 PRISMA diagram.
screened for relevance (Figure 1). In the 87 retained papers (Online
Supplementary File 2), data collection through chart abstraction and
registry data (35.6%, 31/87) or clinician survey (27.6%; 24/87)
was common, as was the reporting of clinician opinions (19.5%;
17/87; Table 1); sample size ranged widely (chart abstraction/ registry
studies:12–8397; clinician surveys: 11–2494; patient surveys: 33–
5302). The majority reported on modications in Europe (35.6%;
31/87) or Asia (25.3%; 22/87), in patients with genitourinary can-
cers (14.9%; 13/87) or across multiple disease sites (37.9%; 33/87).
Of the studies that utilized a comparator (23.0%; 20/87), the same
period in the previous year (55%; 11/20) or the period just prior to
the pandemic (40.0%; 8/20) were the most common comparators.
Most articles focused on modications to surgery (64.4%; 56/87) or
ST (59.8%; 52/87) either alone or in combination with other treat-
ment modalities, while fewer discussed modications to radiotherapy
(34.5%; 30/87).
Treatment modications
Overall
Twenty eight unique treatment modications were reported; the most
prevalent modications, common to all three treatment modalities
(Table 2) were the reduction of in-person care through the utilization
of remote or virtual care (46.0%; 40/87) and reduction in outpa-
tient visits (26.4%; 23/87)—both new patient consultations (24.1%;
21/87) and follow-up visits (14.9%; 13/87). While delays or deferrals
of tests and imaging were reported (13.8%; 12/87), one article cited
improved wait times for imaging due to the overall reduction in out-
patients [23]. The majority of articles reported delays and deferrals,
across all three modalities (surgery: 50%; 28/56, ST: 55.8%; 29/52
and radiotherapy: 56.7%; 17/30). The length of delay or deferral
reported varied by treatment modality, wherein surgery (3.2 days
to 6 months) and radiotherapy (>14 days to 5 months) experienced
the longest delays, while ST delays were comparatively shorter
(1.9 days to 36.7 days). Decisions to modify treatment were report-
edly inuenced by treatment intent, age, comorbidities and frailty or
performance status.
Surgery
Capacity reduction (57.1%; 32/56) was the most commonly reported
modication to surgical care, ranging from cancelling procedures
(7.1%; 4/86) and restricting surgeries to emergencies or patients at
high risk of progression (26.5%; 15/56) to full suspension of surgery
(12.5%; 7/56). Paradoxically, two articles from Italy reported
increased surgical volumes due to prioritization of oncological pro-
cedures for high risk disease and cancellation of non-cancer electives
[24,25]. The number of radical procedures (7.1%; 4/56) was
reduced, and a shift to open rather than laparoscopic surgery was
reported (12.5%; 7/56) to reduce aerosol generation [26,27]. Con-
versely, two articles reported that the use of minimally invasive tech-
niques such as laparoscopy had increased to reduce post-operative
complications and length of hospital stays [28,29]. Few articles dis-
cussed the utilization of ST and/or radiotherapy (17.9%; 10/56) or
hormonal therapy (5.4%; 3/56) as an alternative to surgery, and only
one article specically addressed the impact of surgical restrictions
on the other services, citing increased stress given the concurrent
capacity reductions in ST and radiotherapy [30].
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4Powis et al.
Table 1 Description of retained articles
Characteristic
Retained articles,
n=87 n(%)
Article type Original article 57 (65.5)
Brief report 4 (4.6)
Abstract only 4 (4.6)
Commentary 8 (9.2)
Letter/ Letter to the editor 12 (13.8)
Review/ Critical review 2 (2.3)
Breast 5 (5.7)
Colorectal 8 (9.2)
GI 3 (3.4)
GU 13 (14.9)
Head and neck 7 (8.0)
Gynaecology 5 (5.7)
Lung 3 (3.4)
Other 8 (9.2)
Multiple 33 (37.9)
Disease site
Not specied 2 (2.3)
Region North America 15 (17.2)
Europe 31 (35.6)
Asia 22 (25.3)
Middle East and Africa 5 (5.7)
South and Central America 2 (2.3)
Multiple 12 (13.8)
Single 43 (49.4)Number of cancer
centres Multiple 43 (49.4)
Unknown 1 (1.1)
Study type Chart review/ registry 31 (35.6)
Clinician survey
Online 24 (27.6)
Unknown 3 (3.4)
Patient survey
Online 7 (8.0)
Paper 2 (2.3)
Opinion 17 (19.5)
Other 4 (4.6)
Comparative Yes 20 (23.0)
No 67 (77.0)
Treatment
modality
Sx 27 (31.0)
ST 20 (23.0)
RT 8 (9.2)
Multiple
Sx +ST 10 (11.5)
RT +ST 3 (3.4)
Sx +RT +ST 19 (21.8)
GI=gastrointestinal; GU=genitourinary; Sx=surgery, RT=radiotherapy.
Systemic Therapy
Cancellations and reductions in treatment capacity were less com-
monly reported for ST than surgery (13.5% vs 57 ·1%). Delayed
ST cycles (19.2%;10/52) and discontinuation of on-going regimens
(15.4%; 8/52) were reported. Treatment schedule modications
(19.2%; 10/52) included increasing the interval between infusions for
dose dense regimens to every 3 weeks or hormonal agents to every
3 months (17.3%; 9/52), or decreasing infusion time (1.9%; 1/52).
Alternate regimens (21.2%; 11/52) with longer intervals between
treatments (11.5%; 7/52) or hormonal agents (7.7%; 4/52) were
favoured over dose-dense regimens, and oral drugs over intravenous
(17.3%; 9/52). Few articles reported using lower intensity regimens
(5.8%; 3/52) or dose reductions (3.8%; 2/52) to reduce potential tox-
icities [31–34]. Only one article reported increased prophylactic use
of granulocyte colony stimulating factors [35], likely reecting the
lack of consensus regarding their use, and the shift to utilization of
less toxic regimens.
Radiotherapy
Reduced radiotherapy capacity (33.3%; 10/30), ranging from fewer
treatment slots (16.7%; 5/30) to a full shut down (6.7%; 2/30), and
hypofractionation were common (40%; 12/30). Conversely, one arti-
cle indicated that radiotherapy had increased relative to the year prior
due to the centralization of treatments in cancer hubs [36]. Suspen-
sion of concurrent ST-radiotherapy in favour of radiotherapy alone
was also reported [31,37]. Discontinuation of radiotherapy for on-
going patients (3.3%; 1/30) more infrequent than for patients treated
with ST.
Impact on quality of care
All six quality domains [20] were impacted in some way by the
reported treatment modications; delivery of effective, timely and
equitable care were the quality domains found to be most impacted
(Table 2). Effectiveness (78.6%; 22/28) has been impacted as dose or
frequency modications of evidence-based ST and radiotherapy regi-
mens have been implemented, coupled with resequencing of modali-
ties to compensate for surgical shut downs. Due to widespread delays
and deferrals, delivery of efcient (42.9%; 12/28) and timely (64.3%;
18/28) treatment have been impacted. Suspension of face-to-face care
has the potential to impact the provision of patient-centred (42.9%;
12/28) and equitable (64.3%; 18/28) care particularly for subgroups
without the technological resources to utilize virtual care or those
without access to translators. Cancellation or discontinuation of
treatment for advanced disease, prioritization of curative intent treat-
ments and reductions in new patients have signicant ramications
for equity as they are likely to disproportionately impact subgroups
who experience delayed access to screening and higher stage at diag-
nosis under non-pandemic conditions. Mid-course discontinuation
of radiotherapy and ST, coupled with outpatient clinic closures, pose
consequences for provision of safe care (60.7%; 17/28), as latent
treatment-related toxicities may go without timely diagnosis and
management.
Barriers and facilitators
Barriers and facilitators to maintaining cancer care were reported by
66 articles. Implementation of remote care was reported as a major
facilitator (Figure 2); telephone or video were most common (82.9%;
34/41) though email or mobile applications (Viber [38] or Whatsapp
[39]) were also reported. Low- and middle-income countries that
may lack the technology and infrastructure to deliver care remotely,
reported signicant reductions in care [40–43]. Additional facilita-
tors included the organization of ‘COVID-free’ hubs [36,44–47] and
separated clinical teams [37,48] to minimize cross-contamination in
areas with high infection rates.
Travel bans were cited as a signicant barrier to patients and
providers accessing centres, due to trafc issues and reduced access
to public transportation, as well as medication [42,43,49,50]
and blood product [32,51–53] shortages. Institutions were faced
with increased costs of diagnosis and treatment associated with
the additional infection control measures implemented [31,43,54,
55], as well as reduced revenue from decreased caseloads [42]
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COVID and cancer care quality • Systematic Review 5
Table 2 Cancer treatment modications (n=28) mapped to the Institute of Medicine six domains of quality
Quality domain
Modality Category Reported treatment modications Number of articles reporting (%) Safe Effective Patient centred Timely Efcient Equitable
Overall (87
articles)
Appointments Increased utilization of remote or
virtual care
40 (46.0) X X X X
Reduced outpatient visits 23 (26.4) X X X X
Reduction in number 13(14.9)
Suspension of outpatient care 6 (6.9)
Delayed appointments 4 (4.6)
Reduced new patientsa21 (24.1) X X X X X
Reduction in new patients
Urgent new consults only
Deferral of new patients
Suspension of new patient consults
9 (10.3)
5 (5.7)
5 (5.7)
3 (3.4)
Prioritization of curative intent 14 (16.1) X X X
Reduced follow-ups 13 (14.9) X X X X X
Deferral of follow-ups
Suspension of follow-ups
11 (12.6)
2 (2.3)
No changea6 (6.9)
No change to outpatient care 4 (4.6)
New patients maintained 2 (2.3)
Labs and imaging Delayed labs/ imaging 12 (13.8) X X X
Improved imaging wait timesa1 (1.1)
Supportive care Switch to supportive care only for
palliative/ incurable disease
5 (5.7) X X X X
Reduced access to supportive care 4 (4.6) X X X
Increased prophylactic use of granulo-
cyte colony stimulating factors
1 (1.1)
Surgery (56 Capacity Reduced capacity 32 (57.1) X X X
articles) Reduction in number of surgeries 15 (26.8)
Restricted to emergency, high risk or
symptomatic patients
12 (21.4)
Suspension of surgery
Cancellations
Palliative surgeries not done
7 (12.5)
4 (7.1)
2 (3.6)
Continued.
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6Powis et al.
Table 2 (Continued)
Quality domain
Modality Category Reported treatment modications Number of articles reporting (%) Safe Effective Patient centred Timely Efcient Equitable
Delays/deferrals 28 (50.0) X X XX
Increased number of cancer surgeriesa2 (3.6)
Alternate treatment Switch to Alternate Modality 13 (23.2) X X X X X
modalities Use ST or radiotherapy instead 10 (17.9)
Use hormonal therapy instead 3 (5.4)
Type of surgical
procedure
Reduction in radical procedures 4 (7.1) X
Increase in diverting stoma formation 2 (3.6) X X
Open favoured over laparoscopic 7 (12.5) X X X
Minimally invasive continuinga6 (10.7)
Laparoscopic continuing
Increased use of laparoscopic
4 (7.1)
2 (3.6)
ST (52 articles) Capacity Delayed/deferred treatment 29 (55.8) X X X X X
Discontinuation of ongoing courses 8 (15.4) X X X X X X
Reduced capacity 7 (13.5) X X X
Reduction in number of sessions 4 (7.7)
Cancellations
Cancellation of peri-operative chemo
2 (3.8)
1 (1.9)
No changea10 (19.2)
Schedule Using a modied treatment schedule 10 (19.2) X X X X
Increasing the interval between
treatments
9 (17.3)
Reducing infusion time 1 (1.9)
Regimen type Utilizing an alternate regimena11 (21.2) X X
Favouring regimens with longer
intervals between treatments
6 (11.5)
Favouring hormonal treatments 4 (7.7)
Favouring lower intensity treatments 3 (5.8)
Continued.
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COVID and cancer care quality • Systematic Review 7
Table 2 (Continued)
Quality domain
Modality Category Reported treatment modications Number of articles reporting (%) Safe Effective Patient centred Timely Efcient Equitable
Favouring oral over IV 9 (17.3) X X
Reduction in use of maintenance
therapies
1 (1.9) X X
Intent Increased use of neoadjuvant
chemotherapy
10 (19.2) X X X
Decreased use of neoadjuvant
chemotherapya
1 (1.9)
Dose Dose reduction 2 (3.8) X X
Radiotherapy (30
articles)
Capacity Delay/ deferral 17 (56.7) X X X X X
Reduced capacitya10 (33.3) X X X
Reduced number of treatments 5 (16.7)
Emergency or high risk only
Shut down of radiotherapy
Cancellation
3 (10.0)
2 (6.7)
1 (3.3)
Discontinuation of ongoing courses 1 (3.3) X X X X X X
No changea5 (16.7)
No change in radiotherapy
Increased number of treatments
4 (13.3)
1 (3.3)
Dose Hypofractionation 12 (40.0) X X
Alternate treatment
modalities
Use of alternate treatment modality 4 (13.3) X X X X X
Suspension of concurrent chemo-rads 2 (6.7)
Use of hormonal therapy
Use of induction chemotherapy
1 (3.3)
1 (3.3)
No change to concurrent chemo-radsa2 (6.7)
aRows indicate treatment modications with potential positive impact on care or where no change was reported.
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8Powis et al.
Figure 2 Summary of major barriers and facilitators to maintaining cancer care during the COVID-19 pandemic where reported (n=66 articles).
and fundraising opportunities [33]. Patients faced added treatment
costs from purchasing medications that they would have otherwise
received in hospital [49,56] or from facing economic hardships lead-
ing to treatment abandonment [32]. Lack of resources, including
human resources due to infection and redeployment (16.7%; 11/66),
appropriate equipment or technology due to insufcient infrastruc-
ture or redeployment of ventilators and imaging equipment to the
diagnosis and treatment of COVID patients (19.7%; 13/66), insuf-
cient hospital bed or ICU capacity (15.1%; 10/66) and access to
appropriate personal protective equipment, was cited as a major
barrier. One in three articles indicated that modications, includ-
ing delays and cancellations, were patient initiated (34.8%; 23/66),
out of a fear of contracting COVID at appointments or during
post-treatment recovery due to immunosuppression (60.9%; 14/23).
Discussion
Statement of principal ndings
While some modications to cancer care have been implemented to
specically facilitate COVID care delivery, such as reducing the num-
ber of scheduled surgical resections to decrease the need for ICU
capacity and ventilators, other treatment modications are down-
stream effects, such as the increased use of neoadjuvant chemother-
apy as a result of increased interval from diagnosis to surgery
(Figure 3). Understanding the complex inter-relationships between
treatment modications as well as their downstream outcomes is nec-
essary as we enter the next phases of the pandemic and beyond.
Delivery of effective, timely and equitable care was the quality
domains found to be most impacted. As it will take a considerable
amount of time for the cancer system to resume capacity and adjust
models of care in response to the pandemic, it is highly probable that
the reported treatment delays and modications will be prolonged
and will negatively impact the quality of care and patient outcomes.
Dosing and frequency modications to evidence-based regimens and
untested resequencing of modalities have the potential to signicantly
impact the treatment effectiveness. Some modications may be more
appropriate than others; however, without evidence, their impacts
on disease outcomes are difcult to ascertain.
Interpretation within the context of the wider literature
Our ndings are consistent with published recommendations [57];
reductions in outpatients visits (26.4%) and delays and deferrals
were reported across all three modalities (surgery: 50%; ST: 53.8%
and radiotherapy: 56.7%), as were reductions in surgical capac-
ity (57.1%), favouring alternate ST regimens with longer treatment
intervals or use of oral agents (21.2%) and the use of hypofrac-
tionated radiotherapy (40.0%). However, the majority of published
recommendations were consensus derived, and thus, there is a high
potential for negative impact given there is little evidence from sim-
ilar healthcare disruptions in modern times. While the implemented
modications helped maintain care during the early phase of the pan-
demic, continued resource constraints coupled with on-going care
deferral present signicant challenges going forward as many aspects
of cancer care cannot be safely delayed without implications for prog-
nosis or quality of life. It was anticipated that a reduction in radical
surgery, surgical delays and cancellations would drive the use of ST
and radiotherapy as alternate treatments (17.9%) though few articles
addressed this shift. Coupled with delays and discontinuations of ST
and radiotherapy, this raises concerns about the potential impact on
prognosis, as well as the future economic and resource burden to the
health care system [31,43,54,55] associated with providing more
intensive treatment to advanced cases that may have been curable if
timely treatment had been available [58–60].
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COVID and cancer care quality • Systematic Review 9
Figure 3 Conceptual map of the potential impact of cancer care modications during the COVID-19 pandemic on early, intermediate and late outcomes.
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10 Powis et al.
Implications for policy, practice and research
Cancellation or discontinuation of treatment for incurable disease
(5.7%), prioritization of curative intent treatments (16.1%) and
reductions in new patients (24.1%) have signicant ramications for
equity, given that this is likely to disproportionately impact patients
who have difculty accessing care under normal conditions and are
more likely to present with advanced disease at diagnosis [61]. While
the shift to virtual care has been widespread (46.0%), it highlights
the widening gap for patients with low literacy, language or socioeco-
nomic status who may lack the skills or resources to adequately access
virtual care. Given the high prevalence of COVID in some low- and
middle-income countries, they stand to benet most from remote care
delivery, but lack the infrastructure to implement it [40–43]. Addi-
tionally, little is currently known about the impact of virtual delivery
of care on cancer patients’ experience or outcomes.
Strengths and limitations
The study scope did not look at issues of screening and cancer diag-
nosis, management of treatment-related adverse events or provision
of follow-up care, which are likely to also be impacted, and have
detrimental downstream impacts on the cancer care system [62].
We sought to understand what changes to cancer treatment deliv-
ery had been implemented during the early phase of the COVID
pandemic. As such, we did not evaluate whether the observed mod-
ications to treatment were guideline concordant; this is a potential
area for future research. While our ndings provide an understand-
ing of the broader changes to treatment during the pandemic, the
strength of the evidence is poor given the majority of observed mod-
ications were derived from anecdotal evidence shared by patients
and providers through cross-sectional surveys (patients: 10.3%; clin-
icians: 31.0%) or opinion pieces (19.5%). Given the current body
of evidence, it is difcult to ascertain whether treatment modica-
tions were systematic, if there is signicant provider-level variation
in practice, and to what extent modications to care were driven by
mandate or patient preferences. It is difcult to quantify the impact
of the pandemic on care modication as, of the studies reporting
primary data from chart review or registries (35.6%), only approx-
imately half (51.6%) included a comparator. Additionally, as the
pandemic is ongoing and our ndings include relevant citations from
2019 to October 2020, we do not have a full picture of the impli-
cations for the provision of cancer care. Analyses of administrative
data, once available, may provide a more comprehensive look at the
impact on patterns of cancer treatment delivery. However, given the
reported prevalence of patient-initiated delays and cancellations, it
will be import to take into account drivers of care modications in
planned analyses.
Few studies reported on patient-level factors, such as treatment
intent, age, comorbidities, frailty or performance status, associated
with modications. However, none of the articles included a compre-
hensive analysis of demographic or clinical characteristics associated
with treatment modications or evaluated the impact on outcomes.
Additionally, none of the articles evaluated modications against the
local need for COVID care despite the geographical variability in
severity of the pandemic and degree of responsiveness. As such, there
is an urgent need to quantify the impact of COVID-related changes
on key processes of cancer care and early outcomes and to identify
patient groups that may be at higher risk of negative consequences.
To date, reported modications focus on inputs and change activi-
ties; conceptual maps such as ours are important tools for developing
comprehensive measurement frameworks aimed at quantifying the
impacts on the quality of cancer care delivery and patient outcomes.
Conclusions
The COVID pandemic has had substantial impact on cancer care
delivery thus far. Understanding which components of care are most
affected can help identify the most vulnerable aspects during a crisis,
which can facilitate mitigation plans in the current pandemic and dur-
ing similar disruptions to care in the future. Future research should
focus beyond these change activities and their associated early out-
comes, towards understanding the future economic and resource
implications for the healthcare system.
Supplementary material
Supplementary material is available at International Journal for Quality in
Health Care online.
Acknowledgements
None declared.
Funding
This work was supported by the Princess Margaret Cancer Centre Foundation.
Ethics
Ethics board approval was not required as the study is a literature review.
Author’s contributions
Conception or design (M.P., M.K.K., S.S. and S.A.), data collection
and analysis (M.P., S.H. and C,M.D.), interpretation (M.P., M.K.K.,
S.S. and SA), drafting or critically revising content (M.P., C.M.D.,
S.H., S.S., S.A. and M.K.K.), providing nal approval (M.P., C.M.D.,
S.H., S.S., S.A. and M.K.K.), and accountability for content accuracy
and integrity (M.P., C.M.D., S.H., S.S., S.A. and MKK).
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