Access to Healthcare for Cancer Patients in Lithuania During the COVID-19 Pandemic

Letter to the editor

During the quarantine, cancer patients have limited access to healthcare facilities. Despite the fact, that emergency service must be continued without disruption, there are still many cancer patients who are waiting for diagnostic tests or their treatment (radiotherapy or chemotherapy) had already began.
To find out how many patients did not receive necessary cancer care, Lithuanian Cancer Patient Coalition (lith. POLA -Pagalbos onkologiniams ligoniams asociacija) conducted a flash survey. This organization is the biggest umbrella patient organization in the country, uniting 31 nongovernmental organizations working in the cancer field and representing the interests of cancer patients, and aims to ensure that both patients and their families have access to effective treatment and the best possible informative, social, psychological and mental support. The POLA community flash survey on healthcare access during the COVID-19 pandemic was conducted from May 21st to June 1st. The survey was sent by an e-mail. In total, 670 people responded to the survey and 92.5% of them were cancer patients (Table 1). Almost three quarters of respondents sought medical care during the quarantine, and 34.3% of patients with suspected malignancy were told to wait for the first consultation until the end of quarantine ( Figure 1).     In recent guidelines, it is emphasized that diagnosis should not be compromised during COVID-19 pandemic; only the management of such patients should be tailored to the best available resources [5]. If specific treatment was initiated, 30% of patients did not receive consultation either. Chemotherapy, radiotherapy and surgery were also postponed until the pandemic subsides for 12.5, 21.7 and 29% of patients, respectively (Figure 2). In emergencies (quick worsening of symptoms) only 53.3% of respondents received help in 8 weeks. Some diagnostic tests were also not performed on time -about a third of patients had to wait until the end of quarantine for radiological, endoscopic or blood tests to be performed.
The first wave of the COVID-19 pandemic is well controlled in Lithuania with only 1808 cases positive (66.4/100000), 1501 recovered and 78 deaths (in the time of writing this paper). This means that healthcare system should adapt quite well to the current situation because there is no overload. Perhaps strict policy regarding outpatient visits or hospital admissions made more damage than the COVID-19 pandemic itself.
Other countries across Europe also reported cancer care services diminished dramatically, including UK, Italy, Germany and others [6]. When the first wave of COVID-19 subsides, hospitals will begin to continue their normal service, however, it seems that cancer patients will need some encouragement from healthcare professionals to come and not be afraid to contact the virus [6].
There are already some guidelines published online to help going through the healthcare system crisis [5,[7][8][9]. They are usually based only on expert's opinion, however, it is best what we have today. First, routine screening should be suspended and patients with early or advanced cancer be treated as outpatients as much as possible without referring to the main centres [7]. This crisis enables the use of telemedicine without contacting the patient directly. The focus should be on disease history and symptoms, however, even physical examination can be performed virtually. This approach during the COVID-19 pandemic is especially sufficient for surveillance [8]. The treatment for the first time diagnosed cancer can be initiated only after careful assessment of patient's performance status, comorbidities, biology of disease and likely impact on quality of life if the treatment is initiated [7]. There are few types of cancer where we can expect good outcomes with treatment and the risk of delayed care is much more hazardous than the COVID-19 itself. This includes most patients with acute leukaemia, high-grade lymphoma, testicular, ovarian and small cell lung cancer [9]. Some oncologists see the COVID-19 pandemic not only as a global crisis, but also as an opportunity for clinical research, which would seem unethical under normal conditions [10]. Hypofractionated regimens for patients with limited additional benefit of regular regimens can be prescribed. In addition, neoadjuvant chemoradiotherapy instead of primary surgery can be initiated more freely by the multidisciplinary team. Chemotherapy doses can also be reduced to cause less immunosuppression [10]. On the other hand, all the ongoing preclinical trials should be stopped, unless there is a great early success with tumour-specific trial for which inclusion continues [10].
In conclusion, Lithuanian experience during the COVID-19 pandemic shows that the virus transmission can be successfully stopped. However, the price is paid on the account of patients with chronic diseases including cancer because of diminished access to medical care. About a third of patients did not receive any medical care during the quarantine. The balance between the risk of being infected with SARS-CoV-2 and the damage of delayed diagnosis and treatment of cancer can be achieved only with clear communication in the healthcare system and education of cancer patients and healthcare professionals.