This study was conducted in the last two weeks of April, the first week of May, over a three-week period where we disseminated questionnaires of 50 validated questions to our collaborators globally. We were able to recruit 356 centres from 54 countries in six continents. Actually, the survey was asking about what was the impact of COVID-19 on the cancer care – what are the challenges that were faced by the cancer centres and what are the interventions that they are taking care of in order to overcome these challenges? And the estimated potential harms and the reason for harms, if you will, to cancer patients.

So we found out that actually the majority of the cancer centres, 88% of them, did face somehow some kind of challenge in managing cancer patients during the pandemic. We can get into more details on that. These centres actually represent different kinds of healthcare sectors in these countries. There are governmental hospitals, private hospitals, as well as academic centres. There were standalone cancer centres as well as centres which are part of a bigger organisation. There were small centres that see less than 1,000 new patients a year to large centres seeing more than 10,000 patients a year. So it was actually mixed, that gives you a good idea about the different settings. It was also from different countries which also had, as you can imagine, different income and socioeconomic status.

Could you detail some of the challenges that institutions faced?

We asked them did you face a challenge of cancer care; 88%, as I said, said yes. The question was specifically to try to clarify that - what were the reasons that you altered the usual standard care that you use to deliver to your patients? 55% of the centres said that we did that pre-emptively as precautionary measures. Because the oncologists felt that cancer patients are a vulnerable population, that COVID-19 is a new virus that we did not know the magnitude and the impact that could have been to our cancer patients. So many of the centres did that pre-emptively as precautionary measures, by reducing the visits, switching to other things, to virtual visits, we’ll talk about that if we get the chance.

However, there are other causes that are of concern. For example, about 20%, one out of five centres, said because the system was overwhelmed, an overwhelmed healthcare system with a flood of COVID-19 patients, of course the shift has to switch to acute care and the resources have to be switched. People sometimes think about resources, just the ventilators or ICU, but it’s much more than that. It’s the staff also, it’s the focus of laboratory imaging, everything switched. So when you get an overwhelmed system then acute cases, if you will, the cancer cases, will be taking second priority.

Then there are other… again, around the same percentage said it’s lack of PPE. They did not have enough personal protective equipment. Actually around 46% of the centres said they have some PPE shortage, specifically N95 and so on. Then there was 10% of the centres said it’s because we had lack of access to medications and so on. Because even the flow of supplies, the supply chain, also gets interrupted and maybe the medications don’t get delivered to the centres on time and so on.

What disparity between countries did you see in the challenges faced?

There was, and you will see that in the paper that’s coming in The Journal of Global Oncology later on this month or earlier next month where we mentioned the countries based on their stratification by the World Bank – low income, middle income and high income countries. Yes, the impact on the low income and middle income was higher, so, for example, shortage of PPE was more likely to happen in the low income countries. So there were some disparities.

What are you concluding from these findings?

We concluded that this pandemic impacted cancer care globally, in affluent countries and in poor countries to a varying degree, as you can imagine. That impacted the delivery of cancer care probably for the long term. Unfortunately there is a loss of life and potential patient harm that have been immediate and probably there is other harm that we can’t recognise as the pandemic evolved. But there is a change in the practice that already took place and that is going to last for a long time. For example, switching to a virtual clinic, virtual patient visitation, actually 70% didn’t have physical versus virtual. So 80% of the centres used virtual technology to visit with their patients and about 60% of the participants believe that this is going to stay after the pandemic.

There is also the second change which was accelerated by the pandemic is pushing to delivery of care, remote care, care near patients’ homes. So you find more centres are shipping the medications to patients’ homes or doing lab tests near patients’ homes and so on. So there is some silver lining to this which is probably cutting some of the waste. Probably we were seeing many patients that did not need to be seen that frequently or we could have saved them time if we checked on them by phone or by video and we bring them in only if it’s needed. So there are some positive effects. Nevertheless, the harm is widespread and too costly, actually.

Of course the issue is what are the lessons learned for the future, that’s very important. We have a free text question that we left in the end for the participants to express what should be done in the future or in preparation for the future. The majority said we should have really preparedness plans and be always ready for such a crisis. Stock up enough on PPE, stock up enough on medication and so on. So I hope this pandemic will finish soon with the least possible casualties but we should always be prepared for the second wave of this or other pandemics or other crises which may not be at the same magnitude as COVID but sometimes single institutions may face such a crisis. Actually, these lessons learned from COVID-19 may help the centres manage any crisis in the future better.

Like, for example, in our centres because we were the epicentre in the MERS-CoV crisis so we have so many plans, so many processes and so on that we were able to quickly respond to this and try to learn from lessons in the past. However, the difference here is that COVID-19 is much more widespread. It has a higher infectious rate although the mortality is less but the fact that it has a higher infectious rate makes the number of people overwhelming. That’s why we implemented new things that were not as commonly noticed in the past such as social distancing. So this was emphasised in this crisis more than the others.