Cancer treatment delayed as patient priority lists drawn up

In three separate developments:

• A London trust announced it was cancelling chemotherapy and routine cancer operations for a fortnight due to coronavirus pressure;
• An NHS England covid-19 guidance document indicated palliative care cancer patients will be less likely to receive appropriate treatment; and
• Cancer waiting times guidance has been changed to provide for some urgent referrals for suspected cancer to be sent back to GPs without diagnosis.

Barking, Havering and Redbridge University Hospitals Trust said it had cancelled chemotherapy and routine cancer operations for a fortnight. It said in a statement: “These measures will help us to protect our patients, including those with covid-19, and those with other conditions. They will also enable us to help us be as prepared as possible by training additional clinical teams who are not specialists in respiratory illness.

“We are reviewing these patients to ensure no harm will come to them by delaying their treatment.”

Meanwhile, the cancer coronavirus “specialty guide” from NHS England and NHS Improvement, issued to NHS providers earlier this month, warned: “We need to consider the small possibility that the facility for cancer services may be compromised due to a combination of factors including staff sickness and supply chain shortages among others. This is an unlikely scenario but plans are needed.”

The NHSE/I document advised providers to decide which patients will receive cancer treatments if services are overwhelmed. It also urges them to “make contingency plans for supply chain issues”.

It said: “It is suggested that clinicians begin to categorise patients into priority groups 1-6”, with top priority given to chemotherapy that is seen as “curative therapy with a high (>50 per cent) chance of success”. If a patient is receiving palliative cancer treatment with little chance of surviving more than a year, they will be given lowest priority.

Similarly, providers have been told to deprioritise patients receiving radiotherapy treatments to reduce the chance of cancer returning within 10 years.

For surgical patients, the lowest prioritisation is where “elective surgery can be delayed for 10-12 weeks with… no predicted negative outcome”. Cancer surgeries categorised as urgent or an emergency will be given top priority.

Waiting times

The second NHSE/I document, sent to cancer alliances, said trusts may have to “downgrade” some two-week GP cancer referrals due to coronavirus.

It said: “Where capacity is particularly constrained providers should ensure processes are in place to prioritise particularly urgent referrals, including greater communication between primary and secondary care to downgrade or avoid referrals where possible.”

It continued: “Where referrals are downgraded or avoided outside the usual policies and [National Institute for Health and Care Excellence] guidance, providers should seek to ensure appropriate safety-netting so that if patients deteriorate or their risk of a cancer diagnosis increases, they can be appropriately referred for further investigation.”

It said the guidance “should be interpreted as modifying existing cancer waiting times guidance with immediate effect (19 March 2020) until further notice”.

Charles Swanton, Cancer Research UK’s chief clinician, said: “The coronavirus pandemic is an incredibly challenging and fast moving situation. And we support the hard work of the NHS and government and the steps they are taking.

“The complete picture of how the virus will affect cancer care and over what timeframe is not yet clear. But as the virus becomes more common in the UK, it will undoubtedly add pressure to the NHS, bed and ITU availability and hence service delivery.

“Unfortunately we are starting to see the impact at individual trusts and treatment decisions will have to be based on resource allocation to those most likely to benefit and most in need across all areas of medicine. It’s likely that cancer treatment decisions will be affected, with treatments known to extend overall survival outcomes prioritised.”

An NHSE/I spokesman said: “Hospitals have been told that cancer treatment and other clinically urgent care should continue to be prioritised.”

It comes amid talks about shifting planned cancer care to the private sector.

Karol Sikora, chief medical officer at independent provider Rutherford Health, told HSJ three leading independent providers of cancer care — Rutherford, HCA, and Genesis — have approached NHSE offering to expand the amount of chemotherapy they provide nationally. He said he expected their offer to be accepted imminently.

Professor Sikora said: “There is a lot of confusion and people are in tears about it all — its bad enough to have cancer without having to [go] through this. It is causing immense emotional damage and the consequences are enormous.

“Nobody knows how bad it’s going to get — that’s the trouble. The danger is… if staff are taken away [from cancer treatments] to help patients in ICU on ventilations. Do you keep a [patient] on a vent with 10 per cent chance of survival and throw cancer patients under the bus?”