Assessing the impact of lockdown: Fresh challenges for the care of haematology patients in the COVID‐19 pandemic

Abstract

Worldwide cases of confirmed COVID-19 are approaching three million, and citizens around the world are experiencing unprecedented changes to their lifestyles due to the measures implemented to slow the spread of the disease. Patients with haematological cancers have also made dramatic changes to their lives. The UK Government has recommended shielding for a period of at least 12 weeks1 in order to reduce the risk of exposure to the virus, and this has nurtured a fear of contact with others, and especially with healthcare systems, which are rightly considered as potential sources of infection. Haematology teams have thus radically altered the way their care is delivered.2, 3 Teleconferencing is now the norm, intervals between blood monitoring have been extended, end of treatment scans have often been omitted, maintenance chemotherapies have been suspended, non-curative chemotherapy and radiotherapy has been attenuated or delayed,4 some stem cell transplants have been postponed,5 and clinical trials have largely been paused. These modifications to the delivery of care are intended both to reduce immunosuppression, susceptibility and exposure to COVID-19 infection, as well as to lessen the burden on wider NHS resources. New cases of COVID-19 infection are beginning to decline in the worst affected European countries, giving hope that the first wave of infection may be subsiding. In light of this, consideration should be given to the potential consequences for patients of these initial changes in management, and whether a rebound surge in workload should be expected. To address this question, we assessed basic markers of haematological activity in three time periods at our tertiary hospital. The first interval was the eight weeks at the start of the year (4 January to 28 February), prior to significant UK spread of coronavirus; the second interval was during the transition period (29 February to 20 March) when concern about coronavirus was increasing; and the final interval commenced from the enforced closure of schools as the UK lockdown began in earnest (21 March to 17 April). There has been a 71% fall in the numbers of full blood counts performed from primary care in the four weeks since the lockdown was introduced, and 57% fewer patients referred by e-referral for specialist haematology review. There have also been marked reductions in the numbers of bone marrow biopsies and immunophenotyping samples performed (Table I). Our histopathology department has diagnosed 54% fewer new haematological malignancies in this interval. The reasons for these falls are likely to be multifactorial and include patients’ reluctance to seek medical care, doctors’ reluctance to perform investigations that are perceived as non-urgent but which may increase the risk of exposure to infection, and reduced access to primary care. During the transition period there was a small decrease in haematology outpatient activity, accompanied by a decrease in haematological diagnoses, though not to the same extent as that seen during the lockdown period. It is very likely that a significant rise in new cases will occur as the first wave of the COVID-19 pandemic begins to pass, and that this period of delay might lead to presentations with more advanced disease. Our regional centre treated 24% fewer patients with chemotherapy requiring inpatient or day unit attendance in the four weeks after the lockdown commenced, giving intravenous rituximab 40% less often (Table II). Supportive treatments were also dramatically reduced, with an 84% fall in the administration of zoledronic acid for patients with myeloma, in line with Government guidance.3 In line with this, blood product use decreased, likely due to both a fall in haematology activity, as well as the more general decrease in hospital activity including elective surgery. The decrease in chemotherapy administration reflects attempts to protect vulnerable patients from the risks of COVID-19, as individualised assessments of risk and benefit were made, in consultation with patients, and regimes were attenuated or modified. Careful consideration will need to be given to the management of these patients as the risk of COVID-19 subsides, to determine whether to restart previously suspended regimes, or to re-escalate treatment intensity. NHS England has agreed to permit restarting of treatments where there has been a pause of more than six weeks due to COVID-19. Consensus guidelines may be required to support decision-making in this regard, as there will be little evidence to inform the efficacy of restarting interrupted regimes. Whilst we did not note a marked change in the small numbers of stem cell transplants at our centre over these intervals (Table II), it is likely that they are reduced nationwide, in line with guidance.5 The management of patients whose transplantations have been deferred will require careful, individualised decision-making. For some, disease progression may sadly render such therapy redundant, but for others, expert consideration of the benefits and risks of delayed transplantation will be necessary. There are likely to be difficulties in meeting the demand for these treatments, since this group of patients requires intensive and prolonged medical and nursing care. In the teeth of the pandemic it has been appropriate to deviate from the previously established standards of care for review and monitoring of patients with chronic haematological cancers. In order to free up medical and nursing capacity, we performed 38% fewer outpatient appointments in the four weeks of lockdown (Table II). Our data suggest that over 80% of these appointments were performed remotely during the lockdown. Inevitably, however, for a number of patients there will be adverse consequences to these changes, and we might expect increased rates of relapse or progressive disease becoming apparent at a later stage as hospital systems start to return to normality. Such patients may require treatment more urgently than would normally be expected. Although most hospitals have attempted to maintain cancer wards which are free from patients with COVID-19, this has been challenging due to the high prevalence of the disease in hospitals, asymptomatic healthcare workers, and lack of availability of testing. Even though new cases and deaths are now falling, it is apparent that COVID-19 will continue to circulate in both hospitals and the community for many months. As increased capacity for testing for SARS-CoV-2 becomes locally available, it will be imperative to strive to maintain ward environments that are kept free from this virus to enable high-intensity chemotherapy regimes and stem cell transplantations to be safely delivered. The regular testing of all ward staff and patients, perhaps twice a week or more, offers the potential to rapidly identify and isolate those with infection, before it can spread within a ward.6 Antibody testing, assuming that infection conveys a lasting protection to reinfection, could potentially also assist in the establishment of such a ward. The resilience of healthcare workers is being tested in the most extreme way during this pandemic. Our working lives have been utterly reorganised, and recovery from the first wave of COVID-19 infections will require us to make further changes as we deal with the fallout from the enforced changes in patient management. This is likely to occur whilst departments remain understaffed, since specialist nurses, pharmacists, junior doctors and redeployed consultants will not instantly return to their previous roles. In addition to these professional upheavals in our lives, many of us will experience the premature loss of patients, colleagues, friends or family. Burn out is a risk, and may manifest as the initial pressures of COVID-19 start to ease. Care should be taken to support healthcare workers in this phase. It is likely that as the first wave of COVID-19 recedes, there will be a corresponding rise in demand on haematology clinics, day units and wards to deliver care not only for the anticipated increased numbers of new patients, but also to restart deferred treatments for existing patients. The longer the lockdown is imposed, the greater the rebound surge might be expected to be. Plans should urgently be made to generate the capacity that will be required to deliver treatments for these patients. The reorganisation of care for our patients that has occurred in the last six weeks will continue to require adaptation and regular review, and work will need to be sustained at a time when reserves of emotional strength are at a low ebb and capacity is stretched. We will need to support each other, have periods of rest, and pace ourselves to minimise the psychological fallout of this disaster, and to ensure the optimal management of our patients. We would like to acknowledge Pip Doling for the collection of details of bone marrow biopsies, Kevin Paddon for details of laboratory testing, Julie Staves for transfusion data, and Janice Geaney, Angela Wilkins and Paige Bestley for information about outpatient appointments. GC acknowledges support from the Blood and Stem Cell themes of the Oxford NIHR Biomedical Research Centre. JW conceived the article; JW and AJK drafted the original text; FD, GT, DR, SP and AP collected the data. All authors were involved in revisions and approved the final draft. The authors declare that they have no potential conflicts of interest regarding the present work.