Anticipating the COVID-19-related surge in cancer care demand is urgent in Latin America and the Caribbean
Authors: Cristian A Herrera, Piga Fernández, Afsan Bhadelia, Mauricio Maza
Journal: The Lancet Oncology (2021)

The COVID-19 pandemic has disrupted regular health services in every health system worldwide, and cancer care is no exception. In Latin America and the Caribbean, cancer services have been reported to be foregone or delayed, including first-time visits to oncology services, pathology, cancer surgery, chemotherapy, and screening tests,1Vázquez Rosas T Cazap E Delgado L et al.Social distancing and economic crisis during COVID-19 pandemic reduced cancer control in Latin America and will result in increased late-stage diagnoses and expense.JCO Glob Oncol. 2021; 7: 694-703Crossref PubMed Scopus (18) Google Scholar with similar findings in the paediatric cancer field.2Vasquez L Sampor C Villanueva G et al.Early impact of the COVID-19 pandemic on paediatric cancer care in Latin America.Lancet Oncol. 2020; 21: 753-755Summary Full Text Full Text PDF PubMed Scopus (73) Google Scholar The study by Zachary J Ward and colleagues3Ward ZJ Walbaum M Walbaum B et al.Estimating the impact of the COVID-19 pandemic on diagnosis and survival of five cancers in Chile from 2020 to 2030: a simulation-based analysis.Lancet Oncol. 2021; (published online Sept 3.)https://doi.org/10.1016/S1470-2045(21)00426-5Summary Full Text Full Text PDF Scopus (48) Google Scholar published in The Lancet Oncology goes a step further; using data from five cancer sites in Chile, their study assesses the future effects of delayed diagnosis on cancer outcomes. The study3Ward ZJ Walbaum M Walbaum B et al.Estimating the impact of the COVID-19 pandemic on diagnosis and survival of five cancers in Chile from 2020 to 2030: a simulation-based analysis.Lancet Oncol. 2021; (published online Sept 3.)https://doi.org/10.1016/S1470-2045(21)00426-5Summary Full Text Full Text PDF Scopus (48) Google Scholar estimates that an overburden of 14% of cancer diagnoses is already starting in 2021, with worse cancer stage distribution, predicting an excess in cancer deaths of 10·8% in 2022–24 compared with a counterfactual scenario with no COVID-19. This analysis does not consider eventual treatment delays or issues with quality of care that might further increase these projected negative trends for Chilean patients with cancer. Further, the trends might be worse for marginalised and minority population groups, such as those from indigenous communities. Since other countries in Latin American and the Caribbean are showing similar trends of foregone or delayed cancer services, the findings of this study3Ward ZJ Walbaum M Walbaum B et al.Estimating the impact of the COVID-19 pandemic on diagnosis and survival of five cancers in Chile from 2020 to 2030: a simulation-based analysis.Lancet Oncol. 2021; (published online Sept 3.)https://doi.org/10.1016/S1470-2045(21)00426-5Summary Full Text Full Text PDF Scopus (48) Google Scholar serve as a warning sign for governments and other stakeholders in the region. That business as usual will not be enough to cope with the surge in demand is almost certain, and thus, the response will be crucial for the time-critical care that patients with cancer require. Health systems will face the urgent need to innovate and introduce new service-delivery schemes to increase capacity while aiming as much as possible to maintain quality and assure equity in access to cancer services.4Butler J Finley C Norell CH et al.New approaches to cancer care in a COVID-19 world.Lancet Oncol. 2020; 21: e339-e340Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 5Andall-Brereton G Bromfield B Smith S Spence D Cancer care in the Commonwealth Caribbean in COVID times.Lancet Oncol. 2020; 21: 1007-1009Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar How to maintain these targets is one of the most crucial questions for decision makers, which can be informed by existing and future research. Emphasis should be placed on both ends of the cancer care continuum. On the one hand, prioritising screening efforts for high-risk patients and aiming to identify the largest number of patients with early-cancer stages to compensate for the lost time, will increase the odds of successful treatment and good prognosis.6Maida M Screening of gastrointestinal cancers during COVID-19: a new emergency.Lancet Oncol. 2020; 21: e338Summary Full Text Full Text PDF PubMed Scopus (14) Google Scholar Various frameworks have been proposed, and localised efforts to generate frameworks appropriate for each setting are necessary for adequately prioritising cancer care.7Hanna TP Evans GA Booth CM Cancer, COVID-19 and the precautionary principle: prioritizing treatment during a global pandemic.Nat Rev Clin Oncol. 2020; 17: 268-270Crossref PubMed Scopus (304) Google Scholar On the other hand, palliative care is an area of great concern considering the excess mortality predicted by Ward and colleagues.3Ward ZJ Walbaum M Walbaum B et al.Estimating the impact of the COVID-19 pandemic on diagnosis and survival of five cancers in Chile from 2020 to 2030: a simulation-based analysis.Lancet Oncol. 2021; (published online Sept 3.)https://doi.org/10.1016/S1470-2045(21)00426-5Summary Full Text Full Text PDF Scopus (48) Google Scholar Estimating the need for palliative care was not in the scope of the study, but the need to alleviate pain and other forms of serious health-related suffering experienced by patients with cancer, from the point of diagnosis to the end of life, is expected to increase in the coming years, and this increase has only been exacerbated by the pandemic.8Radbruch L Knaul FM de Lima L de Joncheere C Bhadelia A The key role of palliative care in response to the COVID-19 tsunami of suffering.Lancet. 2020; 395: 1467-1469Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar Given that palliative care is comparatively weak (in terms of access, quality, monitoring, and financial protection) in the health systems of Latin America and the Caribbean,9Pastrana T De Lima L Sánchez-Cárdenas M et al.Atlas de cuidados paliativos en Latinoamerica 2020. IAHPC Press, Houston, TX2021Google Scholar a special emphasis should be placed on this type of care. National opioid-medication reserves have to be increased, whereas rapid basic training on the rational use of opioid medications and on end-of-life conversations must be offered to health professionals at all levels of care. From a patient's perspective, communication will be crucially important, both among health-system actors and between health-system actors and patients. For instance, in most Latin American and Caribbean countries, there are no clear pathways of care for most cancers that both patients and providers are aware of and can rely on, which in many cases generates confusion and delays. Case managers and patient-navigation programmes can help to overcome these issues, with the potential to provide more people-centred services while reducing delays in diagnosis, treatment, and loss to follow-up.10Dalton M Holzman E Erwin E et al.Patient navigation services for cancer care in low-and middle-income countries: a scoping review.PLoS One. 2019; 14e0223537Crossref PubMed Scopus (45) Google Scholar In addition, the number and location of all patients with cancer is unclear because of fragmented surveillance systems. Patient organisations represent a complementary resource to improve information flow and can provide a fundamental interface for connecting patients and their families with the health system, while advocating for system-wide improvements. For instance, the Asociación Chilena de Agrupaciones Oncológicas (ie, the Chilean Association of Oncology Organisation) advocated for the approval of the National Cancer Law in 2020, a key milestone for cancer control in the country, and has been the main voice for patients with cancer during the COVID-19 pandemic in several participation spaces within the government and congress. Other Latin American and Caribbean countries could also enhance the organisation of patient-advocacy efforts and the formal involvement of patients in decision making. Similar studies to that of Ward and colleagues3Ward ZJ Walbaum M Walbaum B et al.Estimating the impact of the COVID-19 pandemic on diagnosis and survival of five cancers in Chile from 2020 to 2030: a simulation-based analysis.Lancet Oncol. 2021; (published online Sept 3.)https://doi.org/10.1016/S1470-2045(21)00426-5Summary Full Text Full Text PDF Scopus (48) Google Scholar can be done in other Latin American and Caribbean countries and elsewhere to inform decision making and health-care provision redesign. The coming surge in cancer-care demand is an issue of urgency for health systems globally. Fundación GIST Chile, led by PF, has received grants to develop educational and support projects for patients with cancer from pharmaceutical companies, including Bayer, Novartis, Sanofi, Pfizer, Lilly, Bristol Myers Squibb, Roche, Merck, Ingalfarma, AstraZeneca, and Biotoscana. AB is co-Chair of the Taskforce on Women and Non-Communicable Diseases. CAH and MM declare declare no competing interests. Estimating the impact of the COVID-19 pandemic on diagnosis and survival of five cancers in Chile from 2020 to 2030: a simulation-based analysisIn addition to a large projected surge in diagnosed cancer cases, we found that delays in diagnosis will result in worse cancer stage at presentation, leading to worse survival outcomes. These findings can help to inform surge capacity planning and highlight the importance of ensuring appropriate health system capacity levels to detect and care for the increased cancer cases in the coming years, while maintaining the timeliness and quality of cancer care. Potential delays in treatment and adverse impacts on quality of care, which were not considered in this model, are likely to contribute to even more excess deaths from cancer than projected. Full-Text PDF