Environment-Friendly and Sustainable Oncological Care Settings in the Times of COVID-19: A Narrative Review

The influence of COVID-19 on global healthcare

To further discuss the importance of COVID-19 on global health, it is necessary to state how the virus can be transmitted. Face-to-face transmission is executed by respiratory droplets and infected secretions such as saliva, and further distance transmission is possible through airborne droplet nuclei. Moreover, the virus can remain viable for some time on different surfaces (e.g., it stays viable for 3 hours on paper, 7 days on plastic, etc.).^11,12 There is no evidence that COVID-19 can be spread via blood contact or transfusion. It is quite hard to track infection rates of COVID-19 as cumulative coefficients of new cases are different per country and at some times of the year, rates were higher. Additionally, the precise number of COVID-19 cases remains unknown, which makes calculations even harder.^13-15

The global pandemic caused by SARS-CoV-2 has led to numerous changes in ordinary lives. People had to stay mostly at their homes and minimize social contact with their friends or beloved ones, events got cancelled, a new stressful environment was introduced to humanity and other lockdown complications. From a positive perspective, after the most severe COVID-19 outbreaks healthcare systems started encouraging people to take more concern about their health and hygiene, and also follow recommendations for maintaining a healthy lifestyle, increasing education about pathogens and the ways how to oppose them. On the other hand, there is no doubt that the biggest advantage of the COVID-19 pandemic was showing that global healthcare is not ready yet to oppose the fast transmission of disease, even though humanity has already witnessed many pandemics throughout history.^12,13,16,17

Several drawbacks of current global healthcare could be mentioned. Numerous countries have implemented late quarantine rules and restrictions which led to poor consequences (for example, the United Kingdom). Not enough money is spent on healthcare in countries; thus, it makes it harder for developing countries to withstand disease and provide full medical support for COVID-19-positive people. Additionally, high medical care costs made it problematic for poorer people to reach medical support even in developed countries. Little investments were put into mental care, as stress and isolated lives increased depression and anxiety in the population. Research on treatment and vaccine development has been relatively fast compared to all previous vaccines development, yet it was not fast enough to save many people’s lives, not to mention that the production of vaccines raises important environmental concerns.¹⁸

Oncological setups during COVID-19 outbreak

The pandemic has imposed a serious challenge to healthcare settings globally. Oncological care settings have faced an unprecedented threat as cancer patients are more likely to have lower levels of immunity and hence require a multidisciplinary treatment approach. Hospital beds have been scarce, decreased supply of medications including life-saving drugs as well as a crisis in healthcare providers including nurses, physicians and health staff. To cope with these crises effectively, there has been a transformation in strategies to promote effective cancer management in oncological setups globally including hospital wards or indoors as well as in outpatient management and clinics.^19,20 This shall continue with minimal resources over a short period and the role of telemedicine in oncological care is gradually evolving in virtual consultations.

The transformation in the delivery of oncological care includes consultations, systemic therapy against cancer, and surgery for patients while preventing them from contracting the virus and other infections effectively. It has been reported that as a result of this transformation or personal choice of the patients, there was a 30% reduction of patients receiving anti-cancer treatment like chemotherapy on an average and up to 50% decline in new cases presenting or have been referred for diagnosis of suspected cancer in March to April 2020.¹⁹ However, emergency cancer care continued, whereas the rest including referrals started to be conducted virtually. To prevent transmission of the virus and other pathogens, safety strategies have been proposed to ensure the compulsory wearing of PPE (personal protective equipment) by patients and caregivers as well as promoting home delivery of some systemic anti-cancer medicines such as Herceptin, administered by subcutaneous route or Tyrosine Kinase inhibitors etc. These enable social distancing and prevent unnecessary hospital visits and save time, making it convenient for both cancer patients as well as healthcare providers.^19-21 In many centres, only those procedures or examinations which were instrumental, clinical and targeted were performed. Separate inpatient units and daycare setups for COVID-19-positive and negative patients have been built to prevent the transmission of infections. Self-isolation has been recommended for COVID-positive or symptomatic staff or patients and a negative swab test was required to return to work in most of the centres.²¹

The usage of personal protective equipment (PPE) has been considered to be the most effective strategy to protect patients and caregivers in cancer clinics against the virus by limiting its transmission (Table – 1) and (Table – 2). It has been the need of the hour to set up a rational approach regarding the usage of PPE effectively in operative settings of cancer management, in cases of COVID-19 positive as well as negative patients. PPEs should be of great help in providing optimum levels of cancer care and reducing the negative effects of any delays in cancer treatment including surgeries. The N95 masks along with 3-ply masks, respirator masks, disposable or reusable gowns, face shields and goggles, wearing double gloves, regular power glasses etc. are integral components of the PPE. It has been reported that N-95 masks/double gloves or gowns (disposable/ reusable) and eye protection devices with or without shoe covers were the most common PPE combination used by cancer surgeons while performing several operations during the pandemic.^20-22 However, there have been complaints of severe stress and discomfort associated with the usage of PPEs by healthcare workers especially for prolonged periods. There have been reports of contact dermatitis, headache, fatigue, difficulty in communication and breathing problems with poor vision, fogging, and irritation of the skin with the usage of different components of PPE.²⁰ The N-95 masks and eye protection component has been attributed with causing maximum discomfort to cancer surgeons. This is aggravated by the presence of pre-existing health illnesses like asthma, migraine, claustrophobia etc. Studies have reported the beneficial impact of minimally invasive surgeries during the pandemic wherever applicable in cancer patients.^21,23 There have been strong recommendations for using laparoscopy during the pandemic.

Table 1. Asian countries and their respective PPE percentage use during Covid-19.

The National Institute for Health and Care Excellence (NICE) has framed a triage system to classify cancer patients by their chances of survival from therapy. This system would be beneficial in guiding physicians to make better decisions considering different clinical aspects of cancer care. Patients who require surgeries or other procedures to be performed can be referred to the newly built cancer centres which have been made COVID-free. A prioritization system has been set up for their surgeries.^22,24,25 According to this, four types of priorities should be considered as follows:

• Priority 1a: Emergency operation- surgery when needed to save a life, to be performed within 24 hours.

• Priority 1b: Urgent operation- surgery required within 72 hours.

• Priority 2: Elective operation- surgery required to be performed within 4 weeks as a life-saving procedure or to prevent disease progression.

• Priority 3: Elective operation- there can be a delay in surgery for up to 10-12 weeks without any prediction of the negative outcome.

Though emergency surgical procedures are being continued to be performed, there is concern regarding elective or planned surgeries in cancer patients. There is a huge concern regarding the postponement of elective surgeries in patients especially with solid tumours because this might lead to disease progression due to delays in operation. This also needs to be balanced against the risk of exposing susceptible individuals to the virus. Studies have reported that by following standard precautionary measures recommended by PHE and RCS however, elective surgeries can be performed safely in cancer patients during the pandemic in acute hospitals.²⁶ There is also a positive finding the patients who did not have increased rates of infection from COVID-19 were admitted post-operatively. Proper screening of patients should be encouraged and proper infrastructure for testing should be developed for this purpose. RCS has recommended that before elective operations, patients must be asymptomatic and should have self-isolated for two weeks and have an RT-PCR test for COVID-19 negative. It has also been recommended for periodic testing of all healthcare providers to reduce transmission of infections.

A study by COVIDSurg Collaborative, as a part of a project by The University of Birmingham and the National Institute for Health Research (NIHR), has reported the fragility in oncological surgery systems globally during lockdowns.^27,28

This is an international, pan-speciality project with a multicentric approach to evaluate several end-points, including 30-day mortality in COVID-19 patients, the impact on safety in operations in cancer setups and its effect on unnecessary delays, as well as its effect on the surgical team and emergency operations. According to this study, every one in seven cancer patients, as residents of regions with full lockdowns, did not undergo elective surgeries and experienced longer delays during their preoperative period. These could lead to reductions in their survival rates as long-term impact. This has suggested that the planned surgeries require strengthening of their infrastructure which includes protected planned operative procedures and long-term investment for critical care in surge capacities to protect the healthcare providers and services during public health emergencies in the future like this pandemic. It has also provided key areas of transforming the practices for safe surgical management globally during the pandemic, as follows:²⁹

1. Framing a proper scientific plan to promote surgeries worldwide which includes postponement of planned surgeries, repurposing rooms for operations (OR) as areas of critical management of patients and surgical workflow.

2. Forming a team approach for promoting emergency operations during COVID-19.

3. Providing health education to healthcare workers on PPE usage and management of COVID-19 to promote safe operations during the times of pandemic.

4. Screening and management of COVID-19 infections while preventing exposure of healthcare providers. E. Build a dedicated space for surgeries during the pandemic as a part of a wider clinical response.

The safe disposal of surgical wastes including post-operative specimens in cases of cancer surgeries is a real challenge during the pandemic. They should be labelled as “COVID-19 suspected” and sealed in the operating rooms (ORs) along with all other human anatomical wastes, body fluids, disposable materials, PPE and gowns (double-bagged), tubings etc. They should have a label on them with a sign implying it is from an OR with either a suspected or confirmed COVID-19 patient and should be safely disposed of following the local guidelines for infectious waste management.^29-31 Following this, the OR must have proper disinfection and sterilization, including anaesthetic equipment and operating table, with a chlorine-based disinfectant or alcohol (minimum of 75%). This will prevent the virus from surviving on hightouch surfaces for a long period.