The Day after Tomorrow: How Should We Address Health System Organization to Treat Cancer Patients after the Peak of the COVID-19 Epidemic?

Abstract

On March 11, 2020, the WHO director general declared COVID-19 a pandemic. This pandemic evolves in successive phases, i.e., phase 1 (the start phase), phase 2 ("the storm"), and phase 3 (the recession). To date, oncology and surgery groups have only given instructions for addressing phases 1 and 2. To prevent excess cancer mortality, health care systems (HCS) need to be restructured. Our aim is to detail the specificities of each epidemic phase and discuss several methods of organization to optimize cancer patient flow during the COVID-19 pandemic, particularly during phase 3. Hospitals must be reorganized in order to create a cancer hub that is free of infection, allowing for the safe treatment of patients. Hospital structures are different, but all allow for the creation of virus-free areas. Screening programs are critical and need to be applied to all people entering the virus-free zone, including health care workers. Some reorganization proposals are internal to a hospital, while others require interhospital collaboration. The heterogeneity and complexity of HCS will make interhospital management difficult. The ministry of health has an important role in managing the cancer crisis. Cancer management should be declared a priority. Oncological and surgical societies must coordinate their efforts to facilitate this prioritization. The anticipation of oncological management during phase 3 of the pandemic is necessary because it requires a complete readjustment of HCS. This adaptation should allow for the continuation of cancer care to prevent excess cancer mortality, as the virus will still be present for a currently undetermined period of time.

Keywords: COVID-19 outbreak; Cancer; Health care systems; Oncology; Pandemic.

Fig. 1

From left to right, the blue curve shows the increase and decrease in the number of infected cases during the 3 phases of the outbreak. During phases 1 and 2, the risk is a shortage of intensive care beds, and the goal of the health authorities is to flatten the growing curve of the virus (curve in blue dots). During this time, cancer patients cannot be treated, which is represented by a decrease in the green curve during the first 2 phases. A waiting list of cancer patients develops during this period. In the absence of anticipatory measures, the capacity of the oncological system will be overwhelmed by the massive influx of cancer patients from the waiting list but also from the normal flow. The objective is to flatten the curve by taking adaptive measures with the aim of not altering the prognosis of cancer patients. The possible second wave of the epidemic has not been represented on these curves. The area under the curve for the light green and dark green curves should be considered as equal.

Fig. 2

Possible reorganization of monobloc hospitals. Areas in blue are virus-free zones, areas in yellow are contaminated viral zones, and areas in green are uncertain viral status zones. All patients use the green road to the triage area. After screening, the patient is redirected according to the presumed viral state to the yellow or blue area. Dedicated elevators are identified and used by dedicated patients. The blue elevator cannot stop on the yellow floors, and the yellow elevator cannot go up to the blue floors. Green floors are shared common areas (technical units, radiology departments, etc.). If a second wave of infection hits the country, the COVID-negative floors will gradually be converted into COVID-positive floors. The yellow and blue arrows show the possible evolution in the case of a second wave.