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Modifications to treatment schedules

Modifications to treatment schedules

What changed?

  • During the COVID-19 pandemic, refinements were considered for individual treatment plans to minimise patients’ exposure to, and risk of harm from, COVID-19, while ensuring the best possible cancer outcomes.1,2,3 Changes to care require careful consideration of the risks and benefits of treatments, and transparent communication with patients to enable their involvement in the decision-making process about the changes.
  • Decisions to modify or delay management include enhanced uptake of existing evidence-into-practice:
    • Implementing hypofractionation of radiotherapy
    • Postponing non-urgent surgery or adjuvant chemotherapy for cancer patients with low risk of progression4
    • Transitioning from intravenous to oral chemotherapy5
    • Reducing duration of treatment administration or increasing intervals between doses of systemic treatments6
    • Temporarily discontinuing immunosuppressive cancer therapies7
    • Temporarily discontinuing medications to minimise the risk of drug interactions.7
    • Adopting a lower threshold for use of more aggressive supportive care interventions such as anti-emetics, use of granulocyte colony stimulating factor (G-CSF) with chemotherapy regimens to reduce risk of febrile neutropenia and outpatient treatment of low-risk patients with febrile neutropenia with oral antibiotics to reduce hospital admission rates.8,9,10

Impact of change

  • The adoption of value-based healthcare practices increases effective, patient-centred cancer care, and can improve quality of life and patient experience.11
  • During the acute phases of the pandemic, prioritisation of patients for treatment using a risk-benefit approach aimed to reduce the impact on hospital and human resource capacity.1
  • However, it may have been difficult for clinicians to calculate the risk-benefit of modifications to treatment, and make judgements on the nature and extent of altering treatment plans.12
  • Some patients have also experienced anxiety or distress resulting from altered plans of care or changes to usual treatment.13

How can high-value changes be embedded or enhanced?

The following strategies were identified in Australian and international literature and by leading Australian cancer experts and consumers. This list is provided to prompt considerations and future strategies to support high-value cancer care in the Recovery phases of the COVID-19 pandemic. 

These strategies are listed at the system-, service-, practitioner-, and patient-levels and are intended to be used by a range of cancer control stakeholders across Australia to support high-value cancer care and improve outcomes for people with cancer.

System-level strategies

  • Establishing a unified way of disseminating nationwide, evidence-based standardised care procedures, including approaches for rapidly updating guidance based on expert-led consensus during the pandemic.1,13
  • Dedicating research to identify treatments with equivalent or non-inferior outcomes and areas where patients would not be disadvantaged from the de-escalation of treatment.13
  • Monitoring and reporting of health system performance to support change and to respond to unwarranted variations in practice.13

Service-level strategies

  • Developing evidence- and consensus-based guidance for health professionals, and standardised and validated risk-stratification protocols to identify patients who are eligible for modifications to treatment. Such tools and best-practice recommendations should be shared through formalised, electronic means that are accessible for all health practitioners,14for example, the eviQ Cancer Treatments Online.15

Practitioner-level strategies

  • Educating and training medical, nursing and allied health practitioners to undertake a patient-centred approach to individualising treatment plans for patients, carefully assessing personal factors and risk status when selecting anticancer therapies.4
  • Consider incorporation of psycho-oncological and evidence-based geriatric care principles into mainstream practice to yield appropriate care for all patients.13
  • Educating health professionals on how to communicate openly and transparently, ensuring clear documentation and appropriate explanation is provided to patients who experience modifications to their treatment during the pandemic. Health professionals should seek support from a culturally-trained health worker or interpreter if required, including incorporating shared decision-making on a case-by-case basis with input from the multidisciplinary care team.16
  • Ensuring health professionals are appropriately educated and skilled in communication strategies, including with Aboriginal and Torres Strait Islander patients and their communities and culturally and linguistically diverse patients and carers.17 For Indigenous people, this should include discussion with the patient and their family regarding the potential benefits and risks of any new or ongoing cancer treatment, ensuring information is accessible and culturally appropriate, with the support of an Aboriginal and/or Torres Strait Islander Health Worker or Hospital Liaison Officer.17>
  • Ensuring goals of patient care are clearly documented and easily accessible in order to minimise undertreatment of patients with excellent prognosis and overtreatment of those with a poor prognosis from both cancer and COVID-19.1

Patient-level strategies

  • Educating and supporting consumers to increase their health literacy, confidence and ability to engage in informed, shared decision-making processes.   

 

References

[1] Segelov E, Underhill C, Prenen H, et al. Practical Considerations for Treating Patients With Cancer in the COVID-19 Pandemic. JCO Oncol Pract. 2020 May 13;OP2000229. doi: 10.1200/OP.20.00229. 

[2] American Society of Clinical Oncology. ASCO Special Report: A guide to cancer care delivery during the COVID-19 pandemic. ASCO, Virginia, United States, 2020. 

[3] Gyawali B, Poudyal BS, Eisenhauer EA. Covid-19 Pandemic—An Opportunity to Reduce and Eliminate Low-Value Practices in Oncology? JAMA Oncol. 2020. doi:10.1001/jamaoncol.2020.2404 

[4] Al-Shamsi HO, Alhazzani W, Alhuraiji A, et al. A Practical Approach to the Management of Cancer Patients During the Novel Coronavirus Disease 2019 (COVID-19) Pandemic: An International Collaborative Group. Oncologist. 

[5] Schrag D, Hershman DL, Basch E. Oncology Practice During the COVID-19 Pandemic. JAMA. 2020;323(20):2005-6. 

[6] National Health Service. Clinical guide for the management of noncoronavirus patients requiring acute treatment: Cancer. 23 March 2020 Version 2. NHS, United Kingdom, 2020. 

[7] Weinkove R, McQuilten Z, Adler J et al. Managing haematology and oncology patients during the COVID-19 pandemic: interim consensus guidance. Med J Aust 2020; 212 (10): 481-9. 

[8] Cancer Council Victoria. Optimal Care Pathways. Accessed: May 2020; https://www.cancervic.org.au/for-health-professionals/optimal-care-pathways 

[9] Advance Care Planning Australia. Advance care planning in Aboriginal and Torres Strait Islander populations. Accessed: August 2020; https://www.advancecareplanning.org.au/for-health-and-care-workers/in-various-settings/advance-care-planning-in-aboriginal-and-torres-strait-islander-populations 

[10] Shukla N, Pradhan B, Dikshit A. A Review of Models Used for Investigating Barriers to Healthcare Access in Australia. Int. J. Environ. Res. Public Health 2020, 17(11):4087. doi: 10.3390/ijerph17114087 

[11] Slavova-Azmanova N, Millar L, Ives A, Codde J, Saunders C. Moving towards value-based, patient-centred telehealth to support cancer care. Deeble Institute for Health Policy Research, Deakin, ACT, 2020. 

[12] Burki TK. Cancer guidelines during the COVID-19 pandemic. Lancet Oncol. 2020; 21(5):623-30. 

[13] National cancer expert or consumer participant, Cancer Australia COVID-19 Recovery and cancer roundtable. Meeting minutes unpublished. 30 June 2020 

[14] Chandra R and Thomas Jr CR. What is our threshold: Departmental planning for radiation oncology’s future in the time of COVID-19. 2020; 149:46-7. 

[15] eviQ Cancer Treatments Online 2020, Cancer Institute NSW, viewed 28 August 2020, 

[16] National Institute for Health and Care Excellence (NICE). COVID-19 rapid guideline: delivery of systemic anticancer treatments NICE guideline [NG161]. Accessed: June 2020; https://www.nice.org.uk/guidance/ng161/chapter/7-Modifications-to-usual-service 

[17] Cancer Australia. Optimal care pathway for Aboriginal and Torres Strait Islander people with cancer. Accessed: August 2020; https://canceraustralia.gov.au/publications-and-resources/cancer-australia-publications/optimal-care-pathway-aboriginal-and-torres-strait-islander-people-cancer