Skip to main content

Cancer care in the time of COVID-19: A conceptual framework

A A

Cancer Australia has undertaken an initiative to develop a conceptual framework for optimal management of cancer during the COVID-19 pandemic - from prevention and early detection through to survivorship and end-of-life care.

Cancer care during a pandemic

During a pandemic, cancer care needs to be tailored to different phases of the pandemic and the multiple competing priorities driving healthcare. These include the likely increased risks to cancer patients of acquiring the infection and of serious illness or mortality; the limitations of resources; the possibility of the healthcare system being overwhelmed; and the risks of delaying cancer diagnosis and treatment.

The approach to cancer care during the COVID-19 pandemic needs to be evidence-based, risk-based and consensus-based. Minimising patients’ exposure to and risk of harm from COVID-19, while ensuring the best possible cancer outcomes, can lead to decisions to alter, modify or delay treatment. These decisions need to involve patients in shared decision making and consider their holistic needs.

Framework for the management of cancer during the COVID-19 pandemic

Cancer care in the time of COVID-19: A conceptual framework for the management of cancer during a pandemic uses published data and guidance to explore system-wide approaches to cancer management during the COVID-19 pandemic. These approaches are in the context of various epidemiological scenarios of COVID-19 cases, across the cancer pathway from prevention and early detection through to survivorship and end-of-life care, and in accordance with the principles of the Optimal Care Pathways for people with cancer.

Opportunities for decision-making about modifications to management based on these principles are mapped according to 3 acute phases (the beginning of the pandemic, approaching health system capacity, and health system capacity exceeded) and 2 recovery phases (early and late) of the pandemic. Second and subsequent waves of infection can also be accommodated.

Some modifications to care will be of permanent value (and the pandemic has therefore driven improvement); telehealth is one example.

This conceptual framework is intended as a useful resource for cancer organisations, health professionals, medical colleges, and policy-makers. While it is designed with the Australian healthcare system and this COVID-19 pandemic in mind, the principles are transferrable to any jurisdiction and for any pandemic.

Read Cancer in the time of COVID-19: A conceptual framework for the management of cancer during a pandemic.

Flattening the curve

An ‘epidemic curve’ shows progression of an illness in an outbreak over time. The curve shape can be altered by a number of community responses, including quarantine, isolation of people with the virus (and their close contacts) and social distancing measures.

The following graph, based on modelling* by the Australian Government in April 2020, depicts three theoretical modelling scenarios in relation to the COVID-19 pandemic:

Modelling COVID-19 Scenarios

Figure 1 – Curves representing possible COVID-19 scenarios comparing weeks since the 
beginning of the outbreak to number of patients with COVID-19.
  • The red curve shows an uncontrolled outbreak where the virus moves rapidly through the community, with no health system or community action to slow the spread.
  • The blue curve shows the effect on patient numbers of quarantine and isolation measures.
  • The green curve shows the additional impact of social distancing measures.
     

Cancer care across the COVID-19 pandemic curves

The following conceptual graph depicts two "COVID-19 curve’ scenarios, in relation to health system capacity:


Figure 2 – Acute and recovery phases of triage and management during the 
COVID-19 pandemic against health system capacity
  • Health system capacity represents the capacity of hospitals to treat patients (based on factors including availability of hospital supplies, healthcare worker resources, personal protective equipment, intensive care unit (ICU) bed and ventilator capacity, and access to pathology and imaging services).
  • Curve A represents a scenario in which demand on the health system rapidly increases during the COVID-19 pandemic, surpasses hospital capacity and overwhelms the health system (similar to scenarios that have occurred in Italy and New York) before entering recovery phases.
  • Curve B is a flattened curve where the health system capacity is not challenged (such as Australia).

Triage and management guidance for cancer care has been categorised into three acute phases (acute phases I, II and III) and two recovery phases (early phase and late phase recovery) (American College of Surgeons 2020).

  • During the acute phases of the pandemic (acute phases I-III), hospitals are either preparing for a surge of COVID-19 patients or managing high volumes of COVID-19 patients.
  • During the recovery phases of the pandemic (early phase recovery; late phase recovery), there is either a stable number of new cases, or a decline in new cases.

Best practice approaches to cancer care will vary depending on: 

  • the phase of the COVID-19 pandemic curve at any particular time; and
  • the relationship between the point in the curve and the health system capacity.

Depending on the number of patients with COVID-19 and the health system capacity, cancer care planning may need to be amended or modified in order to minimise exposure to, and risk of harm from, COVID-19 and improve outcomes for people with cancer.

Optimal cancer care during the COVID-19 pandemic: the Principles

Australia’s cancer survival outcomes are amongst the best in the world. While cancer is a leading cause of death in Australia, mortality rates are decreasing for most cancer types.

Management of cancer is supported by the Optimal Care Pathways for people with cancer, which are designed to guide the delivery of consistent, safe, high-quality and evidence-based care for people with cancer.

The principles underpinning these optimal care pathways have been augmented to support optimal cancer care during the COVID-19 pandemic

Framework for cancer management mapped to pandemic phases

Below is a summary framework for cancer management mapped to pandemic phases across the continuum of care.

Phase

Prevention and
early detection

Presentation, initial
investigations and
referra
l

Diagnosis, staging
and treatment
planning

Treatment

Care after initial 
treatment and
discovery

Managing recurrent
residual or
metastatic disease

End-of-life
care

Curve A

Acute
Phase I

Continue screening

Continue

Continue

Continue

Continue

Continue

Continue

Acute
Phase II

Reduce screening

Continue

Prioritise high-risk
patients

Modify

Modify

Modify

Continue

Acute
Phase III

Hold screening

Hold

Hold

Prioritise high-risk
patients

Modify

Modify

Continue

Early Phase
Recovery

Consider partially
restarting screening

Restart high-risk
patients

Restart high-risk
patients

Restart modified
care

Return to usual
care

Return to usual
​care

Continue

Late Phase
Recovery

Restart screening

Restart all and
catch up plans

Restart all and
catch up plans

Restart all and
catch up plans

Continue

Continue

Continue

Curve B

Acute
Phase I

Continue

Continue

Continue

Continue

Continue

Continue

Continue

Acute
Phase II

Continue

Continue

Continue

Continue

Continue

Continue

Continue

Acute
Phase III

Continue

Continue

Continue

Continue

Continue

Continue

Continue

Read the detailed framework for cancer management mapped to pandemic phases across the continuum of care.


Key links

https://www.health.gov.au/resources/publications/impact-of-covid-19-in-australia-ensuring-the-health-system-can-respond